Avamere Rehabilitation Of Cascade Park
Inspection history, citations, penalties and survey trends for this long-term care facility in Vancouver, Washington.
- Location
- 801 Southeast Park Crest Avenue, Vancouver, Washington 98683
- CMS Provider Number
- 505389
- Inspections on file
- 26
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Avamere Rehabilitation Of Cascade Park during CMS and state inspections, most recent first.
A resident with a history of atherosclerosis of coronary artery bypass grafts was issued an emergency discharge for endangering the safety of others, but the facility documented the discharge location only as the resident's personal car with no address and did not secure confirmed housing or access to shelter or hygiene facilities. The discharge notice was delivered with law enforcement present, and the resident packed belongings and left the same day. The SW confirmed that no housing placement was arranged before discharge, and the resident later reported being escorted out by police and relying on a POA to obtain temporary motel lodging before staying with a friend.
A resident with multiple complex medical conditions, including a stage 4 pressure wound and significant care needs, was discharged home without proper supports, services, or equipment in place. The discharge was authorized by a family member without legal authority, and no home health or wound-care arrangements were made. Facility staff and the resident's provider had documented concerns about the safety of the discharge, and the resident was subsequently hospitalized due to complications from inadequate care at home.
Two residents with cognitive impairment were observed with their beds either in a low position or placed against the wall, used as physical restraints, without the required Safety Device Evaluation, physician's order, or care plan intervention. Staff confirmed that these steps were necessary but had not been completed or documented.
Three residents with significant cognitive and medical conditions did not have comprehensive care plans addressing key aspects of their care, including use of physical restraints, PTSD, antianxiety and anticoagulant medications, and dementia. Staff confirmed that these care plan elements were missing or delayed, despite ongoing treatment and diagnoses.
A resident with severe cognitive impairment and multiple diagnoses did not receive restorative aid services as recommended after discharge from physical therapy. Despite documented recommendations for specific restorative interventions, there was no evidence in the medical record that these services were provided, and staff interviews revealed a lack of awareness and follow-through regarding the resident's restorative care needs.
The facility did not follow physician orders and care plans for two residents: one resident did not have a required bed rail installed to assist with mobility, and another resident with CHF did not have daily weights consistently recorded or significant weight gains reported to the physician as ordered. Staff confirmed these omissions and the lack of required documentation.
A resident with severe cognitive impairment and dementia was prescribed Lorazepam for anxiety, but staff failed to document monitoring for adverse side effects after administration. Interviews with the Resident Care Manager and DON confirmed that monitoring was expected but not completed, and the necessary order for monitoring was delayed by over a month.
Two CNAs transferred a resident on contact precautions without wearing required isolation gowns, despite a physician order and facility expectations for PPE use during such care.
Nursing hours were not accurately posted or updated throughout the day, as required. Instead, staffing information was corrected the following morning, and staff were unaware that real-time updates were necessary. This resulted in daily postings that did not reflect actual staffing changes.
A resident with Type 2 Diabetes Mellitus was admitted without blood glucose monitoring orders despite being on oral diabetic medications. The resident experienced severe hypoglycemia, leading to hospitalization. Facility staff typically relied on Hemoglobin A1C levels rather than routine glucose checks, contrary to the facility's policy for monitoring residents on oral medications.
A resident with a healing Stage 2 pressure ulcer experienced worsening of the ulcer and developed a new one due to inadequate monitoring and delayed treatment. The facility failed to conduct timely skin audits and Braden Risk Assessments, and did not provide necessary pressure-relieving equipment promptly. Lack of communication and documentation among staff further contributed to the resident's condition deteriorating, leading to hospitalization and surgical intervention.
The facility failed to obtain necessary assessments, consents, and physician orders for beds placed against the wall and the use of bed rails for four residents. Observations confirmed the improper use of restraints without documentation, and staff acknowledged the oversight.
The facility failed to maintain dignity in catheter care for two residents with indwelling catheters. Both residents were observed with uncovered foley catheter drainage bags, despite care plans requiring them to be covered. Staff acknowledged the expectation for bags to be covered and not placed on the floor, indicating a lapse in following care plans.
The facility did not ensure a resident was offered the opportunity to participate in care conferences, as only one was documented despite expectations for quarterly meetings. The resident was alert and oriented, and staff interviews confirmed the expectation for quarterly care conferences, which were not met.
A facility failed to review and maintain advance directives (AD) and Durable Power of Attorney (DPOA) documentation for a resident. Despite being alert and oriented, the resident's ADs were not reviewed for several months. Staff acknowledged that the AD should have been reviewed during a care conference, but this did not happen.
Two residents experienced unresolved grievances regarding lost items due to the facility's failure to adhere to its grievance policy. One resident's manual wheelchair went missing after a hospital transfer, and despite reporting it, the issue was not promptly addressed. Another resident reported missing laundry items, which were not fully recovered despite her efforts. The facility's lack of timely communication and action resulted in unresolved concerns.
The facility failed to provide written bed-hold notices to two residents or their representatives during hospital transfers. One resident, severely cognitively impaired, was transferred without documentation of a bed-hold notice. Another resident, moderately cognitively impaired, was hospitalized and returned without a bed-hold notice. Staff acknowledged the oversight and lack of compliance with the requirement to inform residents or their representatives.
A facility failed to develop a comprehensive care plan for a resident with skin conditions, including abrasions and blisters on the feet. Despite physician orders for specific wound care, the care plan lacked focus areas, goals, or interventions for these conditions. Staff interviews revealed the absence of a documented care plan, with the Resident Care Manager and DON acknowledging the oversight.
A resident with Inclusion Body Myositis experienced discomfort and safety risks due to improper wheelchair fit and positioning. Despite complaints and a vendor's acknowledgment of a broken part, the facility failed to assess and address the wheelchair's fit and functionality. Staff were unaware of repair plans, and temporary fixes did not resolve the issue.
The facility failed to follow infection control practices during wound care for a resident with a Stage 4 pressure ulcer and catheter care for another resident. An LPN did not wash hands between glove changes during a dressing change, and a catheter drainage bag was found on the floor without proper covering or hanging. Staff acknowledged these practices were against facility policy.
Failure to Arrange Safe and Orderly Emergency Discharge
Penalty
Summary
The facility failed to provide a safe and orderly discharge for a resident when it processed an emergency discharge without securing an appropriate discharge location, supports, or housing. Facility policy on Discharge Planning, dated 01/09/2002, required Social Services to arrange or assist in arranging necessary services, identify the discharge location, supports, and equipment, and, for residents without an identified discharge location, enlist the support of the assigned Medicaid case manager and other public agencies to secure appropriate housing. The resident was admitted with diagnoses including atherosclerosis of coronary artery bypass graft(s). The Nursing Home Transfer or Discharge Notice, dated 01/29/2026, documented an emergency discharge under the reason that the safety of other individuals in the facility was endangered. The discharge location was recorded as "Car (Personal)" with the address listed as "NA," and the record did not identify an established discharge address or confirmed housing placement where the resident could access shelter or hygiene facilities. Interviews and record review confirmed that no confirmed housing placement was secured prior to discharge. The Administrator stated the discharge was processed as an emergency discharge with law enforcement present when the notice was delivered, and that the resident packed his belongings and left the facility the same day. The Social Worker stated the discharge was processed as an immediate discharge and confirmed that the discharge location was documented as the resident's car, with no confirmed housing placement arranged beforehand. The resident later reported being escorted from the facility by police on the date of discharge, and that his POA secured motel lodging for several days following discharge before he went to stay with a friend. The Administrator later acknowledged that discharge to a hotel would have been preferable to discharge to the resident's vehicle.
Failure to Ensure Safe and Appropriate Discharge for Resident with Complex Needs
Penalty
Summary
The facility failed to ensure a safe and appropriate discharge for a resident with complex medical needs, including sepsis, encephalopathy, Parkinson's disease, a stage 4 sacral pressure wound, and adult failure to thrive. The resident was non-verbal, required significant assistance with activities of daily living, and was dependent for toileting and lower-body dressing. Despite documentation from the primary care provider and facility staff indicating that the resident required a higher level of care and that discharge home would be unsafe, the resident was discharged home without adequate supports in place. Discharge planning was insufficient, as the resident's daughter, who did not have legal authority to act on her behalf, signed the discharge paperwork. There was no documentation that the resident participated in or consented to the discharge decision. The facility did not arrange for home health or wound-care services, and necessary equipment such as a low-pressure mattress was not provided. The resident's significant other, identified as the primary caregiver, did not receive training or instruction regarding the resident's care needs, and staff expressed doubt about his ability to provide the required level of care. Following discharge, the resident was found at home without appropriate care, experiencing pain and complications from the existing stage 4 wound, which led to hospitalization. The facility staff, including nursing and the physician, believed the discharge was unsafe, and there was no evidence that guardianship or Medicaid application processes were pursued to ensure the resident's needs were met. The discharge was documented as against medical advice, but the facility did not fulfill its responsibility to ensure a safe and coordinated transition, resulting in harm to the resident.
Failure to Obtain Required Evaluation and Orders for Physical Restraints
Penalty
Summary
The facility failed to obtain a Safety Device Evaluation and Consent and/or physician's order for two residents who were using physical restraints, as required by facility policy. For one resident with severe cognitive impairment, the bed was observed in a low position multiple times, but there was no documentation of a Safety Device Evaluation, physician's order, or care plan intervention related to this practice. Staff confirmed that such documentation and orders were required but not present in the resident's electronic health record or care plan. For another resident with moderate cognitive impairment, the bed was observed placed against the wall on several occasions, but again, there was no Safety Device Evaluation, physician's order, or care plan intervention documented. Staff interviews revealed that the bed was moved against the wall at the resident's request to prevent rolling out, but staff were unaware of the need for evaluation and documentation. The Director of Nursing confirmed that it was expected for evaluations, consents, and physician's orders to be in place for beds in low positions or against the wall, but these were not completed for the residents involved.
Failure to Develop Comprehensive Care Plans for Residents with Complex Needs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents with complex medical and behavioral needs. For one resident with severe cognitive impairment and a diagnosis of PTSD, the care plan did not address the use of a low bed as a physical restraint, nor did it include a focus, goal, or intervention related to PTSD until several months after admission. Staff interviews confirmed that a care plan for the low bed and PTSD should have been in place upon admission, but these were not initiated until much later. Another resident with severe cognitive impairment and a diagnosis of dementia was prescribed an antianxiety medication, Lorazepam, but the care plan did not address the use of this medication or the resident's dementia diagnosis. The care plan for the antianxiety medication was not initiated until over a month after the medication was ordered, and there was no care plan focus on dementia at all. Staff acknowledged that both the medication and dementia diagnosis should have been included in the care plan from the time of prescription and admission, respectively. A third resident, moderately cognitively impaired and diagnosed with chronic atrial fibrillation, was prescribed an anticoagulant medication, Dabigatran Etexilate Mesylate. The care plan did not include any focus or intervention related to the use of this anticoagulant, despite ongoing administration of the medication. Staff interviews confirmed that the anticoagulant should have been addressed in the care plan, but it was not present.
Failure to Provide Restorative Services as Recommended
Penalty
Summary
The facility failed to provide restorative aid (RA) services to a resident with multiple diagnoses who was severely cognitively impaired and required assistance to maintain their current level of function. Documentation showed that the resident had been recommended for a restorative program following discharge from physical therapy, including specific interventions such as sit-to-stand exercises, use of a transfer pole, and sessions with an Omni Cycle. Despite these recommendations, the resident's electronic health record did not show evidence that the RA services were provided as ordered. Interviews with facility staff revealed a lack of awareness and follow-through regarding the resident's need for restorative services. The Resident Care Manager/Restorative Therapy Manager stated the resident did not meet requirements for a restorative program, while the Director of Rehabilitation confirmed that restorative services had been recommended after physical therapy discharge. The Director of Nursing was not aware that the resident was not receiving the restorative program. This failure to implement the recommended restorative interventions was not in accordance with the facility's policy to maintain residents' highest level of self-care and independence.
Failure to Implement Physician Orders for Physical Restraints and Weight Monitoring
Penalty
Summary
The facility failed to implement physician orders and care plans for two residents, resulting in deficiencies related to physical restraints and weight monitoring. For one resident with moderate cognitive impairment and a history of unsteady gait and dizziness, the care plan and physician orders specified the use of a right-sided 1/4 size bed rail (mobility bar) to assist with bed mobility and transfers. Observations on multiple occasions revealed that the bed rail was not installed, and both staff and the resident confirmed that it had never been put in place since admission, despite the documented order and consent. Another resident, also moderately cognitively impaired and diagnosed with congestive heart failure, had a physician order for daily weights with instructions to notify the physician if weight gain exceeded specified thresholds. Record reviews showed multiple instances of significant weight gain without documentation of physician notification, as well as repeated failures to obtain daily weights on numerous days across several months. Staff interviews confirmed the absence of required documentation and acknowledged that the physician had not been notified as ordered.
Failure to Monitor for Adverse Effects of Antianxiety Medication
Penalty
Summary
The facility failed to monitor for adverse side effects in a resident who was prescribed an antianxiety medication, Lorazepam 0.5mg as needed for anxiety. The resident, who had multiple diagnoses including severe cognitive impairment due to dementia, was admitted to the facility and began receiving Lorazepam according to a physician's order. However, review of the electronic medication administration records for October and November showed that while the medication was administered, there was no documentation of monitoring for adverse side effects. Staff interviews confirmed that monitoring was expected but not performed, and the required order for monitoring was not placed until 32 days after the medication was initially ordered.
Failure to Use PPE During Resident Transfer on Contact Precautions
Penalty
Summary
Staff failed to use appropriate personal protective equipment (PPE) when providing care to a resident on contact precautions. Specifically, during an observed transfer of a resident who was alert, oriented, and dependent on staff for transfers using a Hoyer lift, two certified nurse assistants (CNAs) assisted with the transfer without wearing isolation gowns as required for contact precautions. The resident had a physician order for contact precautions in place. The Director of Nursing confirmed in an interview that staff are expected to wear PPE when transferring residents on contact precautions.
Failure to Accurately Post and Update Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nursing hours were accurately posted and updated daily for all days reviewed. Record review showed that the Daily Staffing Hours postings were not updated throughout the day to reflect actual staffing changes, but instead were taken down and corrected the following morning. Interviews with the staffing coordinator and the DON confirmed that staffing numbers and hours for each shift were not updated as changes occurred, and that the postings provided for review were corrected copies from the next day, not real-time updates. The staff involved were unaware that updates were required throughout the day and acknowledged that the postings were not being completed correctly.
Failure to Monitor Blood Glucose in Diabetic Resident
Penalty
Summary
The facility failed to ensure adequate blood sugar monitoring for a resident receiving oral diabetic medications, which led to a significant health event. The resident, who was cognitively intact and diagnosed with Type 2 Diabetes Mellitus without complications, was admitted without orders for blood glucose monitoring despite being prescribed Metformin and Glipizide. On a particular day, the resident exhibited left-sided weakness, prompting staff to suspect a stroke. However, the resident was later found to have severe hypoglycemia with a blood glucose level of 30 upon being taken to the hospital, where symptoms resolved with normalization of blood sugars. Interviews with facility staff revealed that routine blood glucose checks were not performed for non-insulin dependent diabetic residents unless specifically ordered by a physician. Staff members indicated that they typically relied on Hemoglobin A1C levels for monitoring stable residents. The facility's policy, however, suggested more frequent monitoring for residents on oral medications, especially if poorly controlled. The lack of blood glucose monitoring for this resident, despite the facility's policy and the resident's change in condition, contributed to the oversight and subsequent health event.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure proper care and monitoring of pressure ulcers for a resident, leading to the worsening of an existing ulcer and the development of a new one. Resident 51, who was admitted with a nearly healed Stage 2 pressure ulcer on the coccyx, did not receive documented weekly skin audits for three weeks following admission. Additionally, the Braden Risk Assessments were not conducted consistently, with a significant gap between December 2023 and June 2024. The care plan for skin integrity and nutrition was not initiated until a month after admission, despite the resident being at risk for pressure ulcers. The new pressure ulcer on the right buttock and upper thigh was documented on December 21, 2023, but treatment was not initiated until January 24, 2024, 34 days later. The facility's Wound Management Guidelines were not followed, as the resident's skin alterations were not promptly investigated or addressed. The resident was not provided with appropriate pressure-relieving equipment, such as a special wheelchair cushion or pressure-relieving mattress, until weeks after admission. Staff interviews revealed a lack of communication and documentation regarding the resident's condition and care needs. The Director of Nursing Services was unable to provide an investigation report for the new pressure ulcer, and the Registered Dietitian was not informed of the resident's nutritional risk upon admission. These oversights contributed to the resident's condition deteriorating, resulting in hospitalization for suspected osteomyelitis and surgical intervention.
Failure to Obtain Required Documentation for Bed Restraints
Penalty
Summary
The facility failed to ensure that an assessment, consent, and physician order were obtained for the use of physical restraints, specifically for beds being placed against the wall and the use of bed rails, for four out of five sampled residents. This deficiency was identified through observations, interviews, and record reviews. The facility's policy on the use of restraints, revised in April 2017, mandates that restraints should only be used upon a physician's written order and after obtaining consent from the resident or their representative. Resident 5, who was alert and oriented, was observed multiple times with their bed against the wall and half-length bed rails raised on both sides. However, their electronic health record (EHR) did not contain any physician orders, assessments, or consents for these arrangements. Similarly, Resident 31, who was moderately cognitively impaired, had their bed against the wall without any documented assessment, consent, or physician orders. Observations confirmed the bed's position against the wall on several occasions. Resident 61, who was alert and oriented, also had their bed against the wall without the necessary documentation. When questioned, the resident was unaware of the reason for this arrangement. Resident 189, another alert and oriented resident, had their bed against the wall without any assessment, consent, or physician orders. Staff members, including the Resident Care Manager and the Director of Nursing, acknowledged the lack of required documentation and expressed that assessments, consents, and physician orders should have been completed for these residents.
Failure to Maintain Dignity in Catheter Care
Penalty
Summary
The facility failed to ensure that care and services were provided in a manner that promoted residents' dignity, specifically concerning urinary catheter care for two residents. Resident 11, who was moderately cognitively impaired and had an indwelling catheter, was observed multiple times with the foley catheter drainage bag uncovered, contrary to the care plan that required the drainage bag to be covered for dignity. Observations included the drainage bag hanging off the side of the bed uncovered and, at one point, lying on the floor without a hook or privacy bag. Staff members acknowledged that the drainage bags should be covered and not placed on the floor, indicating a lapse in following the care plan. Similarly, Resident 39, also moderately cognitively impaired with an indwelling catheter, was observed with the foley catheter drainage bag uncovered on several occasions, both in bed and in the rehabilitation gym. The care plan for Resident 39 also required the drainage bag to remain covered, yet observations showed the bag uncovered and visible from the hallway. Staff, including the Director of Nursing Services, confirmed the expectation that catheter drainage bags should be covered and not placed on the floor, highlighting a consistent failure to adhere to the dignity-promoting measures outlined in the residents' care plans.
Failure to Conduct and Document Quarterly Care Conferences
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were offered the opportunity to participate in care conferences, specifically for one resident who was part of a sample of six reviewed for the right to participate in planning care. Resident 53, who was alert and oriented, was admitted to the facility and had a quarterly Minimum Data Set (MDS) assessment conducted. However, the electronic health records (EHR) only documented a care conference on one occasion, despite the expectation that care conferences should occur quarterly, as needed, or during significant changes. Interviews with staff, including the Social Services Coordinator, Social Services Director, and Director of Nursing Services, confirmed that care conferences were expected to be conducted quarterly and documented in the EHR, but this was not done for Resident 53.
Failure to Review Advance Directives
Penalty
Summary
The facility failed to have procedures in place to assist with completing advance directives (AD) and maintaining Durable Power of Attorney (DPOA) documentation for a resident. The resident was admitted to the facility and was noted to be alert and oriented during a quarterly assessment. However, the resident's electronic health record did not show any ADs or documentation that ADs were reviewed since March 2024, despite the resident's care plan indicating they did not want to execute an AD at that time. Staff members acknowledged that the AD should have been reviewed during a care conference in June 2024, but this did not occur.
Failure to Address Grievances on Lost Items
Penalty
Summary
The facility failed to ensure a timely response and resolution to grievances regarding lost items for two residents. Resident 50, who was alert and oriented, reported his manual wheelchair missing after returning from a hospital transfer. Despite informing a Certified Nursing Assistant and filling out a Lost, Misplaced, Damaged Item form, the issue was not promptly addressed. The Social Services Coordinator acknowledged the missing wheelchair and forwarded the matter to the Administrator, who only became aware of the issue much later. This delay in addressing the grievance resulted in the resident not having his concerns resolved in a timely manner. Similarly, Resident 286, also alert and oriented, reported missing personal laundry items shortly after admission. Despite her efforts to retrieve some items from the laundry room, several items remained missing. The Resident Care Manager was unaware of the issue until she found a notification slip in her mailbox, indicating a lack of communication and timely action in resolving the resident's grievance. These incidents highlight the facility's failure to adhere to its grievance policy, leading to unresolved resident concerns.
Failure to Provide Bed-Hold Notices for Hospitalized Residents
Penalty
Summary
The facility failed to provide a written bed-hold notice to residents or their representatives at the time of transfer to the hospital for two of the six sampled residents. Resident 36, who was severely cognitively impaired, was transferred to an acute hospital, but there was no documentation indicating that contact was made with the resident or their family regarding a bed-hold. Staff F, the Admissions Coordinator, acknowledged that the bed-hold agreement should have been documented in the electronic health records (EHR), but was unable to find any such documentation for Resident 36. Similarly, Resident 31, who was moderately cognitively impaired, was hospitalized and returned to the facility without any documentation of a written bed-hold notice. Staff F stated that the admissions department is responsible for completing the bed-hold form and making a progress note if they cannot reach the resident or their representative. However, no bed-hold notice was found for Resident 31. Staff B, the Director of Nursing Services, admitted that the facility did not comply with the requirement to follow up with the resident's representative and offer a bed-hold notice.
Failure to Implement Comprehensive Care Plan for Skin Conditions
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with skin conditions, specifically abrasions and blisters on the feet. The resident, who was alert and oriented, was admitted with an open lesion on the foot. Physician orders detailed specific wound care instructions for multiple abrasions and a blister on the resident's feet, including cleansing and dressing changes. However, the resident's comprehensive care plan did not include any focus area, goals, or interventions related to these skin conditions. During an observation, the resident was seen with foam dressings on the right foot, and staff interviews revealed a lack of a documented care plan for the resident's skin conditions. The Resident Care Manager acknowledged the absence of a care plan and expressed confusion about why it was missing. The Director of Nursing Services confirmed that it was expected for skin care plans to be in place for residents with such conditions, indicating a lapse in the facility's care planning process.
Failure to Ensure Proper Wheelchair Positioning
Penalty
Summary
The facility failed to provide necessary care and services for proper positioning in a wheelchair for a resident diagnosed with Inclusion Body Myositis (IBM). The resident, who was alert and oriented but had functional impairments, required a motorized wheelchair for mobility. Observations revealed that the resident was leaning to the left side in the wheelchair, with the left armrest misaligned and the wheelchair tilted. The resident reported discomfort and stated that the wheelchair did not fit correctly, causing him to run into his bed and the wall due to the controller's position under his stomach. Despite the resident's complaints and the vendor's acknowledgment of a broken part, no follow-up or assessment was conducted to address the fit and functionality of the wheelchair. Staff interviews indicated a lack of communication and responsibility regarding the resident's wheelchair issues. The Resident Care Manager and Director of Nursing Services were unaware of the plan for wheelchair repair, and the Therapy Director could not find documentation of an assessment for the wheelchair fit. The resident care staff attempted temporary fixes, such as padding the bed frame and removing back support pieces, but these actions did not resolve the underlying issue. The failure to assess and address the resident's wheelchair fit and functionality led to discomfort and potential safety risks for the resident.
Infection Control Deficiencies in Wound and Catheter Care
Penalty
Summary
The facility failed to implement proper infection control and prevention practices during a dressing change for a resident with a pressure ulcer. Resident 51, who was alert and oriented, had a Stage 4 pressure ulcer on the right ischium. During an observation of wound care, a Licensed Practical Nurse (LPN) did not wash her hands after removing the old dressing and before putting on clean gloves to continue with the wound care. This action was contrary to the expected procedure as stated by the Infection Control Nurse and the Director of Nursing Services, who both emphasized the importance of hand hygiene between glove changes during wound care. Additionally, the facility did not adhere to its policy regarding catheter care for Resident 11, who had an indwelling catheter and was moderately cognitively impaired. The resident's catheter drainage bag was observed lying on the floor, folded in thirds, without a hook to hang it or a privacy bag to cover it. This was against the facility's policy, which required catheter bags to be kept off the floor and covered. Staff members, including a Certified Nursing Assistant and the Resident Care Manager, acknowledged that the catheter bag should not have been on the floor and should have been properly secured and covered.
Latest citations in Washington
Inaccurate PASARR screening affected two residents. One resident with vascular dementia, depression, and adjustment disorder had a PASARR level one that did not reflect mental health diagnoses, and staff stated it was inaccurate. Another resident with PTSD had a PASARR level one that did not include the PTSD diagnosis, with no additional PASARR level one or level two found in the EHR; staff stated the screening was not accurate and should have been repeated.
Undated open meds were found on 2 medication carts, including an open insulin vial and multiple open eye drop bottles with no dates. An LPN and an RN both stated the items should have been dated when opened, and the DON stated open multidose vials or bottles found without a date should be discarded immediately.
A resident with respiratory failure, HTN, and anxiety became SOB and diaphoretic, received a breathing tx, and was sent by EMS to the hospital. The facility could not locate the required SNF/NF to Hospital Transfer form or other transfer records showing what information was communicated to the receiving provider.
Care plans for two residents were not updated to match their current status and care needs. One resident had PTSD and generalized anxiety disorder and was receiving a psychotropic medication, but the care plan listed monitoring for antipsychotic and anticonvulsant meds that were not prescribed and did not include the anxiety diagnosis or related behaviors and interventions. Another resident had new upper and lower dentures, but the oral/dental care plan only noted edentulous status and difficulty chewing, with no mention of dentures or denture-related interventions.
Failure to Provide Individualized Activities: A resident with anxiety, depression, and weakness was cognitively intact but said they could not attend group activities because of leg problems and wanted more in-room activities. The resident mostly stayed in bed watching TV, and staff documentation showed only limited room visits with no consistent activity documentation despite a care plan goal for participation two to three times per week.
Failure to maintain heel offloading for a resident with a reopened DFU. A resident with dementia and dependence for mobility had a left heel wound that had healed and then reopened; the wound care provider recommended heel floating and pressure relieving boots at all times, but observations showed the resident in bed with heels on the mattress and later reclined in a wheelchair with the heel resting on the footrest strap and no boots in place. Staff stated the resident had not refused the boots or heel floating, and the care plan was not updated after the wound reopened.
Failure to Address Hearing and Vision Services for a Resident: A resident with dementia, bilateral hearing loss, and impaired vision was observed without eyeglasses or a hearing device, despite records showing admission with eyeglasses and a personal sound amplifier. The care plan addressed vision only and did not include hearing-related interventions, while staff interviews confirmed the resident’s hearing was strained and that the resident’s device use and vision needs were not fully reflected in the plan of care.
Respiratory care was not provided consistently for two residents receiving O2. One resident with COPD and chronic respiratory failure had an O2 order missing the indication for use and Sats parameters, no MAR documentation of O2 therapy, and inconsistent Sats charting. Another resident with respiratory failure was observed on continuous O2 via NC, but provider orders for O2 therapy and tubing changes were not present after readmission, despite the care plan stating the resident was dependent on O2.
A resident with dementia, hearing loss, and missing lower teeth had an MDS showing obvious or likely cavities or broken natural teeth, and the care plan identified oral/dental health problems with an intervention to coordinate dental care and transportation. Staff stated the resident’s dental needs were captured on the MDS, but no referral was made for dental services or follow-up with the dentist, and the DON said the lack of referral did not meet expectations.
Inaccurate Meal Intake Documentation: A resident with DM, dysphagia, and protein-calorie malnutrition was observed eating less than 25% of a meal, but the POC documented 76-100% intake. The CNA said the resident usually ate only 25-50% of meals and that intake was sometimes documented based on what a coworker reported. The LPN/RCM and DON stated meal intake should be documented accurately.
Inaccurate PASARR Screening for Two Residents
Penalty
Summary
The facility failed to ensure that two residents were screened for additional mental health supports through the PASARR process. Resident 97 was admitted with diagnoses including vascular dementia, depression, and adjustment disorder, and was able to make needs known. Review of the PASARR level one dated 04/10/2026 showed no mental health diagnoses and no need for a PASARR level two, even though the resident’s record included mental health diagnoses. During interview, the Regional Social Services staff and the Administrator stated the PASARR was inaccurate, needed modifications, and did not meet expectations. Resident 6 was admitted with diagnoses including heart failure, respiratory failure, and PTSD, and was able to make needs known. Review of the PASARR level one dated 03/30/2026 showed no serious mental illness indicators marked and no PASARR level two indicated, and the EHR contained no other documented PASARR level one or level two. The Social Services Director stated the hospital-provided PASARR was reviewed for accuracy and, if inaccurate, another level one would be completed, and stated this resident’s PASARR did not include PTSD and should have had another level one completed. The Administrator also stated the PASARR was not accurate and another level one needed to be conducted, but none could be located in the EHR.
Undated Open Medications on Medication Carts
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications for 2 of 3 sampled medication carts reviewed for medication storage and labeling, including carts on the 400 and 500 halls. On the 500 hall medication cart, an open vial of insulin and an open bottle of eye drops were observed with no dates. During interview, an LPN stated that when an insulin vial or bottle of eye drops is opened, it should be dated immediately and said both items should have been dated upon opening; the LPN stated they would dispose of the undated vial and bottle. On the 400 hall medication cart, two open bottles of eye drops were observed with no dates. During interview, an RN stated both bottles should have been dated as soon as they were opened and said they would get new eye drops and dispose of the undated bottles. The DNS/RN stated that if an eye drop was opened it should have been dated immediately and that any open multidose vial or bottle found without a date should be discarded immediately.
Missing Hospital Transfer Documentation
Penalty
Summary
The facility failed to ensure hospital transfer documentation was completed for one resident who was transferred to the hospital after complaining of not being able to breathe and appearing diaphoretic. The resident had diagnoses of respiratory failure, high blood pressure, and anxiety disorder, and was able to make needs known. A breathing treatment was provided, and the provider agreed to send the resident out for further evaluation, after which emergency transportation took the resident to the hospital. Record review found no documentation showing what information was provided or communicated to the receiving facility for the transfer. Staff stated that transfer documentation should have included a SNF/NF to Hospital Transfer form, the resident's face sheet, and the medication and treatment administration records, but they were unable to locate documentation showing these items were completed or sent for the resident's hospital transfer.
Care plans did not reflect current diagnoses, medications, or denture status
Penalty
Summary
The facility failed to ensure that care plans were revised and accurately reflected residents’ current status and care needs for 2 of 21 sampled residents. Resident 6 was admitted with diagnoses including heart failure, respiratory failure, and PTSD, and was able to make needs known. The EHR showed Resident 6 also had generalized anxiety disorder and was receiving a psychotropic medication, but the current care plan dated 05/05/2026 documented monitoring for side effects of antipsychotic and anticonvulsant medications even though Resident 6 was not prescribed those medications. The care plan also identified PTSD but did not include generalized anxiety disorder or behaviors to monitor and interventions related to PTSD or anxiety disorder. Staff F, LPN/CC, stated the care plan did not accurately reflect the resident’s current status or prescribed medications, and Staff B, DNS, stated it did not meet expectations because it did not address the anxiety disorder or target behaviors and interventions. Resident 71 was admitted with diagnoses including PTSD, high blood pressure, and depression and was able to make needs known. Observation on 05/06/2026 showed a denture cup by the sink with the resident’s name on the lid and new upper and lower dentures dated 01/12/26. The resident stated the lower dentures did not fit well and that denture adhesive had been provided, but the dentures still did not fit right and the resident had not told staff yet. The focused oral/dental care plan, initiated on 06/23/2026, identified the resident as edentulous and having difficulty chewing, but did not show that the resident had dentures or include interventions related to denture use or maintenance. Staff E, CNA, stated they had not seen the resident wear dentures and were unaware of the new dentures, Staff C, LPN/CC, stated the care plan should have been updated when the dentures were obtained, and Staff B, DNS, stated the care plan should have reflected the dentures and interventions.
Failure to Provide Individualized Activities
Penalty
Summary
The facility failed to provide individualized activities for Resident 5, who was admitted with diagnoses including anxiety disorder, depression, and weakness. The admission MDS dated 01/14/2026 showed the resident was cognitively intact. During interviews on 05/03/2026 and 05/06/2026, Resident 5 stated they could not attend in-person activities because of their legs, wanted more activities to occupy them, mostly stayed in bed watching TV, and did not remember the last time activities staff visited to offer activities. The resident also stated activities staff would need to offer something they were able to do because they had difficulty doing some activities. The activities care plan dated 12/26/2026 showed a goal for Resident 5 to participate in activities two to three times per week. Progress notes documented one visit on 12/22/2026 to provide a welcome packet and encourage participation in daily activities, but no further activity documentation was found in the progress notes. Staff H stated room visits should include puzzles, arts and crafts, visiting, and chatting, and that documentation was placed in tasks, but the task record showed no documentation of activities for the past 30 days. Staff J stated paper documentation existed for room visits and that Resident 5 was on a list for room visits every Monday and Wednesday, while the room visit documentation showed only four visits on 01/26/2026, 02/06/2026, 03/10/2026, and 04/08/2026.
Failure to Maintain Heel Offloading for Reopened DFU
Penalty
Summary
The facility failed to consistently implement pressure reducing strategies for a resident with a left heel diabetic foot ulcer that had reopened. The resident was admitted with diagnoses including left hip fracture with surgical repair, a blood clot of the left lower leg, and dementia, and was dependent on staff for mobility and unable to make needs known. The baseline care plan and care plan both included heel offloading interventions, and the wound care provider initially recommended heel floating with pillows or wedge and pressure relieving boots. The wound later resolved, but a weekly skin assessment documented that the left heel wound reopened and was very painful to touch. After the wound reopened, the contracted wound care provider documented that the DFU to the left heel had reopened and recommended the resident wear pressure relieving boots at all times. The current care plan reviewed after the wound reopened did not include new interventions related to the reopened wound. Observations showed the resident seated in a reclined wheelchair with the left foot/heel resting on the footrest strap and no pressure relieving boots in place, and later lying in bed with both heels directly on the mattress without being floated and without boots. Staff interviews indicated the resident had not refused the boots or heel floating, and the LPN/CC and DON stated the resident should have been assessed and the plan of care updated when the wound reopened.
Failure to Address Resident Hearing and Vision Needs
Penalty
Summary
The facility failed to address one resident’s hearing and vision needs. Resident 112 was admitted with diagnoses including a leg fracture, dementia, and hearing loss in both ears, and was able to make needs known. The record showed the resident lost their glasses and was given readers, but the resident did not wear them because they were concerned that wearing glasses that were not their prescription would further degrade their vision. Observation did not show glasses in the resident’s room, and the resident stated they did not use a hearing aid. The resident was observed to be hard of hearing, requiring an elevated voice and repeated questions to understand. The admission MDS dated [DATE] documented adequate hearing with hearing aid and adequate vision with corrective lenses, while the significant change MDS dated [DATE] documented moderate difficulty hearing without a hearing aid and impaired vision without corrective lenses. The care plan initiated 02/24/2026 addressed impaired vision with interventions to arrange consultation with eye care practitioners as needed and remind the resident to wear glasses, but it did not include a focus area or interventions for hearing loss or use of hearing aids. A resident clothing list showed the resident admitted with one pair of eyeglasses and one Super Ear headset personal sound amplifier, yet observation and interview showed the resident in bed without eyeglasses or a hearing device, with the amplifier stored in the bedside table drawer. Staff interviews confirmed the resident’s hearing was strained, that the hearing device and glasses were not being used, and that the resident’s hearing device use should have been included in the plan of care and the resident should have been referred for eye care assessment.
Respiratory Care Orders and Documentation Not Maintained
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for two residents receiving oxygen therapy. One resident with COPD and chronic respiratory failure with hypoxia was observed multiple times lying in bed receiving oxygen at 2 L via nasal cannula. The resident’s oxygen order, dated 02/15/2026, allowed 1 to 4 L per minute continuously via nasal cannula, but it did not include an indication for use or oxygen saturation parameters. The April and May 2026 MARs did not show documentation of oxygen therapy being provided, and the TARs showed only an order to change oxygen tubing if damaged or visibly soiled, not an order for oxygen therapy. Oxygen saturations were not documented consistently daily from 04/01/2026 through 05/04/2026. A second resident with respiratory failure, high blood pressure, and anxiety disorder was observed in the room receiving oxygen at 6 L via nasal cannula on multiple occasions. The resident stated they needed oxygen therapy to breathe, and the care plan identified the resident as dependent on oxygen and to receive oxygen per provider orders. However, provider orders reviewed on 05/04/2026 showed no orders for oxygen therapy or for changing oxygen tubing. Staff stated the oxygen and tubing-change orders had been discontinued when the resident went to the hospital and were not added back to the MAR or TAR when the resident readmitted to the facility.
Failure to Refer Resident With Identified Dental Needs
Penalty
Summary
The facility failed to ensure that Resident 112 received needed dental care. Resident 112 was admitted with diagnoses including a leg fracture, dementia, and hearing loss in both ears. Observation on 05/03/2026 showed the resident had missing lower teeth. The admission MDS, dated [DATE], documented obvious or likely cavities or broken natural teeth, and the care plan dated 02/24/2026 identified oral/dental health problems related to likely cavities or broken teeth with an intervention to coordinate dental care and provide transportation. During interviews, Staff G, Regional Social Services, stated Resident 112's dental needs were captured on the 02/24/2026 MDS and the resident was not referred for dental services. Staff M, Social Services Director, stated residents with dental needs should be referred to social services to be scheduled for assessment by a dental care practitioner, and that Resident 112 should have been referred after the MDS assessment. Staff B, DON, stated residents with identified dental needs should be referred for follow-up with a dentist and that Resident 112 should have been referred to the in-house dental provider; Staff B stated the lack of referral did not meet expectations.
Inaccurate Meal Intake Documentation
Penalty
Summary
The facility failed to accurately document the amount of food eaten for Resident 13, who was admitted with diagnoses including diabetes mellitus, dysphagia, and protein-calorie malnutrition. The quarterly MDS dated 02/12/2026 showed the resident was moderately cognitively impaired. During observation on 05/05/2026 at 12:09 PM, a meal tray was delivered to the resident’s room, set up on a bedside table, and the resident was observed eating slowly, eating less than 25% of the meal, then laying back in bed and closing their eyes while the tray remained in the room. Staff later removed the tray, but the POC documentation for lunch on 05/05/2026 recorded that Resident 13 ate 76-100% of the meal. During interview, the CNA stated the resident typically ate 25-50% of meals and never ate all of the food, and that if they did not pick up a tray they would ask a coworker what the resident ate before documenting it. The CNA stated they were told the resident ate 75-100% of lunch, so that is what was entered. The LPN/RCM stated staff should document meal intake accurately in POC, and the RN/DNS stated it was their expectation that all staff document meal intake accurately.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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