Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
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 Alderwood Manor during CMS and state inspections, most recent first.
A resident with a history of diabetes, peripheral vascular disease, and recent finger amputation did not receive consistent monitoring or documentation of their surgical wound. Although wound care was marked as completed on the TAR, there was little to no documentation in nurse notes about the wound's condition or changes. The resident developed a blister and infection, which was not adequately tracked, resulting in hospitalization and further amputation. Staff interviews revealed inconsistent wound monitoring practices and unclear responsibilities.
The facility failed to ensure proper hand hygiene and hair coverings during food service, risking foodborne illness. A Dietary Aide had visible facial hair without a beard covering, and a Cook wore a bandana that did not contain their hair. The Cook also engaged in improper hand hygiene, such as wiping their head with gloved hands and washing hands inadequately. The facility's policy required head and beard coverings and thorough handwashing, which were not followed.
The facility failed to obtain accurate and timely consents for psychotropic medications for several residents. A resident received sertraline with an incorrect consent, another was given lorazepam without prior consent, and a third had medications consented by a cognitively impaired representative. Additionally, a resident received Trazodone before signing the consent. These oversights were acknowledged by facility staff.
The facility failed to provide adequate ADL assistance for four residents, leading to deficiencies in cleanliness and grooming. A resident reported receiving fewer baths than care planned, while another with severe cognitive impairment received only weekly showers instead of twice-weekly. Observations noted unshaven facial hair and unkempt hair. Another resident had unclean nails and protruding nasal hair, and a fourth resident reported fewer showers than planned. Staff interviews highlighted inconsistencies in care delivery.
The facility failed to properly assess and implement interventions for residents at risk of elopement, as several residents were not included in the Elopement Book, leading to staff unawareness. Additionally, a resident with a history of falls did not receive updated care plan interventions after multiple falls, and two residents were observed smoking unsupervised despite a non-smoking policy, with care plans lacking clear instructions for supervision and storage of smoking materials.
The facility failed to properly store and dispose of medications and medical supplies, with expired medications found in carts, anti-anxiety meds not secured behind two locks, and incomplete narcotic logs. Unsecured lab supplies were found in The Bistro, and temperature logs for storage rooms were incomplete, risking medication effectiveness. Staff acknowledged these issues.
A resident's preferences for waking and bedtime hours were not accommodated or documented in their care plan, despite the facility's policy requiring person-centered planning. The resident expressed a desire to be woken up early to remove bi-pap equipment and preferred an early bedtime, but these preferences were not reflected in the care plan, leading to a risk of diminished quality of life.
A resident with dementia and depression reported missing jewelry, highlighting the facility's failure to provide secure storage for valuables. The facility's policy did not address securing personal belongings, and not all rooms had locked drawers. Staff interviews revealed inconsistencies in offering lock boxes to residents, and the grievance logs lacked documentation of the resident's concerns.
A facility failed to report and investigate abuse allegations as per its policies, involving a resident with verbal and behavioral symptoms. Despite multiple incidents of verbal aggression, the facility did not document investigations or implement protective measures, placing residents at risk for repeated abuse.
A facility failed to notify the State Long-Term Care Ombudsman of a resident's hospital transfer, as required. The resident, who was cognitively intact and had anxiety and opioid dependence, was sent to the hospital after exhibiting severe symptoms. Staff interviews revealed that the necessary transfer notification form was not completed or sent, resulting in a deficiency.
A resident was transferred to the hospital without receiving a required bed-hold notice, which informs them of their right to pay to hold their room/bed during hospitalization. Despite being cognitively intact and having conditions like anxiety and opioid dependence, the resident's record lacked this documentation. Interviews with the DON and Medical Records staff confirmed the oversight.
A facility failed to incorporate PASARR Level 2 recommendations for a resident with bipolar disorder, neglecting to implement environmental and communication strategies to support mental health needs. The care plan lacked documentation of these recommendations, and an observation showed missing items like a visible clock and schedule.
The facility failed to complete required PASARR Level 1 screenings for two residents, risking inappropriate placement and unmet mental health needs. One resident's PASARR was outdated and did not reflect current diagnoses, while another's PASARR did not indicate the need for a Level II evaluation despite documented mental health conditions. The oversight was acknowledged by the facility's administration.
A resident with dementia and paralysis exhibited possible seizure activity, but the facility failed to notify the provider. The incident was not documented in the communication binder, and no vital signs were recorded in the EMR. Staff interviews revealed uncertainty about whether the provider was informed, and the notification sheet was missing. The provider was scheduled to evaluate the resident ten days later.
A resident with a history of paralysis and a fractured femur developed an unstageable pressure ulcer on their left heel due to the facility's failure to monitor and document skin assessments. The resident was resistant to care, and refusals were not documented, leading to a delay in identifying the ulcer. Hospital records indicated pre-existing wounds, but the facility was unaware, contributing to the deficiency.
A facility failed to implement and monitor orthotic devices for a resident with a progressive neurological condition, leading to the use of rolled washcloths instead. The resident experienced discomfort with the prescribed splints, and staff used washcloths to prevent nails from digging into palms. The care plan required orthotics for six hours daily, but there was no documentation of application, monitoring, or management of refusals. The DON acknowledged the lack of monitoring and documentation.
A resident with a history of stroke and moderate cognitive impairment did not receive necessary care to maintain bowel and bladder functions. Despite assessments indicating the need for a timed voiding program, the facility failed to implement such a program, resulting in frequent incontinence. The resident expressed a preference for using the bathroom but was hindered by delayed staff response and lack of structured toileting support. The care plan lacked interventions, and therapy referrals did not address incontinence issues.
The facility failed to maintain clean respiratory equipment for two residents, risking respiratory complications. A resident with heart failure and sleep apnea had an unclean CPAP mask, while another with chronic respiratory failure had a dusty oxygen concentrator filter. The DON confirmed the importance of regular cleaning to prevent breathing issues.
The facility failed to provide consistent dialysis care for two residents. One resident was not consistently evaluated post-dialysis, missing nine evaluations in two months, while another did not receive morning medications on dialysis days, with no blood sugar checks performed. Staff acknowledged the importance of these evaluations and medication administration, but the facility's practices did not align with its policies.
The facility failed to provide trauma-informed care for two residents with histories of trauma. For one resident, the facility did not identify potential triggers or develop a comprehensive care plan, leading to an incident with a male staff member that was not promptly addressed. The other resident, with a history of mental illness, exhibited disruptive behaviors, but the facility did not document specific triggers or involve family in the evaluation process. The care plans lacked guidance for staff to prevent re-traumatization.
Two residents received medications without proper monitoring of vital signs, contrary to prescribed parameters. One resident was given metoprolol despite a low pulse, and another received Carvedilol without documented blood pressure or heart rate checks. The facility's MAR lacked sections for vital sign documentation, leading to these oversights.
The facility failed to develop a complete water management plan to mitigate Legionnaire's Disease risks and did not ensure proper handling of soiled linens. Additionally, a resident with chronic respiratory failure was exposed to infection risks when their nasal cannula was placed back in use after being on the floor without cleaning or replacement.
The facility failed to maintain clean wheelchairs for two residents, one with a history of stroke and hemiplegia and another with heart failure and diabetes. Observations over several days revealed unclean conditions, including food debris and substances on the wheelchairs. The DON confirmed that wheelchairs should be cleaned weekly, and failure to do so was a dignity issue.
A resident with a history of stroke required substantial assistance for transfers, as per their care plan. However, a staff member attempted to transfer the resident alone, resulting in the resident being assisted to the floor and sustaining a fractured arm and clavicle. The staff member did not review the resident's Kardex, which specified the need for two staff members for transfers.
Residents in the facility reported ongoing issues with the dietary services, including not receiving meals according to their preferences and being served items they disliked or were allergic to. Despite attending food committee meetings and filing grievances, residents felt their concerns were not resolved, leading to dissatisfaction and some resorting to buying their own food. Staff interviews revealed communication issues and a lack of effective resolution to the dietary complaints.
The facility failed to thoroughly investigate allegations of abuse and neglect for four residents, including grievances about rough treatment, inadequate staffing, and delayed responses to call lights. Despite residents' complaints, there was no documentation of comprehensive investigations, placing residents at risk for further abuse and neglect.
Failure to Monitor and Document Surgical Wound Leading to Infection and Hospitalization
Penalty
Summary
The facility failed to adequately monitor and document the condition of a surgical wound for one resident who had undergone amputation of the right fingertips due to dry gangrene. Upon admission, the resident had a dressing on the right hand that was not to be removed until a follow-up with the surgeon. After the initial follow-up, daily wound care was ordered and documented as completed on the Treatment Administration Record (TAR), but there was no corresponding documentation in the nurse progress notes regarding the wound's condition or any changes observed during this period. Subsequent surgical follow-ups revealed the development of a large blister and signs of soft tissue infection on the resident's right hand, leading to new wound care orders and antibiotics. While the TAR indicated that wound care was performed, there was no documentation showing that the wound was monitored for increased redness or signs of worsening infection as ordered. Nurse notes contained only brief references to the wound's appearance and infection status, with no detailed assessments or ongoing monitoring documented, especially in the days leading up to the resident's transfer to the hospital for a worsened infection. Interviews with facility staff revealed inconsistent practices and a lack of clarity regarding wound monitoring responsibilities, particularly for surgical wounds. Staff members were either unfamiliar with the resident's wound or had not observed it directly, and the Director of Nursing stated that wound observation forms were not used for surgical incisions at the time. The lack of thorough assessment and documentation contributed to the resident's condition worsening, ultimately resulting in hospitalization and further amputation.
Improper Hand Hygiene and Hair Covering in Food Service
Penalty
Summary
The facility failed to ensure proper hand hygiene and hair coverings were worn and implemented during food service, which placed residents at risk for foodborne illness. Observations revealed that a Dietary Aide, Staff Z, participated in the breakfast tray line with visible facial hair and no beard covering. Additionally, a Cook, Staff Y, was observed with a pink bandana that failed to contain their hair, allowing hair to flow down their forehead and around the sides and back of their head. Staff Y was also seen engaging in improper hand hygiene practices, such as wiping their head with gloved hands, using the same gloves to take food temperatures, and washing their hands for only seven seconds before using a paper towel to wipe down the steamer table. The facility's policy required kitchen staff to always wear head and beard coverings, regardless of their activities, and to wash hands thoroughly for at least 30 seconds. However, Staff Y did not adhere to these guidelines, as evidenced by their inadequate handwashing and improper use of a paper towel. The Dietary Manager, Staff X, confirmed the requirement for head and beard coverings and proper hand hygiene, acknowledging that Staff Y's actions did not comply with the facility's standards. Further observation showed Staff Y wearing a hairnet incorrectly, with hair exposed below the hairnet line.
Failure to Obtain Accurate and Timely Medication Consents
Penalty
Summary
The facility failed to ensure that psychotropic medication consents were accurate and obtained prior to administration for several residents. For Resident 3, the consent form for the medication sertraline was inaccurately documented as being used for somatization instead of depression, as per the physician's order and care plan. This discrepancy was acknowledged by the facility's administrator. Resident 13 was administered lorazepam for anxiety related to dialysis without a consent form being signed prior to the medication's initiation. The consent was only obtained nearly two months later, which was confirmed by the Director of Nursing. This oversight meant that the resident's representative was not informed of the medication's risks and benefits before administration. For Resident 27, the consent for medications Lexapro and Zyprexa was signed by a representative who was also a resident of the facility and had moderate cognitive impairments. This representative was unaware of the medications and their associated risks and benefits. Additionally, Resident 39 received Trazodone for insomnia before the consent was signed, which was acknowledged as a mistake by the Resident Care Manager and the Director of Nursing.
Deficiencies in ADL Assistance and Hygiene
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADLs) for four residents, leading to deficiencies in cleanliness and grooming. Resident 44, who was cognitively intact and dependent on staff for bathing, reported receiving baths only once a week despite a care plan indicating twice-weekly baths. Documentation confirmed the lack of adherence to the care plan, with no records of baths on specified dates. Resident 37, with severe cognitive impairment and paralysis, required assistance for personal hygiene and showering. The care plan specified twice-weekly showers, but records showed only weekly showers were provided. Additionally, Resident 37 was observed with unshaven facial hair and unkempt hair, despite expressing a preference for being clean-shaven with a mustache. Staff interviews revealed inconsistencies in shower scheduling and shaving practices. Resident 9, with moderate cognitive impairments, required substantial assistance for personal hygiene, including nail care. Observations noted unclean nails with a brown substance and protruding nasal hair, which the resident was unaware of. Resident 19, cognitively intact, also reported receiving fewer showers than care planned, with documentation supporting this claim. Staff interviews highlighted the importance of regular showers for hygiene and dignity, yet the facility failed to meet these standards.
Deficiencies in Elopement, Fall Prevention, and Smoking Supervision
Penalty
Summary
The facility failed to ensure that residents identified at risk for elopement were accurately assessed and interventions implemented to prevent elopement for four of five sampled residents. Specifically, Residents 7, 27, 25, and 254 were not properly included in the Elopement Book, which is used to alert staff of residents at risk for elopement. Despite care plans indicating these residents were at risk, the Elopement Books at various locations in the facility did not contain their information, leading to a lack of awareness among staff about their elopement risk. Additionally, the facility did not provide adequate supervision and interventions to prevent falls for Resident 41. The resident, who had a history of falls and was identified as having poor balance and safety awareness, experienced multiple falls outside the facility. Despite these incidents, the care plan was not updated with new interventions to prevent further falls, and there was no documentation of a referral to therapy services to address the resident's mobility and safety issues. The facility also failed to supervise two residents, Residents 24 and 41, who were identified as smokers. Despite the facility's non-smoking policy, these residents were observed smoking outside the facility without staff supervision. Resident 24, who had limited mobility, was seen smoking in unsafe areas, and Resident 41, who was cognitively intact but had physical limitations, was observed smoking on the main road and in the facility's driveway. The care plans for these residents did not provide clear instructions on the supervision required or the safe storage of smoking materials.
Medication Storage and Disposal Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and timely disposal of medications and medical supplies, as observed in two medication carts and two medication storage rooms. Expired medications, including insulin pens and allergy nasal spray, were found in the medication carts, and some insulin pens lacked usage dates. Additionally, anti-anxiety medications were not stored behind the required two locks, and the narcotic logs were not consistently signed by nursing staff at shift changes. These lapses in protocol placed residents at risk of receiving compromised or ineffective medication and increased the potential for drug diversion. In a room called The Bistro, unsecured lab supplies, including intravenous needles and unsealed bottles of red liquid used for stool sample transport, were found in unlocked cabinets and drawers. The room was used for family visits, staff breaks, and corporate visits, and although no residents were wandering in the area, the unsecured items posed a potential safety risk. Furthermore, the temperature logs for the medication storage rooms had multiple omissions, which could affect the effectiveness of stored vaccines. Staff interviews confirmed awareness of these issues, acknowledging the importance of proper storage and monitoring to ensure medication viability and safety.
Failure to Accommodate Resident's Bedtime Preferences
Penalty
Summary
The facility failed to accommodate the bedtime routine preferences of a resident, identified as Resident 44, which was a violation of their right to self-determination and choice. The facility's policy on Person Centered Planning required the development of a care plan that included the resident's goals, preferences, values, and practices, with the resident's participation. However, the care plan for Resident 44 did not reflect their stated preferences for waking and bedtime hours. The resident expressed a desire to be woken up at or before 6:00 AM to remove their bi-pap equipment and preferred to go to bed around 8:00 PM. Despite this, the quarterly assessment and activities evaluation indicated different preferred times, and these preferences were not documented in the care plan. Interviews with staff, including Staff L, the Activities Coordinator, confirmed that the process for identifying and documenting resident preferences was not followed in this case. Staff L acknowledged that although they were responsible for gathering information on resident preferences and adding it to the care plan, Resident 44's care plan did not include instructions for their preferred waking or bedtime hours. This oversight placed the resident at risk for a diminished quality of life, as their preferences were not accommodated or communicated to the staff.
Failure to Provide Secure Storage for Resident Valuables
Penalty
Summary
The facility failed to provide a secure place for residents to store their valuables, as evidenced by the case of a resident who reported missing jewelry. The resident, who had dementia and depression, expressed the importance of having a secure place for their belongings. Upon admission, the facility's policy required personal clothing to be marked and returned to the resident, but it did not address the security of other personal belongings. The resident reported missing a wedding ring and two diamond bracelets, which were not documented on the personal belonging inventory sheet. The resident mentioned the possibility of losing the jewelry at dialysis but was unsure of its whereabouts. Interviews with staff revealed that not all rooms had locked drawers, and newer residents were asked if they wanted a lock box, but this was not consistently communicated to all residents. The resident's room was inspected, and it was confirmed that there were no lock boxes or locking mechanisms available for securing personal items. The staff acknowledged the oversight and indicated that arrangements would be made to provide a lock for the resident's belongings. The grievance logs did not contain any entries related to the missing jewelry, indicating a lack of documentation and follow-up on the resident's concerns.
Failure to Report and Investigate Abuse Allegations
Penalty
Summary
The facility failed to implement its Abuse and Neglect Prohibition Policies and Procedures, specifically in reporting allegations of abuse to the State Agency (SA) within the required timeframe and conducting thorough investigations. This deficiency was identified in the case of one resident, who was cognitively intact but exhibited verbal and behavioral symptoms such as yelling, threatening, and making disruptive sounds. Despite these behaviors, the facility did not document investigations into the psychological impact on other residents or implement protective measures to prevent recurrence. The facility's policies required immediate reporting of abuse allegations to the SA, but incidents involving the resident's verbal aggression were not logged or reported within the specified timeframe. Progress notes indicated multiple instances of verbal aggression and disruptive behavior, yet there was no documentation of investigations or measures taken to address these incidents. The facility's failure to follow its policies placed the resident and others at risk for repeated abuse, as acknowledged by the facility's administrator.
Failure to Notify Ombudsman of Resident's Hospital Transfer
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman about a hospital transfer for one of the residents, identified as Resident 51. This deficiency was identified through interviews and record reviews. Resident 51, who was cognitively intact and had diagnoses including anxiety and opioid dependence, was observed in the early morning hours to be pulling their hair and experiencing severe jerking movements. Following an assessment and direction from the on-call provider, the resident was transferred to the hospital for evaluation. However, there was no documentation indicating that the Ombudsman had been notified of this transfer. Interviews with facility staff revealed a breakdown in the process of notifying the Ombudsman. Staff E, responsible for medical records, stated that the Notice of Transfer or Discharge form should have been filled out and sent to the Ombudsman by Staff F, the receptionist. Upon reviewing Resident 51's record, both Staff E and Staff F confirmed that the form was missing. Staff F explained that once the form was sent to the Ombudsman, it was supposed to be filed in the resident's record, but this step was not completed for Resident 51.
Failure to Provide Bed-Hold Notice
Penalty
Summary
The facility failed to provide a bed-hold notice to a resident or their representative at the time of discharge or within 24 hours of transfer to the hospital. This deficiency was identified for one of the two sampled residents, who was reviewed for hospitalization. The resident, identified as Resident 51, was cognitively intact and had diagnoses including anxiety and opioid dependence. On the early morning of August 29, 2024, the resident exhibited severe jerking movements and was observed pulling their hair, leading to a hospital transfer for evaluation as directed by the on-call provider. Upon review of Resident 51's records, it was found that there was no documentation of a bed-hold notice being provided, as required. Interviews with the Director of Nursing and Medical Records staff revealed that bed-hold notices were supposed to be completed upon admission and again when a resident was transferred to the hospital. However, the Medical Records staff confirmed that the electronic form for the bed-hold notice was not present in the resident's record, indicating it was not completed.
Failure to Implement PASARR Level 2 Recommendations
Penalty
Summary
The facility failed to incorporate specific recommendations from a PASARR Level 2 evaluation for a resident with medically complex conditions, including depression and bipolar disorder. The PASARR Level 2 evaluation recommended environmental and communication strategies to support the resident's mental health needs, such as keeping the room free of obstacles, ensuring it is well-lit during the day, and maintaining a quiet, dark, and cool environment at night. Additionally, the evaluation advised on clear communication, monitoring for changes in behavior, and early intervention to prevent manic episodes. Despite these recommendations, the facility did not document or implement them in the resident's care plan. An observation of the resident's room revealed the absence of a clock or daily schedule in a visible location, as suggested by the PASARR Level 2 evaluation. The deficiency was acknowledged by the facility's administrator, who confirmed that the recommendations should have been incorporated into the care plan.
Failure to Complete Required PASARR Screenings
Penalty
Summary
The facility failed to ensure that a PASARR Level 1 screening was completed as required for two residents, placing them at risk for inappropriate placement and not receiving necessary mental health services. Resident 3 was readmitted to the facility with complex medical conditions, including depression and anxiety disorder, but the medical record lacked a current PASARR Level 1. An outdated PASARR Level 1 from 2020 was presented, which did not recognize the resident's current diagnoses. The administrator and director of nursing acknowledged the oversight and the need for an updated PASARR Level 1. Resident 27 was admitted with diagnoses of depression, anxiety, and dementia. Although a PASARR was completed prior to admission, it failed to indicate the need for a Level II evaluation despite documenting anxiety and a mood disorder. The absence of a Level II evaluation was confirmed by the administrator, who acknowledged the necessity of a referral to meet the resident's care needs.
Failure to Notify Provider of Possible Seizure Activity
Penalty
Summary
The facility failed to notify the provider when a resident, who had no previous diagnosis of seizures, exhibited possible seizure activity. The incident involved a resident with dementia and paralysis from a stroke, who was observed having seizure-like movements while in the dining room with family. Despite the resident's vital signs being within normal limits, there was no documentation of these vital signs in the electronic medical record for the date of the incident. Furthermore, the provider was reportedly notified via a communication binder, but no entry was found in the binder, and no provider progress notes were documented after the incident. Staff interviews revealed that the absence of the notification document made it difficult to confirm whether the provider was aware of the resident's possible seizure. Staff acknowledged that a seizure would constitute a change of condition requiring provider notification. The Director of Nursing later confirmed that the notification sheet could not be located, and the provider was scheduled to evaluate the resident ten days after the initial event. This oversight placed residents at risk of not being assessed for potential decline by their provider, leading to unintended health consequences and decreased quality of life.
Failure to Monitor and Document Pressure Ulcer Development
Penalty
Summary
The facility failed to identify and monitor a pressure ulcer for a resident who was at risk due to decreased mobility and a history of paralysis and a fractured femur. Upon admission, the resident had no pressure ulcers, but a significant change assessment later documented an unstageable pressure ulcer on the resident's left heel. The care plan included interventions such as providing a pressure-relieving mattress and wheelchair cushion, conducting weekly skin checks, and notifying relevant staff if the resident refused care. However, the facility did not document refusals of care or skin assessments, and the pressure ulcer was not identified until a nurse noticed it weeks after admission. The resident had a history of refusing care and was resistant to skin checks, which was not adequately documented by the facility. Hospital records indicated the presence of wounds on both heels prior to admission, but the facility staff were unaware of these wounds. The resident's care plan was updated to address the unstageable pressure ulcer, but the lack of initial documentation and monitoring contributed to the deficiency. The resident's refusal to wear foam boots and the discomfort caused by a leg brace further complicated the situation, leading to the development of the pressure ulcer. Interviews with staff revealed that the resident's refusals were not documented, and the facility did not have a complete understanding of the resident's condition upon admission. The Director of Nursing acknowledged the lack of documentation and stated that a full skin assessment was conducted only after the wound was identified. The facility's failure to document refusals and monitor the resident's skin condition led to the deficiency, as the pressure ulcer was not addressed in a timely manner.
Failure to Implement and Monitor Orthotic Devices for Resident
Penalty
Summary
The facility failed to properly implement and monitor the use of orthotic devices for a resident, identified as Resident 10, who was at risk for contractures due to a progressive neurological condition. Despite being part of a Restorative Nursing Program, Resident 10 was observed using rolled washcloths instead of the prescribed orthotic devices. The resident reported discomfort with the splints, leading to the use of washcloths, which were not consistently effective as one often fell out of the resident's hand. Staff interviews confirmed the use of washcloths to prevent the resident's nails from digging into their palms and to cushion their arms. The care plan for Resident 10 included instructions to apply orthotics to both hands for up to six hours a day, with skin checks each shift. However, there was no documentation of the application, monitoring, or management of the orthotics, nor any record of the resident's refusals or the reasons for them. The Director of Nursing acknowledged the lack of monitoring and documentation regarding the orthotics and the absence of an order in the treatment administration record to ensure compliance with the care plan.
Failure to Implement Toileting Program for Resident
Penalty
Summary
The facility failed to provide necessary care and services to Resident 18, who was admitted with a stroke and moderate cognitive impairment, to maintain and avoid loss of bowel and bladder functions. The resident required substantial assistance for toileting and was frequently incontinent of bowel and bladder. Despite assessments indicating the need for a timed or scheduled voiding program, no such program was implemented. Observations revealed that the resident was often left in bed without timely assistance to use the bathroom, leading to incontinence episodes. The resident expressed a preference for using the bathroom but was unable to do so due to delayed staff response and lack of a structured toileting program. The facility's documentation showed inconsistencies in the assessment of the resident's incontinence and the interventions provided. Various assessments identified different types of incontinence, such as urge, functional, and stress incontinence, but failed to result in a consistent care plan. Although referrals to occupational and physical therapy were made, there was no documentation of evaluations or interventions to address the resident's incontinence. The care plan did not include interventions for a timed or scheduled voiding program, despite the resident meeting the criteria for such a program in multiple evaluations. The Director of Nursing acknowledged the lack of interventions and the conflicting assessment results.
Failure to Maintain Clean Respiratory Equipment
Penalty
Summary
The facility failed to maintain clean oxygen delivery equipment for two residents, leading to potential risks of respiratory complications and infection. Resident 19, who had heart failure and obstructive sleep apnea, required a CPAP machine. Despite a physician's order to clean the CPAP mask daily, observations revealed that the mask was unclean with white splatter inside, and the resident reported that staff had not been cleaning it. The CPAP was also stored in a drawer full of crumbs, indicating a lack of proper hygiene and maintenance. Resident 38, diagnosed with chronic respiratory failure and asthma, required oxygen therapy. The physician's order specified that the oxygen concentrator filter should be cleaned weekly. However, an observation found the filter covered in thick dust debris. The Director of Nursing confirmed the importance of cleaning the equipment to prevent interruptions in oxygen flow and potential breathing difficulties. These observations highlight the facility's failure to adhere to prescribed cleaning protocols for respiratory equipment.
Inconsistent Dialysis Care for Two Residents
Penalty
Summary
The facility failed to provide consistent dialysis care in accordance with professional standards for two residents. Resident 13, who had paralysis and end-stage kidney disease, was not consistently evaluated post-dialysis. The facility's policy required staff to check vital signs and document the resident's status in the Dialysis Communication Binder after each session. However, there were nine instances in September and October 2024 where the post-dialysis evaluation was not completed. Staff D, the Resident Care Manager, acknowledged the importance of these evaluations to monitor for adverse reactions and maintain communication with the dialysis center. Resident 19, diagnosed with heart failure and end-stage kidney disease, did not receive their morning medications on dialysis days. The care plan required blood sugar checks and medication administration at least two hours before or after dialysis. However, the October 2024 medication administration record showed no blood sugar checks before dialysis and inconsistent medication administration on dialysis days. Staff B, the Director of Nursing, confirmed the necessity of monitoring blood sugars and administering medications appropriately. The dialysis clinic stated they did not check blood sugars unless symptomatic and did not administer facility-prescribed medications.
Failure to Provide Trauma-Informed Care
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for two residents, Resident 3 and Resident 25, who were reviewed for trauma-informed care. For Resident 3, the facility did not adequately assess and identify potential triggers that could re-traumatize the resident, nor did it develop and implement a comprehensive Trauma Informed Care Plan. Despite Resident 3's history of physical assault and severe human suffering, the facility's evaluation did not list any triggers, and staff were unaware of what could trigger re-traumatization. An incident involving a male staff member who exhibited intimidating behavior was reported, but the facility did not monitor Resident 3 for adverse reactions until two days later. Resident 25, who was assessed as cognitively intact and had a history of mental illness, also did not receive adequate trauma-informed care. The facility's evaluations identified that Resident 25 had experienced a very stressful event but failed to document what the event was or identify specific triggers. The resident exhibited several disruptive behaviors, including yelling, banging, and verbal aggression, but the care plan lacked trigger-specific interventions to prevent re-traumatization. The facility did not involve family members or representatives in the evaluation process, and the care plan did not provide guidance to staff on how to address the resident's reactions. The deficiencies were acknowledged by the facility's Administrator and Director of Nursing, who recognized the lack of interventions and guidance in the care plans for both residents. The facility's failure to identify triggers, coping mechanisms, and strategies to manage re-traumatization placed the residents at risk for re-traumatization and a diminished quality of life.
Failure to Monitor Vital Signs Before Medication Administration
Penalty
Summary
The facility failed to ensure proper monitoring of blood pressures and heart rates, leading to the administration of medications against prescribed parameters for two residents. Resident 10 had an order for metoprolol, which was to be held if the pulse was below 60 beats per minute. Despite this, the medication was administered on multiple occasions when the resident's pulse was below the threshold. This oversight was acknowledged by Staff D, a Registered Nurse/Resident Care Manager, who confirmed that the medication should have been withheld on those days. Resident 22, who had diagnoses including hypertensive kidney disease and dementia, was prescribed Carvedilol with instructions to hold the medication if the systolic blood pressure was less than 110 or the heart rate was below 60 beats per minute. However, the facility's Medication Administration Record (MAR) lacked a section for documenting vital signs, and the resident received the medication without proper monitoring. Staff J, an LPN, confirmed that there was no place to document the vital signs on the MAR, and vital signs were only taken every other day. Staff D admitted that the monitoring requirement had been overlooked, leading to the administration of the medication without verifying the necessary parameters.
Inadequate Infection Control and Water Management
Penalty
Summary
The facility failed to develop a comprehensive water management plan to address the risk factors associated with Legionnaire's Disease. The plan, last reviewed on March 11, 2024, was incomplete, lacking essential components beyond identifying the facility's water source, contacts, and characteristics. This deficiency was confirmed by the facility's administrator, who acknowledged the need for a more detailed plan. Additionally, the facility did not ensure proper handling of soiled linens, as observed when a nursing assistant transported a soiled gown without placing it in a bag, contrary to infection control protocols. Furthermore, the facility failed to maintain sanitary conditions for oxygen administration for a resident with chronic respiratory failure. The resident's nasal cannula was found on the floor, and a nursing assistant placed it back in the resident's nose without cleaning or replacing it, which was identified as an infection control concern by the infection preventionist.
Failure to Maintain Clean Wheelchairs for Residents
Penalty
Summary
The facility failed to maintain wheelchairs in a clean manner for two residents, which was observed during a survey. Resident 14, who had a history of stroke and hemiplegia, was noted to have moderate cognitive impairments and required substantial to total assistance for all care. Observations on multiple occasions revealed that the resident's wheelchair was unclean, with the left armrest covered in sheepskin and netting that had brown and red substances on it. Additionally, food debris was crusted on the cushion and bottom of the chair. These observations were made over several days, indicating a persistent issue with maintaining cleanliness. Similarly, Resident 19, who was cognitively intact and required substantial to total assistance, was observed with an unclean wheelchair containing food debris. This was noted on several occasions over a few days. An interview with the Director of Nursing confirmed that wheelchairs were supposed to be cleaned weekly, and failure to do so was considered a dignity issue for the residents. The lack of cleanliness in the wheelchairs for these residents was a deficiency in maintaining a safe and dignified environment.
Failure to Follow Transfer Protocol Results in Resident Injury
Penalty
Summary
The facility failed to ensure that a resident was transferred according to their care plan, resulting in harm. The resident, who had a history of a stroke affecting their right side and required substantial assistance with transfers, was supposed to be transferred by two staff members using a gait belt or a sit-to-stand lift. However, Staff A attempted to transfer the resident alone using a gait belt. During the transfer, the resident's legs gave out, and Staff A assisted them to the floor. The wheelchair brake was inadvertently released, causing the wheelchair to slide back, and the resident landed on the floor. Initially, the resident did not report any pain or abnormalities, but later complained of pain, and an x-ray revealed a fractured right arm and clavicle. Staff B, a Registered Nurse, confirmed that Staff A did not review the resident's Kardex, which indicated the need for two staff members for transfers. The Director of Nursing acknowledged that Staff A did not follow the care plan, leading to the resident's injuries.
Failure to Address Dietary Grievances
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve grievances related to dietary issues for eight out of nine residents. Residents reported that their food preferences, as indicated on meal cards, were not being honored. This included not receiving the food they ordered, being served items they disliked, and in some cases, receiving food they were allergic to. Despite attending food committee meetings and voicing their concerns, residents felt that their grievances were not addressed, leading to ongoing dissatisfaction with the dietary services provided. Interviews with residents revealed consistent issues with the facility's food service. Residents expressed frustration over not receiving the meals they selected, with some resorting to purchasing their own food due to dissatisfaction. Specific grievances included being served cold food, not receiving required dietary supplements, and experiencing rude behavior from staff when rejecting meals. The facility's grievance records corroborated these complaints, showing repeated concerns about the kitchen staff not adhering to residents' meal preferences and dietary needs. Staff interviews indicated a lack of effective communication and follow-through on resolving the dietary issues. The Dietary Manager acknowledged the problems but attributed them to misunderstandings about menu processes and a lack of time for cooks to review individual dislikes. Despite attempts to educate staff and involve them in food committee meetings, the issues persisted, with residents continuing to feel that their concerns were not being adequately addressed.
Failure to Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse and/or neglect for four residents, which placed them at risk for further abuse and/or neglect. Resident 4, who had heart disease, filed a grievance about a Licensed Practical Nurse (LPN) being rough and rude. The Director of Nursing (DNS) documented speaking with the resident and ruling out abuse/neglect, but there was no evidence of a thorough investigation, including interviews with the resident and staff. Resident 5, diagnosed with diabetes and paraplegia, reported grievances about two nurses being rude and not being assisted out of bed for three days due to staff unavailability and lack of training with the Hoyer lift. The facility's response involved speaking with the resident and adjusting staffing, but there was no documentation of a comprehensive investigation into the allegations. Similarly, Resident 6, with respiratory disease, reported a lack of staff availability when they were sick, but the facility's response did not include a thorough investigation. Resident 7, with a central nervous system disease, filed a grievance about inadequate staffing and a delayed response to their call light. The facility's response indicated that staffing was adequate, but there was no documentation of a detailed investigation. Interviews with staff revealed that grievances were logged and assigned to relevant departments, but allegations of abuse and/or neglect were not investigated as required, and the grievances were not treated as such.
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 120 citations issued within 25 miles in the last 12 months — 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 Spokane
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Touchmark On South Hill Nursing | 1.8 mi | — | 0 | 0 |
| Spokane Veterans Home | 2.3 mi | — | 1 | 0 |
| South Hill Rehabilitation And Care Center | 2.3 mi | — | 2 | 0 |
| Rockwood South Hill | 3.3 mi | — | 1 | 0 |
| Sunshine Health & Rehab | 4.2 mi | — | 13 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.