Alderwood Park Health And Rehab Of Cascadia
Inspection history, citations, penalties and survey trends for this long-term care facility in Bellingham, Washington.
- Location
- 2726 Alderwood Avenue, Bellingham, Washington 98225
- CMS Provider Number
- 505092
- Inspections on file
- 36
- Latest survey
- January 16, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Alderwood Park Health And Rehab Of Cascadia during CMS and state inspections, most recent first.
The facility failed to honor the preferences of several residents regarding their daily schedules and bathing routines. A resident with severe cognitive impairment was left in their wheelchair for almost an hour after requesting to lay down. Another resident, who preferred showers twice a week, received bed baths instead due to a misunderstanding about their wound VAC. Additional residents experienced delays and inconsistencies in their bathing schedules, highlighting a lack of coordination among staff to ensure resident choices are respected.
The facility failed to maintain a safe environment by not ensuring the availability and condition of transfer slings, addressing gouges in flooring, and ensuring call lights were functional and accessible. Observations revealed damaged slings in use, flooring in disrepair, and call lights not within reach or audible for residents, including those with mobility issues. Staff interviews confirmed these ongoing issues, compromising resident safety and care.
The facility failed to update care plans for three residents, leading to potential risks for unmet care needs. A resident with poor eyesight did not have adequate assistance documented, and their fall mat alarm was not properly positioned. Another resident with a catheter and pressure ulcers lacked documented peri-care and repositioning, and their care plan did not reflect current needs. A third resident's care plan inaccurately listed a discontinued medication. These deficiencies highlight ongoing issues with care plan management.
The facility failed to provide adequate staffing, resulting in delayed responses to call lights and assistance with daily activities. Residents and family members reported long wait times for care, and staffing data showed consistently low weekend staffing levels. Despite attempts to staff according to census and acuity, the facility faced challenges due to call-outs and staff turnover, operating below the allotted nursing service hours.
The facility failed to maintain complete and accurate medical records for four residents, including missing hospice notes, lab results, and blood sugar monitoring. Limited access to the hospice's electronic record system and incomplete documentation of vital signs and care tasks contributed to these deficiencies, placing residents at risk for medical complications.
The facility failed to comply with infection control guidelines, as observed in medication administration, transmission-based precautions, and catheter care. An LPN did not perform hand hygiene or wear PPE while administering insulin. Staff did not adhere to droplet precautions for a resident with RSV, and hand hygiene lapses were noted during catheter care. The facility's infection preventionist and DON were unaware of these issues.
The facility failed to provide necessary assistance for oral care and bathing for three residents dependent on staff. A resident reported receiving only two showers and one bed bath since admission, despite needing extensive assistance. Another resident, totally dependent on staff, received only one shower and one bed bath. A third resident, requiring assistance with oral care, did not receive help with denture removal and cleaning. The DON was unaware of these issues, and there was no shower policy in place.
The facility did not post daily nurse staffing information in an accessible location for two days during a survey. The posted information was outdated and incomplete, lacking updates for the evening and night shifts. The Staffing Coordinator, responsible for the postings, was unaware of the missing information, and the DON confirmed the oversight.
The facility failed to accurately reconcile controlled medications in one of the medication carts. A discrepancy was found when a nurse discovered that the narcotic book indicated remaining tablets, but none were present in the cart. The issue arose because licensed nurses did not sign out the last doses in the narcotic book, although they documented administration in the MAR. The Director of Nursing confirmed the expectation for nurses to check the narcotic book for accuracy and report discrepancies.
The facility failed to ensure proper medication management and storage, with unlocked medication carts and unsecured controlled substances. Expired medications and vaccines were found, indicating lapses in monitoring. Staff interviews revealed gaps in responsibility and knowledge regarding medication storage requirements.
The facility failed to provide timely lab results for two residents, leading to potential complications. One resident experienced delays in UTI testing, while another faced issues with stool sample processing. Staff expressed concerns about the contracted lab's reliability and were seeking local services to improve turnaround times.
A resident with COPD and sleep apnea had their CPAP machine brought into the facility, but the staff failed to obtain a physician order for its use and did not perform routine cleaning. The resident's care plan did not include the CPAP machine, and staff were unaware of its presence, leading to a deficiency in respiratory care.
A resident with multiple diagnoses, including schizophrenia and muscle weakness, did not receive adequate assistance with ADLs in an LTC facility. The resident was left without proper meal assistance, as caregiver agency staff arrived late, and incontinence care was inconsistent, with the resident found soaked in urine. The facility's care plan was outdated, leading to a lack of coordination in the resident's care.
The facility failed to provide adequate assistance with activities of daily living, including personal hygiene and bathing, for two residents who were dependent on staff. One resident received only two baths in 17 days, while another received only one bed bath in two weeks. Observations and interviews revealed that both residents had food remnants on their bodies and expressed dissatisfaction with their hygiene care.
The facility failed to manage a resident's constipation according to physician orders and bowel protocol. The resident experienced multiple periods without a bowel movement, refused medications, and there was no documentation that the provider was notified. This deficiency was a repeat citation from previous surveys.
Failure to Honor Resident Preferences in Daily Schedules and Bathing
Penalty
Summary
The facility failed to honor the preferences and choices of several residents regarding their daily schedules and bathing routines. Resident 7, who has severe cognitive impairment, requested to lay down after breakfast but was left in their wheelchair for almost an hour before being assisted. This delay occurred despite the resident's known routine of either attending an activity or laying back down after breakfast, which requires assistance from two staff members and a mechanical lift. Resident 50, who is cognitively intact and has a stage 4 pressure ulcer, expressed a preference for showers twice a week, as documented in their care plan. However, they were receiving bed baths instead, allegedly due to their wound VAC, despite no physician orders contraindicating showers. Staff were unaware of the resident's documented preference for showers, leading to a failure in honoring the resident's choice. Residents 69, 276, and 31 also experienced issues with their bathing and daily schedules. Resident 69, who is cognitively intact, was made to wait several hours to go to bed despite their preference to do so earlier. They also received fewer showers than preferred. Resident 276, with mild cognitive impairment, preferred two showers a week but often received bed baths instead. Resident 31, who requires total assistance for transfers, preferred morning showers to participate in activities but often had to wait until later in the day due to staff availability. These failures to accommodate resident preferences were discussed with facility management, highlighting a lack of coordination and communication among staff to ensure resident choices are respected.
Deficiencies in Equipment, Flooring, and Call Light Accessibility
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment, as evidenced by several deficiencies observed during the survey. The facility did not ensure that transfer equipment, specifically slings, was available and in good condition. Interviews with staff and residents revealed a shortage of appropriate slings, with some staff using shower slings as regular slings due to unavailability. Observations in the laundry room showed slings with faded labels and frayed seams, which were still being used by staff. The Director of Nursing Services acknowledged the issue and stated that staff should use a chart to select the appropriate sling based on the resident's weight, but damaged slings were still found in circulation. The facility also failed to maintain the flooring in a safe condition. Observations noted gouges in the flooring down to the subfloor in the hallways and rooms. The Maintenance Director was aware of the issue and mentioned having some extra flooring for repairs but was uncertain if there was enough to address all the damaged areas. This lack of maintenance posed a risk of injury to residents and staff. Additionally, the facility did not ensure that call lights were functional and within reach of residents. Several instances were observed where call lights were not audible or accessible to residents, including two residents with a history of falls and mobility issues. Maintenance reports indicated multiple call light repairs in the past month, and staff interviews confirmed the ongoing issues with call light functionality. The Director of Nursing Services was unaware of the extent of the problem, which compromised the residents' ability to call for assistance when needed.
Care Plan Deficiencies in Resident Management
Penalty
Summary
The facility failed to review and revise care plans to accurately reflect the conditions and needs of three residents, leading to potential risks for unmet care needs and diminished quality of life. Resident 34, who was receiving hospice services and had severe cognitive impairment, was observed struggling with poor eyesight. Despite the resident's inability to see their food and the need for assistance, the care plan only mentioned the need for large print materials during activities and did not address the resident's visual impairment adequately. Additionally, the fall mat alarm intended to prevent falls was not consistently placed under the resident's feet, despite a history of falls. Resident 50, who had an indwelling catheter and a history of UTIs, did not have peri-care documented in their care plan, which is essential for preventing infections. The resident expressed concerns about the lack of catheter care, and staff interviews revealed that peri-care was not included in the care plan or Kardex. Furthermore, the resident, who had a stage 4 pressure ulcer, was observed lying on their back for extended periods without repositioning, contrary to standard care practices for pressure ulcer management. The resident was also found without a pressure-relieving cushion in their wheelchair, which was necessary to prevent further skin breakdown. Resident 56's care plan inaccurately reflected the use of a hypnotic medication for insomnia, which had been discontinued months prior. This discrepancy highlights the facility's failure to update care plans following changes in the resident's condition or medication regimen. The repeated deficiency from a previous survey indicates ongoing issues with care plan management and revision within the facility.
Staffing Deficiencies Lead to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of its residents, as evidenced by interviews with residents and family members, as well as a review of staffing data and resident council minutes. Residents reported long wait times for call light responses, assistance with daily activities, and medication delivery. The facility's past four quarters of payroll-based journal (PBJ) reports indicated consistently low weekend staffing levels, with no improvements over the past year. The facility assessment revealed a high number of residents requiring two-person assistance for daily care, yet the staffing schedules for February 2025 showed numerous unstaffed shifts, particularly on weekends. The resident council minutes documented ongoing concerns about staffing, including delays in call light responses and medication administration. Interviews with residents and family members corroborated these issues, with reports of wait times ranging from 8 to 45 minutes for assistance. Staff interviews indicated that the facility attempted to staff according to census and acuity, but faced challenges due to call-outs and staff turnover. The facility had multiple openings for NACs and LPNs, and relied on agency staff to fill gaps. Despite efforts to address staffing shortages, the facility continued to operate below the allotted nursing service hours, as evidenced by the staff postings for late February 2025.
Incomplete Medical Records and Documentation Deficiencies
Penalty
Summary
The facility failed to maintain complete, accurate, and accessible medical records for four residents, which included missing hospice provider notes and orders, lab monitoring results, and complete blood sugar monitoring. For Resident 5, who was readmitted on hospice services, there was no documentation of visits by the hospice nurse or provider since readmission. The hospice documentation was kept in a separate electronic record system (EPIC) that was not accessible to the licensed staff, leading to incomplete medical records. Resident 34, admitted with heart failure, stroke, and heart attack, also lacked hospice progress notes in their medical records. The hospice agency communicated changes through verbal updates and faxed orders, but the progress notes were not integrated into the facility's electronic medical records. This lack of documentation was due to limited access to the hospice's electronic record system by the facility staff. Resident 276's records showed missing documentation for vital signs, wound care, and other monitoring tasks on specific dates. Similarly, Resident 1, who required insulin treatment for diabetes, had no documentation of blood sugar checks prior to insulin administration, despite having a monitoring device. The device's results were not uploaded into any software or app, and the care plan was not updated to reflect the use of the glucose monitoring system. These deficiencies in record-keeping placed residents at risk for medical complications and unmet care needs.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure compliance with infection prevention and control guidelines, as observed in several instances involving staff and residents. During medication administration, a Licensed Practical Nurse (LPN) did not perform hand hygiene or wear personal protective equipment (PPE) while administering insulin to a resident with diabetes and bacteremia. The LPN used bare hands to manipulate the resident's clothing and injected the insulin without gloves, subsequently leaving the room without performing hand hygiene. In another instance, the facility did not adhere to transmission-based precautions for a resident who tested positive for Respiratory Syncytial Virus (RSV). Despite the resident being on droplet isolation precautions, staff members were observed entering the resident's room without the required gown and eye protection. Additionally, staff failed to replace their surgical masks after exiting the isolation room, contrary to the facility's expectations and training. Furthermore, during catheter care for a resident with a Foley catheter and colostomy bag, staff members did not perform hand hygiene between glove changes. Staff were observed donning new gloves without using alcohol-based hand rub (ABHR) after removing soiled gloves, and continued to provide care and handle equipment without proper hand hygiene. The facility's infection preventionist and Director of Nursing Services were unaware of these lapses, which were not in line with the facility's policies and training.
Deficiency in Providing Assistance for ADLs
Penalty
Summary
The facility failed to provide necessary assistance for oral care and bathing for three residents who were dependent on staff for these activities of daily living. Resident 69, who was cognitively intact and required extensive assistance for bathing, reported receiving only two showers and one bed bath since admission, despite expressing a preference for two showers a week. Documentation confirmed that Resident 69 had only three bathing tasks recorded. Similarly, Resident 276, who had mild cognitive impairment and was totally dependent on staff for bathing, reported receiving only one shower and one bed bath since admission, with records confirming a lack of regular bathing. Resident 20, who had mild cognitive impairment and required assistance with oral care, reported sleeping with dentures in their mouth and expressed a desire for them to be removed and cleaned nightly. Despite recommendations from dental notes for staff to assist with brushing and denture removal, interviews with staff revealed that oral care was not provided. The Director of Nursing Services was unaware of any issues with oral care or bathing not being completed, and there was no shower policy in place, only a standard of care. This deficiency was a repeat issue from a previous statement of deficiencies.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nurse staffing information was posted in a location readily accessible to residents and visitors, and that it included the required information on two of the six days during the recertification survey. On February 23, 2025, at 7:45 AM, the posted nurse staffing information was observed to be dated February 21, 2025, with no updated forms for February 22 or 23, 2025. The posted information for February 21, 2025, was incomplete, showing only the total actual hours worked for the day shift, while the evening and night shifts were left blank. Staff H, the Staffing Coordinator, was responsible for posting the daily staffing information and relied on another staff member to complete it on weekends. However, Staff H was unaware of why the postings for February 22 and 23, 2025, were not completed. Staff B, the Director of Nursing Services, confirmed that Staff H was responsible for the postings and was unaware of the missing information for those dates.
Failure to Reconcile Controlled Medications
Penalty
Summary
The facility failed to ensure a system was in place to accurately reconcile controlled medications, specifically narcotics, in one of the five medication carts reviewed. During an observation and interview, a Registered Nurse, Staff V, was counting narcotic medications and found discrepancies in the narcotic book for the [NAME] Cart. The book indicated that there should be one tablet left on two separate pages, but there were no narcotic medications present in the cart. Staff V acknowledged the discrepancy and stated that the count was incorrect, indicating that the pages should show zero. Staff V planned to inform the Resident Care Manager (RCM) to initiate an investigation. Further investigation by Staff L, a Licensed Practical Nurse and RCM, revealed that the licensed nurses who administered the last doses of the medications failed to sign them out in the narcotic book, although they had signed their initials in the Medication Administration Record (MAR) indicating the medications were given. Staff L stated that the process for counting narcotics required licensed nurses to review every page of the narcotic book for accuracy and report any discrepancies to the RCM. The Director of Nursing Services, Staff B, confirmed the expectation that licensed nurses should check every page of the narcotic book and report discrepancies to the RCM or DNS. The facility was able to reconcile the narcotic book for the [NAME] Cart.
Medication Management and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper management and storage of medications and biologicals, leading to several deficiencies. During observations, two medication carts were found unlocked and unattended, with over-the-counter medications and bubble-packed medicine cards accessible. Additionally, controlled medications, specifically Lorazepam, were stored in a refrigerator that was not affixed to the floor, and the container holding the medication was not secured. This lack of secure storage for controlled substances was a significant oversight. Furthermore, the facility did not adequately monitor the expiration dates of medications and vaccines. Expired medications, including Loratadine and Simethicone, were found in medication carts, and expired Afluria flu vaccines were discovered in a refrigerator. Interviews with staff revealed that the night shift nurse was responsible for checking and discarding expired medications, but this process was not effectively implemented, leading to expired items remaining in use. The Director of Nursing Services was unaware of the requirement for controlled medications to be stored in a firmly affixed container, indicating a gap in knowledge and adherence to regulations.
Delayed Laboratory Results Impact Resident Care
Penalty
Summary
The facility failed to provide timely laboratory results for two residents, which had the potential for negative complications due to delays in obtaining and following up on laboratory results. Resident 277, who was admitted with multiple diagnoses including diabetes and kidney disease, reported symptoms of a urinary tract infection (UTI) but experienced delays in testing and receiving results. Despite the resident's complaints and a physician's order for a urinalysis, the sample was not processed due to logistical issues with the contracted lab, which resulted in a delay in diagnosis and treatment. Resident 279, admitted with septic shock and nutritional deficiency, also experienced delays in laboratory testing. A stool sample was collected to test for Norovirus and other infections, but the sample was not processed due to being overfilled. The contracted lab's slow turnaround time and logistical challenges in sample collection and processing contributed to the delay in obtaining results, which could have impacted the resident's care and treatment. The facility's Director of Nursing and other staff members expressed concerns about the reliability and timeliness of the contracted lab services. They reported ongoing issues with sample processing and communication from the lab, which often resulted in the need for re-collection of samples. The facility was actively seeking local lab services to improve turnaround times and ensure timely and accurate diagnostic testing for residents.
Failure to Obtain Order and Clean CPAP Machine
Penalty
Summary
The facility failed to ensure a physician order was obtained and routine cleaning was provided for a CPAP machine for a resident. The resident, who was admitted with chronic obstructive pulmonary disease, obstructive sleep apnea, and chronic respiratory failure, had their CPAP machine brought into the facility from home. However, the Admission Minimum Data Set assessment did not code the CPAP machine, and the resident's care plan did not include the use of the CPAP machine. During an observation and interview, the resident stated that the staff had not cleaned their CPAP machine. The Order Summary Report showed no order for CPAP machine usage or cleaning. Staff members, including a Licensed Practical Nurse and the Director of Nursing Services, were unaware of the CPAP machine's presence and confirmed the absence of an order for its use or cleaning.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for a resident who was dependent on staff for care. The resident, who had diagnoses including paranoid schizophrenia, urine retention, overactive bladder, and muscle weakness, was unable to communicate effectively and required extensive assistance with meals, bed mobility, transfers, toileting, and hygiene. Despite these needs, the facility did not consistently provide the necessary care, as evidenced by observations and interviews with staff and caregiver agency personnel. On multiple occasions, the resident was left without proper meal assistance, as the caregiver agency staff responsible for feeding them arrived after breakfast was served, leaving the meal untouched for extended periods. Additionally, the facility staff did not adequately monitor or assist the resident with incontinence care, as the resident was found soaked in urine on at least one occasion. Interviews with staff revealed inconsistencies in the care provided, with some staff members acknowledging the resident's refusal of care and others failing to perform essential tasks such as brushing the resident's teeth. The facility's care plan for the resident was not updated to reflect the involvement of the caregiver agency, leading to a lack of coordination and oversight in the resident's care. The Director of Nursing Services admitted to not reviewing the care plan until recently, indicating a lapse in ensuring that the resident's needs were met. This deficiency in care placed the resident at risk for a diminished quality of life, as their basic needs for hygiene, nutrition, and comfort were not consistently addressed.
Failure to Provide Adequate Assistance with ADLs
Penalty
Summary
The facility failed to provide assistance with activities of daily living, including personal hygiene and bathing, for two residents who were dependent on staff for these needs. Resident 1, diagnosed with cerebral palsy and joint pain, required substantial assistance with personal hygiene and bathing. However, documentation showed that Resident 1 received only two baths in 17 days. Observations and interviews revealed that Resident 1 often had food remnants on their shirt, indicating a lack of assistance with cleaning up after meals, which bothered the resident. Resident 3, diagnosed with stroke, paralysis, and major depressive disorder, also required substantial assistance with personal hygiene and bathing. Documentation showed that Resident 3 received only one bed bath in two weeks. Observations and interviews revealed that Resident 3 had food remnants on their body and in their hair, and expressed a desire for more frequent showers. Staff interviews confirmed that residents should be offered baths regularly and that refusals should be documented and followed up with education on personal hygiene. This deficiency was a repeat citation from a previous survey.
Failure to Manage Constipation in Resident
Penalty
Summary
The facility failed to ensure the needed care and services for a resident with constipation, muscle weakness, and pain. The resident had physician orders for Polyethylene Glycol (MiraLAX) daily, Milk of Magnesia (MOM) as needed if no bowel movement (BM) for three days, and Bisacodyl suppository if MOM had no results. Despite these orders, the resident experienced multiple periods without a BM, including five days from 04/15/2024 to 04/19/2024, four days from 04/27/2024 to 04/30/2024, and six days from 05/01/2024 to 05/06/2024. The resident refused the Polyethylene Glycol on several occasions, and there was no documentation that the provider was notified of these refusals or the lack of BMs. MOM and Bisacodyl suppository were not administered as per the bowel protocol during these periods. Interviews with staff revealed that the nurses were responsible for managing residents' BMs and following the bowel regimen. However, there was a lack of consistent documentation and communication regarding the resident's medication refusals and bowel movements. The nursing progress note and hospice visit summary indicated that the resident had gone eight days without a BM and had refused the bowel medications, but there was no indication that the provider was notified. This deficiency was a repeat citation from previous surveys conducted on 03/26/2024 and 04/23/2023.
Latest citations in Washington
A resident with cerebral palsy and a court-appointed guardian experienced multiple episodes of nausea, vomiting, loose stools, abdominal discomfort, fatigue, and later refusal of meals and medications, leading to changes in the care plan including close monitoring, lab testing, and IV fluid administration. Despite a facility policy recognizing court-appointed guardians as resident representatives with decision-making authority, staff did not document any notification to the guardian during these changes in condition or treatment decisions. The guardian reported not being contacted when the resident stopped eating or developed stomach issues and felt the facility did not respect the guardianship, while the DON acknowledged there were multiple missed opportunities to notify the guardian of the resident’s change from baseline.
A resident with depression, anxiety, moderate cognitive impairment, and urinary incontinence, care-planned for q2h checks and assistance with toileting, was found by a visitor to be soaking wet, unusually agitated, and reporting they had been told to wait to be changed and referred to with a derogatory remark. The visitor filed a written grievance alleging abuse/neglect related to delayed incontinence care and removal of the resident’s tablet as a consequence. Although an incident report noted that the matter was reported to the state and that the resident was not soaking wet, a CNA who actually changed the resident later reported the resident’s brief, pants, wheelchair, and socks were soaked and that the resident was acting timid and repeatedly saying they had to sit for five minutes, but this CNA was never interviewed. The DON acknowledged not investigating the resident’s behavior or interviewing this CNA, and the grievance official acknowledged the facility did not fully investigate or communicate findings and resolution to the complainant, resulting in a failure to follow the facility’s grievance policy.
A resident with dementia, respiratory failure, and heart failure developed new shortness of breath with an O2 sat of 90%, and a physician ordered transfer to the ED for tx and eval. An RN completed an SBAR, notified the MD and family, and reported to the oncoming nurse that the resident needed ED transfer and that paramedics should be contacted, then left the facility. Instead of calling 911 for this emergent respiratory distress, staff arranged non-emergent transport through a contracted ambulance service, resulting in the resident remaining at the facility for several hours without pickup until the dispatcher later instructed staff to call 911. The DON stated that 911 is expected to be used for emergent conditions and the contracted service only for non-emergent transport.
A resident with anoxic brain injury, dysarthria, and documented lack of decisional capacity alleged physical abuse and expressed fear of their identified representative, yet social services only reported the allegation to the state and did not complete an incident report, revise the care plan, or implement protective interventions. The same representative continued to be treated as the resident’s decision-maker and visited frequently, with staff noting suspicious odors of foreign substances and concerns about possible illicit substance use. Psychiatry later documented concern that the representative was providing illicit substances, and the resident was subsequently hospitalized for altered mental status and overdose, after which the representative was banned. Key staff, including the DON, unit manager, and administrator/abuse coordinator, were unaware of the initial abuse allegation, and social services did not timely explore or clarify legal decision-making authority or alternative representation for the resident.
A resident with severe cognitive impairment, osteoarthritis, and spinal spondylosis, care planned for 2-person Hoyer transfers, was being moved by two CNAs using a mechanical lift when one corner loop of the sling became disengaged, causing the resident to fall about four feet, strike the floor and the lift, and sustain head abrasion, multiple rib fractures, and lumbar vertebral fractures. Facility policy required staff to verify secure sling attachment, examine hooks, clips, fasteners, and strap stability, and ensure the sling bar was sound before lifting, but during this transfer the sling loop detached despite staff believing it was properly fastened and hearing it click into place; post-incident assessment showed the loop had come loose, the sling appeared in good condition, and a CNA later reported thinking one of the round metal disks on the lift might have been slightly loose, while maintenance logs documented no prior concerns with the lifts or slings.
The facility failed to revise and individualize care plans to reflect current needs and preferences for multiple residents, including one cognitively intact resident with hemiplegia, hemiparesis, and mononeuropathy who had bilateral shoulder surgery and could not tolerate BP measurements on the upper arms but preferred forearm readings. Despite repeatedly informing staff, this preference was not documented in the care plan or Kardex, and direct care staff and the RN/UM were unaware of it. Another cognitively intact resident with hemiplegia, contractures, and weakness reported they were supposed to get out of bed for two hours daily, but some NACs did not know this, even though the MAR/TAR contained an order to document times up and back to bed. The surveyors concluded that care plans were not accurately revised for several residents, placing them at risk for unidentified and unmet care needs and diminished quality of life.
Surveyors found that two residents with hemiplegia, hemiparesis, weakness, and contractures did not receive restorative nursing services, including ROM exercises and splint/brace or orthotic assistance, after therapy discharge. Although PT and OT discharge summaries documented established restorative ROM and transfer programs, recommended PROM to affected extremities, and recommended splint/brace use and assistance with orthotic wear, these recommendations were not entered as restorative referrals in the EHR. As a result, the residents’ care plans and records showed no restorative programs, and both residents reported that therapy and restorative exercises had stopped, while the DON, rehab director, and MDS coordinator confirmed they were unaware of and had not implemented the recommended restorative services.
A resident with cancer, cognitive impairment, and declining strength experienced multiple unwitnessed falls, most occurring while attempting to toilet or move toward the bathroom, culminating in a fractured ankle requiring ED treatment. Although assessments identified fall and incontinence risks and the facility’s policy required individualized interventions, the comprehensive care plan lacked a toileting plan and did not include several interventions that were discussed in incident investigations, such as consistent wheelchair placement and frequent rounding for bathroom assistance. Staff reported relying on verbal reminders and education to use the call light, despite acknowledging the resident’s impulsivity and failure to call for help, and the resident’s bed remained furthest from the bathroom while repeated bathroom-related falls occurred without the trend being recognized or addressed in the care plan.
A resident with a history of acute urinary retention and acute kidney injury had a Foley catheter deemed permanent by the hospital, with instructions that it not be removed in the SNF. At a later urology visit, the catheter was removed, and the resident returned with no new orders documented. Facility staff did not document bladder assessments, post-void residuals, or urine output, and CNA documentation showed the resident did not void that evening. Over the next day, the resident had vomiting, poor intake, altered level of consciousness, tachycardia, hypotension, and no documented wet briefs. A bladder scan eventually showed more than 2000–2500 mL of retained urine, and a new catheter drained a large volume. The resident and a roommate reported moaning, crying out in pain, and repeatedly alerting staff that the resident was not urinating and that the catheter was not draining, while nurses documented catheter care when no catheter was in place and later had to flush and replace the catheter due to continued complaints.
Surveyors found that nurses and nurse aides did not consistently administer medications according to professional standards and facility policy. Multiple residents reported that agency nurses were slow with medications, did not fully follow instructions, and often gave routine meds late. Observations showed an LPN administering expired Humalog/Lispro insulin well past the scheduled time, an LPN giving several scheduled meds (including Tizanidine) late and all at once, and an RN attempting to give sliding-scale insulin nearly two hours late, which a resident refused after already eating. Another resident received Methocarbamol two hours late after questioning the RN, and a resident on scheduled Tramadol had doses given without timely documentation, with a discrepancy between the narcotic count and pills remaining. These events demonstrated failures in timely administration, use of non-expired medications, and immediate, accurate MAR and narcotic documentation.
Failure to Notify Court-Appointed Guardian of Resident’s Clinical Changes
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s court-appointed guardian of significant clinical changes and care decisions, contrary to its own policy and state requirements. The facility’s policy on Resident Representatives, revised 02/2021, states that a resident representative includes a court-appointed guardian or conservator and that the facility treats the representative’s decisions as those of the resident to the extent delegated or required by the court. Resident 1, admitted with cerebral palsy, had a Superior Court guardianship letter dated 02/07/2025 indicating a guardian of person and conservator of the estate with full authority, identifying Collateral Contact 1 (CC1) as the guardian. Despite this, multiple clinical events and changes in condition were documented without any corresponding documentation that CC1 was notified. Progress notes and provider notes show that Resident 1 experienced an episode of nausea and vomiting, frequent loose stools, abdominal discomfort, bloating, worsening fatigue, generalized weakness, and later refusal of meals and medications over at least a 24-hour period, with observations that the resident appeared frailer, more fatigued, and had no energy or interest to talk. The provider developed care plans including close monitoring for deterioration, sending stool to the lab, and later initiating IV fluids for rehydration, with a plan to call family/POA for discussion. However, there was no documentation that the guardian was notified at any of these points, including when IV fluids were started. CC1 reported that they were not contacted when the resident stopped eating or developed stomach issues, and expressed that the facility did not respect their guardianship and that involvement in care planning took too long. The DON confirmed on record review that there were many opportunities to notify the guardian when the resident’s condition changed from baseline and that there was no evidence staff did so.
Failure to Thoroughly Investigate and Resolve Resident Grievance Regarding Incontinence Care and Staff Conduct
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and resolve a grievance alleging neglect and disrespect toward a resident, as required by its grievance policy. The resident had depression, anxiety, moderate cognitive impairment, occasional urinary incontinence, and required moderate assistance with toileting, with a care plan directing staff to check the resident every two hours, ask about toileting needs, and ensure they were clean and dry. A collateral contact reported arriving to visit the resident and finding them soaking wet and agitated, with behavior that was not typical for the resident. The collateral contact documented in a written grievance that the resident’s tablet was off, the resident appeared upset, and the resident reported being told they had to wait five minutes to be changed and that staff would change their “nasty *ss” in five minutes, leading the collateral contact to believe the resident had been given a consequence of no tablet and sitting in wet clothes, which they characterized as abuse/neglect and requested immediate removal of the responsible staff and a report filed. The facility documented receipt of the grievance and created an incident report indicating the matter was reported to the state agency, and that the unit manager interviewed the collateral contact and the resident, with the resident described as confused and denying being soaking wet. The incident report stated that a different nursing assistant was assigned to assist with the brief change and that the unit manager believed the resident was not soaking wet, and that the resident and collateral contact were satisfied when they left the room. However, a CNA who actually changed the resident reported that the resident’s brief was soaked through their pants onto the wheelchair and their socks were soaked, and that the resident was timid, repeatedly saying they had to sit for five minutes, and not acting like themselves; this CNA stated they were never interviewed or asked about the grievance or the resident’s condition. The DON acknowledged not interviewing this CNA or investigating the resident’s behavior and why they were upset, and the unit manager did not recall whether the collateral contact was present during follow-up and did not believe they followed up with the collateral contact regarding the grievance. The administrator, identified as the Grievance Official, stated the facility should have thoroughly investigated the grievance and discussed findings and resolution with the collateral contact, indicating the grievance process was not fully carried out in accordance with policy and WAC 388-97-0460.
Failure to Obtain Timely Emergency Transport for Resident in Respiratory Distress
Penalty
Summary
The deficiency involves the facility’s failure to obtain timely emergency medical services for a resident experiencing new-onset respiratory distress. The resident had dementia, respiratory failure, and heart failure, with severe cognitive impairment and a need for substantial assistance with activities of daily living. On the day the resident was sent to the hospital, a collateral contact observed the resident having difficulty breathing, appearing unable to get enough air, and looking as if they were sleeping or unconscious, and reported this to staff with a request to contact the doctor. An SBAR Communication Form documented that the resident was experiencing shortness of breath that had not occurred before, with an oxygen saturation of 90%. The physician was notified and ordered the resident sent to the emergency department for treatment and evaluation, and the collateral contact was notified shortly thereafter. Progress notes later documented that, despite the order for emergency department transfer, the resident was still awaiting pickup by Olympic transportation several hours later, with no estimated time of arrival. At approximately 3:30 AM, the dispatcher informed the facility that they could not provide transportation and instructed that 911 be called; only then was 911 contacted and the resident transported to the hospital via ambulance for respiratory distress. The RN caring for the resident stated they completed the SBAR, notified the physician and family, and at the end of their shift reported to the oncoming nurse that the resident needed to be sent to the emergency department for respiratory distress and that paramedics should be contacted, then left assuming 911 would be called. The DON stated that staff are expected to contact 911 for emergent conditions such as shortness of breath or respiratory distress, and that Olympic Ambulance is used only for non-emergent transport.
Failure to Provide Social Service Advocacy After Abuse Allegation and Questionable Representative
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate medically-related social services and advocacy for a resident following an allegation of abuse and concerns about the resident’s representative. The resident had an anoxic brain injury, dysarthria, moderate cognitive impairment, and was dependent on staff for activities of daily living. A hospital palliative care note documented that the resident lacked decisional capacity, had no DPOA, that the legal next of kin (CC4) did not want to be part of care decisions, and that care decisions were being deferred to another contact (CC5). CC5 accompanied the resident on admission, signed admission forms, and was listed as the primary contact in the medical record profile. On a date in February, during communication therapy, the resident reported that CC5 had done something to them, pounded their hands on their chest, recalled being hit in the back of the head by an unknown person, and stated they were sometimes afraid of CC5. A social services staff member reported this allegation to the state agency but did not complete a facility incident report, did not initiate care plan changes or interventions, and took no further action. CC5 continued to be treated as the resident’s representative, and progress notes documented CC5 at the bedside on multiple dates, including an entry noting the room smelled like foreign substances and that CC5 was seen waking the resident and then asking the nurse to administer pain medications. A psychiatry note later documented concern that CC5 was providing the resident with illicit substances and stated it would be prudent for the resident to identify a POA. Subsequently, the resident was found unresponsive, transported to the hospital, and later readmitted after altered mental status and overdose, with a provider note stating that CC5 posed a significant danger to the resident and was banned from visiting. After readmission, staff attempted to contact CC4 for consent to treat but initially reached someone who stated they were not CC4. The social service director acknowledged that, beyond reporting the initial allegation, no additional interventions were implemented, that CC5 continued to be used as the resident’s representative after the allegation, and that they had not explored legal authority for decision making following the abuse allegation or concerns about substances. The social service assistant reported they did not speak with the resident about the hospital stay or CC5 and did not complete an incident report or care plan changes after the allegation. The unit manager and DON were unaware of the initial abuse allegation, and the administrator, who served as abuse coordinator, also stated they were unaware of the allegation and that an investigation should have been initiated and a representative for the resident investigated at a minimum.
Injury from Mechanical Lift Sling Detachment During Transfer
Penalty
Summary
The facility failed to ensure a safe mechanical lift transfer when a resident was being moved with a Hoyer lift and sling, resulting in a fall and injury. Facility policy for using a mechanical lifting machine required staff to securely attach sling straps to the sling bar according to manufacturer’s instructions, double-check the security of the sling attachment before lifting, examine all hooks, clips, or fasteners, check strap stability, and ensure the sling bar was securely attached and sound. Despite these requirements, during a transfer for dinner, two CNAs placed the sling under the resident, attached the loops at each corner of the sling to the lift, and raised the resident off the bed into the space between the bed and wheelchair when the bottom left corner of the sling became disengaged from the lift. The resident involved had multiple diagnoses including osteoarthritis, cervical and thoracic spondylosis, and Alzheimer’s disease, with the Minimum Data Set documenting severely impaired cognitive skills for daily decision-making. The resident’s care plan required the assistance of two staff during Hoyer lift transfers. During the transfer, the resident fell approximately four feet, landing on her buttocks, bouncing, and then falling backward and striking her head on the leg of the Hoyer lift. Hospital records documented that the resident sustained an abrasion to the back of the head, fractures of the 6th, 7th, 8th, and 10th ribs, and fractures of the 1st and 2nd lumbar vertebra. Staff interviews and observations showed that staff believed the sling loops had been securely fastened and reported hearing the loops click into place before lifting. One CNA stated that they had barely lifted the resident off the bed when the bottom left loop became disconnected and the resident fell. Another CNA reported being shocked and unable to figure out what had happened. A nurse who assessed the resident and then examined the equipment after the fall noted that one of the loops of the sling had become disengaged but stated the sling appeared to be in good condition. During a later demonstration, a CNA indicated she thought one of the round metal disks on the lift might have been a little loose. Maintenance logs for Hoyer slings and lifts for the preceding months documented no concerns with the slings or lifts, and the DON acknowledged expecting a citation due to the resident’s injury from the fall.
Failure to Revise Care Plans to Reflect Resident Needs and Preferences
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize comprehensive care plans to reflect residents’ current needs and preferences, as required by its own care planning policy. For one resident with hemiplegia, hemiparesis following cerebrovascular disease, and mononeuropathy of the upper limb, the admission MDS showed intact cognition and upper extremity impairment. This resident reported having bilateral shoulder surgery and an inability to tolerate blood pressure measurements on the upper arms due to pain, and stated a preference for BP measurements on the forearms. The resident reported having informed multiple nursing staff of this preference, but staff continued to place the cuff on the upper arms. Review of the resident’s care plan and Kardex showed no interventions or instructions regarding forearm BP cuff placement. A NAC confirmed they were unaware of the preference until the resident told them directly and that this instruction was not documented in the Kardex. The RN/Unit Manager, who stated they were responsible for revising and reviewing care plans when there were changes, also confirmed they were not aware of the resident’s preference and that it should have been updated in the care plan. Another resident, readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, contracture of the left hand, and weakness, was cognitively intact and required maximum assistance for bed mobility per a quarterly MDS. This resident stated they were supposed to get out of bed for two hours every day, but some NACs were not aware of this care requirement. Review of the resident’s March 2026 MAR/TAR showed an order to document the time the resident got up and the time they returned to bed daily. The report states that, overall, the facility failed to revise care plans accurately to reflect residents’ needs for three of four residents reviewed for care plan revision, placing them at risk for unidentified and unmet care needs and a diminished quality of life.
Failure to Implement Restorative Nursing and Splint/Brace Programs After Therapy Discharge
Penalty
Summary
The deficiency involves the facility’s failure to provide restorative nursing services, including range of motion (ROM) exercises and splint/brace assistance, to maintain or prevent decline in mobility and contractures for two residents with significant motor impairments. The facility’s undated Restorative Nursing Services policy stated that residents would receive restorative care as needed to achieve and maintain optimal functioning and that residents may initiate a restorative program upon discharge from rehabilitative care. Despite this, surveyors found that residents with documented hemiplegia, hemiparesis, weakness, and contractures were not placed on restorative programs and had no restorative interventions documented in their electronic health records (EHRs). Resident 1 was admitted with hemiplegia and hemiparesis following cerebrovascular disease, a left lower leg fracture, and weakness, and the admission MDS showed intact cognition, moderate assistance needs for bed mobility and transfers, and one-sided upper and lower extremity impairment. During observation, the resident was seen lying in bed with a bent inward left forearm and hand and reported no longer receiving therapy or nursing-assisted exercises. The care plan initiated in January showed no restorative services, and the care plan history and EHR contained no restorative nursing interventions. However, the PT discharge summary from February documented that restorative ROM and transfer programs had been established and trained, including PROM to the left upper and lower extremities and stand-by assist with transfers, and the OT discharge summary recommended a splint/brace to prevent contracture. The OT stated that the splint/brace was not tried due to lack of time before insurance was discontinued, and both the Director of Rehab and the MDS coordinator confirmed there was no restorative referral in the EHR and they were unaware of the recommendations. Resident 2 was readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, a left-hand contracture, and weakness, and the quarterly MDS showed intact cognition, maximum assistance needs for bed mobility, total assistance for transfers, bilateral upper and lower extremity impairment, and no therapy or restorative programs. The resident reported that therapy had been discontinued months earlier and that no restorative staff were assisting with exercises. The care plan and EHR showed no restorative services. OT evaluation documented left upper extremity ROM impairment, a left-hand contracture, and prior use of a left orthotic to manage flexion tone, and the OT discharge summary recommended restorative care and assistance with donning/doffing the orthotic. The PT discharge summary recommended restorative programs if Medicaid Part B services did not continue. The Director of Rehab confirmed therapy was discontinued and that restorative nursing programs were recommended, but both the Director of Rehab and the MDS coordinator stated there were no restorative referrals in the EHR after readmission, and the MDS coordinator confirmed the resident had no restorative programs since readmission.
Failure to Implement Effective Fall and Toileting Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision, identify fall trends, and implement progressive, resident-centered interventions for a resident with multiple falls and declining strength. The facility’s own Falls and Fall Risk Management policy required staff to identify interventions related to residents’ specific risks and causes to prevent falls and minimize complications. The resident’s Care Area Assessment identified cancer-related risks for pain, falls, and ADL decline, and stated that falls and urinary incontinence would be addressed in the care plan with an objective of improvement and risk minimization. However, the comprehensive care plan did not include a urinary or ADL care plan and contained no toileting plan, despite the resident’s identified risks and prior fall history. Over a series of falls, the resident repeatedly fell while attempting to toilet or move toward the bathroom, yet the facility did not recognize or address this pattern in its investigations or care planning. The resident had multiple unwitnessed falls: next to the bed while getting up to use the restroom, in the bathroom while standing to use the toilet, and near or in the bathroom on several occasions. Incident investigations and post-fall assessments documented environmental factors such as clutter, items on the floor, water on the floor, and issues with footwear, as well as the resident’s increasing weakness, impulsivity, poor safety awareness, and poor insight into limitations. Interventions documented in investigations and risk reviews included encouraging use of the front-wheeled walker, keeping the wheelchair and walker accessible, ensuring proper footwear and non-skid socks, and providing resident education on safe transfers, ambulation, and assistive device use. However, several of these planned interventions, including placement of the wheelchair and frequent rounding/toileting assistance, were not added to or reflected in the care plan as stated. Staff interviews further showed that the resident frequently fell while trying to go to the bathroom and that staff relied on verbal education and reminders to use the call light, even though the resident often did not use it. Staff acknowledged the resident’s impulsivity and tendency to get up independently despite instructions, and one staff member stated that nursing assistants were verbally instructed to offer bathroom assistance, but this intervention was not documented in the care plan. The resident’s bed remained the one furthest from the bathroom throughout the stay, and none of the facility’s investigations identified the trend of bathroom-related falls or addressed toileting options in the care plan. Ultimately, the resident sustained a left ankle fracture after another bathroom-related fall, requiring transfer to the emergency department for evaluation and treatment, and later records documented additional fractures and a decline in condition. The surveyors concluded that the facility’s failures placed residents at risk of repeated falls and injuries.
Failure to Monitor Urinary Retention After Foley Removal Leading to Prolonged Pain
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and monitor a resident for complications associated with an indwelling urinary catheter and urinary retention, particularly after catheter removal. The resident had a history of acute kidney injury due to urinary retention, which improved after Foley catheter placement in the hospital. Hospital discharge documentation indicated the catheter was placed for acute urinary retention, was deemed permanent, and included instructions that, given the resident’s significant retention and acute renal failure, staff at the skilled nursing facility should not attempt Foley removal. The facility’s catheter care plan directed staff to empty the catheter as needed and record output in milliliters, but review of the last 30 days of documentation showed continence was not rated due to the indwelling catheter and there was no documented urinary output in milliliters on the treatment administration records. The resident had a scheduled urology appointment at which the urinary catheter was discontinued. Upon return from this appointment, nursing documentation initially indicated no new orders, and an alert note later stated the catheter was discontinued and staff were monitoring for retention or pain. However, there was no documented bladder assessment or urinary output following catheter removal. Nursing assistant documentation showed that the resident did not void on the evening shift that same day. Despite the catheter having been removed, the treatment administration record showed staff continued to document provision of catheter care on subsequent shifts when no catheter was in place. Over the next day, the resident experienced vomiting, decreased oral intake, and an altered level of consciousness, with vital signs showing tachycardia and low blood pressure, and staff documented decreased urine output. A bladder scan performed later revealed more than 2000–2500 milliliters of urine in the bladder, and an indwelling catheter was reinserted, initially draining a large volume of urine. The provider note indicated the resident had not eaten since the prior night, was unable to hold down fluids, and staff were unsure whether the resident had urinated in incontinence briefs, with no wet briefs reported since the resident’s return from the hospital after catheter removal. The provider expressed concern that the documented early-morning wet brief might not be accurate given the large bladder volume on scan and stated this should require further investigation. Subsequent notes described the resident moaning and complaining of pain, with limited urine output in the catheter bag and staff flushing and then replacing the catheter due to continued complaints. Interviews with the resident, the roommate, and staff indicated the resident was crying out and moaning in pain, the roommate repeatedly alerted staff that the resident was not urinating and that the catheter was not draining, and staff had to seek assistance to replace the catheter. Facility leadership and clinical staff later acknowledged that typical practice after catheter removal would include contacting the provider, placing the resident on alert, performing post-void residuals with bladder scans, and documenting monitoring, which was not done in this case.
Medication Administration Delays, Documentation Errors, and Use of Expired Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff with appropriate competencies and skill sets to administer medications according to professional standards of practice, facility policy, and prescriber orders. The facility’s medication administration policy required medications to be given as prescribed, in accordance with manufacturers’ specifications and good nursing principles, with no expired medications used, and doses administered within 60 minutes of the scheduled time and documented immediately after administration. Multiple residents reported that agency nurses often gave medications late, did not read full instructions, or were slow in bringing medications, and that routinely scheduled medications were not consistently provided without residents having to ask. Surveyors observed several specific medication administration failures. For a resident with diabetes, an LPN drew up and administered Humalog/Lispro insulin from a multi-dose vial that had been opened and dated “02/16” with no year, making it expired per policy, and administered the dose nearly 1 hour and 45 minutes after it was due. Another resident with care plan instructions to receive medications as ordered had multiple scheduled medications (Gabapentin, Oxybutynin, Baclofen, and Tizanidine) that were ordered at specific times throughout the day; the LPN was observed administering all four together and acknowledged that at least one (Tizanidine) was late, while the resident reported that receiving them together at that time was typical and not at their request. For another diabetic resident, an RN checked blood sugar and prepared sliding scale Humalog/Lispro insulin almost two hours after the scheduled time; the resident refused the insulin, stating they had already finished lunch. Additional deficiencies were identified with other residents’ pain and scheduled medications. One resident with a pain care plan and an order for Methocarbamol four times daily at set times approached the cart requesting Methocarbamol and Tylenol; the RN initially stated the Methocarbamol had already been given, but then administered it two hours after it was due when the resident pointed out the scheduled timing. For another resident with a risk for pain care plan and Tramadol ordered three times daily at specific times, an LPN retrieved a PRN pain medication while the electronic record showed no 8:00 AM medications documented; the LPN stated they had given them but had not yet documented. Later, an RN prepared the 2:00 PM Tramadol dose, and review of the narcotic count showed a discrepancy between the number of pills documented and the number remaining in the card. The RN stated they had given the 8:00 AM Tramadol but had not signed it out, then signed out both the 8:00 AM and 2:00 PM doses at that time. Residents interviewed consistently reported that medications were sometimes or frequently late, that agency nurses did not always follow instructions, and that they often had to request medications that were routinely scheduled.
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