Sunnyside Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Sunnyside, Washington.
- Location
- 721 Otis Avenue, Sunnyside, Washington 98944
- CMS Provider Number
- 505226
- Inspections on file
- 45
- Latest survey
- March 9, 2026
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Sunnyside Healthcare Center during CMS and state inspections, most recent first.
The facility failed to honor resident choice regarding shower times when it eliminated the shower aide role and reassigned showers to NAs, splitting them between day and evening shifts without consulting residents. A resident who was independent with ADLs but had moderately impaired cognition reported being moved to evening showers without being asked, despite preferring daytime showers. Another resident with post-stroke paralysis and moderately impaired cognition was routinely awakened early for showers, although their representative stated the resident preferred to sleep in and bathe in the afternoon; an NA confirmed this resident’s shower was always done first, before breakfast. A third resident with diabetes, paraplegia, and depression, who was cognitively intact and required substantial assistance, reported being informed of the staffing change but not given any choice between day or evening showers, despite assessments indicating that making choices about customary routines and activities was very important to all three residents.
The facility did not ensure residents were involved in decisions about their restorative and therapy services when frequencies and durations were reduced. One resident with diabetes and paraplegia, who had intact cognition and required assistance with ADLs, had an AROM program reduced from six to three sessions per week and reported not being informed of the change or the shortening of sessions. Another resident with post-stroke left-sided weakness, lung disease, and HTN had an AROM program similarly reduced, while the resident’s representative stated they had been told at a care conference that services were being provided daily and were not informed of any changes. These actions were inconsistent with the facility’s policy requiring resident participation in person-centered care planning, including changes to the type, amount, frequency, and duration of care.
A resident with rheumatoid arthritis and spinal compression fractures, who required extensive assistance with ADLs, had a standing q6h narcotic pain medication order but experienced multiple missed doses when the facility ran out of the medication. The resident reported significant pain and stated staff told them the pharmacy would not refill the narcotic until a new prescription was obtained and that no backup dose was available from the emergency supply. An LPN and the DON confirmed that the established refill process—requesting refills when seven doses remained and using emergency backup narcotics with a pharmacy authorization code if needed—was not followed, and confusion with the pharmacy order prevented timely access to the narcotic medication.
Three residents with various medical conditions, all cognitively intact and at least partially independent with eating, consistently received meals that were not hot, with food and plates arriving cold. Residents reported their concerns to dietary staff and filed grievances, but the issue persisted. Staff confirmed awareness of the problem and cited lack of equipment and funding as contributing factors, resulting in meals not being served at a safe and appetizing temperature.
A broken pipe under the kitchen floor led to restroom water backing up into the kitchen, resulting in unsanitary conditions. Staff used a shop vac to remove water from a soiled catch basin, with exhaust blowing onto open meal carts, and were unable to maintain proper dishwashing and sanitation. The Infection Preventionist was not involved in planning, and the kitchen was deemed unsanitary by staff.
A resident with multiple health conditions and moderate cognitive impairment was served meals on paper plates with a plastic spork for an extended period, reportedly due to a broken dishwasher. The resident expressed distress and a loss of dignity as a result. The DON was unaware of the use of disposable mealware and stated that decisions regarding meal service items were handled by the kitchen.
Two residents with physical impairments affecting their hands were unable to eat independently after the facility switched to plastic sporks and disposable dishware due to a kitchen issue. Both residents, who were cognitively intact and previously able to eat with metal or regular plastic utensils, reported difficulty and dissatisfaction with the sporks. Staff were aware of the complaints but had limited alternatives, and facility leadership was not fully informed about the ongoing use of disposable items.
The facility failed to maintain a sanitary environment by not consistently cleaning vents and changing filters in dining rooms, hallways, the kitchen, and the laundry room. Observations showed significant dust and dirt buildup, with some vents having spider webs and broken slats. Staff interviews revealed inadequate cleaning schedules, and records showed inconsistencies in maintenance documentation. The administrator acknowledged the need for more frequent monitoring and cleaning.
Two residents in an LTC facility received opioid pain medications without proper documentation of administration and effectiveness. One resident, receiving end-of-life care, had no record of morphine administration, while another recovering from surgery had incomplete documentation for oxycodone. The lack of documentation hindered the facility's ability to assess pain management effectiveness.
A visually impaired resident experienced psychosocial harm after being moved to a new room without proper orientation or consideration of their preferences. The resident, who had a history of anxiety and depression, struggled with the unfamiliar layout, leading to frustration and a decline in their usual activities. Staff noted the resident's increased sadness and frustration, and the resident's representative expressed dissatisfaction with the facility's handling of the room change.
A facility experienced a 12% medication error rate due to errors by an LPN, including incorrect dosing and failure to administer medications on time. One resident received an incorrect dose of Vitamin D, while another did not receive Colchicine or Zofran as prescribed. The DON noted that LNs should order refills timely and seek assistance if behind.
The facility failed to maintain a safe and sanitary kitchen environment, with ceiling damage and floor hazards posing risks of cross-contamination and foodborne illness. Staff acknowledged the issues but lacked a system for preventive maintenance.
A resident with blindness and anxiety was moved to a different room without prior written or verbal notification to them or their representative. The facility's policy requires notification and consent before room changes, but this was not documented or followed, as confirmed by interviews with staff and the resident's representative.
A resident reported rough handling by a night shift NA, but the facility failed to log or report the allegation to the State Agency. Despite the resident informing a day shift NA, and the issue being discussed with an LPN, the Social Service Director and DON were unaware of the incident, indicating a failure in the reporting process.
A resident reported rough handling by a night shift NA, describing the staff as rude. Despite informing a NA and an LPN, no investigation was initiated, and management was not informed. The facility's policy requiring investigation and staff removal was not followed.
A resident with severely impaired cognition signed a binding arbitration agreement without the involvement of their legal representative, contrary to facility policy. Staff interviews confirmed the resident's inability to understand the agreement, and the resident's representative, who held power of attorney, was not informed of the agreement.
The facility failed to implement infection control measures for Legionella, as evidenced by incomplete maintenance of water heaters and ice machines. Over ten months, required tasks were neglected, leading to mold-like biofilm growth in the ice machine. Staff interviews revealed a lack of awareness and involvement in the Water Management Plan, with the Maintenance Director and Assistant admitting to not following protocols. The Administrator and Infection Preventionist acknowledged the deficiencies.
Failure to Honor Resident Choice in Shower Scheduling
Penalty
Summary
The facility failed to honor residents' rights to self-determination and choice regarding shower times when it changed the shower schedule and eliminated the dedicated shower aide. The facility's Resident Rights policy from 02/2021 stated that residents had the right to a dignified existence and self-determination. Despite this, when the Director of Nursing Services and the Administrator implemented a change effective 03/01/2026, requiring NAs to perform showers on their own residents and splitting showers between day and evening shifts due to budget cuts and staffing changes, residents were not consulted or given a choice between day and evening showers. The Director of Nursing Services acknowledged that residents were not given a choice and stated they assumed residents would not want evening showers and that the workload needed to be split between shifts. The Administrator also stated residents should have been given a choice and was not aware that they had not been consulted. Resident 1, admitted with a right knee dislocation, anxiety, and a need for assistance with personal care, had a comprehensive assessment dated 01/06/2026 showing independence with ADLs, moderately impaired cognition, and that it was very important for them to make choices about customary routines and activities. Resident 1 reported they were not informed of the shower schedule change, were assigned to evening showers, and preferred daytime showers, stating they wished staff had asked their preference. Resident 2, admitted with left-sided weakness/paralysis after a stroke, lung disease, and high blood pressure, was dependent on one to two staff for ADLs, had moderately impaired cognition, and also had an assessment indicating it was very important to make choices about routines and activities. Resident 2’s representative reported staff woke the resident early for showers, which the resident disliked, and that the resident preferred to sleep in and shower in the afternoon; a NA confirmed they had always completed this resident’s shower first, before breakfast. Resident 3, admitted with diabetes, paraplegia, and depression, required substantial assistance for showers, was cognitively intact, and had an assessment indicating the importance of making choices about routines and activities. Resident 3 stated they were told the shower aide would no longer provide showers and that they were not given a choice of day or evening showers.
Failure to Involve Residents in Changes to Restorative Care Plans
Penalty
Summary
The facility failed to ensure residents were provided the opportunity to participate in decisions about their care and treatment, specifically related to restorative nursing and therapy services. Facility policy dated 03/2022 stated that residents had the right to participate in the development and implementation of their comprehensive person-centered care plan, including determining the type, amount, frequency, and duration of care, receiving the services in the care plan, and seeing and signing the care plan after significant changes. For one resident with diabetes, paraplegia, and depression, whose comprehensive assessment showed intact cognition and a need for partial to maximum assistance with ADLs, the medical record documented a restorative nursing AROM program at a frequency of six times per week. The care plan, initiated on 10/30/2025, was later modified on 03/05/2026 to reduce the AROM frequency to three times per week. During interview, this resident reported frustration about the change in therapy services, stating they were not informed of the reduction from six to three days per week and that session length had been cut from 30 minutes to 20 minutes. A second resident, with left-sided weakness/paralysis after a stroke, lung disease, and hypertension, was assessed as dependent on one to two staff for ADLs and having moderately impaired cognition. This resident’s care plan showed an AROM program initiated at six times per week, which was also reduced to three times per week on 03/05/2026. In an interview, the resident’s representative stated that at a recent care conference they were told the resident was receiving restorative nursing services every day, but they did not know if that was occurring and were not informed of any changes in services. These findings showed that changes in restorative/AROM frequency and duration were made without informing or involving the residents or their representative as required by the facility’s person-centered care planning policy.
Failure to Ensure Continuous Availability of Ordered Narcotic Pain Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure accurate acquiring, receiving, dispensing, and administering of drugs for one resident. The resident had rheumatoid arthritis and a history of spinal compression fractures, required maximum assistance for activities of daily living, and had intact cognition. A physician’s order dated 10/01/2025 directed that a narcotic pain medication be administered every six hours for rheumatoid arthritis. Review of the January 2026 MAR showed multiple missed doses of this narcotic pain medication on 01/27/2026 and 01/28/2026, as well as the midnight dose on 01/29/2026. During observation and interview, the resident reported that the facility did not have their narcotic pain medication available, resulting in six missed doses, and described pain throughout their body, including hands, back, feet, and elbows. The resident stated staff told them the medication had run out and the pharmacy would not refill it until a new prescription was written, and that there was no backup supply available from the emergency supply. Staff interviews confirmed that the facility’s processes for refilling and administering medications were not followed. An LPN explained that the standard process was to request refills when the medication card reached the blue section, indicating seven doses remaining, and that if a medication ran out before the refill arrived, a dose could be obtained from the emergency backup supply using a pharmacy authorization code. For this resident, the LPN stated there was a problem receiving the narcotic from the pharmacy, and although the provider was contacted and a new prescription sent, staff were unable to obtain an authorization code from the pharmacy due to confusion with the order, resulting in the resident going without the narcotic pain medication until the pharmacy resolved the issue. The DON stated that narcotic refills were to be requested at least seven days before the resident ran out and acknowledged that the process for refilling and administering medications was not followed. The Administrator stated that licensed nurses were responsible for communicating with the provider and pharmacy to ensure residents had needed medications and to request refills before medications were depleted.
Failure to Serve Meals at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to serve meals at a preferred temperature for three residents reviewed for food temperatures. Observations and interviews revealed that residents consistently received meals that were not hot, with food and plates often arriving cold. One resident, who was independent with ADLs and cognitively intact, reported repeated experiences of cold food, voiced concerns to the Dietary Manager, and filed a grievance, but noted that nothing was done. Another resident, dependent on staff for ADLs but independent with eating, also reported consistently cold meals, lack of plate warmers or covers, and stated that grievances had not led to any changes. A third resident, with similar dependencies and cognitive status, expressed a preference for hotter meals and reported informing staff about the issue. Staff interviews confirmed awareness of the ongoing complaints regarding cold food. The Dietary Manager acknowledged the purchase of thermal pellets intended to keep food warm but indicated that the necessary warming device had not been approved for purchase, and the kitchen lacked insulated carts. The Administrator was also aware of the issue and stated that additional parts were needed for the plate warmers, but there were insufficient funds to purchase them. Despite food leaving the kitchen at the appropriate temperature, the facility was unable to ensure that meals arrived to residents at a safe and appetizing temperature.
Unsanitary Kitchen Conditions Due to Plumbing Failure
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in the Main Kitchen, as required for food preparation and storage safety. A broken pipe under the kitchen floor caused water from restrooms to back up into the kitchen through the drains, resulting in unsanitary conditions. Observations revealed a soiled catch basin with dark brown residue, folded blankets placed over drains, and a shop vac being used to remove water from the catch basin. The shop vac's exhaust was directed onto open meal delivery carts, and staff reported that the kitchen and dishwasher area were not sanitary and should not be used. The dishwasher was out of service due to drainage issues, and staff had to switch to alternative dishwashing methods, which were insufficient to keep up with meal demands. Staff interviews confirmed that the drain problem began several days prior, with backflow of water that smelled and appeared contaminated. The restrooms adjacent to the kitchen were locked and out of service, and the dishwasher could not be used without the shop vac. The Infection Preventionist was not involved in planning for cross-contamination prevention and was unaware of the extent of the issue. The Dietary Manager and other staff described the backflow as brown and gunky, and the Director of Nursing Services stated the kitchen was not sanitary. The facility's policy required maintaining a clean and sanitary food service area, which was not met due to the ongoing plumbing failure and inadequate interim measures.
Failure to Provide Dignified Dining Experience Due to Use of Disposable Mealware
Penalty
Summary
The facility failed to provide a dignified dining experience for a resident who was reviewed for dignity. The resident, who had diagnoses including heart failure, arthritis, and weakness, required substantial assistance with activities of daily living and supervision for eating, and had moderately impaired cognition but was able to express their needs. During an observation and interview, the resident was found sitting in their room, visibly upset and crying, with a Styrofoam cup of ice water and a meal served on a paper plate with a plastic spork. The resident reported feeling that their dignity was taken away due to being served meals on disposable items for an extended period, attributing this to a broken dishwasher as communicated by staff. The Director of Nursing Services (DON) was interviewed and stated they were not aware that paper products were being used for meal service and indicated that maintaining resident dignity involved staff training and the grievance process. The DON also stated they were not involved in the decision to switch to paper items, as it was considered a kitchen issue. The facility's policy on resident rights emphasized the importance of treating residents with respect, kindness, and dignity, in accordance with federal and state laws.
Failure to Provide Appropriate Eating Utensils and Dishware for Residents with Physical Limitations
Penalty
Summary
The facility failed to ensure that two residents maintained their ability to eat independently by not providing appropriate eating utensils and dishware. One resident with rheumatoid arthritis and deformed fingers reported difficulty using the provided plastic spork and Styrofoam containers, stating that these made it hard to access and eat food. This resident preferred metal silverware and found the spork unusable due to their arthritis, despite informing staff of the issue. Another resident with Parkinson's disease and neuropathy also reported being unable to use the plastic spork, stating they could feed themselves with a metal fork or, to some extent, a plastic fork, but not with the spork. Both residents were cognitively intact and had previously been able to eat independently or with minimal assistance. The use of plastic sporks and disposable dishware began after a kitchen pipe broke, rendering the dishwasher unusable. The dietary manager confirmed that regular plastic utensils ran out, leading to the exclusive use of sporks. Nursing staff were aware of resident complaints and would substitute a regular plastic fork if available, but supplies were limited. The director of nursing was not aware of the switch to disposable items, and the administrator believed the use of paper/plastic products was only for a single meal, not an ongoing practice. This lack of coordination and communication resulted in residents not receiving the necessary goods and services to maintain their ability to eat independently.
Facility Fails to Maintain Sanitary Environment Due to Inadequate Vent Cleaning
Penalty
Summary
The facility failed to maintain a sanitary and homelike environment by not consistently cleaning the heating and air exchange vents and changing the filters in various areas, including four dining rooms, three hallways, the kitchen, and the laundry room. Observations revealed significant dust and dirt buildup on vents, with some vents having visible spider webs and broken slats. The presence of built-up dust and dirt was noted in the Garden, Private, Transition Care Unit, and [NAME] dining rooms, as well as in Hallways 100, 200, and 300, and the kitchen's dry storage and dishwashing areas. In the laundry room, thick dust and lint were observed on the vents, exhaust pipes, and water piping, indicating a lack of regular cleaning. Interviews with staff revealed that the responsibility for cleaning vents was divided between housekeeping and maintenance, with maintenance being responsible for higher areas. However, the maintenance director admitted to cleaning vents only every six months and lacked a schedule for changing filters, relying instead on visual assessment. The facility's records showed inconsistencies in the documentation of cleaning and maintenance activities, with some entries lacking completion details. The administrator acknowledged that daily walkthroughs should have been conducted to identify areas needing more frequent cleaning. The maintenance director recognized the need to restructure the cleaning process to ensure more frequent monitoring and cleaning of vents and filters.
Failure to Document Opioid Administration and Effectiveness
Penalty
Summary
The facility failed to provide goods and services that met professional standards of care for two residents who were administered opioid pain medications. For Resident 3, who had severe cognitive impairment and was receiving end-of-life care, there was no documentation of morphine sulfate administration on the medication administration record (MAR) or in the nursing progress notes on the day it was given. Staff D, the LPN responsible, recalled administering the medication but did not document it, leaving no record of the resident's symptoms or the medication's effectiveness. Resident 7, who was recovering from surgery and experiencing moderate pain, also experienced a lack of proper documentation. The resident received oxycodone for pain, but Staff E, the LPN, failed to document the assessment of pain or the effectiveness of the medication in the MAR and progress notes for one of the doses. This lack of documentation made it difficult to assess the frequency and effectiveness of the pain management provided to the resident. The Assistant Director of Nursing expressed concern over the lack of documentation, as it hindered the ability to review and determine the effectiveness of pain management. The Director of Nursing acknowledged the issue and indicated that steps were being taken to address the problem, although specific corrective actions were not detailed in the report.
Failure to Accommodate Visually Impaired Resident's Needs
Penalty
Summary
The facility failed to accommodate the needs and preferences of a visually impaired resident, Resident 6, leading to psychosocial harm. Resident 6, who was legally blind and had a history of anxiety, depression, and end-stage renal disease, was moved to a new room without proper orientation or consideration of their preferences. The resident's care plan indicated a preference for room arrangements that promoted independence, such as having the bed on the right side, but the new room setup did not reflect these preferences. The resident expressed discomfort with the new environment, which was not addressed in the care plan. Resident 6 had previously expressed dissatisfaction with a roommate due to cleanliness and odor issues, leading to a request for a room change. Despite the request, the move to a new room was not handled with the necessary support, as therapy staff were not involved, and the resident was not oriented to the new environment. This lack of orientation and the unfamiliar room setup caused Resident 6 to experience difficulty navigating the space, leading to frustration and a decline in their usual activities and mood. Observations and interviews revealed that Resident 6 struggled with the new room's layout, including the bathroom and closet, which were not conducive to their needs. The resident's inability to find their way around the room independently led to a decrease in their social interactions and activities, such as walking to the dining room and listening to music. Staff noted the resident's increased frustration and sadness, and the resident's representative expressed dissatisfaction with the facility's handling of the room change, highlighting the lack of communication and support for Resident 6 during the transition.
Medication Administration Errors and Delays
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by a 12% error rate observed during a medication pass. Staff O, a Licensed Practical Nurse, made three errors out of 25 opportunities for error. One error involved administering an incorrect dose of Vitamin D to Resident 16, who had intact cognition and was diagnosed with diabetes and vitamin D deficiency. Staff O dispensed only one tablet of Vitamin D instead of the required two tablets, resulting in an incorrect dose being administered. Another error involved Resident 32, who had moderately impaired cognition and was diagnosed with diabetes and gout. Staff O failed to administer Colchicine due to an empty medication card and did not reorder the medication in time. Additionally, Resident 32 did not receive Zofran before breakfast, as required, because Staff O was delayed in the medication pass after assisting with a difficult resident. This led to Resident 32 refusing the medication due to an upset stomach. The Director of Nursing Services acknowledged that LNs should order refills when the medication card reaches the highlighted blue column and should seek help if they fall behind in their duties.
Facility Fails to Maintain Safe and Sanitary Kitchen Environment
Penalty
Summary
The facility failed to maintain a safe, functional, and sanitary environment in the kitchen area, which posed risks of cross-contamination and foodborne illness to residents. During an observation, it was noted that the ceiling above the dishwasher hood had missing plaster and drywall, with chunks falling onto the hood. Dust balls with fuzzy black spots were also observed hanging from the ceiling over the freezers and refrigerators. Staff H, the Dietary Manager, confirmed that a water leak had caused the ceiling damage, which had been reported to maintenance and the administrator but remained unaddressed. Additionally, the kitchen floor had several areas of concern, including an open floor area in front of the sinks with exposed underflooring, which posed a tripping hazard. There were multiple seam separations in the linoleum flooring, missing flooring pieces, and accumulations of black substances in various areas. Staff F, the Maintenance Director, acknowledged responsibility for cleaning and repairing these areas but admitted that there was no operational system for preventive maintenance or scheduled repairs. The administrator also recognized the need for a kitchen project to address these issues.
Failure to Notify Resident of Room Change
Penalty
Summary
The facility failed to provide written notification of a room change to Resident 6 or their representative, as required by their policy. Resident 6, who was admitted with diagnoses including blindness and anxiety, was transferred to a different room without prior written or verbal notification to the resident or their representative. The medical record review showed no documentation of notification or the reason for the room change from 11/15/2024 to 11/19/2024. Interviews with the Resident Representative and facility staff revealed that the notification process was not followed. The Resident Representative confirmed they did not receive any notification before the room change. Staff P, the Social Service Director, stated that they usually notify and obtain consent prior to a room change, but acknowledged that the resident and/or representative had not signed the notice of room change. Staff B, the Director of Nursing Services, also confirmed that the process involves obtaining consent and making appropriate notifications before a room change.
Failure to Report Alleged Abuse
Penalty
Summary
The facility failed to report allegations of potential abuse and/or neglect to the State Agency for one resident, which placed residents at risk for unidentified abuse or neglect. The facility's policy required reporting allegations of abuse to the appropriate authority, but this was not followed in the case of a resident who reported rough handling by a night shift nursing assistant (NA). The resident, who was cognitively intact and able to communicate their needs, reported that the NA was rough during perineal care and had a mean demeanor. The resident informed a day shift NA about the incident, but no grievance or allegation was logged or reported to the State Agency. Interviews with staff revealed that the day shift NA informed an LPN about the resident's allegations, and they both discussed the incident with the resident. However, the Social Service Director and the Director of Nursing Services were unaware of the allegations, indicating a breakdown in communication and reporting processes. The Director of Nursing Services acknowledged that the concerns should have been reported to both the DNS and the State Agency, but the correct process was not followed.
Failure to Investigate Allegation of Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of abuse involving a resident, identified as Resident 69, who was cognitively intact and able to communicate their needs. The resident reported an incident of rough handling by a night shift nursing assistant (NA), describing the staff member as rude and likening their behavior to that of a linebacker. Despite the resident's report to Staff II, a nursing assistant, and Staff JJ, an LPN, no formal grievance or investigation was initiated as required by the facility's policy. Staff II and Staff JJ both acknowledged being informed of the resident's concerns and identified the night shift NA involved as Staff KK. However, they failed to report the incident to management, which resulted in no investigation being conducted. The Director of Nursing Services and the Social Service Director confirmed they were not informed of the allegation, and the Administrator acknowledged that the correct process was not followed, as the investigation should have been initiated and the staff member in question should have been removed from duty pending the investigation.
Failure to Ensure Cognitive Capacity for Arbitration Agreement
Penalty
Summary
The facility failed to ensure that a resident had the cognitive capacity to understand the nature and implications of entering into a binding arbitration agreement. This deficiency was identified for one resident, who was admitted with diagnoses including a leg fracture, heart complications, and difficulty walking. A comprehensive assessment indicated that the resident had severely impaired cognition. Despite this, the resident signed an arbitration agreement without the involvement of a legal representative, which was contrary to the facility's policy that requires a legal representative to sign if the resident is not cognitively intact. Interviews with staff and the resident's representative revealed that the resident was confused and unaware of signing the arbitration agreement. The resident's representative, who held power of attorney, was not informed of the agreement and stated that the resident was not capable of understanding or signing documents. Staff involved in the admission process acknowledged that the resident's cognitive impairment should have necessitated the legal representative's signature on the arbitration agreement. The failure to ensure proper understanding and representation during the signing of the arbitration agreement led to the identified deficiency.
Inadequate Implementation of Infection Control Measures
Penalty
Summary
The facility failed to implement components of their infection prevention and control precautions regarding Legionella testing protocols and procedures. The facility's Water Management Plan (WMP) was not adequately followed, as evidenced by the lack of monthly flushing of water heaters and sanitization of the ice machine. Over a ten-month period, these tasks were only completed three times, leaving seven months without proper maintenance. During an inspection, a black, fuzzy, mold-like biofilm was observed on the underside of the ice collecting bin in the ice machine, indicating a failure to maintain control measures. Interviews with facility staff revealed a lack of awareness and involvement in the development and execution of the WMP. The Maintenance Director, who was not involved in the WMP's creation, admitted to not knowing the process if control measures were unmet. The Maintenance Assistant also confirmed that the ice machine was not sanitized in the past month. The facility's Administrator acknowledged that the biofilm growth showed control measures were not within acceptable ranges, and the Infection Preventionist confirmed that the ice machine appeared to have mold growth, which should have been regularly cleaned.
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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