Latest reports, citations, and penalties from CMS data
Inspection records revealed that staff failed to administer prescribed breathing treatments on multiple occasions in March 2025....
One resident with atrial fibrillation, cardiomyopathy, and heart failure experienced repeated delays in receiving critical medications throughout June 2024....
Two residents experienced dangerous delays in receiving ordered laboratory work that could have detected serious health problems....
Multiple staff members interviewed during the overnight inspection confirmed the staffing crisis....
The most concerning violations involved the mishandling of urinary catheter equipment and oxygen tubing, both of which require strict sanitation procedures....
## Leadership Failures Compound Initial Violation The abuse incident was significantly worsened by systematic failures in the facility's response....
However, federal surveyors identified a fundamental flaw in the facility's approach....
The resident's medical condition required strict avoidance of fatty and greasy foods....
The incident involved **60 oxycodone/acetaminophen tablets** belonging to one resident and **30 oxycodone tablets** belonging to another....
The family had installed the hidden camera due to concerns about their loved one's treatment....
The citation references WAC 388-97-0640 (6)(a)(b), indicating violations related to facility operations and resident care standards....
Adequate staffing in nursing homes is essential for maintaining residents' dignity and preventing serious medical complications....
Inspectors found that a resident prescribed antibiotics for a urinary tract infection was not properly tracked or monitored according to established protocols....
Despite having physician orders for continuous one-to-one monitoring since October 2024, staff failed to provide the required supervision....
These safeguards protect vulnerable residents who depend on staff for proper medication management and prevent potential diversion of controlled substances....
The violations affected Resident 7, who had been admitted in January 2024 with type 2 diabetes, diabetic kidney disease, and diabetic nerve damage....
The facility provided oxygen to residents without proper physician orders and failed to maintain basic infection control standards for oxygen equipment....
However, the manufacturer's expiration date on each package showed April 2025 - meaning the medications had expired more than a month earlier....
The missed medications included **Levetiracetam**, a critical anti-seizure medication prescribed at 750 mg twice daily....
The inspection revealed that two out of three observed care episodes involved improper hand hygiene practices during perineal care....