Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
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 Gig Harbor Health And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to prevent physical abuse between cognitively impaired residents when, in one incident, a resident with dementia and agitation grabbed and pulled another resident’s arm after offering a marker, and in another incident, a resident with dementia hit another resident on the head in the dining area after the second resident self-propelled to the same table. Staff, including a CNA, an LPN, and a restorative aide, reported these events and described separating the residents and assessing for injury, but the incidents still resulted in residents being subjected to physical abuse despite an existing abuse policy intended to protect them.
The facility failed to accurately document two significant resident incidents in the medical record. In one case, a resident was struck in the head by another resident in the dining room, but no progress note entry was made for the resident who was hit. In another case, a cognitively intact resident choked during lunch, became unresponsive, and staff performed the Heimlich maneuver, initiated CPR, called 911, and the resident was transported to the hospital; however, the progress note omitted documentation of provider notification and the subsequent emergency interventions and transfer. These omissions did not meet accepted professional standards for medical record documentation.
A resident with multiple cardiac conditions, muscle weakness, unsteadiness, and a recent AICD placement reported that an RN told them to transfer and clean themself in the bathroom and stated they would have to do it themself or stay there forever. A CNA later found the resident in the bathroom, was told about the RN’s statements, and learned the resident had transferred and cleaned themself despite pain and left arm restrictions, but the CNA only informed the oncoming CNA and did not notify a supervisor because the resident asked them not to. Another CNA subsequently learned of the allegation and reported it to a nurse, but by then the facility’s policy and regulatory requirements for immediate reporting of abuse allegations to management and state authorities had already been violated.
A resident with dementia and moderate cognitive impairment, who ambulated independently on a locked unit, was taken by the hand into another resident’s room and had their breasts touched inappropriately by a severely cognitively impaired resident with dementia, aphasia, and a history of sexually inappropriate behaviors toward staff. Despite multiple documented incidents of this behavior, the facility did not timely add specific interventions to the behavior care plan, and when 1:1 supervision was later ordered, CNAs did not consistently maintain line-of-sight observation, allowing the resident to move out of visual range and into their room with the door closed. Staff interviews showed awareness of the sexually inappropriate behaviors but a lack of clear, pre-existing care plan guidance on how to manage them.
Staff failed to immediately report a witnessed incident of resident-to-resident sexual abuse involving two cognitively impaired residents, one with dementia and anxiety and the other with dementia, aphasia, and a cognitive communication deficit. A CNA discovered one resident in another’s room being touched on the breasts and notified an LPN, who documented an alert report but did not promptly notify the administrator, state agency, or police as required by facility policy and state guidelines. The incident was not reported to the state agency until the following day, well beyond the required two-hour reporting timeframe, despite staff interviews indicating they understood abuse should be reported immediately to supervisors and the DSHS hotline.
The facility did not provide timely emergency care or complete required post-fall monitoring for three residents who experienced falls, including a resident on anticoagulants who suffered a head injury and was not promptly sent for medical evaluation, resulting in serious harm. Documentation of alert charting was also incomplete or missing for multiple falls, despite staff and policy expectations.
Two residents with cognitive impairment did not consistently receive the correct size of briefs due to supply shortages, resulting in discomfort and inadequate containment of urine. Staff confirmed that brief shortages led to the use of incorrect sizes or delays in obtaining supplies, and the administrator was unaware of the need for daily supply order approvals.
A resident with a positive TB screening and inconclusive chest x-rays was not managed according to infection control standards, as the care plan was not updated, the local health jurisdiction was not promptly notified, and appropriate precautions were not clearly implemented or documented. Staff were uncertain about the correct type of precautions, and there was no systematic monitoring or intervention for possible TB exposure among staff or other residents.
The facility did not provide enough nursing staff to meet residents' needs, leading to missed showers, delayed call light responses, and a high number of falls. A resident dependent on staff for transfers was left in bed for several days without basic hygiene care, while another went weeks without a shower or hair wash. Staff reported caring for up to 15 residents at a time and struggling to complete care tasks, especially on weekends.
A resident with moderate cognitive impairment received an antibiotic that was not ordered, after a nurse failed to enter a verbal order into the electronic system, did not administer the medication as prescribed, and used another resident's discontinued medication. Required documentation for a change in condition was also not completed, and the medication was not pulled from the automated dispensing system as expected.
A resident with severe cognitive impairment and a recent hip surgery experienced a fall that was not reported or investigated at the time of the incident. The responsible nurse failed to notify management or implement risk management procedures, and the event was only discovered after the resident developed acute hip pain, leading to a delayed investigation that identified a dislocated hip arthroplasty.
A resident with anemia, who was cognitively intact, was physically harmed when a CNA abruptly pushed their wheelchair, causing knee injury and pain. The CNA, already suspended due to multiple abuse allegations, acted after expressing frustration at the resident's pace. The incident was reported about a week later, and the facility's investigation confirmed the CNA's involvement.
A resident with chronic pain was left without a fentanyl patch for 59 hours due to the facility's failure to ensure medication availability and obtain an alternative prescription. Despite severe pain reports, staff did not utilize available resources or contact the provider for a substitute, leading to significant discomfort for the resident.
Two residents experienced falls due to inadequate supervision and failure to follow care plans requiring two-person assistance during bed mobility. One resident sustained injuries requiring hospital evaluation, while the other had an assisted fall with no injuries. The root cause was identified as staff not adhering to the care plans.
The facility failed to implement effective infection control measures, leading to a widespread outbreak of respiratory illness among residents. Despite recommendations, the medical director did not fully follow CDC guidelines, resulting in delayed testing and treatment. Staff frequently neglected PPE protocols, and shared equipment was not sanitized properly, further contributing to the spread of infection.
The facility's QAPI program failed to self-identify and sustain corrections for deficiencies, leading to repeated and widespread issues. The DNS and Administrator acknowledged the need for improvement in the QAPI process. Deficiencies included infection control, residents' rights, and care planning.
Two residents in an LTC facility experienced unaddressed grievances, one involving a disruptive roommate and the other missing personal property. Despite expressing concerns to staff, no grievance forms were filed, and the facility's grievance logs showed no records of these issues.
The facility failed to provide written notification of transfer reasons to two residents hospitalized, as required by regulations. One resident with a history of stroke and atrial fibrillation was transferred without written notice, and another with a below-knee amputation and diabetes was also sent to the hospital without written notification. Staff confirmed that while verbal notifications were made, written documentation was not provided.
The facility failed to properly screen residents with mental health disorders for additional supports using the PASRR process. Four residents with diagnoses such as depression, anxiety disorder, and bipolar disorder were not referred for necessary PASRR level two evaluations, despite indications. Interviews with staff confirmed these oversights did not meet expectations.
The facility failed to conduct timely care conferences for four residents, as required by policy. Despite being able to communicate their needs, these residents had not participated in care conferences within the expected timeframes, with the last conferences occurring several months prior. Staff interviews confirmed that the facility was behind on scheduling these conferences, which are expected to occur quarterly.
The facility failed to provide adequate restorative care for three residents, leading to deficiencies in maintaining or improving their range of motion. One resident with arthritis and spinal stenosis was not included in a restorative program despite recommendations. Another resident with a hand contracture did not receive necessary interventions, and a third resident with hemiplegia lacked a care plan for ROM. Staff interviews confirmed the absence of a restorative program due to staffing issues.
The facility failed to consistently document pre and post dialysis assessments and maintain communication with the dialysis center for two residents requiring dialysis. Incomplete records and missing information were noted, and staff interviews confirmed that the documentation did not meet expectations.
The facility failed to use nonpharmacological interventions (NPI) before administering PRN pain medications for three residents, leading to a deficiency in medication management. A resident with an amputation and depression received PRN pain medication multiple times without documented NPI. Another resident with bipolar disorder and COPD received acetaminophen for pain without NPI documentation. A third resident with a history of amputation and diabetes also received PRN acetaminophen without NPIs being attempted. Staff interviews confirmed the lack of adherence to the protocol.
A medication error rate exceeding five percent was identified when an LPN administered metoclopramide and 12 other medications to a resident at incorrect times, contrary to the provider's orders. The medications were given at 9:19 AM instead of the specified times of 7:00 AM and 8:00 AM. The DON confirmed that the expectation for correct timing was not met.
The facility failed to properly store and label medications, with unsupervised medications left on a nurses' station counter and incomplete temperature logs for medication storage refrigerators. Medication carts contained undated or expired medications, and staff acknowledged these deficiencies. The DON confirmed that medications should be secured and monitored appropriately.
The facility failed to ensure residents understood arbitration agreements, leading to a deficiency in informed consent. A resident with hemiplegia and cognitive deficits, another with bipolar disorder, and a third with dementia signed agreements without understanding them. Staff relied on judgment to assess residents' ability to sign, resulting in inadequate handling of arbitration agreements.
The facility failed to implement an effective Antibiotic Stewardship Program, leading to inappropriate antibiotic use for several residents. The infection preventionist did not review antibiotic utilization daily, and provider orders lacked specific indications for use. This oversight placed residents at risk for adverse outcomes. Staff acknowledged the failure to document reasons for antibiotic use, which did not meet facility expectations.
A resident receiving duloxetine for depression did not receive information on the risks and benefits, nor was consent obtained, as required by facility protocol. Interviews with staff confirmed this oversight, which did not meet the facility's expectations.
A resident with paraplegia and cognitive communication deficit reported verbal mistreatment by staff, including accusations and inappropriate questioning, which was witnessed by other staff members. The facility's incident report lacked proper documentation, and the Administrator initially failed to recognize the incident as abuse, contrary to the facility's abuse prevention policy.
A resident with paraplegia and cognitive communication deficit reported an incident where a staff member accused them of theft and gang involvement, which was not documented or reported by the facility. The Administrator later acknowledged the oversight, recognizing the need for state reporting as per policy.
A facility failed to report and investigate an allegation of abuse involving a resident who felt unsafe due to another resident's behavior. The incident was reported to a receptionist but was not documented or investigated, as confirmed by the DNS.
The facility failed to accurately complete MDS assessments for two residents, leading to potential risks for unmet care needs. One resident was not coded for corrective lenses despite having new prescription glasses, and another resident's antibiotic therapy and continuous oxygen use were not accurately reflected in the MDS. Staff interviews confirmed the inaccuracies.
The facility failed to develop and implement comprehensive care plans for four residents, leading to unmet care needs. A resident with arthritis and spinal stenosis lacked a care plan for mobility interventions, while another with a hand contracture had no plan for restorative nursing or therapy devices. A third resident with hemiplegia had no range of motion interventions, and a fourth with sepsis had no care plan for their PICC line or antibiotic therapy. Staff interviews confirmed the absence of necessary care plans.
A resident with muscle weakness and difficulty walking did not receive scheduled showers and facial hair removal, as documented inaccurately by staff. Observations showed the resident with long facial hair, and interviews revealed discrepancies in care documentation, with staff acknowledging the inaccuracies and failure to meet scheduled care requirements.
The facility failed to follow provider orders for two residents, leading to missed dressing changes and undocumented orthostatic blood pressure readings. Additionally, a resident experienced improper wheelchair positioning, which was not addressed despite staff awareness. These deficiencies were acknowledged by the facility's nursing leadership.
A resident with a history of stroke, diabetes, and kidney failure required new glasses due to nearsightedness. Despite a physician's request for eye care services in March, the facility failed to follow up adequately, resulting in unmet vision needs. An appointment was initially scheduled but rescheduled due to the optometrist's unavailability, with no further documented attempts to reschedule.
A resident with a leg fracture and muscle weakness did not receive adequate continence care due to a lack of proper care plan updates. Despite therapy's recommendation for two-person assistance for toileting, the care plan only included a one-person assist with a bedpan. This led to the resident experiencing incontinence as staff were unable to provide timely assistance.
The facility failed to provide correct nutrition and implement dietary and fluid restrictions for several residents. A resident with kidney disease did not receive a low-salt diet as recommended. Another resident with a gastrostomy tube received less nutritional formula than ordered, resulting in weight loss. Additionally, a resident dependent on artificial nutrition received insufficient formula, and a resident with kidney failure had no fluid restriction orders despite medical recommendations. The DNS acknowledged these deficiencies.
A resident with heart failure, endocarditis, and kidney failure requiring dialysis was found with a CPAP machine that lacked proper care instructions in their EHR. The resident reported difficulty in getting aides to add water to the machine, and the water chamber was observed to contain unclear water with particles. The DON acknowledged the failure to monitor and initiate care plans for personal CPAP machines.
A facility failed to provide necessary social services to a resident after a traumatic event involving a roommate's visitor's arrest. The resident, with a history of leg fracture and diabetes, expressed feeling unsafe and ignored, with no follow-up from social services despite the facility's policy requiring such actions. Staff interviews confirmed a lack of awareness and follow-up on the resident's emotional needs.
The facility failed to monitor behaviors for two residents on psychotropic medications, risking adverse effects and diminished quality of life. One resident with anxiety and PTSD was not monitored for medication effectiveness, while another with anxiety and depression lacked behavior monitoring orders in the MAR. The DON acknowledged these deficiencies.
The facility failed to monitor and address high temperatures in the South Clean Utility Fridge, with numerous instances recorded above 40 degrees without corrective action. Staff interviews revealed a lack of communication and action, as the maintenance department was unaware of the issue despite the fridge being monitored by housekeeping and kitchen staff.
A resident with severe cognitive impairment and under hospice care was inappropriately restrained by two staff members during a COVID-19 test. One staff member held the resident in a choke hold while the other administered the nasal swab, despite the resident's visible distress and attempts to refuse. The incident was witnessed and confirmed as abuse by both an outside agency staff member and an LPN from the facility.
A resident who sustained a head injury after a fall did not receive timely medical care as per facility policy. Despite profuse bleeding from a head wound, the RN administered first aid and notified the provider, who did not issue new orders. Four hours later, after the resident expressed feeling unwell, the RN called 911 for emergency transfer. Staff interviews confirmed that the standard of care for such injuries was not initially followed.
The facility failed to administer prescribed medications and perform necessary wound care for three residents, leading to severe health complications. One resident was hospitalized in septic shock due to incomplete antibiotic therapy, another had a surgical wound left untreated for seven weeks, and a third experienced delays in infection diagnosis and treatment, worsening psychiatric symptoms.
The facility failed to properly assess or re-assess two residents for elopement risk and did not update their care plans with necessary interventions. One resident eloped and was found at home, while another attempted to exit through an employee door. Elopement drills were not conducted as required.
Failure to Prevent Resident-to-Resident Physical Abuse Among Cognitively Impaired Residents
Penalty
Summary
The facility failed to protect residents’ right to be free from physical abuse when it did not prevent or adequately manage resident-to-resident altercations involving cognitively impaired residents. One incident involved a resident with severe cognitive impairment and dementia who was offered a marker by another severely cognitively impaired resident with dementia and agitation. When the first resident attempted to take the marker, the second resident grabbed the first resident’s arm and pulled on it. Staff later reported that the second resident had been self-propelling in a wheelchair in the hallway and, as they passed the first resident, they grabbed the resident’s arm. These events occurred despite the facility’s abuse policy, dated 10/20/2022, which recognized each resident’s right to be free from abuse. In a separate incident, another severely cognitively impaired resident with dementia was observed being hit in the head by a different severely cognitively impaired resident with dementia. A restorative aide reported that the resident who was struck had self-propelled to the table where the other resident was sitting, and the seated resident then hit the approaching resident on the head. The LPN on duty stated that the incident was reported to them after the residents were returned to the unit during mealtime, and they assessed the resident who had been hit after the residents were separated. These incidents demonstrate that residents experienced physical contact amounting to abuse from other residents, contrary to the facility’s stated policy and regulatory requirements to prevent abuse.
Failure to Accurately Document Resident Incidents and Emergency Response
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly and accurately document resident incidents in accordance with accepted professional standards. For one resident involved in a resident-to-resident altercation, progress notes for the resident who was struck in the head did not contain any documentation of the incident, despite interviews confirming that the resident was hit by another resident in the dining room. Staff, including the Administrator and the RN/Director of Nursing Services, acknowledged that documentation for this resident should have been completed in the progress notes regarding the altercation. For another resident, who was cognitively intact per the annual MDS, the facility’s progress note documented that the resident began choking during lunch, that the CNA called the LPN, that the resident was pulled forward in bed, that another nurse performed the Heimlich maneuver twice, and that the resident reported something had moved down their throat before becoming unresponsive. However, the progress note did not include documentation of provider notification or what occurred after the resident became unresponsive. Interviews with involved staff revealed that additional actions were taken, including contacting another nurse for assistance, obtaining the crash cart, applying oxygen, calling the family, initiating CPR, calling 911, and the resident’s transfer to the hospital, none of which were reflected in the written progress note. The Administrator and RN/DNS stated that the progress note should have included information about provider notification, initiation of CPR, and transfer to the hospital.
Failure to Timely Report Resident’s Abuse Allegation Involving Required Assistance With Toileting
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of verbal and potential physical abuse involving one resident. The facility’s abuse policy, revised 10/20/2022, required all alleged violations involving abuse to be reported immediately, but not later than two hours after the allegation was made, to the administrator or designee and to state officials, including the state survey agency and adult protective services. The Nursing Home Guidelines (Purple Book) also required staff-to-resident allegations to be reported to the DSHS Hotline, logged within five days, and reported to police or 911. Resident 1, who had diagnoses including myocardial infarction, sepsis, unsteadiness on feet, muscle weakness, cardiomyopathy, and a recently placed AICD with instructions not to use the left arm, was moderately cognitively impaired per the 5-day MDS. On 03/07/2026, a facility incident investigation documented that an RN (Staff F) assisted the resident to the bathroom and told the resident they needed to transfer themself to and from the toilet, and when the resident asked if Staff F would return to help them off the toilet, Staff F stated the resident would have to transfer themself or stay there forever. Later that evening, a CNA (Staff E) answered the resident’s call light and found the resident in the bathroom; the resident reported they had already transferred and cleaned themself because Staff F had told them to do it themself or stay there forever. Staff E reported this concern only to the oncoming CNA at shift change and did not notify a supervisor, stating they did not report the allegation because the resident asked them not to. The next day, another CNA (Staff G) documented that the resident reported significant left arm pain and disclosed the prior day’s allegation, which Staff G then reported to their supervisor. Interviews confirmed that Staff E had recently received abuse training, including instruction to report all allegations of abuse and to report them within two hours to the abuse coordinator and/or supervisor, and that abuse should be reported even if a resident requests that it not be. The facility failed to follow its own policy and regulatory requirements for immediate reporting of an abuse allegation when Staff E did not escalate the resident’s report beyond informing the oncoming CNA.
Failure to Prevent Sexual Abuse and Timely Address Escalating Sexually Inappropriate Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from sexual abuse and to timely implement appropriate interventions for a resident with escalating sexually inappropriate behaviors. Facility policy on abuse required immediate assessment and protection of residents following any allegation or observation of abuse, as well as prompt revision of the care plan with interventions to minimize recurrence. Despite this, the facility did not act in accordance with its policy when confronted with repeated sexually inappropriate behaviors by one resident toward staff, which preceded an incident of sexual contact with another resident. Resident 1 was admitted with dementia and anxiety disorder, was moderately cognitively impaired per the MDS, and resided on a locked unit due to wandering and exit seeking. Resident 1 was able to ambulate independently without assistive devices. On the date of the incident, Resident 1 was found in another resident’s room and reported that the other resident had taken them by the hand into the room and touched their breasts inappropriately. Resident 1 later stated they did not want to be touched and could not understand why the other resident had touched them. Staff interviews confirmed that Resident 1 had been led into the other resident’s room and touched on the breasts. Resident 2, who had dementia, aphasia, and a cognitive communication deficit and was severely cognitively impaired per the MDS, had documented sexually inappropriate behaviors toward staff on multiple days, including touching a CNA inappropriately, motioning a CNA to get into bed, rubbing a social worker’s arm and directing them toward the bed, and exposing their genitals to a CNA. Despite these documented behaviors, Resident 2’s behavior care plan did not include interventions for sexually inappropriate behaviors until after the incident involving Resident 1. One-to-one supervision was initiated the following day, and observations showed that even after this was ordered, staff did not consistently maintain line-of-sight supervision, allowing Resident 2 to move out of visual range and into their room with the door closed. Staff interviews indicated that some staff were aware of Resident 2’s sexually inappropriate behaviors but did not have clear guidance or care plan interventions to manage these behaviors prior to the substantiated incident of sexual abuse involving Resident 1.
Failure to Timely Report Witnessed Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to immediately report a witnessed incident of sexual abuse between residents to the state agency and other required authorities. Facility policy on abuse required that all alleged violations involving abuse be reported immediately, but no later than two hours after the allegation was made, to the administrator or designee and to officials including the state survey agency and adult protective services. The Nursing Home Guidelines (Purple Book) further specified that resident-to-resident sexual abuse/assault incidents must be reported to the DSHS hotline, logged within five days, and that police or 911 be called. Resident 1, who had dementia and anxiety disorder and was assessed as moderately cognitively impaired, was admitted on a specified date. Resident 2, who had dementia, aphasia, and a cognitive communication deficit and was assessed as severely cognitively impaired, was also admitted on a specified date. On 02/02/2026 at 11:45 AM, an incident report documented that Resident 1 was touched inappropriately by Resident 2. A progress note at 12:45 PM the same day showed that a CNA found Resident 1 in Resident 2’s room being touched on the breasts by Resident 2 and notified the nurse, who then wrote an alert report to inform managers of the incident. However, the state agency report showed the incident was not reported until 02/03/2026 at 10:42 AM, outside the required two-hour timeframe. Incident investigation documentation showed the nurse did not immediately report the inappropriate touching to the administrator, state agency, or police, despite being a mandated reporter. During interviews, multiple CNAs, LPNs, and an RN described that abuse should be reported promptly to supervisors and the DSHS hotline, and the Administrator and DNS later stated they only became aware of the incident the following morning while reviewing progress notes and that the incident should have been reported immediately to leadership, DSHS, and the police within two hours.
Failure to Provide Timely Emergency Care and Post-Fall Monitoring
Penalty
Summary
The facility failed to provide timely emergency services and thorough documentation for three residents who experienced falls, resulting in a deficiency related to quality of care. One resident, who was on a blood thinning medication, suffered an unwitnessed fall with a head injury. Despite having a laceration above the eye and being at high risk for intracranial bleeding, the resident was not sent for immediate medical evaluation. Instead, the resident was monitored in the facility, and only after a significant change in condition, including delayed response and unequal pupils, was the resident transferred to the emergency department. Hospital records confirmed a large subdural hematoma requiring emergency surgery, and the resident was later placed on comfort care. For two other residents who experienced falls, the facility's response was inconsistent. Both residents were not on blood thinners but were sent to the emergency department for evaluation after their falls, one with a head laceration and the other with head pain. However, the facility failed to complete required alert charting and post-fall monitoring every shift for 72 hours as outlined in facility policy. Documentation was missing or incomplete for multiple falls, and alert charting was not consistently performed as expected by facility leadership. Interviews with staff confirmed that the expectation was for alert charting to be completed every shift for 72 hours following a fall, but this was not consistently done. The deficiency was further supported by a review of facility policies and external clinical guidelines, which emphasize the need for rapid assessment and intervention for residents on anticoagulants who sustain head injuries. The lack of timely emergency response and incomplete documentation placed residents at risk for medical complications and delayed care.
Failure to Consistently Provide Appropriate Toileting Supplies
Penalty
Summary
The facility failed to consistently provide necessary toileting supplies, specifically briefs, for two residents with moderate cognitive impairment who required staff assistance for toileting hygiene. One resident reported that the facility had run out of their size of brief on three occasions since admission, resulting in the use of smaller briefs that were uncomfortable and did not adequately contain urine, leading to leakage. Another resident stated that staff sometimes used larger briefs when the correct size was unavailable, which did not always prevent wetness. Both residents were able to communicate their needs, and their experiences were corroborated by staff interviews. Staff, including a CNA and Central Supply personnel, confirmed that the facility occasionally ran out of briefs and would substitute with different sizes or obtain supplies from a sister facility, sometimes with delays of up to 12 hours. The administrator was unaware of the need for daily approval of supply orders and acknowledged that the facility should not have been running out of briefs. These actions and inactions resulted in residents not consistently receiving appropriate toileting supplies, as required.
Failure to Implement Proper Infection Control for Suspected Tuberculosis Case
Penalty
Summary
The facility failed to follow infection control standards in the management of a resident suspected of having tuberculosis (TB). According to the facility's own policy, residents with suspected or confirmed TB should be immediately placed on droplet precautions pending transfer, and only admitted if the facility is equipped with a private airborne infection isolation room. The resident in question had a positive PPD test and subsequent positive QuantiFERON gold test, with chest x-rays that could not rule out TB. Despite these findings, the care plan was not updated to reflect the suspicion of TB, the initiation of droplet precautions, or the treatment for pneumonia. The facility did not notify the local health jurisdiction (LHJ) promptly after the positive PPD test, waiting six days before making contact. Staff interviews revealed uncertainty about the correct type of precautions for TB, with the Director of Nursing Services (DNS) acknowledging that airborne precautions are typically required for TB, not droplet precautions as stated in the facility's policy. There was also a lack of documentation and timely communication with the LHJ regarding the resident's status and the facility's actions. Additionally, the facility did not implement interventions for possible TB exposure among staff or other residents, relying instead on verbal communication for monitoring signs and symptoms. The care plan was not reviewed or updated at key points when new information about the resident's condition became available. These lapses in infection control practices and communication placed residents, staff, and visitors at risk for contracting and spreading infections.
Insufficient Staffing Resulting in Unmet Resident Care Needs and Increased Falls
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents across three of four halls, resulting in unmet care needs and increased risk of falls. Review of facility records showed that a significant percentage of residents required assistance with activities of daily living, such as bathing, dressing, transferring, and toileting. Despite policies stating that staffing levels were reviewed daily and adjusted as needed, incident logs revealed a high number of resident falls over several months. Interviews with staff indicated that CNAs were often responsible for caring for up to 15 residents at a time, making it difficult to complete necessary care tasks, especially on weekends when staffing was lower. Staff also reported having to stay late to finish tasks and being frequently asked to cover open shifts. Observations and interviews with residents further highlighted the impact of insufficient staffing. One resident, who was dependent on two staff for transfers and had recently been diagnosed with pneumonia, reported not receiving scheduled showers, not being out of bed for six days, and not having their teeth brushed. Another resident stated they had not had a shower for at least two weeks and had not had their hair washed in about a month. Staff interviews confirmed that administrative nursing staff were counted in the nursing hours per patient day (PPD), but these staff were not always available on weekends. The deficiency was cited under WAC 388-97-1080 (1) and 1090 (1).
Failure to Prevent Significant Medication Error Due to Improper Order Entry and Administration
Penalty
Summary
A significant medication error occurred when a nurse failed to enter a provider's verbal order for an antibiotic (Rocephin 1 gm IM) into the electronic medication administration system (Point Click Care) and did not administer the medication as ordered. Instead, the nurse administered Ceftriaxone 2 gm/Dextrose 50 ml via the clysis system, which was not ordered for the resident. Additionally, the nurse used medication that was prescribed for another resident, which had been discontinued and was awaiting return to the pharmacy. The nurse also failed to complete the required documentation for a change in condition and did not place the resident on alert charting as required by facility policy. The resident involved was moderately cognitively impaired and had multiple diagnoses. Review of the resident's medication administration records showed no antibiotic order was present at the time of administration. The facility's policies required that all medication orders, especially verbal orders, be immediately and accurately recorded in the resident's medical record, including all necessary details such as drug name, strength, dosage, route, and frequency. The nurse did not follow these procedures, resulting in the administration of an unprescribed medication and lack of proper documentation.
Failure to Promptly Investigate and Report Resident Fall
Penalty
Summary
The facility failed to conduct a prompt and thorough investigation following a fall experienced by a resident who was assessed as severely cognitively impaired and had recently undergone surgical repair for a right hip dislocation. The fall, which occurred on 04/06/2025, was not reported by the responsible licensed nurse at the time of the incident, and nurse management was not notified. Risk management procedures and immediate interventions were not implemented as required by facility policy. The incident only came to light when the resident developed new onset pain, prompting an investigation on 04/14/2025, which revealed a dislocation of the right hip arthroplasty without acute fracture. Record review and staff interviews confirmed that the facility's policy for investigating and reporting accidents and incidents was not followed. The nurse supervisor/charge nurse did not promptly report the accident to the administrator or initiate and document an investigation at the time of the fall. The lack of timely notification and intervention was acknowledged by the Director of Nursing Services, who stated that a thorough investigation should have been conducted and documented immediately after the fall.
Failure to Protect Resident from Physical Abuse by CNA
Penalty
Summary
A resident, assessed as cognitively intact and admitted with anemia, experienced physical harm when a Certified Nursing Assistant (CNA) abruptly moved the resident's wheelchair while the resident was self-propelling from the dining room to their room. The CNA reportedly told the resident they were moving too slowly and needed to be passed, then pushed the wheelchair, causing the resident's knee to hit the side of the chair. The resident experienced immediate pain and swelling in the knee, which was later evaluated by x-ray and determined to have no injury, with swelling expected to resolve on its own. The resident did not report the incident immediately, waiting about a week before informing facility staff. The facility's investigation documented that the CNA involved had been identified in three separate abuse allegations recently. At the time the incident was reported, the CNA was already suspended pending a decision from the corporate Human Resources department regarding termination. The facility's abuse policy defines abuse as the willful infliction of injury or punishment resulting in physical harm, pain, or mental anguish, and requires that residents be protected from such actions.
Failure to Provide Adequate Pain Management
Penalty
Summary
The facility failed to ensure the availability of pain medications and did not obtain a provider's order for an alternative pain medication of similar strength for a resident experiencing chronic pain. Resident 1, who was admitted with chronic pain due to lumbar spine stenosis and degenerative disc disease, was prescribed a fentanyl transdermal patch to be applied every 72 hours. However, the Medication Administration Record (MAR) indicated that the patch was not in place for three consecutive shifts, and a new patch was not applied until 59 hours later, leaving the resident without adequate pain management. During this period, Resident 1 reported severe pain, rating it as a 10 on the pain scale, and expressed discomfort due to the absence of the fentanyl patch. Nursing notes documented that the resident had a difficult night without the patch and that the pharmacy was delayed in sending a new one. Despite the availability of pain patches in the Cubex and the option to contact the provider for an alternative medication, the facility staff did not take appropriate actions to manage the resident's pain effectively. This oversight resulted in the resident experiencing significant pain and discomfort.
Inadequate Supervision Leads to Falls in Residents
Penalty
Summary
The facility failed to provide adequate supervision and assistance during bed mobility care for two residents, leading to falls and injuries. Resident 1, who was admitted with multiple diagnoses and required substantial assistance with activities of daily living, experienced a fall from bed when a single staff member attempted to provide care alone, despite the care plan requiring two caregivers. This incident resulted in Resident 1 sustaining injuries that required hospital evaluation. The root cause was identified as inadequate staffing during in-bed care. Similarly, Resident 2, who was receiving hospice services and required substantial assistance, also experienced a fall during care. The care plan for Resident 2 specified the need for two staff members during care due to the resident's fear of rolling off the bed. However, the staff failed to adhere to this plan, resulting in an assisted fall. Although no injuries were noted, the root cause was again identified as the failure to follow the care plan requiring two-person assistance.
Inadequate Infection Control and Outbreak Management
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, leading to the transmission of a communicable disease among residents. The facility did not implement transmission-based precautions (TBP) in a timely manner for residents exhibiting symptoms of respiratory illness. Specifically, residents were not tested for influenza or COVID-19, nor were they placed on droplet precautions or administered antiviral medications like Tamiflu as per the facility's outbreak protocols. This failure resulted in several residents being hospitalized with complications such as pneumonia, sepsis, and acute kidney injury. The facility's outbreak management was inadequate, as evidenced by the lack of timely communication and action from the infection preventionist and medical director. Despite recommendations from the local health jurisdiction to follow CDC guidelines for influenza outbreak management, the medical director chose not to implement these recommendations fully, opting instead to provide antiviral treatment only to symptomatic residents. This decision contributed to the spread of the illness, affecting a significant portion of the resident population. Additionally, the facility did not adhere to proper transmission-based precautions and enhanced barrier precautions. Observations revealed that staff frequently entered rooms without appropriate personal protective equipment (PPE), failed to sanitize shared equipment between uses, and did not follow hand hygiene protocols. The laundry process also lacked proper sanitation, with visible debris and grime on washing machine gaskets not being cleaned between loads. These lapses in infection control practices placed residents, staff, and visitors at increased risk of exposure to communicable diseases.
Failure in QAPI Program Leads to Repeated Deficiencies
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Performance Improvement (QAPI) program effectively self-identified deficiencies and developed or implemented effective plans of action to sustain corrections for previously identified deficiencies. This failure led to repeated deficiencies, a pattern of deficiencies, widespread deficiencies, and a pattern of actual harm that placed residents at repeated risk for unmet needs. During interviews, the Director of Nursing Services (DNS) acknowledged being informed of infection control issues upon taking over the position in July 2024, but expected these issues to have been resolved by then. The DNS admitted that improvements could be made in the QAPI process to reduce repeated deficiencies. The facility conducted QAPI meetings but failed to self-identify deficiencies, recognize unsustained corrections of previously identified deficiencies, or make timely revisions to action plans. The Administrator admitted to being aware of some improvements but not others and acknowledged the need for better engagement with the QAPI process. The report lists numerous deficiencies, including issues related to residents' rights, grievances, abuse and neglect, reporting of alleged violations, care planning, and infection control, among others. These deficiencies were not effectively addressed or sustained, leading to repeated citations and harm.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to properly address grievances for two residents, leading to a deficiency in honoring residents' rights to voice grievances without discrimination or reprisal. Resident 14, who has bipolar disorder and COPD, expressed increased anxiety and dissatisfaction due to a disruptive roommate. Despite multiple progress notes indicating Resident 14's distress and dissatisfaction with the offered solution of earplugs, no grievance was filed, and the Social Services Director was unaware of the situation. The Administrator acknowledged that a grievance should have been initiated, and the resident should have been offered a room change or the first available room. Similarly, Resident 66, who has a left below-knee amputation and diabetes, reported missing personal property, specifically two jackets, to various staff members, including a nurse aide, a nurse, and laundry staff. Despite these reports, no grievance form was completed, and the grievance logs showed no record of the missing items. The Administrator confirmed that the expectation was for staff to assist residents with grievance forms for missing items, but this was not done for Resident 66.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide written notification of the reason for transfer or discharge to the resident or responsible party for two residents who were hospitalized. Resident 38, who had a history of stroke, high blood pressure, and paroxysmal atrial fibrillation, was transferred to the hospital on 11/29/2024. The electronic health records showed no documentation of a written notice being provided to Resident 38 or their responsible party regarding the transfer. Staff interviews revealed that while verbal notifications were made, there was no written documentation provided. Similarly, Resident 66, who had diagnoses including a left below-knee amputation, infection, and diabetes, was sent to the hospital for evaluation on 08/22/2024. There was no documentation found indicating that the resident or their representative was notified in writing of the reason for the transfer. Staff interviews confirmed that written notices were not provided to residents or their representatives for hospital transfers, which is a requirement under the relevant regulations.
Failure in PASRR Screening for Mental Health Disorders
Penalty
Summary
The facility failed to ensure that residents with mental health disorders were properly screened for additional mental health supports using the Preadmission Screening and Resident Review (PASRR) process. Specifically, four residents with diagnoses of depression, anxiety disorder, and bipolar disorder were not referred for a PASRR level two evaluation despite indications that such referrals were necessary. For instance, Resident 53, who was admitted with a diagnosis of depression, had a PASRR level one indicating the need for a level two referral, which was not completed. Similarly, Resident 5, with diagnoses including anxiety disorder, depression, and bipolar disorder, had serious mental illness indicators on their PASRR level one but was not referred for a level two evaluation. Additionally, Resident 8, who was readmitted with anxiety disorder and depression, was not referred for a PASRR level two evaluation despite the presence of mood disorder indicators. Resident 66, admitted with a diagnosis of depression and receiving antidepressant medication, was not marked for serious mental illness on the PASRR level one, and no level two evaluation was conducted. Interviews with the Social Services Director and the Administrator confirmed that these oversights did not meet the facility's expectations for mental health screening and referral processes.
Failure to Conduct Timely Care Conferences
Penalty
Summary
The facility failed to conduct timely care conferences with residents or their responsible parties for four of the seventeen sampled residents, specifically Residents 17, 35, 47, and 65. This deficiency was identified through interviews and record reviews, which revealed that these residents had not participated in care conferences within the expected timeframes. Resident 17, who was able to communicate their needs, had not attended a care conference since July 2024, despite being readmitted to the facility. Similarly, Resident 35, also capable of expressing their needs, last attended a care conference in March 2024. Resident 47, who was admitted with chronic pain and dementia, had their last care conference in April 2024, and Resident 65, who could also communicate their needs, had not attended a care conference since May 2024. Interviews with facility staff, including the Social Services Director and the Administrator, confirmed that the facility's policy was to offer care conferences upon admission and quarterly thereafter. However, the Social Services Director admitted that they were behind on scheduling these conferences for long-term residents. The Administrator reiterated the expectation for quarterly care conferences, indicating a lapse in adherence to the facility's care planning procedures. This failure to conduct timely care conferences placed the residents at risk for unmet needs and a diminished quality of life, as they were not adequately involved or informed about their care plans.
Deficiency in Restorative Care for Residents
Penalty
Summary
The facility failed to provide adequate care and services to maintain or improve the range of motion (ROM) for three residents, leading to a deficiency in their care. Resident 17, who had arthritis, muscle weakness, and spinal stenosis, was not included in a restorative nursing program despite recommendations from a physical therapy evaluation. The resident's care plan lacked interventions for maintaining lower extremity function, and the last documented restorative program progress note was dated several months prior. Staff interviews confirmed that Resident 17 should have been on a restorative program to maintain mobility. Resident 35, who had a contracture of the right hand and other mobility issues, did not receive restorative nursing services. Observations showed the resident was unable to use a therapy device independently, and there were no care plan interventions for managing the contracture. Staff interviews revealed a lack of awareness and application of necessary devices, and the Director of Rehabilitation acknowledged the absence of a care plan to protect the resident's hand and prevent further contracture. Resident 20, diagnosed with right-side hemiplegia and osteoarthritis, also did not receive appropriate restorative care. The resident's care plan lacked interventions for ROM, and a previous focus on managing contractures was resolved without explanation. Observations indicated that necessary equipment, such as foot drop boots, was not being used, and staff interviews confirmed the discontinuation of the restorative program due to staffing issues. The Director of Rehabilitation noted the need for a restorative program to maintain residents' functional levels post-therapy.
Incomplete Dialysis Documentation and Communication
Penalty
Summary
The facility failed to consistently conduct and document pre and post dialysis assessments and ensure ongoing communication with the dialysis center for two residents requiring dialysis. Resident 65, who had a history of stroke, diabetes, and kidney failure, was readmitted to the facility and required dialysis three times a week. However, the dialysis communication records for several dates in December 2024 were incomplete, with missing information and signatures. Interviews with the Unit Manager and Director of Nursing Services confirmed that the records did not meet expectations and should have been completed. Similarly, Resident 66, diagnosed with diabetes and end-stage kidney disease, also required dialysis three times a week. The dialysis communication forms for late November and early December 2024 were found to have blank sections that should have been completed by facility staff and the dialysis center. Interviews with a Licensed Practical Nurse and the Director of Nursing Services revealed that the forms were expected to be filled out accurately, and if the dialysis center did not complete their section, the staff should have contacted them to fill in the information or documented it in a progress note.
Failure to Implement Nonpharmacological Interventions Before PRN Pain Medications
Penalty
Summary
The facility failed to implement nonpharmacological interventions (NPI) before administering as-needed (PRN) pain medications for three residents, leading to a deficiency in medication management. Resident 53, who was admitted with an acquired absence of the right leg above the knee and depression, received PRN pain medication 16 times over two months without any documented NPI. Staff interviews confirmed that NPIs were not provided as required, which did not meet the facility's expectations. Similarly, Resident 14, diagnosed with bipolar disorder and chronic obstructive pulmonary disease, received 18 doses of acetaminophen for pain without NPI documentation, despite the absence of an elevated temperature. Resident 66, with a history of left below-knee amputation and diabetes, also received PRN acetaminophen without NPIs being attempted, as indicated by the medication administration record. Staff interviews corroborated the lack of adherence to the protocol of using NPIs before administering PRN pain medications.
Medication Administration Timing Error
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, as evidenced by 13 errors in 31 opportunities during medication administration for one of the sampled residents. Specifically, a Licensed Practical Nurse (LPN) administered metoclopramide and 12 other medications to a resident at incorrect times, contrary to the provider's orders. The metoclopramide was ordered to be given at 7:00 AM with meals, and the other medications were to be administered at 8:00 AM. However, the LPN administered all medications at 9:19 AM. The Director of Nursing Services acknowledged that the expectation was for nurses to follow the correct time of administration, which did not occur in this instance.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications across multiple areas, including three medication carts and two medication rooms. Medications belonging to a resident were left unsupervised on the North Nurses' Station counter, which included packets of Seroquel and Tamsulosin. Staff X, an LPN, acknowledged that these medications should have been locked away. Additionally, the temperature logs for the medication storage refrigerators in both the South and North medication rooms were incomplete, with numerous undocumented temperature checks for November 2024. Staff J, the Resident Care Manager, confirmed that the temperature should have been documented by the assigned nurses. Further observations revealed issues with medication carts. The Run 3 medication cart contained a bottle of atropine sulfate without a date of opening or label, and refresh eye drops that were not dated when opened. The Peak 1 medication cart had expired insulin, and the Run 4 medication cart had multiple eye drops that were either not dated or potentially expired. Staff members, including RNs and LPNs, acknowledged these deficiencies. The Director of Nursing Services confirmed that medication refrigerators should be monitored for temperature twice a day and that multidose medications should be dated when opened and discarded when expired. The Director also stated that all medications should be secured behind a lock and not left unsupervised.
Failure to Ensure Understanding of Arbitration Agreements
Penalty
Summary
The facility failed to adequately explain and ensure understanding of arbitration agreements for three residents, leading to a deficiency in informed consent. Resident 75, who was admitted with hemiplegia, hemiparesis, and a cognitive communication deficit, signed an arbitration agreement without a date and later stated they did not understand what it was. They recalled being too sick to sign legal documents at the time of admission. Similarly, Resident 14, diagnosed with bipolar disorder and a cognitive communication deficit, signed the agreement without a date and later expressed a lack of understanding of the document, stating they were not in a condition to sign documents upon admission. Resident 31, with dementia and a cognitive communication deficit, signed and dated the arbitration agreement but also lacked understanding of its implications. Interviews with facility staff revealed that the arbitration agreements were presented with admission paperwork, and the staff relied on their judgment to determine if residents could sign their own documents. Staff T, the Admission Director, acknowledged that the previous admissions coordinator did not adequately complete their duties, including the handling of arbitration agreements. Staff A, the Administrator, confirmed that the admission staff assessed residents' ability to sign documents based on their perceived level of confusion. This oversight placed residents at risk of forfeiting their right to a jury trial and seeking restitution for facility errors.
Failure in Antibiotic Stewardship Program Implementation
Penalty
Summary
The facility failed to implement an effective Antibiotic Stewardship Program, which is crucial for promoting appropriate antibiotic use, reducing unnecessary antibiotic use, and decreasing antibiotic resistance. The deficiency was identified through interviews and record reviews, revealing that the facility did not ensure criteria were met for antibiotic use and did not include indications for use or type of infection in provider orders for six of ten sampled residents. This oversight placed residents at risk for potential adverse outcomes associated with inappropriate and unnecessary antibiotic use. The facility's policy required the infection preventionist to review antibiotic utilization daily, but this was not effectively carried out. Specific cases highlighted include Resident 9, who was prescribed antibiotics without being included in the infection control line listing, and Resident 26, who was treated for a urinary tract infection without sufficient evidence or culture results. Staff interviews revealed that orders should have included specific indications for use, but this was not consistently done. The infection preventionist and Director of Nursing Services acknowledged the failure to review and log new antibiotics daily, as well as the lack of documentation for the reason for antibiotic use, which did not meet the facility's expectations.
Failure to Obtain Consent for Antidepressant Use
Penalty
Summary
The facility failed to provide necessary information and obtain consent for the use of an antidepressant medication for one resident, identified as Resident 53. Resident 53, who was admitted with a diagnosis of acquired absence of the right leg above the knee and depression, was receiving duloxetine daily for depression. However, the electronic health record (EHR) review revealed that the risks and benefits of duloxetine were not communicated to the resident, and consent for its use was not obtained. Interviews with the Unit Manager and the Director of Nursing Services confirmed that the facility's protocol required nursing staff to provide information on risks and benefits and obtain signed consent before starting an antidepressant, which was not done in this case, failing to meet the facility's expectations.
Failure to Prevent Verbal Abuse of a Resident
Penalty
Summary
The facility failed to ensure an environment free from verbal abuse for a resident, identified as Resident 45, who was reviewed for abuse. Resident 45, who has paraplegia and a cognitive communication deficit, reported an incident where a staff member accused them of buying all the potato chips from a vending machine and questioned them about being in a gang and breaking into the staff member's car. This incident was witnessed by other staff members who laughed at the resident. The resident reported feeling verbally mistreated and was visibly upset, as noted in a progress note dated 11/17/2024. The facility's incident report lacked documentation of findings, actions taken, and witness accounts. During an interview, the Administrator acknowledged speaking with Resident 45 but did not initially identify the complaint as an allegation of abuse. The Administrator later recognized the need to classify the incident as such after reviewing the progress note. The facility's policy on abuse prevention, dated April 2023, mandates the protection of residents from abuse by anyone, including facility staff, but this policy was not effectively implemented in this case.
Failure to Report Allegation of Abuse
Penalty
Summary
The facility failed to identify and report an allegation of abuse involving a resident, referred to as Resident 45, who was admitted with diagnoses including paraplegia and cognitive communication deficit. Resident 45 was capable of communicating their needs and reported an incident where a staff member accused them of buying all the potato chips from a vending machine and questioned them about being in a gang and breaking into the staff member's car. This incident, which occurred in the presence of other staff members who laughed at the resident, was reported by Resident 45 to a staff member. Despite the report, the facility's Accident and Incident Log for the relevant period did not include any documentation of this allegation. The Administrator, identified as Staff A, acknowledged having spoken to Resident 45 but did not recognize the complaint as an allegation of abuse initially. Staff A later admitted that the incident should have been reported to the state, as per the facility's Abuse Prevention Program policy, which mandates reporting any allegations of abuse within required timeframes.
Failure to Report Allegations of Abuse
Penalty
Summary
The facility failed to thoroughly report allegations of abuse for one of the sampled residents, Resident 85, which placed residents at risk of repeated potential abuse, neglect, or mistreatment, and a diminished quality of life. Resident 85, who was admitted with diagnoses including a fracture of the right lower leg, injury of the right ankle, and diabetes, expressed feeling unsafe after an incident involving a male resident walking and yelling in the hallway early in the morning. Resident 85 reported the incident to Staff U, a receptionist, but the incident was not documented in the facility's incident log for November or December 2024. Staff U mentioned they thought they reported the occurrence but could not recall to whom. Staff B, the DNS, confirmed that the incident was not reported and investigated in a timely manner to rule out abuse, which did not meet the facility's expectations.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for two residents, leading to potential risks for unmet care needs. Resident 69, who was admitted with systemic lupus erythematosus and depression, was inaccurately assessed as having adequate vision without corrective lenses. However, it was revealed through interviews and record reviews that the resident had received new prescription glasses in June 2024, which was not reflected in the MDS completed on 09/03/2024. The MDS Coordinator admitted to not observing the resident with glasses and acknowledged the need for modification of the MDS. Resident 346, admitted with sepsis, a local infection, and COPD, was also inaccurately assessed. The admission MDS failed to code the resident's antibiotic therapy and continuous oxygen use correctly. Observations and record reviews showed the resident was receiving intravenous antibiotic therapy and continuous oxygen at 2 liters per minute, yet the MDS was coded for intermittent oxygen use and did not reflect the high-risk medication. The MDS Coordinator and the Director of Nursing Services both confirmed the inaccuracies in the coding for Resident 346's MDS.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for four residents, leading to unmet care needs and potential negative outcomes. Resident 17, who was readmitted with arthritis, muscle weakness, and spinal stenosis, utilized a wheelchair and was dependent on staff for transfers. However, there was no care plan addressing restorative nursing programs or interventions for range of motion to maintain function related to impaired mobility. Similarly, Resident 35, with a contracture of the right hand and muscle weakness, did not have a care plan for restorative nursing programs or interventions for the use of a therapy carrot to manage the contracture. Resident 20, admitted with right side hemiplegia and osteoarthritis, required extensive assistance with activities of daily living and had both upper and lower extremity impairments. Despite these needs, there was no intervention for range of motion related to the extremity impairment in the care plan. Staff interviews revealed that the facility did not have a restorative nursing program in place, and the expectation was that mobility and range of motion should have been addressed in the care plan. Resident 346, admitted with sepsis and a local infection, had a PICC line in place for intravenous antibiotic therapy. However, there was no active care plan for the PICC line or for managing the sepsis. Staff interviews confirmed the absence of a care plan for the antibiotics, IV line, or infection, which should have been addressed. The deficiencies highlight a lack of individualized care planning for residents with specific medical needs, as required by regulations.
Inaccurate Documentation and Inadequate ADL Care for Resident
Penalty
Summary
The facility failed to provide and accurately document necessary care and services for a resident, specifically in relation to scheduled showers and facial hair removal. Resident 35, who was readmitted to the facility with conditions including contracture of the right hand, muscle weakness, and difficulty in walking, required partial assistance with showering twice a week. However, observations over several days showed the resident with long facial hair, and the resident reported not receiving showers as scheduled. The resident's electronic health records indicated inconsistencies in documentation, with records showing both a lack of showers on scheduled days and inaccurate entries suggesting daily showers. Interviews with staff revealed further discrepancies in the documentation and care provided. Staff Z, a CNA, confirmed the resident's shower schedule but noted that the documentation inaccurately reflected the resident receiving showers multiple times a day. Staff AA, an RN, acknowledged the resident's request for facial hair removal and the inaccuracies in the shower documentation. The Director of Nursing Services also recognized the documentation errors, noting that the resident did not receive showers twice a week as scheduled, and that documenting 'Not applicable' on a scheduled shower day was not acceptable.
Deficiencies in Following Provider Orders and Wheelchair Positioning
Penalty
Summary
The facility failed to follow provider's orders for two residents, leading to deficiencies in care. Resident 66, who was admitted with a left below-knee amputation, infection, and diabetes, did not receive daily dressing changes as ordered by the provider. The resident reported that the dressing changes were missed on multiple occasions, and staff failed to document or communicate the missed care to subsequent shifts. This lack of adherence to the care plan was acknowledged by the facility's nursing leadership as not meeting expectations. Resident 8, who was readmitted with anxiety disorder, depression, and paroxysmal atrial fibrillation, had orders for monthly orthostatic blood pressure measurements. However, the facility failed to document the standing blood pressure readings in the electronic health record, despite staff initials indicating the task was completed. The Unit Manager and Director of Nursing Services confirmed the absence of documentation and acknowledged that the expected procedures were not followed. Resident 17, who utilized a wheelchair for mobility due to arthritis, muscle weakness, and spinal stenosis, experienced issues with improper wheelchair positioning. The resident reported that the footrests did not fit correctly, and they were unable to maintain proper positioning, leading to discomfort. Despite being aware of the issue, staff did not document or address the need for a reassessment of the wheelchair fit. The Director of Rehabilitation confirmed the inappropriate positioning and the need for a therapy referral, which had not been obtained.
Failure to Provide Timely Vision Services for a Resident
Penalty
Summary
The facility failed to provide necessary vision services for a resident, identified as Resident 65, who was reviewed for communication sensory needs. Resident 65, who had a history of stroke, diabetes, and kidney failure, expressed the need for new glasses due to nearsightedness and had informed the staff about this need approximately a month prior to the interview conducted on 12/05/2024. The resident's electronic health record indicated that a request for eye care services was completed and signed by the attending physician on 03/25/2024. Despite the request being made, there was no follow-up documentation in the resident's electronic health record regarding the eye care referral. The Social Services Director confirmed that an appointment was initially scheduled for August 2024 but was rescheduled to September 2024 due to the optometrist's unavailability. However, there was no documentation of further attempts to reschedule the appointment. The Administrator acknowledged that the resident's vision issues should have been addressed back in March 2024, indicating a failure to meet the facility's expectations.
Failure to Provide Adequate Continence Care
Penalty
Summary
The facility failed to provide necessary care and assistance to maintain continence for Resident 394, who was admitted with a fracture of the left leg, asthma, and muscle weakness. The resident was able to communicate their needs and required assistance to move out of bed. Despite therapy recommendations for a two-person assistance for toileting, the care plan only included a one-person assist with a bedpan and lacked specific instructions for toileting services. This oversight led to the resident being unable to receive timely assistance, resulting in episodes of incontinence. On one occasion, the resident reported being fully soiled by the time staff arrived to assist them. The resident also mentioned that therapy had previously assisted them to use the toilet and indicated that two strong staff members could help with the transfer. However, a weekend charge nurse stopped the staff from assisting the resident, citing that it was not allowed. The Director of Nursing Services acknowledged that the nursing department failed to update the care plan with therapy's instructions, which did not meet the facility's expectations.
Failure to Implement Dietary and Fluid Recommendations
Penalty
Summary
The facility failed to ensure that residents received the correct amounts of supplemental nutrition and that diet recommendations and fluid restrictions were implemented. Resident 19, who had diagnoses including kidney disease and heart failure, reported that the facility did not follow their provider's dietary and fluid recommendations. The resident was offered foods high in sodium, contrary to the provider's order for a low-salt diet and specific fluid intake. The Director of Nursing Services (DNS) acknowledged that the recommendations were not forwarded to the provider, which did not meet the facility's expectations. Resident 34, diagnosed with conditions such as hemiplegia and malnutrition, required a specific amount of nutritional formula via a gastrostomy tube. However, the medication administration record (MAR) showed that the resident received less than the ordered amount on multiple occasions, leading to a weight loss of 10 pounds over 60 days. The Resident Care Manager (RCM) and DNS confirmed that the resident did not receive the ordered nutrition, which was below the facility's standards. Resident 81, with diagnoses including cerebral infarction and diabetes, was dependent on staff for nutrition via an artificial route. The MAR indicated that the resident received only one carton of Jevity formula instead of the ordered two cartons on several occasions. The DNS stated that this was due to a nurse's error. Additionally, Resident 74, who had heart failure and kidney failure, was supposed to be on a fluid restriction as per their renal doctor's recommendation. However, there were no orders or instructions on fluid restriction in the resident's care plan, which the DNS admitted did not meet expectations.
Failure to Provide Proper Respiratory Care for a Resident
Penalty
Summary
The facility failed to provide respiratory care according to professional standards of practice for a resident who was reviewed for respiratory care. Resident 74, who was admitted with diagnoses of heart failure, endocarditis, and kidney failure requiring dialysis, was observed with a CPAP machine next to them. The resident expressed that the aides were reluctant to add water to the machine, and it was difficult to get a nurse's assistance. The resident's electronic health record (EHR) lacked any order or care plan regarding the CPAP machine or instructions for its care. An observation revealed the CPAP machine's water chamber contained unclear water with floating white/grayish particles. The Assistant Director of Nursing acknowledged the issue and initiated cleaning. The Director of Nursing Services stated that nurses were expected to monitor personal CPAP machines and initiate orders and care plans, which was not done in this case.
Failure to Provide Social Services After Traumatic Event
Penalty
Summary
The facility failed to provide medically related social services to Resident 85, who was involved in a traumatic experience in their room. Resident 85, who was admitted with a fracture of the right lower leg, injury of the right ankle, and diabetes, expressed feeling unsafe and mentally exhausted after a male resident approached their room and a previous incident where their roommate's visitor was arrested for attempted murder in front of them. Despite these events, Resident 85 reported that staff did not check on their well-being or provide emotional support, leading to feelings of being ignored. Interviews with facility staff revealed a lack of awareness and follow-up regarding Resident 85's emotional needs. The Social Service Director was unaware of the resident's concerns, and the Director of Nursing Services acknowledged the arrest event as stressful, expecting social services to provide follow-up, which did not occur. The facility's policy required social services to identify emotional needs and maintain individualized care plans, but this was not adhered to, resulting in unmet needs and diminished quality of life for Resident 85.
Failure to Monitor Behaviors for Residents on Psychotropic Medications
Penalty
Summary
The facility failed to adequately monitor behaviors for two residents who were prescribed psychotropic medications, which are intended to affect mental status. Resident 57, who was admitted with anxiety and post-traumatic stress disorder, was observed sitting in a dark room and expressed having night terrors. Despite being administered multiple antidepressant and antianxiety medications, there was no behavior monitoring in place to assess the effectiveness of these medications or the behaviors experienced by the resident. The Director of Nursing Services acknowledged the absence of behavior monitors, which did not meet the facility's expectations. Similarly, Resident 8, who was readmitted with anxiety disorder and depression, received antidepressant and antipsychotic medications without corresponding behavior monitoring orders documented in the medication administration record (MAR) for a specific period. An existing order to monitor behaviors did not specify the reason, and the Unit Manager confirmed that behavior monitoring related to the use of these medications was not conducted as required. The Director of Nursing Services also confirmed that the behavior monitoring for Resident 8 did not meet expectations, as it should have been documented in the MAR.
Failure to Monitor Refrigerator Temperatures
Penalty
Summary
The facility failed to monitor refrigerator temperatures and take corrective action for the South Clean Utility Fridge, which was one of three resident refrigerators reviewed. Observations on December 10, 2024, revealed that the temperature logs for November and December 2024 were posted on the fridge, indicating that the refrigerator temperature should not exceed 40 degrees. However, the review of the logs showed that in November 2024, 11 of 31 AM temperatures and 16 of 31 PM temperatures were recorded above 40 degrees, with no comments made for these temperatures. Similarly, in December 2024, 3 of 10 AM temperatures and 1 of 10 PM temperatures were recorded above 40 degrees, again with no comments made. Interviews with staff revealed a lack of communication and action regarding the temperature issues. The Dietary Manager stated that the fridge was monitored by housekeeping staff, and the kitchen staff was responsible for ensuring correct temperatures. The Environmental Services Director confirmed that they monitored the fridge Monday through Friday and would notify maintenance if temperatures were too high. However, the Maintenance Assistant was unaware of any temperature issues, indicating a breakdown in communication. The Administrator acknowledged that the monitoring did not meet expectations, as temperatures above 40 degrees should have been reported to maintenance.
Resident Subjected to Inappropriate Physical Restraint During COVID-19 Test
Penalty
Summary
The facility failed to ensure a resident was free from physical restraints, which is a violation of their Abuse Prevention Program policy. The incident involved a resident with severe cognitive impairment, dementia, and other mental health issues, who was dependent on staff for daily living activities and was under hospice care. During a COVID-19 test, two staff members were observed restraining the resident inappropriately. One staff member held the resident in a choke hold while the other administered the nasal swab, despite the resident's visible distress and attempts to refuse the procedure. The incident was witnessed by both an outside agency staff member and a licensed practical nurse (LPN) from the facility. The LPN observed the resident struggling and noted their face was bright red, indicating distress. The LPN instructed the staff to stop the procedure. The Director of Nursing Services and the facility administrator both confirmed the incident was substantiated as abuse, as the resident's right to refuse was not respected, and the use of physical restraint was inappropriate.
Failure to Provide Timely Medical Care After Resident Fall
Penalty
Summary
The facility failed to provide timely medical care for a resident who sustained a head injury after a fall. According to the facility's policy on managing falls and fall risk, immediate medical treatment should be obtained if there is evidence of injury. However, after the resident fell and sustained a 3-centimeter vertical wound on the back of the head that bled profusely, the registered nurse administered first aid and notified the guardian and provider. Despite the bleeding, the provider did not issue new orders and planned to see the wound later that day. The resident's vital signs were documented as within normal limits. Four hours after the fall, a family member requested an emergency transfer to the hospital, but the RN initially explained that the situation was being monitored and did not appear to be an emergency. However, when the resident expressed feeling unwell, the RN agreed to call 911, and the resident was transferred to the hospital for emergency evaluation. Interviews with staff, including the Director of Nursing Services, indicated that the standard of care for a head injury with bleeding should involve immediate assessment, first aid, physician notification, and calling 911 for emergency transfer, which was not initially followed in this case.
Failure to Administer Medications and Perform Wound Care
Penalty
Summary
The facility failed to ensure residents received treatment and care in accordance with professional standards of practice. For Resident 1, the facility did not administer the prescribed IV Zosyn antibiotic on multiple occasions and failed to document or notify the physician about the resident's adverse reactions and refusals. This led to Resident 1 being admitted to the hospital in septic shock due to incomplete antibiotic therapy. Additionally, the facility did not follow up on a faxed order for a new antibiotic, resulting in further delays in treatment. Resident 2's surgical wound care was inadequately managed. The facility did not document or perform the necessary wound assessments and dressing changes as per the hospital discharge orders. Despite Resident 2's allergy to adhesive tape, the original dressing was left unchanged for seven weeks, leading to complications. The facility staff failed to communicate with the surgeon to obtain appropriate wound care orders and did not address the resident's refusal of care effectively. For Resident 3, the facility did not carry out the psychiatrist's recommendation for lab work to test for infection, nor did they notify the primary care provider about the recommendation. When a physician later ordered a urinalysis to evaluate for a possible UTI, the order was not executed promptly, and the nursing staff was unaware of the pending order. This lack of coordination and communication resulted in delays in diagnosing and treating potential infections, exacerbating Resident 3's psychiatric symptoms.
Failure to Assess and Mitigate Elopement Risk
Penalty
Summary
The facility failed to ensure that two residents were properly assessed or re-assessed for elopement risk and that their care plans were updated to include interventions to mitigate or prevent elopement. Resident 1, who had diagnoses including rib fractures, alcohol abuse, and alcohol withdrawal, exhibited exit-seeking behavior and was found wandering multiple times. Despite these behaviors, the resident was not reassessed for elopement risk, and the care plan was not updated. Eventually, Resident 1 eloped from the facility and was found at home with a spouse who was unable to care for them. The facility's Elopement Risk Binder did not contain an information sheet with a photo for Resident 1, and staff had not conducted elopement drills as required by the facility's policy. Resident 2, diagnosed with Alzheimer's disease, was initially assessed as not at risk for elopement. However, the resident's care plan indicated a risk for wandering, and subsequent assessments documented increased wandering behavior. Despite these changes, the resident was not reassessed for elopement risk, and the care plan was not updated with new interventions. Resident 2 was moved from an alarmed unit to an unalarmed unit due to a change in medical condition, and was later found attempting to exit the facility through an employee door. The Director of Nursing Services acknowledged that a reassessment and care plan update should have been conducted at the time of the resident's change in condition. Interviews with facility staff revealed that elopement drills had not been conducted monthly as required by the facility's policy. The Director of Nursing and the Administrator both indicated that the facility's policy was to develop a care plan based on the risk for elopement and to place resident information sheets with photos in the Elopement Risk Binder. However, these steps were not followed for the residents in question, leading to the deficiencies noted in the report.
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 931 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Gig Harbor
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cottesmore Of Life Care | 1.4 mi | — | 17 | 0 |
| Eliseo | 3.8 mi | — | 5 | 0 |
| Heron's Key | 4.2 mi | — | 10 | 0 |
| Avamere Transitional Care Of Puget Sound | 4.2 mi | — | 56 | 0 |
| Park Rose Care Center | 5.8 mi | — | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Gig Harbor Health And Rehabilitation.
100% money-back within 48 hours.
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.