Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mira Vista Care Center during CMS and state inspections, most recent first.
A resident experienced an acute neurological change with symptoms such as facial droop, slurred speech, arm weakness, and visual problems, but staff did not immediately notify the responsible party and did not document timely follow-up with the physician as previously instructed. Facility policy required prompt physician contact based on urgency and notification of the resident representative for changes in condition, yet progress notes lacked evidence that either emergency contact was informed when the change was first identified, and there was no documentation that the physician was called back within the specified timeframe. The resident was later transferred to a hospital, where an acute stroke was confirmed, and staff interviews acknowledged that such symptoms constituted a critical situation requiring concurrent physician and family notification.
Deficiencies were found in infection control practices, including improper PPE use and inadequate signage for residents on transmission-based precautions. Staff entered rooms of residents with infectious conditions, such as C. difficile, norovirus, ESBL, and those with PEG tubes, without donning required PPE or following organism-specific hand hygiene protocols. Observations and staff interviews revealed inconsistent understanding and implementation of facility policies and posted instructions.
Two residents prescribed antidepressant medications did not receive required monitoring for target behaviors, side effects, or depressive symptoms. One resident experienced a serious medication side effect and was started on a new antidepressant without appropriate monitoring or care plan updates. Staff confirmed that monitoring measures and non-pharmacological interventions were not implemented for either resident.
The facility did not consistently follow physician orders for medication administration, including required blood pressure and heart rate checks, resulting in multiple instances where medications were given outside of prescribed parameters or without proper documentation. Staff interviews confirmed expectations for monitoring and documentation, but records showed repeated omissions and lack of routine auditing, affecting several residents with heart failure and hypertension.
Dietary staff did not follow required hand hygiene protocols when changing gloves and failed to wear beard nets as required by facility policy, resulting in unsanitary food preparation conditions.
Surveyors found that two residents' medical records were incomplete and not systematically organized. One resident's chart lacked required documentation for a significant change PASSR evaluation, and another resident's care plan conference note was missing key interdisciplinary team input and essential care plan elements, including hospice services. Staff interviews confirmed delays and gaps in documentation.
A resident reported being left alone in a wheelchair for six hours, but the incident was not identified or reported as abuse or neglect, nor was it investigated according to policy. Additionally, a staff member had not completed required annual abuse and neglect training, indicating lapses in both grievance handling and staff education.
A resident with multiple health conditions reported being left alone in a wheelchair for six hours, resulting in soreness. Although the grievance was documented and addressed by an LPN and marked as resolved by the Administrator, there was no evidence of a formal investigation into the allegation of abuse or neglect, as required by facility policy. Staff interviews confirmed that such an incident should have been investigated, but no documentation of an investigation was found.
A resident with a history of antibiotic-resistant UTI and DVT was not scheduled for a recommended cystoscopy and infectious disease consult, leading to ongoing discomfort. The deficiency was due to miscommunication and lack of a formal scheduling policy, with staff unaware of the need for appointments until informed by a nurse practitioner.
The facility's policy failed to address safe storage of foods brought in by visitors, prohibiting personal refrigeration units in resident rooms and not allowing outside food in facility storage. This led to residents being unable to store uneaten perishable items, impacting their quality of life.
The facility failed to ensure a clean, comfortable, and homelike environment, with observations revealing stained carpets, broken blinds, damaged walls, and dirty floors across all units. The administrator acknowledged the poor condition and mentioned ongoing repairs but lacked specific plans for addressing these issues. This was a repeat deficiency from a previous survey.
The facility failed to maintain food safety standards, with a broken refrigerator seal, moldy pickles, and improper temperatures in storage units. The kitchen had cobwebs, debris, and spills, while the freezer had ice buildup and unidentified food. Staff acknowledged cleaning issues and unlogged maintenance needs, risking food contamination.
A resident with a history of stroke and vascular disease sustained a sunburn during an outing due to the facility's failure to identify sun exposure risks and provide adequate supervision. The resident's care plan lacked sunblock use guidelines, and staff did not offer sunblock, despite its availability. The facility also lacked a policy on sunburn prevention, and staff interviews were not conducted following the incident.
The facility failed to honor food preferences for two residents, impacting their quality of life. One resident was unable to store personal food items due to facility policy, while another resident's dietary preferences were not documented or considered, leading to dissatisfaction with the facility's food offerings.
The facility failed to assist two residents in formulating Advance Directives (AD), risking their right to have medical treatment preferences honored. One resident had an incomplete Durable Power of Attorney (DPOA) document, while another expressed interest in an AD and DPOA but received no follow-up. Staff were unaware of these deficiencies, contributing to the issue.
The facility failed to provide adequate assistance with ADLs for three residents, leading to unmet care needs. A resident with multiple medical conditions struggled to eat independently due to lack of adaptive equipment and staff assistance. Another resident with cancer and COPD was unable to reach their meal tray, and a third resident did not receive consistent oral hygiene care. Staff interviews revealed a lack of awareness and compliance with care plans, highlighting systemic issues in care provision.
Facility staff failed to follow infection control practices for two residents with urinary catheters. A resident's catheter bag was emptied without cleansing the spout, and hand hygiene was not performed between glove changes. Another resident's catheter tubing was observed dragging on the ground multiple times, despite care plan instructions to secure it. These actions increased the risk of infection.
A resident reported missing personal property, including cash, after being admitted to the hospital. Despite attempts to retrieve their belongings, the facility did not log any grievances, and staff interviews revealed a lack of communication and follow-up. Eventually, some items were found, but the cash was not mentioned, highlighting the facility's failure to address the grievance timely.
A resident was discharged to a hospital and denied re-admission to the facility without receiving a written transfer discharge notice or being informed of their appeal rights. The facility also failed to notify the State Long-Term Care Ombudsman. Staff cited drug use and disruptive behavior as reasons for non-readmission, while the resident was left without support in a distant facility.
A facility failed to provide a written bed hold notice to a resident or their representative upon transfer to a hospital, as required by policy. The resident's medical records lacked documentation of the notice, and interviews with staff revealed confusion about who was responsible for providing it. The resident confirmed not receiving any information about a bed hold.
A facility failed to follow physician orders for a hospice referral for a resident with multiple health issues, including chronic respiratory failure and a history of cancer. Despite a referral being made by an ARNP, it was not acted upon by social services, leaving the resident without requested hospice support. Interviews revealed a breakdown in the facility's process for handling hospice referrals.
Failure to Immediately Notify Physician and Family of Acute Neurological Change
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify the resident’s responsible party and to update the physician timely when there was a significant change in condition for one resident who was later hospitalized with an acute stroke. The facility’s policy on change in condition, revised in April 2025, required the nurse to use clinical judgment to contact the physician based on urgency and to notify the resident representative of the change. The resident’s face sheet listed two emergency contacts. A progress note documented that at 5:30 AM on 01/04/2026 a change in condition was identified, the on‑call physician was notified, and instructions were given to monitor the resident and call back if the condition did not clear or worsened within 30 minutes. There was no documentation that the responsible party was notified at that time, nor that the physician was called back within 30 minutes as instructed. Later documentation on the same date at 10:11 AM by an RN showed the resident had acute neurological changes, including facial droop, slurred speech, left arm flaccidity, and visual problems. The note indicated the spouse arrived at 8:00 AM and was notified of the change in condition, and that the physician was notified that the family was declining transfer to the hospital, but it did not document immediate notification of either responsible party when the change was first identified. The note also recorded that the second emergency contact arrived at 9:00 AM and agreed to hospital transfer. An emergency room note from a local hospital at 9:40 AM confirmed an acute stroke. A CNA reported observing the resident at 6:00 AM with leaning to one side and inability to focus gaze and stated they summoned the RN, who assessed the resident at 6:10 AM. In interviews, the RN acknowledged that new onset arm weakness and visual problems would be a critical situation warranting physician and family notification and could not recall why the family was not called, while the Assistant DON confirmed that acute neurological changes should be a priority and that documentation did not show immediate family notification or that the physician was contacted again within 30 minutes as previously directed. The survey cited WAC 388-97-0320(1)(b-d).
Deficient Infection Control Practices and PPE Compliance
Penalty
Summary
Multiple deficiencies were identified in the facility's infection prevention and control practices, specifically related to the use of personal protective equipment (PPE) and appropriate signage for residents requiring transmission-based precautions. For a resident with recent norovirus and Clostridium difficile infections, the posted contact precautions signage did not specify the need for soap and water hand hygiene, which is required for enteric organisms. Staff interviews confirmed that signage should have included these organism-specific instructions, and observations revealed that contract staff entered the resident's room without donning PPE, stating they had not noticed the sign. Another resident with a newly placed PEG tube was ordered to be on Enhanced Barrier Precautions (EBP), but no EBP signage was displayed on the door during multiple observations. Staff were observed providing high-contact care, such as administering medication via the PEG tube, without donning appropriate PPE. Staff interviews confirmed that EBP should have been implemented upon the resident's admission, but this was not consistently followed. A third resident, readmitted with an ESBL-resistant infection, had contact enteric precautions signage posted, instructing staff to gown and glove upon room entry. However, staff were observed entering the room and handling items such as lunch trays without wearing PPE, stating they believed PPE was only necessary when providing direct care. Interviews with staff revealed a lack of understanding regarding the requirement to don PPE upon room entry, as indicated by the posted signage and facility policy.
Failure to Monitor Psychotropic Medication Use and Side Effects
Penalty
Summary
The facility failed to ensure that two residents received appropriate medication-specific monitoring for psychotropic medications, specifically antidepressants. One resident, with a history of depression and anxiety, was admitted and subsequently hospitalized after experiencing a side effect from their antidepressant medication, resulting in Syndrome of Inappropriate Antidiuretic Hormone (SIADH) and low sodium levels. Despite the resident's history and diagnosis, there was no depression symptom monitoring in place upon admission, and after a new antidepressant was started, there was no implementation of target behavior monitoring, side effect monitoring, or updates to the care plan. The resident had also initially denied depression symptoms but later disclosed ongoing depression, which was confirmed by a standardized screening tool, yet no monitoring was initiated following this disclosure. Another newly admitted resident with a diagnosis of depression was prescribed two different antidepressant medications without any associated behavior monitors, medication side effect monitors, or non-pharmacological interventions. Staff interviews confirmed that these monitoring measures were not in place for this resident. The lack of monitoring and care plan updates for both residents was acknowledged by facility staff, who stated that these components had been missed.
Failure to Adhere to Medication Administration Parameters and Documentation Standards
Penalty
Summary
The facility failed to follow professional standards of practice in medication administration for three residents with diagnoses including congestive heart failure (CHF) and hypertension (HTN). For one resident, there was no documentation that blood pressure (BP) or heart rate (HR) were monitored prior to administering eight of eleven doses of Carvedilol, despite physician orders requiring these checks. Staff interviews confirmed that vital signs should be checked and documented before administering medications with parameters, but records showed missing documentation for multiple doses. Another resident received Carvedilol and Hydralazine outside of the physician-ordered parameters on several occasions, with missing documentation of HR for five of nine doses and administration of medications when vital signs were outside the specified limits. Staff acknowledged the expectation to document and review vital signs before medication administration, but also stated that there was no routine audit for medications given outside parameters, and errors were only addressed if discovered incidentally. A third resident was administered Metoprolol and Midodrine outside of the established parameters, as evidenced by the medication administration record (MAR) showing doses given when systolic blood pressure was below or above the ordered thresholds. Staff confirmed that medications had been administered outside of parameters but were unable to fully review all relevant dates due to difficulties navigating the electronic record system. These failures to adhere to physician orders and document required assessments led to the identified deficiencies.
Failure to Ensure Sanitary Food Preparation and Staff Hygiene
Penalty
Summary
Facility staff failed to adhere to safe and sanitary food preparation practices in the kitchen, as observed during meal tray assembly. Specifically, two dietary staff members with beards were not wearing beard nets, contrary to the facility's dress policy requiring hair and beards to be effectively restrained with appropriate hair restraints, including beard nets. Staff N, the Dietary Supervisor, stated that beard nets were not necessary if beards were trimmed short, despite both staff members having facial hair. Additionally, multiple instances were observed where Staff N did not perform proper hand hygiene when changing gloves. Staff N was seen putting on gloves without washing hands prior to food preparation, removing gloves without washing hands, and repeatedly donning new gloves without handwashing in between tasks. In interviews, Staff N acknowledged the facility's process required handwashing before applying new gloves and when changing tasks, but did not follow these procedures during the observed meal preparation activities.
Incomplete and Disorganized Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete, accurate, and systematically organized medical records for two residents. For one resident with a history of depression and anxiety, the electronic chart contained two Preadmission Screening and Resident Reviews (PASSR). The second PASSR indicated an evaluation was required for a significant change, but there was no documentation of such an evaluation in the resident's chart or in the progress notes. Staff interviews revealed uncertainty about the follow-up on the PASSR, and no notes were found regarding the required evaluation. For another resident admitted with hospice enrollment, the care plan documentation was incomplete. The care plan conference note indicated only social services attended, and key elements such as disease diagnosis, health and skin conditions, special treatments, medication reconciliation, and various care plans were left blank. There was also no documentation regarding hospice care services. Staff interviews confirmed that the care conference documentation was not completed in a timely manner, with the responsible staff still working on it ten days after the conference.
Failure to Identify and Report Abuse Allegation; Lapse in Staff Training
Penalty
Summary
The facility failed to identify and respond appropriately to a grievance that constituted an allegation of abuse or neglect for one resident. Specifically, a resident with diagnoses including orthostatic hypotension, cellulitis, dementia, and malnutrition reported being left alone in a transport wheelchair for six hours, resulting in significant discomfort. The grievance, documented by the facility, indicated the resident was left unattended from 1:00 PM to 7:00 PM. Despite this report, the incident was not escalated as an allegation of abuse or neglect, nor was it reported to the state agency or investigated as required by facility policy and regulatory standards. Interviews with staff revealed uncertainty about the process for handling such grievances, with some staff indicating they would notify a nurse or administrator, but no clear action was taken to treat the report as a potential abuse or neglect case. Additionally, the facility failed to ensure that all staff received annual abuse and neglect training as required. Review of training records showed that one staff member had not completed the required training within the past 12 months. Staff interviews confirmed that annual training was expected, but there was a lack of clarity regarding the last training dates. These failures in both grievance handling and staff training placed residents at risk for abuse, neglect, and associated harm.
Failure to Investigate Alleged Abuse/Neglect Following Resident Grievance
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of abuse or neglect for a resident who reported being left alone in a wheelchair for six hours, resulting in extreme soreness. The resident, who had diagnoses including orthostatic hypotension, cellulitis of the left leg, dementia, malnutrition, and required assistance with personal care, filed a grievance stating they were left unattended from 1:00 PM to 7:00 PM. The grievance was documented and addressed by a Licensed Practical Nurse and marked as resolved by the Administrator, but there was no evidence of a formal investigation into the allegation as required by facility policy. Record review showed no documentation in the resident's progress notes regarding the grievance or any investigation on the relevant dates. Interviews with facility staff confirmed that such a report should have been escalated and investigated as a potential abuse or neglect case. Despite requests for further documentation, no additional information was provided to demonstrate that an investigation took place, indicating a failure to follow the facility's abuse prevention and investigation policy.
Failure to Schedule Recommended Medical Appointments
Penalty
Summary
The facility failed to coordinate and schedule necessary medical appointments and procedures for a resident who was readmitted after hospitalization for antibiotic-resistant urinary tract infection and deep venous thrombosis in both legs. The resident's Urology After Visit Summary recommended a cystoscopy evaluation and a referral to an infectious disease provider, but these were not scheduled 39 days after the recommendation. The resident continued to experience discomfort, as noted by ongoing complaints of burning when urinating. The deficiency was attributed to a lack of coordination and communication among staff. Staff B, an LPN/Supervisor, stated that scheduling was part of Staff C's duties, but the after-visit summary was misplaced, and Staff C was unaware of the need for scheduling until informed by a nurse practitioner. Despite attempts by the urology clinic to contact Staff C, no communication was received due to a change in phone. The facility lacked a formal policy for scheduling follow-up appointments, contributing to the oversight.
Deficiency in Policy for Storing Outside Food
Penalty
Summary
The facility failed to ensure their policy regarding foods brought in from outside sources included provisions for safe storage and clear distinction from facility food. The policy, titled 'Resident/Personal Food Storage' and dated July 2024, allowed residents to receive food from visitors but prohibited personal refrigeration units in resident rooms due to electrical load concerns. Additionally, the policy did not permit the storage of outside food in facility pantries or refrigeration units, requiring that any perishable food not consumed on the day of opening be discarded. During an interview, the Administrator confirmed that residents were not allowed to store outside food in facility refrigerators and were required to dispose of uneaten perishable items, as personal refrigerators were not an option. This policy placed residents at risk of decreased quality of life by limiting their ability to have food items of their choice safely stored in the facility.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment across all three units observed, as evidenced by stained carpets, broken blinds, damaged walls, and dirty floors. Observations on specific dates revealed dirty and sticky floors in resident rooms, scattered wrappers, and dirty paper towels. Additionally, the facility's hallways had missing baseboards, carpet seams pulling apart, and various dark stains on the carpets, including large stains near specific rooms. The wainscot in one hallway was marked with drip-like staining and scraped areas, and there were rips in the carpet in another hallway. Further observations noted broken blinds in several rooms, with some slats completely missing. Walls in certain rooms had large gouged areas and exposed sheetrock. During an interview, the facility's administrator acknowledged the poor condition of the carpets and mentioned that bids for new flooring had been obtained, but no replacement timeline was scheduled. The administrator also stated that repairs and housekeeping were ongoing but did not provide specific plans to address the other issues. This deficiency was a repeat from a previous survey conducted in July 2023.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that resident meals were prepared and stored in accordance with professional standards of food safety. During observations, the walk-in refrigerator was found with a broken door seal and a temperature of 45 degrees Fahrenheit, while the temperature log inaccurately recorded it as 38 degrees Fahrenheit. An opened and undated bucket of pickles with mold was found inside the refrigerator. The walk-in freezer had a three-inch layer of ice on the door and contained unidentified food with unclear dating. The freezer temperature was 9 degrees Fahrenheit. The kitchen preparation area was observed with cobwebs, debris, and black particles, and the flooring had black markings and discoloration. The unit refrigerator also had a temperature of 45 degrees Fahrenheit, with sticky spills and debris inside. Interviews with staff revealed that the kitchen was cleaned daily, but deep cleaning occurred only every six months. The Dietary Manager acknowledged the mold on the pickle bucket and the broken refrigerator seal, which had been reported to maintenance but not logged. The Maintenance Staff confirmed the broken seal and ice buildup, noting that the repair was not logged. The Administrator stated that the refrigerator seal was broken by a delivery person and was awaiting replacement. These deficiencies left residents at risk for food contamination and foodborne illnesses.
Failure to Prevent Sunburn During Resident Outing
Penalty
Summary
The facility failed to identify the risk of sun exposure and provide adequate supervision and interventions to prevent a sunburn for a resident who was cognitively intact but required assistance with dressing and had impaired range of motion. The resident, who had a history of stroke, high blood pressure, and peripheral vascular disease, sustained a first-degree sunburn on their forehead and arms during an outing. The resident's care plan did not address sunblock use or sunburn prevention prior to the incident, and the facility lacked a policy related to sunblock use or sunburn prevention. The Medication Administration Record (MAR) indicated that sunblock was only available from the 15th of each month, and the resident was not offered sunblock during the outing. Staff interviews revealed that the resident was not aware of the availability of sunblock, and there was no documentation of staff offering sunblock. The facility's incident report did not include interviews with staff who worked during the weekend of the incident, and there was no evidence of staff education on offering sunblock to residents. The Director of Nursing Services was unable to determine why the sunblock order was revised after the incident.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor and facilitate resident preferences for food storage and dietary choices, impacting two residents. Resident 43, who has been at the facility since 2021 and is cognitively intact, expressed frustration over the inability to store personal food items, such as salad dressing, in the facility's refrigerators. The facility's policy prohibits residents from storing personal food in facility refrigerators or having personal refrigeration units in their rooms, leading to the disposal of Resident 43's perishable items. This policy was confirmed by the facility's administrator, who stated that residents must consume perishable items immediately or dispose of them, as the facility does not allow storage of outside food items. Resident 28, admitted with conditions including high blood pressure and a broken leg, reported dissatisfaction with the facility's food, describing it as bland and lacking flavor. The resident stated they had not been interviewed about their food preferences since admission, and their electronic medical record lacked documentation of their dietary likes or dislikes. The dietary supervisor admitted to not having met with Resident 28 to discuss their preferences, despite the facility's protocol to do so within 72 hours of admission. This oversight resulted in Resident 28 not having their dietary preferences considered, as evidenced by an inaccurate menu without meal choices.
Failure to Assist Residents in Formulating Advance Directives
Penalty
Summary
The facility failed to obtain and/or offer assistance to residents and/or their representatives to formulate Advance Directives (AD) for two residents, which placed them at risk of losing their right to have their stated preferences and decisions honored regarding medical treatment and end-of-life care. Resident 26 was admitted with diagnoses including stroke, high blood pressure, and peripheral vascular disease. The facility had a one-page Durable Power of Attorney (DPOA) document for Resident 26 that lacked a date and signature. Staff involved in the admission process were not aware of the incomplete documentation, as the admission occurred before their employment. Resident 28, admitted with high blood pressure, atrial fibrillation, and a broken right leg, signed an Advanced Directive receipt indicating interest in formulating an AD. However, there was no documentation in the medical record regarding the formulation, coordination, or execution of an AD. Social Services staff acknowledged that Resident 28 expressed interest in an AD and a DPOA but had not followed up to develop these documents. This lack of follow-up contributed to the deficiency noted in the report.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for three residents, leading to unmet care needs and diminished quality of life. Resident 11, who has multiple medical conditions including Multiple Sclerosis and hemiplegia, was observed struggling to eat independently due to limited range of motion and lack of adaptive equipment. Despite the care plan indicating the need for one-person assistance during meals, staff did not provide the necessary help, leaving the resident to attempt eating without success. Additionally, Resident 11 reported not receiving regular showers or being turned in bed as required, which was corroborated by staff interviews. Resident 33, diagnosed with lung cancer, leukemia, and COPD, also experienced neglect in meal assistance. Observations showed that their lunch tray was out of reach, and they were unable to consume their meal without help. Despite the care plan indicating the need for setup assistance, staff failed to provide the necessary support, leaving the resident dependent on their roommate to voice their need for help. Staff interviews revealed a lack of awareness regarding the residents' needs for meal assistance, highlighting a systemic issue in the facility's care provision. Resident 28, with a history of high blood pressure and a broken leg, was found to have inadequate oral hygiene care. Despite being able to brush their teeth independently when sitting up, observations indicated that their hygiene products were not within reach and showed no signs of recent use. Staff interviews confirmed that oral care was not consistently offered or provided, contradicting the care plan's directives. This deficiency was noted as a repeat issue from the previous year, indicating ongoing non-compliance with care standards.
Infection Control Deficiencies in Catheter Care
Penalty
Summary
Facility staff failed to adhere to proper infection control practices during catheter care for two residents. Resident 222, who was admitted with Parkinson's disease, urinary retention, and a history of falls, was observed having their catheter bag emptied by a nursing technician without the spout being cleansed before or after the procedure. Additionally, the staff member did not perform hand hygiene between changing gloves. This oversight was acknowledged by the staff member, who admitted that an alcohol wipe should have been used to cleanse the spout. Resident 43, who has a long-term urinary catheter due to neurogenic bladder, was observed multiple times with their catheter tubing unsecured and dragging on the ground. This occurred both outside the facility and within the facility, as the resident self-propelled in their wheelchair. The care plan for Resident 43 included an intervention to secure the catheter to prevent kinking and accidental removal, but this was not followed, leading to the tubing dragging on various surfaces, which poses a risk for infection.
Failure to Resolve Resident Grievance on Missing Personal Property
Penalty
Summary
The facility failed to resolve grievances related to missing personal property for a resident who was cognitively intact and had been admitted to the facility. The resident's inventory of personal effects included items such as a belt, cash, a hat, a necklace, a suitcase, shoes, and a knee brace. After being admitted to the hospital, the resident reported missing property, including cash and other personal items, to the State Hot Line. Despite the resident's attempts to retrieve their belongings, the facility did not log any grievances regarding the missing items in their grievance logs for May, June, and early July. Interviews with facility staff revealed a lack of communication and follow-up regarding the resident's missing items. The Interim Director of Nursing Services and Social Services Staff were aware of the situation but had not resolved it. The Business Office Manager indicated that a grievance form would not be completed if the resident had discharged. Eventually, the Director of Admissions found the resident's items in the Boiler room, including some of the missing items, but the cash was not mentioned. The facility's failure to address the resident's grievance in a timely manner placed residents at risk for unresolved missing personal property.
Failure to Provide Transfer Discharge Notice and Ombudsman Notification
Penalty
Summary
The facility failed to provide a written transfer discharge notice to a resident who was discharged to a hospital and subsequently refused re-admission to the facility. This deficiency involved a resident who was cognitively intact and had been admitted with multiple medical conditions, including type 2 diabetes, high blood pressure, and complications from a left below-knee amputation. The resident was sent to the hospital following a wound care clinic appointment due to issues with their amputation. Despite the facility's policy requiring written notice of transfer or discharge, the resident did not receive such notice, nor were they informed of their appeal rights. Interviews with facility staff revealed that the decision not to readmit the resident was made by the prior Director of Nursing Services, with input from the admissions department. The resident expressed confusion and distress over the refusal of re-admission, as they had no prior issues with the staff and were forced to relocate to a distant facility, away from their support system. Additionally, the facility failed to notify the Office of the State Long-Term Care Ombudsman about the discharge, further compounding the deficiency. The hospital case worker indicated that the facility cited drug use and disruptive behavior as reasons for the non-readmission, while a nursing supervisor mentioned the resident's demanding nature and medication hoarding as contributing factors.
Failure to Provide Bed Hold Notice
Penalty
Summary
The facility failed to provide a written bed hold notice to a resident or their representative at the time of transfer to a hospital or within 24 hours of the transfer. This deficiency was identified for one of the three residents reviewed for hospitalizations. The facility's policy, dated November 2016, requires that residents or their representatives be informed in writing of their right to a bed hold when transferred to a general acute care hospital. However, a review of the medical records for the resident in question showed no documentation of a bed hold notification being provided. Interviews with facility staff revealed a lack of clarity regarding the responsibility for providing the bed hold notice. The Director of Admissions indicated that nursing staff typically completed the bed hold form and forwarded it to medical records for uploading into the electronic medical record. However, the form was not found in the resident's records. Additionally, a Licensed Practical Nurse/Nurse Supervisor believed that Social Services would handle the bed hold notification after a resident was sent to the hospital. The resident confirmed that they did not receive any information or sign any documents regarding a bed hold.
Failure to Follow Hospice Referral Orders
Penalty
Summary
The facility failed to follow physician orders to obtain a hospice referral for a resident who was experiencing a change in condition. This oversight involved a resident who was admitted with multiple diagnoses, including adult failure to thrive, chronic respiratory failure, thrombocytopenia, a history of cancer, heart disease, depression, and anxiety. A hospice referral was made by an Advanced Registered Nurse Practitioner (ARNP) on 05/28/2024, which was intended to be placed in the Social Services box for further action. However, the referral was not acted upon, leaving the resident without the hospice support they and their spouse had requested. Interviews with facility staff revealed a breakdown in the process of handling hospice referrals. The ARNP, who initiated the referral, was unaware of why the order was not followed, despite having discussed hospice care with the resident and their spouse. The Social Services Manager stated they had not seen the referral in their box and therefore did not proceed with the hospice referral. The Interim Director of Nursing Services confirmed that the facility's process was to pass hospice referrals to social services for implementation but could not explain why this particular referral was not processed. This failure placed the resident at risk of not receiving necessary end-of-life support.
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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.
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Nursing homes near Mount Vernon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of Mount Vernon | 1.4 mi | — | 9 | 0 |
| Life Care Center Of Skagit Valley | 6.6 mi | — | 3 | 0 |
| Josephine Caring Community | 12.4 mi | — | 28 | 0 |
| Soundview Rehabilitation And Health Care Inc | 14.4 mi | — | 32 | 0 |
| Arlington Health And Rehabilitation | 18.3 mi | — | 16 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.