Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 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 Richmond Beach Rehab during CMS and state inspections, most recent first.
The facility failed to report an allegation of sexual abuse to the State Agency after a resident reported that another resident called her over, touched her face, told her she was pretty, and kissed her without consent, leading to increased anxiety and avoidance of activities. The cognitively intact resident disclosed the incident through a grievance and to social services, and staff, including the Activities Director, Social Services Coordinator, Administrator, and DON, became aware of the allegation. Facility policy defines sexual abuse as non-consensual sexual contact and requires mandated reporters to immediately report all alleged violations to the Administrator, state agency, and other required agencies, and the Administrator acknowledged that a non-consensual kiss meets the definition of sexual abuse. Despite this, the incident was not entered into the incident log or reported externally, with the Administrator stating they did not report it because the resident did not want the matter to go further.
Surveyors identified multiple infection control lapses, including a laundry aide transporting uncovered clean clothes and reusing a linen cover that had fallen to the floor, an LPN entering a droplet precaution room without required eye protection, and a nurse practitioner and an RN performing wound care without gowns despite Enhanced Barrier Precautions. An LPN also failed to properly disinfect a shared glucometer between residents and did not clean the rubber seal of a Liraglutide pen with alcohol before attaching a new needle, contrary to policy and manufacturer instructions. In addition, a urine-filled urinal was left on a bedside table next to a meal tray, which staff acknowledged should not have occurred.
A resident who had previously received PPSV23 and PCV13 met CDC criteria for an additional pneumococcal vaccine dose and had signed consent to receive PCV20, but review of the EHR showed no documentation that PCV20 was ever administered. The facility’s policy required offering pneumococcal vaccines and following current CDC recommendations, and both the IP and DON acknowledged the expectation that the resident should have received the vaccine, yet the dose was not provided or recorded.
A resident with a pressure ulcer did not receive prescribed wound care due to the unavailability of Dakin's solution. Despite the resident's report and staff awareness, the physician was not notified, and no alternative treatment was ordered. The resident's wound was treated with wet-to-dry dressing instead, contrary to the physician's order.
The facility failed to ensure accurate PASARR screenings for several residents, leading to missed Level II referrals for those with Serious Mental Illness (SMI) or Intellectual Disabilities (ID). This oversight involved incomplete or incorrect PASARR forms for residents with conditions such as anxiety, depression, and delusional disorders, placing them at risk of not receiving appropriate care.
The facility failed to accurately complete daily nurse staffing forms with actual hours worked for each shift over six days. Observations showed that the posted forms lacked the required information for nursing staff, including RNs, CNAs, and LPNs. The DON admitted to not filling out the actual hours due to previous training. The facility's policy required this information to be recorded, and the Administrator confirmed the need for accurate postings.
The facility failed to properly label and store medications, including insulin pens and a bronchodilator inhaler, and did not remove expired supplies. Additionally, the facility did not adhere to CDC guidelines for vaccine storage, as refrigerator temperatures were not checked twice daily despite storing RSV vaccines. Expired intravenous starter needles were also found in the medication room refrigerator.
A long-term care facility was found to have multiple infection control deficiencies, including improper disinfection of insulin pens, inadequate hand hygiene, and improper storage of personal care items and PPE. Additionally, hand hygiene supplies were lacking in medication rooms, and shared transfer lift equipment was not disinfected between uses, increasing the risk of infection.
A facility failed to notify the State LTC Ombudsman in writing about a resident's transfer to the hospital, as required by their policy. The Social Services Assistant responsible for sending the notice did not document the communication or retain a fax receipt. The Administrator confirmed the expectation for written notification and documentation of such communications.
A facility failed to accurately assess a resident's condition by not documenting oxygen use during the MDS assessment look-back period. The resident, admitted with asthma and respiratory failure, had received oxygen, as noted in the TAR, but this was not captured in the MDS. The Case Manager acknowledged the oversight, and the DON confirmed the expectation for accurate assessments per the RAI Manual.
The facility failed to provide baseline care plan summaries to two residents within 48 hours of admission, as required by policy. Reviews of the residents' EHRs showed no documentation of the summaries being provided, and interviews with staff confirmed the oversight. The residents did not receive the necessary written summaries outlining their care plans, which should have included goals, medication, dietary instructions, and services.
The facility failed to properly store oxygen tubing and cannulae for two residents, leading to a deficiency in respiratory care. One resident's tubing was found hanging on a wheelchair with nasal prongs touching the floor, while another's was on the floor beside their bed. Staff confirmed that the supplies should have been stored in a bag when not in use to prevent cross-contamination.
A facility failed to consistently evaluate and document a resident's dialysis care, despite a care plan requiring monitoring for infection at the access site. Staff interviews revealed a lack of awareness and adherence to the care plan, with some unaware of the access site's location and others acknowledging the order was not reinstated upon readmission. The DON confirmed the oversight, and the resident reported no consistent evaluations post-treatment.
Failure to Report Resident’s Allegation of Non-Consensual Sexual Contact
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse to the State Agency as required by its own policy and state regulations. The facility’s abuse policy, dated September 2022, states that all suspected, alleged, or actual cases of resident abuse, including sexual abuse defined as non-consensual sexual contact of any type with a resident, must be thoroughly investigated and reported to the Administrator, state agency, and all other required agencies when there is reasonable suspicion that abuse has occurred. A cognitively intact resident (Resident 1) reported via a grievance on 02/04/2026 that another resident (Resident 2) had called her over outside his room, put his hands on her face, told her she was pretty, and kissed her. Resident 1 stated this kiss was not wanted or consensual, that she felt scared, avoided the activities room because Resident 2 was there, and did not want to return to the facility after a hospital stay unless Resident 2 was removed. Staff interviews and documentation showed that Resident 1’s anxiety increased and she stopped attending activities after the incident. The incident was known to multiple staff members, including the Activities Director (Staff B), the Social Services Coordinator (Staff C), and the Administrator (Staff A) and DON, yet it was not reported to the State Agency. Staff B documented that Resident 2 continued to make inappropriate comments and behaviors and acknowledged hearing him say “you’re pretty” to residents, including Resident 1. Staff C reported that Resident 1 described Resident 2 telling her she was pretty, saying “he come here,” and kissing her, and that Staff C believed the kiss was not mutual and that Resident 1 was shocked. Staff C reported the allegation to the Administrator and DON. The Administrator (Staff A) acknowledged that a non-consensual kiss reported by a resident constitutes an allegation of sexual abuse that should be reported to the State Agency and stated that they usually report resident-to-resident incidents. However, Staff A admitted that the incident between Resident 1 and Resident 2 was not reported, explaining that Resident 1 did not want the matter to go further or be widely known and that they wanted to honor her wishes. Review of the incident logs for January, February, and March 2026 confirmed there was no documentation that this allegation of sexual abuse was reported to the State Agency.
Multiple Infection Control Lapses in Linen Handling, PPE Use, Wound Care, Glucometer Disinfection, Medication Technique, and Urinal Placement
Penalty
Summary
The deficiency involves multiple failures in the facility’s infection prevention and control practices by several staff members in different care processes. A laundry aide transported clean clothes on a rolling rack that was not fully covered, contrary to facility expectations and CDC guidance for linen transport. During transport, the linen cover fell to the floor, and the aide picked it up and placed it back on top of the rack containing clean clothes instead of treating it as soiled and sending it to dirty laundry. The laundry manager and the infection preventionist both stated that clean linens and clothes were expected to be fully covered during transport and that any linen that touched the floor was considered soiled and should be placed in dirty laundry. Another deficiency occurred in the use of PPE for a resident on droplet precautions. An LPN entered a droplet precaution room wearing a gown and gloves but only had prescription eyeglasses on and did not use required eye protection such as a face shield or goggles, despite signage outside the room indicating that eye protection was required. The LPN stated they were unsure if prescription eyeglasses counted as PPE. The infection preventionist and the DON both stated that prescription eyeglasses were not considered PPE and that staff were expected to wear appropriate eye protection when caring for residents on droplet precautions. Additional infection control failures were identified during wound care and medication-related procedures. A nurse practitioner and an RN performed wound care on a resident with a sacral pressure injury requiring dressing changes three times a week, wearing only gloves and no gowns, even though they acknowledged that wound care required Enhanced Barrier Precautions and that gowns should have been worn. For another resident with orders for blood glucose checks before meals and at bedtime, an LPN cleaned a shared glucometer with an alcohol wipe instead of disinfecting it with Sani-cloth or bleach-based wipes between uses, contrary to facility policy and infection control standards. The same LPN also prepared and administered a Liraglutide injection using a pen device without wiping the rubber stopper with an alcohol swab before attaching a new needle, despite manufacturer instructions requiring this step and facility expectations for antiseptic technique. A further deficiency involved improper handling of a resident’s personal care item in relation to food service. A resident’s urinal, filled with urine, was observed on the bedside table next to the resident’s meal tray. A CNA confirmed that the urinal should not have been on the table next to the meal tray and that it should have been emptied. The infection preventionist and the DON both stated they did not expect a urine-filled urinal to be placed next to a meal tray and that it should have been emptied and kept away from the bedside table.
Failure to Administer Indicated Pneumococcal Vaccine per CDC Guidelines
Penalty
Summary
The facility failed to ensure that pneumococcal vaccination was up to date for one resident in accordance with its own policy and current CDC recommendations. The facility’s pneumococcal vaccine policy, dated October 2025, required that all residents be offered pneumococcal vaccines and that administration follow current CDC guidelines. CDC’s Adult Immunization Schedule Notes indicated that an adult who had previously received both PCV13 and PPSV23, but had not received PPSV23 at age 65 or older, should receive one dose of PCV20 or PCV21 at least five years after the last pneumococcal vaccine dose. Record review showed the resident had received PPSV23 on 02/14/2001 and PCV13 on 11/12/2018, meeting criteria for an additional pneumococcal vaccine dose. Further review of the resident’s records showed that on 03/10/2024 the resident had signed a Vaccination History and Consent form agreeing to receive Prevnar 20 (PCV20). However, review of the electronic health record did not show any documentation that Prevnar 20 was administered. During an interview and joint record review, the Infection Preventionist confirmed that the facility followed CDC guidelines, acknowledged the signed consent for Prevnar 20, and stated there was no documentation that the vaccine had been given. The DON also stated the expectation that the resident would have received the pneumococcal vaccination per CDC guidelines. This lack of administration and documentation for the agreed-upon and indicated pneumococcal vaccine constituted the deficiency.
Failure to Provide Prescribed Wound Care for Resident
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with a pressure ulcer, consistent with professional standards of practice. The resident, who had an unstageable pressure ulcer related to a deep tissue injury, reported not receiving wound treatment according to their physician's order due to the unavailability of the prescribed wound cleaning solution, Dakin's solution. Despite having an order to apply moistened gauze with Dakin's solution, the solution was not available from 12/23/2024 to 01/03/2025, and there was no documentation that the resident's physician or wound consultant was notified about this issue. Staff interviews revealed that the resident's wound was being treated with wet-to-dry dressing instead, without notifying the physician or obtaining a new wound care order. The Resident Care Manager acknowledged that the pharmacy and the resident's physician should have been notified when the prescribed solution was unavailable, and the Director of Nursing confirmed that an alternative wound treatment order should have been obtained. The lack of communication and failure to follow protocol placed the resident at risk for deterioration of their pressure ulcer and a diminished quality of life.
Failure to Ensure Accurate PASARR Screening
Penalty
Summary
The facility failed to ensure the accuracy and completion of the Preadmission Screening and Resident Review (PASARR) forms for several residents, which is crucial for identifying individuals with Serious Mental Illness (SMI) or Intellectual Disabilities (ID) who may be inappropriately placed in nursing homes. The report highlights that the PASARR forms for five residents were either incomplete or incorrect, leading to a lack of necessary Level II PASARR referrals. This oversight placed the residents at risk of not receiving appropriate care and services tailored to their specific needs. For Resident 41, the PASARR form was marked for a mood disorder but failed to include the resident's anxiety disorder, and no Level II referral was made. Similarly, Resident 67's PASARR form included anxiety disorder but omitted the depressive disorder, and no Level II referral was completed. Resident 36's form marked mood and anxiety disorders but did not include delusional disorder, and a Level II referral was not sent. Resident 46's form included PTSD and anxiety but omitted major depressive disorder, and no Level II evaluation was indicated. Lastly, Resident 20's form did not mark major depressive disorder, and no Level II referral was completed. Interviews with staff revealed a lack of understanding and adherence to the updated PASARR regulations, which require a Level II referral for any SMI indicators. Staff members acknowledged the discrepancies and admitted to missing necessary corrections and referrals. The facility's social services department was responsible for reviewing PASARR documents for accuracy, but the oversight in these cases indicates a failure to comply with the regulatory requirements, as outlined in the Washington Administrative Code (WAC) 388-97-1915.
Failure to Accurately Complete Daily Nurse Staffing Forms
Penalty
Summary
The facility failed to ensure the daily nurse staffing form was accurately completed with actual hours worked for each shift over a period of six days. Observations on multiple days revealed that the posted daily nursing staffing forms did not include the actual hours worked for each shift by the nursing staff, which included Registered Nurses, Certified Nursing Assistants, and Licensed Practical Nurses. This omission was confirmed during an interview with the Director of Nursing Services, who stated that they had not been filling out the actual total hours due to training received from a previous staffing coordinator. The facility's policy required that shift staffing information must be recorded on a form for each shift, including the actual hours worked during that shift for each category and type of nursing staff. The Administrator acknowledged that daily nurse staff postings need to be visible and available with the actual hours filled out.
Deficiencies in Medication Labeling, Storage, and Expired Supplies Management
Penalty
Summary
The facility failed to ensure proper labeling and storage of drugs and biologicals, as well as the removal of expired supplies, in accordance with professional standards. During an observation, a Licensed Practical Nurse (LPN) did not date two newly opened insulin pens before storing them in the medication cart. Additionally, a prescription bronchodilator inhaler was found with an incomplete label that did not come from the pharmacy, lacking the necessary prescription or pharmacy label. The facility also did not adhere to the Centers for Disease Control and Prevention (CDC) guidelines for vaccine storage. The Cascade medication room refrigerator's temperature was only checked once a day, despite the presence of a Respiratory Syncytial Virus (RSV) vaccine, which requires twice-daily temperature checks. Similarly, the [NAME] medication room refrigerator had missing temperature records and was also checked only once daily, despite storing an RSV vaccine. Expired medical supplies were found in the Baker medication room refrigerator, including intravenous starter needles with an expired date. The facility's Director of Nursing Services and other staff acknowledged these deficiencies, stating that the facility followed CDC guidelines and that expired supplies should have been discarded.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices, as evidenced by multiple deficiencies observed during the survey. One significant issue involved the improper disinfection of insulin pens and inadequate hand hygiene practices during medication administration for a resident. A Licensed Practical Nurse (LPN) was observed administering insulin doses without performing hand hygiene after removing gloves and before donning new ones. Additionally, the insulin pens were placed on a sink counter and stored in the medication cart without being cleaned, contrary to the facility's policy and CDC guidelines. Another deficiency was noted in the storage of personal care items and Personal Protective Equipment (PPE). Personal hygiene items were found unbagged and placed directly on the bathroom floor, which is against the facility's policy that requires such items to be bagged and stored properly. Furthermore, isolation carts for Enhanced Barrier Precautions (EBP) were improperly stocked, with non-PPE items like chips, cups, and linens stored alongside PPE. Some carts lacked essential PPE such as gowns, and staff were unaware of the correct PPE to be stored, indicating a lack of adherence to CDC guidelines and facility expectations. The facility also failed to provide adequate hand hygiene supplies in medication rooms and did not ensure the disinfection of shared transfer lift equipment between resident uses. Observations revealed that handwashing stations lacked necessary supplies like paper towels and hand sanitizer. Additionally, a Hoyer lift used for transferring residents was not disinfected between uses, increasing the risk of cross-contamination. Staff interviews confirmed these lapses, with some staff unaware of the need to disinfect equipment after each use, despite the facility's policy and OSHA standards requiring such practices.
Failure to Notify State LTC Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to properly notify the Office of the State Long Term Care (LTC) Ombudsman in writing regarding the transfer of a resident to the hospital. This deficiency was identified during a review of the facility's policy and resident records. The policy, revised in March 2021, mandates that a copy of the transfer or discharge notice be sent to the State LTC Ombudsman at the same time it is provided to the resident and their representative. However, a review of Resident 36's nursing progress notes from September 30, 2024, to November 25, 2024, revealed no documentation indicating that the notice of transfer was sent to the Ombudsman office. Interviews with facility staff further highlighted the deficiency. Staff I, a Social Services Assistant, acknowledged their responsibility for completing and faxing the transfer notice form to the State LTC Ombudsman office. However, they admitted there was no documentation or fax receipt confirming that the notice had been sent. Additionally, Staff A, the Administrator, confirmed the expectation that the Ombudsman office should have been notified in writing about the resident's hospital transfer and that such communications should have been documented.
Failure to Accurately Assess Resident's Oxygen Use
Penalty
Summary
The facility failed to accurately assess a resident's condition by not capturing the use of oxygen during the Minimum Data Set (MDS) assessment look-back period. The resident, who was admitted with asthma and respiratory failure, had received oxygen during the look-back period, as documented in the Treatment Administration Record (TAR). However, this was not reflected in the MDS assessment, which is a critical tool for evaluating the resident's care needs. The oversight was identified during an interview and joint record review with the Case Manager, who acknowledged that the MDS should have included the oxygen use. The Director of Nursing Services confirmed that the expectation was for staff to adhere to the Resident Assessment Instrument (RAI) Manual and complete MDS assessments accurately. This failure to document the resident's oxygen use placed the resident at risk for unidentified and/or unmet care needs, potentially affecting their quality of life.
Failure to Provide Baseline Care Plan Summaries
Penalty
Summary
The facility failed to develop baseline care plans and provide a written summary of these plans to two residents, identified as Residents 40 and 151, within 48 hours of their admission. This deficiency was identified through interviews and record reviews. The facility's policy, revised in March 2022, mandates that a written summary of the baseline care plan, including goals, medication, dietary instructions, and services, be provided to residents or their representatives. However, reviews of the Electronic Health Records (EHR) for both residents showed no documentation that such summaries were provided. Resident 40's EHR lacked any evidence of a written summary being given, while Resident 151, who had intact cognition, confirmed not receiving the summary. Staff interviews revealed that the baseline care plan was supposed to be developed upon admission, with the summary provided by social service personnel. However, both the Resident Care Manager and the Social Services Director acknowledged the absence of documentation indicating that the summaries were given. The Director of Nursing Services also confirmed the expectation that these plans should be developed and provided within the specified timeframe.
Improper Storage of Oxygen Tubing and Cannulae
Penalty
Summary
The facility failed to ensure proper storage of oxygen tubing and cannulae for two residents, leading to a deficiency in respiratory care. Resident 17, who was admitted with diagnoses including congestive heart failure and asthma, had a physician's order for oxygen via nasal cannula as needed for shortness of breath. Observations on two separate occasions revealed that Resident 17's oxygen tubing and cannula were not stored properly when not in use, with the nasal prongs touching the floor. Staff K, an LPN, confirmed that the tubing and cannula should have been stored in a bag when not in use. Similarly, Resident 46, who was admitted with diagnoses including congestive heart failure, asthma, and chronic respiratory failure with hypoxia, had a physician's order for supplemental oxygen. An observation showed that Resident 46's oxygen tubing and cannula were found on the floor beside their bed instead of being stored properly. Staff N, an LPN, acknowledged that the tubing should have been bagged when not in use and stated that it should be discarded. Both the Resident Care Manager and the Director of Nursing Services confirmed the expectation that oxygen therapy supplies should be stored in a bag when not in use to prevent cross-contamination.
Failure to Consistently Evaluate Dialysis Care
Penalty
Summary
The facility failed to consistently evaluate and document the dialysis care for a resident who required such services. The resident, who was cognitively intact and received dialysis three times a week at an offsite center, had a care plan directing staff to monitor and report any signs of infection at the dialysis access site. However, the facility's records showed no consistent evaluation or documentation of the resident's condition after dialysis treatments. Interviews with staff revealed a lack of awareness and adherence to the care plan, with some staff unaware of the location of the dialysis access site and others acknowledging that the order to check the site was not reinstated upon the resident's readmission. The Director of Nursing Services confirmed that the order to check the dialysis access site was not placed back when the resident was readmitted, and there was an expectation for staff to evaluate and document the resident's condition after each dialysis treatment. The resident also reported that the facility never checked the dialysis access site or evaluated them consistently after treatments. This oversight placed the resident at risk for unmet care needs and potential deterioration of their chronic condition.
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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 Shoreline
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bridges To Home | 1.9 mi | — | 9 | 0 |
| The Broadview Center | 3.2 mi | — | 15 | 1 |
| Pine Ridge Post Acute | 3.3 mi | — | 18 | 0 |
| Edmonds Post Acute | 3.4 mi | — | 60 | 0 |
| Avamere Rehabilitation Of Shoreline | 4 mi | — | 11 | 0 |
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