Northwoods Lodge
Inspection history, citations, penalties and survey trends for this long-term care facility in Silverdale, Washington.
- Location
- 2321 Schold Place Northwest, Silverdale, Washington 98383
- CMS Provider Number
- 505484
- Inspections on file
- 24
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Northwoods Lodge during CMS and state inspections, most recent first.
Two residents did not receive PT and OT services as outlined in their care plans due to missed sessions, delayed initiation of therapy, and limited weekend staffing. One resident experienced delays in brace management, and another left the facility against medical advice after filing a grievance about insufficient therapy services. Staff confirmed that absences and limited coverage contributed to the missed treatments.
A resident with severe cognitive impairment and high risk for pressure ulcers developed avoidable full-thickness wounds due to the facility's failure to implement adequate preventive measures and timely treatment. Despite initial assessments indicating high risk, the care plan lacked necessary interventions, and documentation was inconsistent, leading to hospitalization and surgical intervention.
The facility failed to properly monitor and maintain IV access devices for two residents. One resident with a midline catheter did not have documented measurements or assessments, and another with a PICC line lacked documentation of required measurements. These omissions risked negative health outcomes.
The facility failed to properly assess and document the use of mobility bars for three residents, leading to a deficiency in physical restraint use. A resident was unable to use the bars effectively due to limited motion, and the EHR lacked necessary documentation for consent, orders, and assessments. Staff acknowledged the oversight, which placed residents at risk of harm or entrapment.
The facility failed to maintain food safety and sanitation standards, with missing temperature logs, expired and moldy food items, and uncovered food during transportation. Staff interviews revealed a lack of adherence to protocols, placing residents at risk of foodborne illness.
The facility failed to implement proper infection control measures, including TBPs for AGPs, EBPs for residents with wounds or devices, and contact precautions. Additionally, the Legionella Water Management Program was outdated, and sharps containers were not replaced when full, increasing the risk of infection and cross-contamination.
The facility's antibiotic stewardship program failed to maintain accurate documentation for three residents, leading to inappropriate antibiotic use. A resident was prescribed antibiotics without a necessary culture, another had incorrect symptom onset dates and missing culture information, and a third lacked documentation of symptoms and culture results. Staff acknowledged these discrepancies and the failure to meet McGeer's Criteria.
The facility failed to conduct care conferences for several residents, including those who were cognitively intact and those with impairments. Residents and their representatives were not given the opportunity to participate in care planning, leading to a lack of involvement in their long-term care needs.
A resident who was cognitively intact and required assistance with bathing was not provided showers as per their preference, despite being scheduled for them. The facility's inability to accommodate the resident's mobility needs with a Hoyer lift led to the resident receiving bed baths instead. The administrator confirmed that the resident should have received showers if they could be transferred to a shower chair.
The facility failed to provide written transfer/discharge notices to two residents during their hospitalization. One resident, who was cognitively intact, and another who was moderately cognitively impaired, were transferred without documentation of the required notices. Staff members acknowledged the oversight, and the absence of these notices placed the residents and their representatives at risk of not making informed decisions.
The facility failed to provide written bed hold notices during hospital transfers for two residents, one moderately cognitively impaired and the other cognitively intact. Staff interviews confirmed that the bed hold policy was not followed during transfers, and the facility's administrator acknowledged the oversight.
A facility failed to implement a baseline care plan within 48 hours for a newly admitted resident requiring oral suctioning and NPO status. The plan lacked instructions for AGP precautions and oral care, which were acknowledged as necessary by the Resident Care Manager.
A facility failed to implement a comprehensive care plan for a resident with decreased upper extremity function and moderate cognitive impairment. The care plan lacked specific guidance on meal assistance, leading to the resident being unable to open food items and consume meals. Staff confirmed the care plan did not address the resident's cubital tunnel syndrome, affecting hand function, which was noted in hospital records.
A facility failed to re-assess and revise the care plan for a resident with fractures and diabetes, leading to inadequate skin care and bathing services. The care plan lacked specific instructions for interventions, and observations showed non-compliance with care directives. Additionally, the resident's urinary tract infection was not treated with antibiotics as required. Staff interviews revealed inconsistencies in understanding the resident's care needs, placing the resident at risk for skin impairment and diminished quality of life.
The facility failed to meet professional standards of practice for four residents. A resident refused multiple doses of a prescribed laxative without provider notification. Another resident received morphine sulfate outside the ordered pain parameters. A third resident's midline catheter lacked proper maintenance documentation. Lastly, a resident's partial albuterol dose was incorrectly documented as a full dose, and the provider was not notified.
The facility failed to implement both pharmacological and non-pharmacological interventions for bowel management for two residents, leading to a deficiency in care. One resident experienced chronic constipation due to long-term opioid use, with improper medication administration and lack of non-pharmacological interventions. Another resident had orders for PRN medications but experienced multiple days without bowel movements, with no interventions documented or administered.
A facility failed to follow safety precautions for enteral feeding for a resident with Inclusion Body Myositis and dysphagia. The resident reported increased GI upset and reflux due to inconsistent checks of enteral tube placement and gastric residuals by nurses. An RN was observed not performing these checks before administering a bolus feed, contrary to facility policy and the resident's care plan.
The facility failed to obtain physician orders for respiratory care for two residents, leading to potential risks. A resident using oxygen therapy had no documented physician's order, and another resident with a CPAP machine had no specific settings known by staff. The administrator acknowledged the oversight in obtaining necessary orders.
A resident with a preference against beef continued to receive beef meals despite multiple requests for substitutions. The facility's dietary staff acknowledged the oversight, as the resident's preferences were not properly updated in the kitchen records, leading to meal dissatisfaction.
A resident with severe cognitive impairment and a history of falls suffered a hip fracture due to inadequate supervision and inconsistent implementation of safety measures. Staffing shortages and a room change further contributed to the incident. Another resident was found outside the facility, highlighting a lack of proper monitoring and documentation.
The facility failed to thoroughly investigate allegations of abuse, neglect, and accident hazards for several residents, leading to deficiencies in care. A resident with severe cognitive impairment experienced a fall due to inadequate supervision and environmental hazards. Another resident was found in the parking lot, indicating a lapse in supervision, while a third resident reported rough treatment by male CNAs without proper investigation. A fourth resident's fall was not thoroughly investigated to determine the root cause.
The facility did not ensure timely treatment and care for residents with a history of falls and cognitive impairment. Following an unwitnessed fall, one resident experienced a significant change in cognition and status, showing signs of confusion, pain, and decreased oral intake. There was a delay in provider notification and inadequate neurological assessments, leading to an emergency hospital transfer with multiple fractures and severe sepsis. Similarly, two other residents at risk for falls did not receive consistent neurological assessments post-fall, with delays and incomplete documentation. Staff interviews revealed discrepancies in neuro check completion and communication with providers, despite existing facility policies.
Failure to Provide Scheduled PT and OT Services per Care Plan
Penalty
Summary
The facility failed to provide specialized rehabilitative services, specifically Physical Therapy (PT) and Occupational Therapy (OT), as outlined in the care plans for two residents. One resident, admitted with fractures to the left humerus and hip, was scheduled to receive OT five times per week but only received four sessions over eight days. This resident also experienced delays in having a hinged elbow brace removed due to lack of available therapists, despite a physician's order allowing for its removal during the day. Nursing staff did not remove the brace, stating they were not comfortable doing so without therapy staff present, even though the Rehabilitation Director later confirmed they could have performed the task. Another resident, admitted with hypercalcemia and functional decline, was to receive PT six times per week but only received five sessions over eleven days, with services starting three days after admission. This resident reported dissatisfaction with the lack of therapy services, submitted a grievance, and ultimately discharged against medical advice. Staff interviews confirmed that therapy sessions were missed due to staff callouts and limited weekend coverage, impacting the delivery of care as planned.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to implement adequate measures to prevent the development of avoidable pressure ulcers and to properly assess, monitor, and obtain timely treatment orders for a resident. The resident, who was admitted with conditions including blastocystitis, weakness, and polyneuropathy, was severely cognitively impaired and required extensive assistance for positioning and transfers. Initial assessments noted redness on the buttocks, but there was no documentation on whether the redness was blanchable, and the care plan lacked identified skin impairment risks or interventions. Despite a high-risk Braden score, the facility's documentation and interventions were insufficient. Nursing progress notes initially recorded redness and an open area on the resident's buttocks, but subsequent notes failed to consistently document skin-related concerns. By the time the resident was transferred to the hospital, they had developed multiple full-thickness wounds, including pressure injuries that required surgical intervention and intravenous antibiotics. The facility's failure to document detailed descriptions, staging, or measurements of the resident's wounds in the Electronic Health Record (EHR) contributed to the deficiency. Additionally, the care plan did not include necessary interventions such as pressure-reducing devices or a turning and repositioning program, which were crucial given the resident's high risk for pressure ulcers. The lack of consistent monitoring and appropriate interventions led to the resident's hospitalization and surgical treatment for pressure ulcers.
Failure to Monitor and Maintain IV Access Devices
Penalty
Summary
The facility failed to ensure proper monitoring and maintenance of intravenous (IV) access devices for two residents receiving IV therapy. For Resident 33, who was admitted with a midline catheter for IV antibiotic therapy, the facility did not document the required measurements and assessments. Specifically, there were no records of the midline external length or upper arm circumference being measured upon insertion or during weekly dressing changes. Additionally, the facility did not change the needleless injection caps weekly or assess the midline insertion site as required. Similarly, for Resident 103, who had a PICC line for IV medication, the facility did not document the arm circumference or external catheter length upon admission or during the resident's stay. Although staff signed off on changing the PICC dressing and performing measurements, there was no place provided to record these measurements, and they were not documented in the electronic health record. These omissions placed both residents at risk for potential negative health outcomes.
Deficiency in Assessment and Documentation for Mobility Bars
Penalty
Summary
The facility failed to ensure proper assessment and documentation for the use of mobility bars for three residents, leading to a deficiency in the use of physical restraints. Resident 103, who was cognitively intact, was observed with bed mobility bars but was unable to effectively use them due to limited motion. The facility's Electronic Health Record (EHR) lacked documentation for consent, orders, risk and benefits assessments, or care plan information for the mobility bars. Staff Z, the Rehabilitation Director, acknowledged that the necessary assessments and consents were not completed at the time of installation, and no assessment was provided to document Resident 103's ability to use the bedrails. Similarly, Residents 8 and 33 were observed using mobility bars without proper documentation in their EHRs, including orders, care plans, assessments, or consents. Staff C, the Case Manager, confirmed the absence of these documents and acknowledged the need for assessments by the therapy department. The facility's administrator, Staff A, also recognized the lack of necessary documentation and assessments, which did not meet the facility's expectations. This oversight placed residents at risk of accidents, harm, or entrapment related to the use of mobility bars.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards in food storage, preparation, and service, which placed residents at risk of foodborne illness and unsanitary conditions. Observations revealed missing entries in the food storage and dishwasher temperature logs, indicating a lack of consistent monitoring. Expired food items, such as Worcestershire sauce and cooking wine, were found in the kitchen, and a moldy container of tartar sauce was observed in the walk-in refrigerator. Additionally, uncovered foods were transported to residents' rooms and dining areas, increasing the risk of contamination. Staff interviews highlighted a lack of awareness and adherence to proper food safety protocols. The Dietary Manager acknowledged the missing log entries and the presence of expired and moldy food items, admitting that these should have been addressed. Furthermore, the Dietary Manager admitted to not covering certain food items during transportation, which could lead to contamination. An incident involving a dietary aide using a non-sanitized pen after it was dropped on the floor further demonstrated lapses in maintaining sanitary conditions.
Inadequate Infection Control and Water Management Practices
Penalty
Summary
The facility failed to consistently implement transmission-based precautions (TBPs) for residents undergoing aerosol-generating procedures (AGPs). For Resident 105, who was on continuous AGP for suctioning, there was no indication on the AGP sign outside the room about the start or end of the procedure. Staff members entered the room without appropriate protective equipment, such as N-95 masks and eye protection. Similarly, for Resident 40, the AGP sign lacked necessary information, and staff entered the room without proper protective gear, unaware of the CPAP usage. Resident 33, who used a CPAP machine overnight, also had no AGP signage outside their room, leading to staff being uninformed about the precautions needed. The facility also failed to implement Enhanced Barrier Precautions (EBPs) for residents with wounds or indwelling medical devices. Resident 17, who had a leg wound, did not have EBP signage outside their room, and staff performed wound care without wearing gowns or practicing proper hand hygiene. Resident 33, who had a urinary catheter, IV, and drain, also lacked EBP signage, resulting in staff not wearing gowns during care. This lack of signage and protective measures increased the risk of cross-contamination and infection. Additionally, the facility's Legionella Water Management Program (LWMP) was outdated and did not meet current industry standards. The program lacked a comprehensive team, and the facility did not actively identify or manage hazardous conditions for Legionella growth. The LWMP diagram was incomplete, and there was no process for monitoring empty rooms or flushing faucets. Furthermore, sharps containers in several rooms were observed to be full, posing a risk of injury and infection. Staff failed to address the full containers promptly, despite being notified of the issue.
Inaccurate Antibiotic Stewardship Program Documentation
Penalty
Summary
The facility failed to maintain an accurate and complete antibiotic line listing as part of its antibiotic stewardship program, affecting three residents. For Resident 30, the facility prescribed Macrobid for a urinary tract infection without obtaining a necessary urine culture to confirm the presence of an organism susceptible to the antibiotic. The antibiotic line listing inaccurately recorded symptoms and culture dates, and the symptoms listed were inconsistent with the resident's condition, as they had a urinary catheter in place. Staff A admitted that the McGeer's Criteria were not met, and the provider was not notified of this discrepancy. Resident 354's antibiotic line listing contained errors, including incorrect symptom onset dates and missing culture information. The resident was prescribed antibiotics without documented symptoms or culture results to justify the treatment. Staff A acknowledged that the resident did not meet McGeer's Criteria and that the line listing should have included symptoms related to pneumonia, which were absent. For Resident 355, the antibiotic line listing lacked documentation of symptoms, culture results, and stop dates for the antibiotics. The resident was on antibiotics until discharge, but this information was not updated in the line listing. Staff A confirmed that without a culture, it was impossible to determine the organism's susceptibility to the antibiotic, and there was no documentation of a conversation with the provider when McGeer's Criteria were not met.
Failure to Conduct Care Conferences for Residents
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were offered the opportunity to participate in care conferences, which is a critical component of person-centered care planning. This deficiency was identified for five out of six sampled residents. Resident 21, who was cognitively intact, reported not having a care conference since admission, and the facility's records confirmed this absence. Similarly, Resident 156, who was moderately cognitively impaired, had a care conference scheduled but it was canceled without documentation of the rationale. Resident 154, also cognitively intact, was not contacted to set up a care conference despite expressing interest in discharge planning. Resident 40, with moderate cognitive impairment, requested a care conference, but it was not scheduled. Resident 25, who was severely cognitively impaired, had a representative who had to reach out to the case worker to understand the discharge plan, as no care conference had been held. The facility's administrator acknowledged these oversights, indicating that the lack of care conferences did not meet the facility's expectations. These failures placed residents at risk of a diminished quality of life by not involving them in their long-term care planning.
Failure to Honor Resident's Bathing Preferences
Penalty
Summary
The facility failed to honor the bathing preferences of a resident, identified as Resident 103, who was cognitively intact and required assistance with bathing and transfer. Despite being scheduled to receive showers on specific days, Resident 103 was given bed baths instead. The resident expressed a desire for showers but was informed that due to mobility issues and the inability of the Hoyer lift to fit in the shower room, they could only receive bed baths. Staff D, the Resident Care Manager, explained that residents who required a Hoyer lift and could not transfer would receive bed baths. However, the facility's administrator, Staff A, stated that residents should receive showers if they could be transferred to a shower chair, aligning with their preferences. The discrepancy between the resident's preference and the facility's actions led to the deficiency, as the expectation was for Resident 103 to receive showers as per their preference.
Failure to Provide Transfer/Discharge Notices for Hospitalized Residents
Penalty
Summary
The facility failed to provide a written transfer/discharge notice to two residents, identified as Residents 30 and 40, during their hospitalization. Resident 30, who was cognitively intact, was transferred to the hospital without documentation of a transfer/discharge notice being offered or provided. Staff E, the Admissions Coordinator, acknowledged that the notice should have been sent with the resident at the time of transfer, but was unable to confirm if it was done. Staff A, the Administrator, confirmed that the notice should have been completed in the electronic health record system, Point Click Care, but found no evidence of its completion. Similarly, Resident 40, who was moderately cognitively impaired, was transferred to the hospital without documentation of a transfer/discharge notice. Staff G, the Resident Care Manager, was unsure if the notice was reviewed with the resident or their representative, and Staff E confirmed the absence of a transfer notice. Staff A also did not find any documentation of the notice being completed. This lack of documentation and communication placed the residents and their representatives at risk of not being able to make informed decisions about the transfers.
Failure to Provide Bed Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide written bed hold notices at the time of transfer to the hospital for two residents, which is a requirement under WAC 388-97-0120 (4). Resident 40, who was moderately cognitively impaired, was transferred to the hospital and returned without any documentation in the Electronic Health Record (EHR) indicating that a bed hold notice was offered or provided. Staff interviews revealed that the bed hold policy was only addressed upon admission and not during hospital transfers, which was acknowledged as a mistake by the facility's administrator. Similarly, Resident 30, who was cognitively intact, was also transferred to the hospital and returned without a bed hold notice being documented in their EHR. The Admissions Coordinator confirmed that a bed hold notice should have been sent with the resident at the time of transfer, but it was not found. The facility's administrator confirmed that the bed hold notices should be offered during hospital transfers and acknowledged the oversight in both cases.
Failure to Implement Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for Resident 105, who was reviewed for new admission. This deficiency involved the omission of critical care instructions for the resident, who was admitted with orders for oral suctioning, an aerosol-generating procedure (AGP), and an NPO (nothing by mouth) status. The baseline care plan did not identify the need for suctioning or AGP precautions, nor did it address the resident's NPO status. Additionally, there were no instructions provided to staff on how to perform oral care for the resident given their NPO status, such as using moistened toothettes or specifying who should provide the care. Staff D, the Resident Care Manager, acknowledged that these elements should have been included in the baseline care plan.
Failure to Implement Comprehensive Care Plan for Resident with Self-Care Deficits
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan for Resident 13, who was admitted with decreased function in the upper extremities and moderate cognitive impairment. The care plan, dated 12/17/2024, identified self-care deficits and a potential nutritional risk but did not provide specific guidance on the level of assistance required during meals. This lack of detailed instructions led to Resident 13 being unable to open a protein drink and a cocoa packet during breakfast and being unable to cut a chicken breast during lunch, resulting in the resident not consuming the meals. Observations on 01/08/2025 revealed that Resident 13 struggled with meal consumption due to their inability to open food items and the call light being out of reach. Staff V, a CNA, confirmed that the task list, which is based on the care plan, did not specify the assistance needed for meals. Additionally, Staff C acknowledged that Resident 13's history of cubital tunnel syndrome, which affects hand function, was noted in hospital discharge records but was not addressed in the care plan. This oversight placed the resident at risk for decreased intake and a diminished quality of life.
Failure to Re-assess and Revise Care Plan for Resident
Penalty
Summary
The facility failed to re-assess and revise the care plan for a resident, identified as Resident 23, who was admitted with fractures of the left shoulder and hip, and type 2 diabetes with neuropathy. The care plan, dated 12/04/2024, indicated a risk for skin impairment due to surgical incision, left shoulder sling, and immobility, with interventions such as floating bilateral heels and using an arm sling. However, there were no specific directions for the ON/OFF schedule of the sling, and assistive devices were not included in the care plan. Observations revealed that the resident's heels were not floated, and foam boots were not in place, despite being signed off in the Treatment Administration Record. Additionally, the care plan did not include the foam boots, and the resident reported discomfort from their use. The care plan also failed to address the resident's urinary tract infection adequately, as no antibiotics were being administered despite the condition being noted. Furthermore, the resident expressed a desire for showers but only received bed baths, contrary to the care plan's instructions for bathing services. Staff interviews revealed confusion about the resident's bathing capabilities, with discrepancies between the care plan and staff understanding. These failures in care planning and execution placed the resident at risk for skin impairment, delayed care services, and diminished quality of life.
Failure to Meet Professional Standards of Practice
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice for four residents. Resident 105, who was admitted with severe hypoglycemia, fecal impaction, and as a Clostridium difficile carrier, refused polyethylene glycol doses multiple times over a 12-day period. Despite this pattern of refusal, there was no documentation indicating that the provider was notified, which was confirmed by the Resident Care Manager. Resident 304 had a physician's order for morphine sulfate extended release to be administered for pain levels of 6-10, but the medication was administered six times for pain levels below the ordered parameters, including a pain level of 0 on one occasion. Resident 33 received intravenous ertapenem via a midline catheter for 28 days, but there were no orders or documentation for essential midline maintenance and monitoring tasks, such as measuring the external length and upper arm circumference, changing injection caps, assessing the insertion site, or flushing the midline. Resident 49 had an order for albuterol nebulization as needed for a cough, but during an observation, the resident requested to stop the treatment early. The nurse documented a full dose instead of the partial dose given and failed to notify the provider, which was acknowledged as not meeting expectations by the Administrator/Director of Nursing Services.
Failure in Bowel Management for Two Residents
Penalty
Summary
The facility failed to implement both pharmacological and non-pharmacological interventions for bowel management for two residents, leading to a deficiency in care. Resident 45, who was admitted with a diagnosis of a wedge compression fracture and required pain medication, experienced chronic constipation due to long-term opioid use. Despite having orders for docusate sodium and senna, the resident's bowel elimination record showed multiple days without bowel movements, and both medications were improperly administered on the same day. Additionally, PRN medications were not ordered until several weeks after admission, and no non-pharmacological interventions were documented or implemented in the care plan. Similarly, Resident 8, who was cognitively intact and able to communicate needs, had orders for PRN medications including MiraLax, bisacodyl suppository, and mineral oil enema for bowel management. However, the resident's bowel record indicated several instances of three consecutive days without bowel movements, and no PRN medications were administered during these periods. Staff interviews confirmed the lack of pharmacological and non-pharmacological interventions, and the facility's expectations for bowel management were not met, as documented interventions were absent.
Failure to Follow Enteral Feeding Safety Precautions
Penalty
Summary
The facility failed to ensure safety precautions were followed prior to administering enteral nutrition for Resident 105, who was reviewed for enteral nutrition. The facility's policy required licensed staff to check enteral tube placement and gastric residuals before each feeding and medication administration. However, it was observed that these checks were not consistently performed, placing the resident at risk for adverse outcomes such as increased abdominal distention, reflux, and aspiration. Resident 105, who was cognitively intact and had a diagnosis of Inclusion Body Myositis and dysphagia, required enteral feeding to meet nutritional needs. The resident reported experiencing increased gastrointestinal upset and reflux since admission, which they attributed to the inconsistent checks of their enteral tube placement and gastric residuals by facility nurses. During an observation of Resident 105's bolus feeding, a registered nurse did not check the enteral tube placement or the resident's gastric residual prior to administering the bolus feed or flushes, as ordered. This was confirmed by the Resident Care Manager, who acknowledged that the checks should have been performed. The resident's enteral orders specified the administration of Jevity 1.5 and Osmolyte 1.5 via enteral tube at specific times, with instructions to check residuals and tube placement before feeding and medication administration. Despite these orders, the failure to adhere to the facility's policy and the resident's care plan led to the deficiency identified in the report.
Failure to Obtain Physician Orders for Respiratory Care
Penalty
Summary
The facility failed to obtain physician orders for the use of a continuous positive airway pressure (CPAP) machine and oxygen therapy for two residents, leading to potential risks for unmet care needs and respiratory complications. Resident 21, who was cognitively intact, was observed using a nasal cannula with an oxygen concentrator set at 2.5 liters per minute, yet there was no physician's order documented in the Electronic Health Record (EHR) for this oxygen therapy. Staff members confirmed that an order was necessary for administering oxygen, but none was found for Resident 21. Resident 40, diagnosed with Obstructive Sleep Apnea and moderately cognitively impaired, had a CPAP machine at their bedside. Although an order was placed for the CPAP machine to be used at night and during naps, the specific settings were not known by the staff because the machine was rented and preset. The facility administrator acknowledged that an order for the CPAP settings should have been placed upon admission, but it was only recently added.
Failure to Accommodate Resident Dietary Preferences
Penalty
Summary
The facility failed to provide food that accommodated the preferences and allergies of Resident 30, who was cognitively intact and had been admitted to the facility. Despite the dietitian visiting Resident 30 multiple times to document their food preferences, including a request to substitute beef with fish due to a preference against beef, the resident continued to receive meals containing beef. This was confirmed through observations and interviews, where Resident 30 expressed dissatisfaction with the meals and reported receiving beef stew and meatballs made with beef, despite their stated preferences. The dietary staff, including the Dietary Manager and Dietitian, acknowledged the oversight in not updating Resident 30's dietary preferences in the kitchen records. The Dietitian confirmed that Resident 30 had previously complained about receiving beef and should not have been served beef items. The Dietary Manager provided dietary change slips that documented Resident 30's request to replace beef with fish, yet the resident still received beef meals, indicating a failure in the communication and implementation of dietary preferences within the facility.
Inadequate Supervision and Documentation Lead to Resident Falls
Penalty
Summary
The facility failed to provide the necessary level of supervision to prevent avoidable accidents for residents, particularly for one resident who experienced a fall resulting in a hip fracture. This resident, who had severe cognitive impairment and a history of falls, was not consistently monitored as required by their care plan. The care plan specified one-to-one supervision and the use of a sensor alarm, but these interventions were not consistently implemented. On the night of the fall, staffing shortages led to inadequate supervision, and the resident's sensor alarm was not in place. The resident had been moved to a room further from the nurses' station, which reduced the ability for frequent visual checks. This move, combined with the lack of consistent one-to-one supervision, contributed to the resident's fall. The facility did not have a standard form for assessing fall risk or documenting interventions, leading to inconsistent implementation of safety measures. The staff on duty were not able to provide the required supervision due to being assigned multiple residents, including others who also required one-to-one supervision. Additionally, the facility failed to document the supervision provided to another resident who was found outside the facility, indicating a lack of proper monitoring and documentation. The facility's failure to document and implement the necessary supervision interventions placed residents at risk for injury and diminished quality of life. The lack of a comprehensive assessment and consistent intervention implementation highlights the deficiencies in the facility's approach to fall prevention and resident safety.
Inadequate Investigation of Abuse and Neglect Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse, neglect, and accident hazards for several residents, leading to deficiencies in care. Resident 1, who had severe cognitive impairment and was at risk for falls, experienced a fall due to the absence of a one-to-one sitter, a wet floor, and a recent room change. The investigation did not fully evaluate these contributing factors or obtain statements from all potential witnesses, including the staff responsible for the missing bed alarm. Resident 2, with moderate cognitive impairment, was found in the facility parking lot, indicating a lapse in supervision. Despite the incident, the facility could not provide documentation of a thorough investigation. Similarly, Resident 3, who had no cognitive impairment, reported rough treatment by male CNAs, but the investigation failed to identify the staff involved or update the resident's care plan to reflect their request for no male agency staff. Resident 4, with moderate cognitive impairment, reported a fall in the bathroom, resulting in pain and bruising. The investigation did not include interviews or a summary to determine the root cause of the fall. In all cases, the facility's investigations were incomplete, lacking thorough evaluations and necessary documentation, which compromised resident safety and care quality.
Deficiency in Timely Treatment and Care Post-Fall
Penalty
Summary
The facility failed to ensure residents received timely treatment and care in accordance with professional standards of practice, leading to a deficiency in care. In the case of Resident 1, who had a history of falls and cognitive impairment, the facility did not promptly address a significant change in cognition and status following an unwitnessed fall. Despite documented signs of confusion, pain, and decreased oral intake, there was a lack of timely provider notification and inadequate neurological assessments. This failure resulted in Resident 1 being emergently transferred to the hospital with multiple fractures and severe sepsis, indicating a lapse in monitoring and response to changes in condition. Similarly, for Resident 2 and Resident 3, both at risk for falls and cognitively impaired, the facility did not consistently perform neurological assessments following unwitnessed falls. Neuro checks were delayed, not completed at recommended intervals, and lacked proper documentation. Resident 2 reported a fall hours after it occurred, with delayed initiation of neuro checks, while Resident 3 had a significant delay of over 14 hours before neuro checks were initiated post-fall. These deficiencies in timely assessment and monitoring post-falls put residents at risk for undetected injuries, complications, and compromised quality of care. Staff interviews revealed discrepancies in the completion and documentation of neuro checks, with staff acknowledging lapses in assessment and communication with providers. Despite facility policies outlining the frequency and protocol for neurological assessments post-falls, there was a failure to consistently adhere to these guidelines, leading to gaps in care delivery and missed opportunities for early intervention. The lack of thorough and timely assessments following changes in residents' conditions highlights systemic issues in monitoring and responding to residents' needs effectively.
Latest citations in Washington
Inaccurate PASARR screening affected two residents. One resident with vascular dementia, depression, and adjustment disorder had a PASARR level one that did not reflect mental health diagnoses, and staff stated it was inaccurate. Another resident with PTSD had a PASARR level one that did not include the PTSD diagnosis, with no additional PASARR level one or level two found in the EHR; staff stated the screening was not accurate and should have been repeated.
Undated open meds were found on 2 medication carts, including an open insulin vial and multiple open eye drop bottles with no dates. An LPN and an RN both stated the items should have been dated when opened, and the DON stated open multidose vials or bottles found without a date should be discarded immediately.
A resident with respiratory failure, HTN, and anxiety became SOB and diaphoretic, received a breathing tx, and was sent by EMS to the hospital. The facility could not locate the required SNF/NF to Hospital Transfer form or other transfer records showing what information was communicated to the receiving provider.
Care plans for two residents were not updated to match their current status and care needs. One resident had PTSD and generalized anxiety disorder and was receiving a psychotropic medication, but the care plan listed monitoring for antipsychotic and anticonvulsant meds that were not prescribed and did not include the anxiety diagnosis or related behaviors and interventions. Another resident had new upper and lower dentures, but the oral/dental care plan only noted edentulous status and difficulty chewing, with no mention of dentures or denture-related interventions.
Failure to Provide Individualized Activities: A resident with anxiety, depression, and weakness was cognitively intact but said they could not attend group activities because of leg problems and wanted more in-room activities. The resident mostly stayed in bed watching TV, and staff documentation showed only limited room visits with no consistent activity documentation despite a care plan goal for participation two to three times per week.
Failure to maintain heel offloading for a resident with a reopened DFU. A resident with dementia and dependence for mobility had a left heel wound that had healed and then reopened; the wound care provider recommended heel floating and pressure relieving boots at all times, but observations showed the resident in bed with heels on the mattress and later reclined in a wheelchair with the heel resting on the footrest strap and no boots in place. Staff stated the resident had not refused the boots or heel floating, and the care plan was not updated after the wound reopened.
Failure to Address Hearing and Vision Services for a Resident: A resident with dementia, bilateral hearing loss, and impaired vision was observed without eyeglasses or a hearing device, despite records showing admission with eyeglasses and a personal sound amplifier. The care plan addressed vision only and did not include hearing-related interventions, while staff interviews confirmed the resident’s hearing was strained and that the resident’s device use and vision needs were not fully reflected in the plan of care.
Respiratory care was not provided consistently for two residents receiving O2. One resident with COPD and chronic respiratory failure had an O2 order missing the indication for use and Sats parameters, no MAR documentation of O2 therapy, and inconsistent Sats charting. Another resident with respiratory failure was observed on continuous O2 via NC, but provider orders for O2 therapy and tubing changes were not present after readmission, despite the care plan stating the resident was dependent on O2.
A resident with dementia, hearing loss, and missing lower teeth had an MDS showing obvious or likely cavities or broken natural teeth, and the care plan identified oral/dental health problems with an intervention to coordinate dental care and transportation. Staff stated the resident’s dental needs were captured on the MDS, but no referral was made for dental services or follow-up with the dentist, and the DON said the lack of referral did not meet expectations.
Inaccurate Meal Intake Documentation: A resident with DM, dysphagia, and protein-calorie malnutrition was observed eating less than 25% of a meal, but the POC documented 76-100% intake. The CNA said the resident usually ate only 25-50% of meals and that intake was sometimes documented based on what a coworker reported. The LPN/RCM and DON stated meal intake should be documented accurately.
Inaccurate PASARR Screening for Two Residents
Penalty
Summary
The facility failed to ensure that two residents were screened for additional mental health supports through the PASARR process. Resident 97 was admitted with diagnoses including vascular dementia, depression, and adjustment disorder, and was able to make needs known. Review of the PASARR level one dated 04/10/2026 showed no mental health diagnoses and no need for a PASARR level two, even though the resident’s record included mental health diagnoses. During interview, the Regional Social Services staff and the Administrator stated the PASARR was inaccurate, needed modifications, and did not meet expectations. Resident 6 was admitted with diagnoses including heart failure, respiratory failure, and PTSD, and was able to make needs known. Review of the PASARR level one dated 03/30/2026 showed no serious mental illness indicators marked and no PASARR level two indicated, and the EHR contained no other documented PASARR level one or level two. The Social Services Director stated the hospital-provided PASARR was reviewed for accuracy and, if inaccurate, another level one would be completed, and stated this resident’s PASARR did not include PTSD and should have had another level one completed. The Administrator also stated the PASARR was not accurate and another level one needed to be conducted, but none could be located in the EHR.
Undated Open Medications on Medication Carts
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications for 2 of 3 sampled medication carts reviewed for medication storage and labeling, including carts on the 400 and 500 halls. On the 500 hall medication cart, an open vial of insulin and an open bottle of eye drops were observed with no dates. During interview, an LPN stated that when an insulin vial or bottle of eye drops is opened, it should be dated immediately and said both items should have been dated upon opening; the LPN stated they would dispose of the undated vial and bottle. On the 400 hall medication cart, two open bottles of eye drops were observed with no dates. During interview, an RN stated both bottles should have been dated as soon as they were opened and said they would get new eye drops and dispose of the undated bottles. The DNS/RN stated that if an eye drop was opened it should have been dated immediately and that any open multidose vial or bottle found without a date should be discarded immediately.
Missing Hospital Transfer Documentation
Penalty
Summary
The facility failed to ensure hospital transfer documentation was completed for one resident who was transferred to the hospital after complaining of not being able to breathe and appearing diaphoretic. The resident had diagnoses of respiratory failure, high blood pressure, and anxiety disorder, and was able to make needs known. A breathing treatment was provided, and the provider agreed to send the resident out for further evaluation, after which emergency transportation took the resident to the hospital. Record review found no documentation showing what information was provided or communicated to the receiving facility for the transfer. Staff stated that transfer documentation should have included a SNF/NF to Hospital Transfer form, the resident's face sheet, and the medication and treatment administration records, but they were unable to locate documentation showing these items were completed or sent for the resident's hospital transfer.
Care plans did not reflect current diagnoses, medications, or denture status
Penalty
Summary
The facility failed to ensure that care plans were revised and accurately reflected residents’ current status and care needs for 2 of 21 sampled residents. Resident 6 was admitted with diagnoses including heart failure, respiratory failure, and PTSD, and was able to make needs known. The EHR showed Resident 6 also had generalized anxiety disorder and was receiving a psychotropic medication, but the current care plan dated 05/05/2026 documented monitoring for side effects of antipsychotic and anticonvulsant medications even though Resident 6 was not prescribed those medications. The care plan also identified PTSD but did not include generalized anxiety disorder or behaviors to monitor and interventions related to PTSD or anxiety disorder. Staff F, LPN/CC, stated the care plan did not accurately reflect the resident’s current status or prescribed medications, and Staff B, DNS, stated it did not meet expectations because it did not address the anxiety disorder or target behaviors and interventions. Resident 71 was admitted with diagnoses including PTSD, high blood pressure, and depression and was able to make needs known. Observation on 05/06/2026 showed a denture cup by the sink with the resident’s name on the lid and new upper and lower dentures dated 01/12/26. The resident stated the lower dentures did not fit well and that denture adhesive had been provided, but the dentures still did not fit right and the resident had not told staff yet. The focused oral/dental care plan, initiated on 06/23/2026, identified the resident as edentulous and having difficulty chewing, but did not show that the resident had dentures or include interventions related to denture use or maintenance. Staff E, CNA, stated they had not seen the resident wear dentures and were unaware of the new dentures, Staff C, LPN/CC, stated the care plan should have been updated when the dentures were obtained, and Staff B, DNS, stated the care plan should have reflected the dentures and interventions.
Failure to Provide Individualized Activities
Penalty
Summary
The facility failed to provide individualized activities for Resident 5, who was admitted with diagnoses including anxiety disorder, depression, and weakness. The admission MDS dated 01/14/2026 showed the resident was cognitively intact. During interviews on 05/03/2026 and 05/06/2026, Resident 5 stated they could not attend in-person activities because of their legs, wanted more activities to occupy them, mostly stayed in bed watching TV, and did not remember the last time activities staff visited to offer activities. The resident also stated activities staff would need to offer something they were able to do because they had difficulty doing some activities. The activities care plan dated 12/26/2026 showed a goal for Resident 5 to participate in activities two to three times per week. Progress notes documented one visit on 12/22/2026 to provide a welcome packet and encourage participation in daily activities, but no further activity documentation was found in the progress notes. Staff H stated room visits should include puzzles, arts and crafts, visiting, and chatting, and that documentation was placed in tasks, but the task record showed no documentation of activities for the past 30 days. Staff J stated paper documentation existed for room visits and that Resident 5 was on a list for room visits every Monday and Wednesday, while the room visit documentation showed only four visits on 01/26/2026, 02/06/2026, 03/10/2026, and 04/08/2026.
Failure to Maintain Heel Offloading for Reopened DFU
Penalty
Summary
The facility failed to consistently implement pressure reducing strategies for a resident with a left heel diabetic foot ulcer that had reopened. The resident was admitted with diagnoses including left hip fracture with surgical repair, a blood clot of the left lower leg, and dementia, and was dependent on staff for mobility and unable to make needs known. The baseline care plan and care plan both included heel offloading interventions, and the wound care provider initially recommended heel floating with pillows or wedge and pressure relieving boots. The wound later resolved, but a weekly skin assessment documented that the left heel wound reopened and was very painful to touch. After the wound reopened, the contracted wound care provider documented that the DFU to the left heel had reopened and recommended the resident wear pressure relieving boots at all times. The current care plan reviewed after the wound reopened did not include new interventions related to the reopened wound. Observations showed the resident seated in a reclined wheelchair with the left foot/heel resting on the footrest strap and no pressure relieving boots in place, and later lying in bed with both heels directly on the mattress without being floated and without boots. Staff interviews indicated the resident had not refused the boots or heel floating, and the LPN/CC and DON stated the resident should have been assessed and the plan of care updated when the wound reopened.
Failure to Address Resident Hearing and Vision Needs
Penalty
Summary
The facility failed to address one resident’s hearing and vision needs. Resident 112 was admitted with diagnoses including a leg fracture, dementia, and hearing loss in both ears, and was able to make needs known. The record showed the resident lost their glasses and was given readers, but the resident did not wear them because they were concerned that wearing glasses that were not their prescription would further degrade their vision. Observation did not show glasses in the resident’s room, and the resident stated they did not use a hearing aid. The resident was observed to be hard of hearing, requiring an elevated voice and repeated questions to understand. The admission MDS dated [DATE] documented adequate hearing with hearing aid and adequate vision with corrective lenses, while the significant change MDS dated [DATE] documented moderate difficulty hearing without a hearing aid and impaired vision without corrective lenses. The care plan initiated 02/24/2026 addressed impaired vision with interventions to arrange consultation with eye care practitioners as needed and remind the resident to wear glasses, but it did not include a focus area or interventions for hearing loss or use of hearing aids. A resident clothing list showed the resident admitted with one pair of eyeglasses and one Super Ear headset personal sound amplifier, yet observation and interview showed the resident in bed without eyeglasses or a hearing device, with the amplifier stored in the bedside table drawer. Staff interviews confirmed the resident’s hearing was strained, that the hearing device and glasses were not being used, and that the resident’s hearing device use should have been included in the plan of care and the resident should have been referred for eye care assessment.
Respiratory Care Orders and Documentation Not Maintained
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for two residents receiving oxygen therapy. One resident with COPD and chronic respiratory failure with hypoxia was observed multiple times lying in bed receiving oxygen at 2 L via nasal cannula. The resident’s oxygen order, dated 02/15/2026, allowed 1 to 4 L per minute continuously via nasal cannula, but it did not include an indication for use or oxygen saturation parameters. The April and May 2026 MARs did not show documentation of oxygen therapy being provided, and the TARs showed only an order to change oxygen tubing if damaged or visibly soiled, not an order for oxygen therapy. Oxygen saturations were not documented consistently daily from 04/01/2026 through 05/04/2026. A second resident with respiratory failure, high blood pressure, and anxiety disorder was observed in the room receiving oxygen at 6 L via nasal cannula on multiple occasions. The resident stated they needed oxygen therapy to breathe, and the care plan identified the resident as dependent on oxygen and to receive oxygen per provider orders. However, provider orders reviewed on 05/04/2026 showed no orders for oxygen therapy or for changing oxygen tubing. Staff stated the oxygen and tubing-change orders had been discontinued when the resident went to the hospital and were not added back to the MAR or TAR when the resident readmitted to the facility.
Failure to Refer Resident With Identified Dental Needs
Penalty
Summary
The facility failed to ensure that Resident 112 received needed dental care. Resident 112 was admitted with diagnoses including a leg fracture, dementia, and hearing loss in both ears. Observation on 05/03/2026 showed the resident had missing lower teeth. The admission MDS, dated [DATE], documented obvious or likely cavities or broken natural teeth, and the care plan dated 02/24/2026 identified oral/dental health problems related to likely cavities or broken teeth with an intervention to coordinate dental care and provide transportation. During interviews, Staff G, Regional Social Services, stated Resident 112's dental needs were captured on the 02/24/2026 MDS and the resident was not referred for dental services. Staff M, Social Services Director, stated residents with dental needs should be referred to social services to be scheduled for assessment by a dental care practitioner, and that Resident 112 should have been referred after the MDS assessment. Staff B, DON, stated residents with identified dental needs should be referred for follow-up with a dentist and that Resident 112 should have been referred to the in-house dental provider; Staff B stated the lack of referral did not meet expectations.
Inaccurate Meal Intake Documentation
Penalty
Summary
The facility failed to accurately document the amount of food eaten for Resident 13, who was admitted with diagnoses including diabetes mellitus, dysphagia, and protein-calorie malnutrition. The quarterly MDS dated 02/12/2026 showed the resident was moderately cognitively impaired. During observation on 05/05/2026 at 12:09 PM, a meal tray was delivered to the resident’s room, set up on a bedside table, and the resident was observed eating slowly, eating less than 25% of the meal, then laying back in bed and closing their eyes while the tray remained in the room. Staff later removed the tray, but the POC documentation for lunch on 05/05/2026 recorded that Resident 13 ate 76-100% of the meal. During interview, the CNA stated the resident typically ate 25-50% of meals and never ate all of the food, and that if they did not pick up a tray they would ask a coworker what the resident ate before documenting it. The CNA stated they were told the resident ate 75-100% of lunch, so that is what was entered. The LPN/RCM stated staff should document meal intake accurately in POC, and the RN/DNS stated it was their expectation that all staff document meal intake accurately.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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