Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Olympia Transitional Care And Rehabilitation during CMS and state inspections, most recent first.
A resident with dementia, behavioral disturbances, and documented wandering and elopement risk, residing in a secure dementia unit with a wander guard in place, was able to leave the building through a window whose alarm did not sound when opened. The window screen from the resident’s room was later found on the ground outside, and the resident returned by ringing the front entrance doorbell. Facility leadership reported that window alarms were visually checked and that batteries were changed on a periodic basis, but they could not provide documentation of regular functional testing of the window alarms in the secure dementia unit.
A resident with Parkinson’s disease, hyperparathyroidism, and cognitive impairment had an elevated calcium level and provider orders for PTH, vitamin D, and ionized calcium testing. On two separate occasions, ordered PTH and ionized calcium labs were not performed because no specimens were received by the lab, despite facility policy requiring completion and follow-up of ordered tests and tracking of pending or missing results. Later, after additional lab orders including a CMP, the lab reported a critical calcium value, and the resident was transferred to the hospital, where a markedly elevated calcium level and related diagnoses were documented. The Administrator acknowledged that the ordered labs were not obtained and that nursing was responsible for ensuring collection, submission, and receipt of lab results.
The facility did not consistently assess and document non-pressure skin injuries for a resident on antiplatelet therapy, failed to provide bowel care according to physician orders and protocol for three residents, and did not report dental pain for a resident with cognitive impairment. These actions resulted in missed monitoring, delayed interventions, and unaddressed pain.
The facility failed to maintain an effective infection prevention and control program, with incomplete infection surveillance data, lack of action on infection trends, and repeated lapses in staff hand hygiene and use of personal protective equipment during resident care. Laundry processes were also inadequate, leading to cross-contamination, and two residents did not receive COVID vaccinations despite documented consent.
The facility did not ensure complete and accurate documentation or evaluation of antibiotic use for three residents, including missing infection details, lack of timely culture results, and failure to notify providers when prescribed antibiotics were not indicated or when organisms were resistant. The Infection Preventionist confirmed these lapses, which included incomplete logs and missing provider notifications.
A resident's trust account balance was not transferred to the state Office of Financial Recovery within the required timeframe following the resident's discharge due to death. The trust account still held funds several months after discharge, as confirmed by the business office manager.
The facility did not ensure care plans were reviewed and updated to reflect the actual care needs of four residents, including one with a NPO order who was inappropriately directed to receive oral intake, another whose dental and oral care needs were not addressed, a resident with constipation lacking a care plan, and a resident on a diuretic whose care plan failed to document this medication.
The facility did not meet professional standards in several areas, including failure to document and address a resident's skin impairment, inaccurate documentation and provision of oral care for a resident who was NPO, incomplete documentation of treatments for two residents, and failure to administer an influenza vaccine to a resident despite consent and vaccine availability. Staff interviews and record reviews confirmed that required care and documentation were not consistently provided or accurately recorded.
A resident with moderate cognitive impairment, dependent on staff for ADLs, did not receive adequate bathing or oral care. The resident's bathing preferences were not documented, and only one shower was provided over 18 days, with unclear documentation of sponge baths. Oral care was provided only once, despite orders for twice-daily care, and necessary supplies were unavailable. Staff interviews and observations confirmed these deficiencies.
A resident with severe cognitive impairment had a critical lab result that was not reported to the provider for over two days due to a name mismatch in the EHR, resulting in the result being placed in an unmatched category and not seen by staff. The facility's process relied on both lab calls and daily EHR checks, but lacked an alert system for new results, leading to the delay.
A resident with a surgical incision required daily wound care per physician's orders, which was not completed as documented. A nurse admitted to misunderstanding the treatment order, leading to missed dressing changes. The oversight was confirmed by the DON, and the resident was at risk for prolonged wound healing and infection.
The facility failed to provide timely lab services for two residents, risking delayed treatment. One resident had missing lab results due to equipment issues and lack of follow-up, while another had lab results not documented or forwarded as required. The DON acknowledged these lapses, contributing to the deficiency.
A resident with chronic health conditions and severe pain, dependent on staff for bed mobility, fell and broke their leg when a CNA attempted to reposition them alone, contrary to the care plan requiring two-person assistance. Concerns about the bed size and safety were previously raised but not addressed, leading to the incident.
The facility failed to provide timely toileting and bathing assistance for several residents, leading to prolonged discomfort and potential health risks. A resident with PTSD waited over three hours for incontinence care, while another fell attempting to self-transfer due to long wait times. Additionally, residents dependent on staff for bathing were observed with poor hygiene, indicating missed and undocumented showers.
Failure to Monitor and Maintain Functioning Window Alarms in Secure Dementia Unit
Penalty
Summary
The facility failed to ensure that window alarms in a secure dementia unit were adequately monitored and functioning to prevent elopement. A resident with dementia, behavioral disturbances, wandering behaviors, and impaired safety awareness was assessed as cognitively impaired and at high risk for elopement, with a documented history of attempts to leave a previous facility unattended. The resident’s care plan identified elopement risk and wandering, and a wander guard was implemented as an intervention. The resident had a physician’s order to reside in the secured dementia unit. Despite these identified risks and interventions, the resident was able to exit the facility through a window in the secure dementia unit. A progress note documented that the window screen from the resident’s room was found on the ground outside and that the resident had likely exited through the window, walked around the exterior of the building, and then rang the front entrance doorbell to return. The facility’s investigation determined that the resident left the facility unattended through an alarmed window that did not sound when opened, and that the window alarm had malfunctioned. The Administrator and Plant Operations Manager reported that window alarms were visually checked and reportedly tested or had batteries changed approximately quarterly, but they were unable to provide documentation of functional checks for the window alarms in the secure dementia unit.
Failure to Complete Ordered Laboratory Tests for Resident With Hyperparathyroidism
Penalty
Summary
The facility failed to ensure ordered laboratory tests were completed and followed up for a resident with hyperparathyroidism and elevated calcium levels. Facility policy required that laboratory services ordered by a provider be obtained, that results and pending or missing labs be included in shift report, and that pending or missing labs be followed up in daily clinical meetings. The resident, admitted with Parkinson’s disease and hyperparathyroidism and documented cognitive impairment, had a calcium level of 12.2 (normal 8.6–10.2). A provider ordered PTH, vitamin D, and ionized calcium testing, but laboratory results for that date showed PTH and ionized calcium were not performed because no specimen was received. A subsequent provider note documented that PTH and ionized calcium had not been performed and were reordered. A later physician order again directed that PTH and ionized calcium be obtained, but laboratory results again showed these tests were not performed due to no specimen being received. Another order was written for a CBC and CMP, and on that date the lab called the facility with a critical calcium value, after which the resident was transferred to the hospital. Hospital records documented a calcium level of 17 and admission for acute pulmonary embolism, aspiration pneumonia, and hypercalcemia. During interview, the Administrator acknowledged that the resident had provider orders for PTH and ionized calcium on two separate dates, that the lab indicated specimens were not obtained on those dates, and that nursing was responsible for ensuring labs were collected, sent, and results received as ordered.
Failure to Monitor Skin, Provide Bowel Care, and Report Dental Pain
Penalty
Summary
The facility failed to ensure routine assessment and monitoring of non-pressure skin injuries for a resident with moderate cognitive impairment who was on high-risk antiplatelet therapy. Upon admission, staff documented the presence of bruising on multiple body areas but did not provide specific descriptions, measurements, or detailed locations of the bruises. Subsequent weekly skin evaluations noted the presence of a surgical incision and multiple bruises, but again lacked comprehensive documentation regarding the size, color, and evolution of the bruises. A large bruise extending from the abdomen to the back was observed but not properly documented or monitored, and the care plan instructions for daily skin inspection and monitoring for antiplatelet complications were not followed as there was no direction on the MAR or TAR for staff to monitor the bruising. The facility also failed to provide bowel care in accordance with physician orders and facility protocol for three residents. For one resident, there were multiple periods where the resident went several days without a bowel movement and did not receive the prescribed PRN bowel medications, such as Miralax or Dulcolax suppository, as required by the protocol. Another resident experienced similar lapses, with extended periods without a bowel movement and no administration of bowel medications after the required timeframe. A third resident, who was on hospice care, also went several days without a bowel movement, and the prescribed bowel care was not administered or documented, with confusion over medication discontinuation and lack of notification to the power of attorney. Additionally, the facility failed to report dental pain for a resident with severe cognitive impairment and obvious dental issues. The resident was observed to have a missing front tooth and reported pain in that area on multiple occasions. Oral hygiene records showed frequent refusals of care, and a CNA reported that the resident refused oral care due to pain but did not notify a nurse as required. The DON confirmed that such refusals due to pain should have been reported to nursing staff for further action, but this did not occur.
Infection Control Program Deficiencies and Lapses in Standard Precautions
Penalty
Summary
The facility failed to fully implement an effective Infection Prevention and Control Program, as evidenced by incomplete and inaccurate infection surveillance data, lack of ongoing monitoring and analysis, and failure to document or act on identified infection trends. Specifically, infection control line listings for January and February did not match the Infection Control Reports, with missing or incomplete documentation of signs, symptoms, diagnostic testing, and microorganism identification. For example, several urinary tract infections and skin infections were either not listed or lacked supporting clinical data, and no action or staff education was documented in response to a trend of yeast infections among female residents. Staff did not consistently follow standard precautions, enhanced barrier precautions (EBP), or perform proper hand hygiene during resident care. Observations revealed that staff entered rooms and provided care to residents on EBP without donning appropriate personal protective equipment or performing hand hygiene before and after glove use. In one instance, a CNA provided oral care to a resident with a gastrostomy without wearing a gown or gloves and failed to perform hand hygiene. In another, a CNA caring for a resident with a suprapubic catheter repeatedly changed gloves without hand hygiene and misunderstood the requirements of EBP. Additionally, a nurse providing wound care to a resident with multiple wounds changed gloves multiple times without hand hygiene, and no hand sanitizer was available at the bedside. Laundry services were also found to be deficient, with soiled linen being improperly handled and cross-contaminated with clean laundry due to the absence of a separating door and lack of hand hygiene by staff. Environmental surfaces in the laundry area were covered in lint and not properly maintained. Furthermore, the facility failed to administer COVID vaccinations to two residents despite having obtained consent, with no documentation or explanation for the missed vaccinations. These failures were confirmed through staff interviews and direct observation.
Failure to Implement Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, as evidenced by incomplete and inaccurate documentation and evaluation of antibiotic use for three residents. For one resident started on Augmentin for a suspected respiratory infection, the infection control log lacked documentation of the infection type, signs and symptoms, diagnostic results, and whether McGeer's Criteria were met. There was no record of the chest x-ray being obtained or results being communicated to the provider, and the required reassessment and documentation were not completed. The Infection Preventionist confirmed these omissions and that the criteria for antibiotic treatment were not met. Another resident was started on doxycycline for a wound infection, but the documentation did not include the presenting signs and symptoms, the specific microorganisms identified, or their sensitivity to the antibiotic. The most recent wound culture was outdated and showed resistance to doxycycline, yet there was no evidence the provider was notified. A third resident was started on Macrobid for a urinary tract infection, but the organism identified was resistant to the prescribed antibiotic, and again, there was no documentation that the provider was informed. These failures were confirmed by the Infection Preventionist during interviews and record reviews.
Delayed Transfer of Resident Trust Funds After Discharge
Penalty
Summary
The facility failed to transfer the trust account balance of a resident who was on Medicaid and discharged due to death on 12/23/2024. Review of the resident's trust account ledger showed a remaining balance of $106.46 on the date of discharge. As of 04/01/2025, staff confirmed that the trust balance had not yet been conveyed to the state Office of Financial Recovery (OFR) as required. This inaction resulted in a delay in the reconciliation of the resident's trust funds, contrary to regulatory requirements.
Failure to Maintain Accurate and Updated Care Plans for Multiple Residents
Penalty
Summary
The facility failed to ensure that care plans were reviewed, revised, and accurately reflected the care needs of four residents. For one resident with a NPO order due to dysphagia, multiple care plans inappropriately directed staff to offer or encourage oral food and fluid intake, which conflicted with the resident's dietary restrictions. Another resident with significant dental issues and recommendations for twice-daily oral care did not have these needs or recommendations incorporated into their care plans, despite documented dental consults identifying decayed teeth and specific oral hygiene instructions. A third resident, assessed as constipated on the MDS and reporting ongoing constipation, did not have a care plan developed or implemented to address this issue. Additionally, a fourth resident prescribed a diuretic and identified as severely cognitively impaired had a care plan that incorrectly stated the resident was not on a diuretic and lacked any section addressing diuretic use, despite medication records confirming daily administration. These deficiencies were confirmed by staff interviews and record reviews, indicating that the care plans did not accurately reflect the residents' current needs and conditions.
Failure to Meet Professional Standards in Documentation and Care Delivery
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice in several areas, as evidenced by inaccurate or missing documentation and failure to follow physician orders. For one resident with severe cognitive impairment, staff did not accurately document a visible skin impairment on the left ankle, despite observations of redness and scabbing under a wander guard. Skin assessments in the electronic health record repeatedly stated no new skin issues, and staff confirmed the impairment was not documented as required. Another resident, who was dependent on staff for oral care and had orders for twice-daily oral care due to being NPO, reported not receiving oral care as ordered. Staff interviews revealed that oral care was not provided on multiple occasions, and a nurse signed the Medication Administration Record (MAR) for oral care that was not actually completed. The Director of Nursing confirmed that documentation was inaccurate, as the nurse had signed for care not provided. Additionally, two residents had incomplete documentation on their MAR and Treatment Administration Record (TAR) for various treatments, including wound care, catheter care, and application of skin products. Staff could not confirm whether these treatments were completed, and there was no documentation of completion or resident refusal. In another case, a resident who had consented to an influenza vaccination did not receive it, despite the vaccine being available, and the MAR was signed off as "Other/See nurse Notes" with a note stating the vaccine was out of supply, which was later contradicted by the infection preventionist.
Failure to Provide Adequate Bathing and Oral Care for Dependent Resident
Penalty
Summary
The facility failed to provide adequate bathing and oral care for a dependent resident who was admitted with moderate cognitive impairment and required staff assistance for activities of daily living. Upon review, it was found that the resident's bathing preferences were not documented upon admission, and the resident received only one shower in an 18-day period, with staff documenting sponge baths on other days. However, the facility did not have a clear policy defining a sponge bath, and the resident reported that the care provided did not meet their expectations for cleanliness. The resident also reported a strong foul odor and unclean appearance, which was confirmed by observation. Additionally, the resident received oral care only once during the same period, despite physician orders for twice-daily oral care due to NPO status from dysphagia. Staff interviews revealed that oral care supplies were unavailable, and neither CNAs nor RNs consistently provided or documented oral care as required. The resident's room lacked any oral care items, and staff acknowledged that oral care was not consistently provided. These failures were confirmed through record review, staff interviews, and direct observation.
Delayed Notification of Critical Lab Result Due to EHR Matching Error
Penalty
Summary
The facility failed to ensure the timely reporting of a critical laboratory result to the provider for one resident. According to the facility's policy, critical laboratory values are to be reported to the attending physician or provider immediately. In this case, a resident who was severely cognitively impaired had a critical lab value collected and resulted, but the provider was not notified until over two and a half days later. The delay was due to a misspelling of the resident's name, which caused the result to be placed in an unmatched category in the electronic health record (EHR) system, preventing it from being seen promptly by staff. Staff interviews confirmed that the process for handling critical lab results relies on both direct calls from the laboratory and diligent daily checks of the EHR results tab by nursing staff. However, there was no notification system in place to alert staff to new results, and if a call from the laboratory was missed, results could go unnoticed. The Director of Nursing Services acknowledged that the delay in notifying the provider did not meet expectations and was directly related to the unmatched lab result in the EHR.
Failure to Follow Physician's Orders for Wound Care
Penalty
Summary
The facility failed to complete wound care per physician's orders for a resident, identified as Resident 2, who was admitted with diagnoses including diabetes, orthopedic aftercare following surgical amputation, and peripheral vascular disease. The resident had a 21.5-centimeter surgical incision with staples and required specific wound care as per a physician's order dated 08/12/2024. The order specified that the surgical incision on the left knee should be cleaned with wound cleanser, skin prep applied, and covered with a dry dressing daily, along with an ace wrap as needed. However, the electronic treatment administration record (ETAR) indicated that the treatment was not signed as completed on 08/12/2024 and was incorrectly documented as completed on 08/13/2024 and 08/14/2024. A registered nurse, identified as Staff C, admitted to not performing the dressing changes on 08/13/2024 and 08/14/2024, mistakenly believing the order was for monitoring the dressing rather than changing it. This oversight was acknowledged by the Director of Nursing Services, Staff B, who confirmed that the surgical dressing was not changed daily as ordered on the specified dates. The resident was no longer at the facility at the time of the acknowledgment. The failure to adhere to the physician's orders placed the resident at risk for prolonged wound healing and infection, as noted in a provider's note dated 08/14/2024, which described the management of the wound as unacceptable.
Failure to Provide Timely Laboratory Services
Penalty
Summary
The facility failed to provide timely laboratory services for two residents, leading to a risk of delayed identification and treatment of health conditions. Resident 3, who was admitted with diagnoses including aftercare following hip joint prosthesis and osteomyelitis, had weekly lab tests ordered, including CBC, CMP, ESR, and CRP. However, there were missing lab results for specific dates, and the facility did not have the appropriate equipment to draw blood on one occasion. Additionally, there was no documentation of attempts to complete the missing labs or notify the provider about the issues encountered. Resident 4, admitted with orthopedic aftercare and arthritis due to bacteria in the right hip, also had lab tests ordered, but there was no documentation of the results in the medical record. The Director of Nursing Services acknowledged that the lab results were not forwarded to the Infectious Disease office as ordered, and the results were not available for nurses to review. This lack of documentation and follow-up on lab results contributed to the deficiency identified by the surveyors.
Failure to Follow Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that residents were free from avoidable accidents, specifically for one resident who required assistance with Activities of Daily Living (ADLs) and bed mobility. The resident, who had no cognitive issues but suffered from chronic health conditions and severe pain, was dependent on staff for toileting hygiene and bed mobility. The care plan specified that two staff members were needed for bed mobility, but this was not followed. On one occasion, a CNA attempted to reposition the resident alone, resulting in the resident rolling off the bed and sustaining a broken leg. The incident occurred despite previous concerns raised about the resident's bed size and the difficulty staff had in positioning the resident safely. The facility's policy required adherence to individualized care plans, which included using two people for bed mobility. However, the CNA did not follow this directive, leading to the resident's fall and subsequent injury. The resident expressed that the bed was too narrow and lacked siderails, contributing to the fall. The Director of Nursing confirmed that the care plan was not followed during the incident.
Deficiencies in Toileting and Bathing Assistance
Penalty
Summary
The facility failed to provide timely toileting assistance for several residents, leading to prolonged periods of discomfort and potential health risks. Resident 1, who was dependent on staff for toileting due to a broken leg and PTSD, reported waiting over three hours for incontinence care after requesting assistance. This delay resulted in Resident 1 sitting in a soiled brief through breakfast. Similarly, Resident 8, who had memory problems and required assistance for toileting, experienced long wait times for help, leading to a fall while attempting to self-transfer to the commode. Resident 9, who was on diuretics and required substantial assistance for transfers, also reported extended wait times for toileting assistance, sometimes over an hour. The facility also failed to provide adequate bathing services for some residents. Resident 3, who had severe cognitive problems and was dependent on staff for bathing, was observed with dark matter under their nails and a strong urine odor, indicating a lack of proper hygiene care. The facility's records showed inconsistencies in documenting showers and nail care for Resident 3, with no evidence of regular bathing as per the care plan. Resident 4, who had severe cognitive problems and was dependent on staff for bathing, was frequently observed with greasy, uncombed hair and a musty odor, suggesting infrequent bathing. The facility's records showed missed and undocumented showers, with no evidence of attempts to address refusals or preferences for bathing. Additionally, Resident 11 experienced similar issues with bathing services, with records showing missed and undocumented showers. The facility's failure to adhere to care plans and provide timely assistance for activities of daily living, such as toileting and bathing, resulted in inadequate care for the residents, compromising their dignity and quality of life.
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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 Olympia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Woodard Creek Health & Rehabilitation | 0.1 mi | — | 11 | 0 |
| Panorama City Conv & Rehab Ctr | 1.6 mi | — | 6 | 0 |
| Regency Olympia Rehabilitation And Nursing Center | 2.5 mi | — | 15 | 0 |
| Crystal Cove Post Acute | 2.7 mi | — | 38 | 0 |
| Lacey Post Acute & Rehabilitation | 3.7 mi | — | 8 | 0 |
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