Bailey-boushay House
Inspection history, citations, penalties and survey trends for this long-term care facility in Seattle, Washington.
- Location
- 2720 East Madison, Seattle, Washington 98112
- CMS Provider Number
- 505476
- Inspections on file
- 19
- Latest survey
- July 16, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Bailey-boushay House during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and agitation was allowed to leave their unit unaccompanied, contrary to their care plan, and was not monitored by staff or security. As a result, the resident was involved in a verbal altercation and was struck by another individual. Staff interviews and documentation confirmed that the required supervision and care plan protocols were not followed.
The facility did not include required recertification survey results and plans of correction for two years in the Past Survey Results binder, as mandated by policy. The DON and Administrator confirmed the omission, which prevented residents, representatives, and visitors from reviewing these documents as required.
Surveyors found that MDS assessments were not accurately completed for four residents, including failures to document opioid use, incorrectly coding for delusions without supporting EHR documentation, not interviewing a family member for activity preferences when a resident could not communicate, and coding insulin administration without a physician's order. Staff acknowledged these errors and confirmed that the assessments should have been completed accurately.
Multiple residents with serious mental illness or related diagnoses did not have their Level I PASARR assessments accurately completed or updated, and required referrals for Level II evaluations were not made, despite clear indicators. Staff interviews confirmed that the PASARR process was not followed as required, resulting in incomplete documentation and missed referrals.
The facility did not include its name on daily nurse staffing postings for five consecutive days, as required by policy. Both the Charge RN and DON confirmed the omission during interviews and record reviews.
Surveyors found that vaccines were stored in a medication refrigerator with temperatures below the recommended range on multiple occasions, and no required work orders were filed. Additionally, N95 masks in a medication cart were not labeled with expiration dates, and staff could not locate the original packaging to verify shelf life. These failures to follow storage and labeling protocols placed residents at risk for compromised or ineffective medications and supplies.
Surveyors found that staff failed to label and date multiple opened and prepared food items in a reach-in cooler, including milk, a dairy beverage, cooked roast beef, and kielbasa sausage. Staff and leadership confirmed these items should have been labeled and dated according to facility policy.
Staff failed to consistently remove used PPE inside resident rooms and did not perform hand hygiene between glove changes, as required by facility policy and CDC guidelines. These lapses were observed among CNAs, an RN, and housekeeping staff during routine care and cleaning activities, with staff interviews confirming inconsistent understanding and adherence to infection control protocols.
A resident with depression was started on an antidepressant without informed consent being obtained prior to the first dose, as required by facility policy. Staff confirmed that the consent form was completed months after medication administration began, and that informed consent should have been documented in the EHR before starting the medication.
A resident's personal funds were not transferred to their representative or estate within the required timeframe after discharge. Despite facility policy mandating return of funds within one week, the transfer occurred over nine months later, as confirmed by record review and staff interviews.
Two residents prescribed psychotropic medications, including an antianxiety drug and an antidepressant, were not monitored for adverse side effects as required by facility policy. Staff confirmed that monitoring was expected but not documented or ordered for either resident.
A resident who experienced a significant decline, including the need for a feeding tube and increased dependence for mobility and eating, did not have a Significant Change in Status Assessment (SCSA) completed as required. Staff interviews confirmed that an SCSA should have been done following these changes, but it was not documented.
Two residents did not have comprehensive care plans addressing their specific needs: one resident on apixaban lacked a care plan for anticoagulant use and monitoring for side effects, and another resident with PTSD did not have their trauma history or triggers documented or addressed. Staff confirmed these omissions during record reviews and interviews.
The facility did not update care plans for two residents to reflect significant information: one resident's ongoing refusal to wear a safety apron while smoking and another resident's stated activity preferences identified in the MDS. Staff and leadership confirmed these omissions, which were evident in care plan documentation and interviews.
A resident's assessed preferences for activities such as listening to music, going outside, and being around animals were not incorporated into their care plan, resulting in the resident remaining in their room without being offered individualized or group activities. Staff confirmed the lack of personalized activity offerings and documentation showed no activities outside the resident's room were provided.
A resident with a diagnosis of PTSD was not adequately assessed for trauma-informed care or specific triggers, despite facility policy and staff expectations. The resident's care plan did not document their trauma history or identify interventions for PTSD, and staff interviews confirmed that no specific assessment for PTSD triggers was conducted.
A resident receiving apixaban for blood clots was not adequately monitored for adverse side effects, as required by facility policy. Review of medical records and interviews with nursing staff, including an RN, MDS Coordinator, and DON, confirmed that there was no physician's order or documentation for monitoring adverse effects of the anticoagulant, resulting in a failure to ensure proper oversight of high-risk medication use.
The facility did not ensure that residents receiving paid feeding assistance were properly assessed for program appropriateness, nor did it verify that staff providing this assistance had completed required training. A resident with swallowing difficulties received feeding assistance without documented assessment, and another was assisted by a staff member unable to provide proof of training. Facility policy required both assessments and verified training, but these were not documented or completed.
A resident reported an allegation of sexual abuse by a visitor to a social worker, but the facility delayed reporting it to the State Agency for three days, contrary to policy requiring immediate reporting. Staff involved acknowledged the delay, and the Assistant Director of Nursing confirmed the expectation for immediate reporting.
The facility failed to complete admission and annual MDS assessments within the required timelines for four residents, with delays ranging from 54 to 105 days. Staff acknowledged the late completion, which could impact residents' care needs and quality of life.
The facility failed to complete quarterly MDS assessments within the required 14-day timeframe for eight residents, with delays ranging from 14 to 99 days. Staff acknowledged the late completions, which were identified through interviews and record reviews, despite following the RAI manual guidelines.
The facility did not discard expired food items in the Kitchen Dry Foods Storage Area, as observed during a survey. Expired tortillas were found, and both the Food Services Manager and Administrator acknowledged that these items should have been discarded by their expiration date, posing a risk to residents.
The facility failed to include a flow diagram in its water management program to monitor Legionella growth and did not follow Enhanced Barrier Precautions (EBP) for a resident with a history of MDRO. The absence of EBP signage and PPE use during high-contact care activities was confirmed by staff.
A resident was not informed of the risks and benefits before using a transfer pole, as required. The resident used the pole daily, but there was no documentation of informed consent. Staff interviews revealed a lack of awareness about the need for consent, and the facility's Assistant Director of Nursing expected such documentation.
The facility failed to report abuse allegations to the State Agency for two residents. One resident reported being hit by a staff member, and another complained of rough care, but neither incident was reported or properly investigated. Staff interviews revealed confusion and miscommunication regarding the reporting process, leading to this deficiency.
A resident reported rough care by nurses, but the facility failed to thoroughly investigate the allegation as required by their policy. The complaint was noted in resident council minutes but not logged in incident or grievance logs. Staff involved were unaware of the need for a formal investigation, leading to an incomplete response and lack of reporting to the State Agency.
A facility failed to provide written notification of hospital transfers to a resident and their representative, as required by regulations. Staff members, including a charge nurse and social worker, confirmed that their practice was to notify by phone only, with no written documentation provided. This deficiency was identified through a review of the resident's clinical records and staff interviews.
A resident was transferred to the hospital without receiving a bed-hold notice, as required by the facility's policy. The absence of documentation in the resident's EHR was confirmed by staff interviews, indicating a failure to inform the resident or their representative about their right to hold their bed during hospitalization.
A resident's MDS assessment inaccurately coded tube feeding and failed to document fall incidents. The resident, with dysphagia, had tube feeding discontinued but was still coded for it in the MDS. Additionally, two near falls were not recorded. The MDS Coordinator acknowledged the errors, and the Assistant DON expected accurate assessments.
A facility failed to ensure a resident's PASRR form accurately reflected their mental health diagnoses, including anxiety and unspecified psychosis. The admissions staff relied on the hospital to complete the PASRRs and were unaware of the inaccuracy, which was not marked for serious mental illness. The Assistant Director of Nursing expected accurate completion and follow-up for incorrect PASRRs.
The facility failed to provide baseline care plans to two residents upon admission, as required by their policy. Although the care plans were reviewed with the residents, there was no documentation that copies were provided. Staff admitted to not offering baseline care plans, only providing comprehensive care plans during care conferences, which contradicted the facility's policy.
A facility failed to create a comprehensive care plan for a resident receiving oxygen therapy. Despite a physician's order for oxygen via nasal cannula, the care plan lacked details on oxygen management. Staff interviews confirmed the expectation for an oxygen care plan, highlighting a risk for unmet care needs.
The facility failed to update care plans for two residents, leading to potential risks for unmet care needs. One resident's care plan inaccurately indicated the use of dentures, which were lost, while another resident's plan did not reflect the discontinuation of tube feeding in favor of oral intake. Staff confirmed the inaccuracies, and the need for care plan revisions was acknowledged by facility coordinators.
A resident used a transfer pole daily to assist with moving in and out of bed, but the facility failed to conduct a safety assessment prior to its use. Observations showed the pole was unstable, and staff interviews confirmed the lack of a formal assessment. The Rehab Manager, responsible for such assessments, admitted that none was conducted, and the Assistant Director of Nursing confirmed the absence of documentation.
A resident with a feeding tube was not provided appropriate care as a registered nurse failed to check gastric residual volumes (GRV) before administering tube feeding, contrary to the facility's policy. The resident's care plan required GRV checks to ensure proper tube placement and feeding tolerance. Both the Charge Nurse and Assistant Director of Nursing confirmed the expectation for staff to perform GRV checks before connecting residents to enteral formula.
The facility failed to conduct timely AIMS assessments for three residents on antipsychotic medications, risking unnecessary medication use and side effects. A resident on Quetiapine lacked an assessment before May 2024, another on Seroquel hadn't been assessed since March 2023, and a third on Olanzapine had no assessments. Staff confirmed these should have been done quarterly.
The facility failed to document that two residents received education on the risks and benefits of the pneumonia vaccine, as required by policy. Despite receiving the vaccine, there was no record in their EHRs indicating they were informed. Staff interviews confirmed the lack of documentation, highlighting a gap in ensuring residents were fully informed before vaccination.
Failure to Provide Required Supervision and Follow Safety Care Plan
Penalty
Summary
The facility failed to provide necessary supervision and follow the safety care plan for a resident with severe cognitive impairment and agitation. The resident's care plan required that staff accompany them when leaving the unit or, if staff were unavailable, that security be notified. Despite these requirements, the resident was allowed access to the elevator and went to the first-floor lobby unaccompanied and without security being informed. During this time, the resident was involved in a verbal exchange and was struck in the face by another individual. Interviews with facility staff, including the Infection Preventionist/Charge Nurse, Assistant Director of Nursing, and Director of Nursing, confirmed that the resident was not accompanied as required and that the care plan was not followed. Documentation and investigation reports also indicated that staff did not provide the necessary supervision or notify security, as outlined in the resident's care plan. This lapse in supervision and failure to adhere to the care plan placed the resident at risk for injury.
Failure to Maintain Accessible Survey Results Binder
Penalty
Summary
The facility failed to ensure that the Past Survey Results binder included the most recent recertification survey results and associated plans of correction for two of the past three years reviewed (2023 and 2024). During a review of the binder, it was found that the recertification survey results and plans of correction dated 03/24/2023 and 06/13/2024 were missing. The facility's policy required that survey reports, certifications, complaint investigations, and plans of correction for the preceding three years be available for review by any individual upon request, and that a copy of the most recent survey report and any plans of correction be kept in a binder in the residents' day room. Interviews with the DON and Administrator confirmed that the responsibility for maintaining and updating the Past Survey Results binder rested with the DON, and that the process involved placing survey results in the binder upon receipt. Both staff members acknowledged that the required documents for 2023 and 2024 were not present in the binder at the time of review. The DON stated that while survey results and plans of correction were accessible online and could be printed upon request, the physical binder did not contain the necessary documents, thereby preventing residents, their representatives, and visitors from exercising their right to review past survey results and the facility's plans of correction.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for four out of thirteen residents reviewed. For one resident, the Medication Administration Record (MAR) showed that an opioid was administered during the MDS look-back period, but this was not documented in Section N of the MDS. The MDS Coordinator acknowledged that the opioid use should have been marked, indicating inaccurate MDS coding. Another resident's quarterly MDS indicated the presence of delusion in Section E, but there was no supporting documentation in the Electronic Health Record (EHR) for this behavior during the observation period. The MDS Coordinator was unable to find any evidence to support the coding of delusion and confirmed it should not have been coded. The Director of Nursing stated that MDS assessments are expected to be coded accurately. For a third resident, the MDS indicated that the resident was rarely or never understood and did not complete the activity preferences interview with the resident's family or significant other, as required when the resident cannot communicate. The MDS Coordinator admitted that no attempt was made to contact the family or significant other. In the fourth case, the MDS showed that a resident received an insulin injection during the observation period, but there was no physician's order for insulin, and the MDS Coordinator confirmed that insulin should not have been coded. The Director of Nursing reiterated the expectation for accurate MDS completion.
Failure to Accurately Complete and Update PASARR Assessments and Referrals
Penalty
Summary
The facility failed to ensure accurate completion and timely updating of Level I Pre-admission Screening and Resident Review (PASARR) assessments for multiple residents with diagnoses or indicators of serious mental illness (SMI), intellectual disabilities (ID), or related conditions (RC). For several residents, including those with documented diagnoses of psychotic and anxiety disorders, the Level I PASARR forms were either not updated to reflect current diagnoses or did not result in appropriate referrals for Level II evaluations, despite SMI indicators being present. In some cases, the original Level I PASARR was completed years prior and had not been revised to account for new or updated mental health diagnoses. Record reviews and interviews with facility staff revealed that residents with marked SMI indicators on their Level I PASARR forms did not have corresponding Level II referrals, as required by facility policy and regulatory standards. Staff interviews confirmed awareness that these residents should have had updated Level I PASARR assessments and referrals for Level II evaluations, but these actions were not completed. For example, one resident with a diagnosis of depression and marked anxiety and psychotic disorders on their PASARR did not have an updated assessment or referral, and another resident's PASARR failed to indicate their known anxiety disorder. The facility's policy states that any indicators of SMI, ID, or RC on the Level I PASARR should prompt a referral for a Level II assessment. However, the review found that for at least five residents, the PASARR process was not followed as required, resulting in incomplete or inaccurate documentation and a lack of necessary referrals. These deficiencies were confirmed through joint record reviews and staff interviews, which consistently indicated that the expected procedures for PASARR completion and referral were not adhered to.
Failure to Include Facility Name on Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to accurately complete and post the daily nurse staffing form to include the facility's name for five consecutive days. Observations and record reviews showed that the posted documents titled 'Licensed and Unlicensed Staff in our Nursing Home Today' did not reflect the facility name on any of the reviewed dates. Staff interviews confirmed that the responsible personnel, including the Charge RN and the DON, acknowledged the omission of the facility name from the posted staffing forms. The facility's own policy, updated in November 2022, requires that the facility name be included on the daily staffing form, but this was not followed during the period reviewed.
Improper Storage and Labeling of Biologicals and Medical Supplies
Penalty
Summary
The facility failed to properly store biologicals and medical supplies according to established protocols and manufacturer recommendations. Specifically, COVID-19 and influenza vaccines were stored in a medication refrigerator on the 2nd floor, where temperature logs showed that the internal temperature fell below the acceptable range of 36-46 degrees Fahrenheit on three separate occasions. Despite facility policy requiring staff to notify the Facilities Manager and file a work order when temperatures are out of range, no work orders were filed for these incidents. Staff interviews confirmed that both the Charge RN and Facilities Manager were not notified as required, and that vaccines were indeed stored in the affected refrigerator during these periods. Additionally, the facility failed to ensure that medical supplies, specifically 3M 1860 N95 masks stored in the West 3 medication cart, were labeled with expiration dates. During an observation, unbagged N95 masks were found in the medication cart without their original packaging, and staff were unable to reference the expiration date as the box could not be located. The Director of Nursing confirmed the expectation that all supplies should have an expiration date available for staff reference, which was not met in this instance. These failures were identified through observation, interview, and record review, and were in direct violation of the facility's own policies and manufacturer guidelines. The lack of proper storage and labeling placed residents at risk for receiving compromised or ineffective biologicals and medical supplies.
Failure to Label and Date Food Items in Refrigerator
Penalty
Summary
Surveyors observed that the facility failed to handle and store food items in accordance with professional standards and its own policy. During a joint observation of the reach-in cooler with a Nutrition Assistant, several food items were found to be either unlabeled or undated, including an opened container of Ultra brand milk, an opened container of Thick & Easy dairy beverage, a resealable plastic bag containing brownish-colored sliced food items identified as cooked roast beef, and a food item wrapped in aluminum foil identified as kielbasa sausage. Staff interviews confirmed that these items should have been labeled and dated upon opening or preparation, as required by facility policy. The facility's policy on Food Receiving and Storage, revised in November 2022, specifies that all foods stored in the refrigerator must be covered, labeled, and dated. Both the Nutrition Assistant and the Executive Chef acknowledged during interviews that the observed food items did not meet these requirements. The Administrator also confirmed the expectation that staff properly label and date food items. The failure to follow these procedures was identified during the survey and documented as a deficiency.
Failure to Follow Proper PPE Removal and Hand Hygiene Procedures
Penalty
Summary
Multiple staff members failed to follow proper infection prevention and control practices, specifically regarding the removal of personal protective equipment (PPE) and hand hygiene. Observations showed that staff, including CNAs and an RN, exited contact isolation rooms without removing used gowns and gloves inside the room as required. In some cases, used PPE was disposed of in bins located outside the resident rooms, contrary to facility policy and CDC guidelines. Staff interviews revealed a lack of consistent understanding and adherence to the correct procedures for PPE removal, with some staff admitting to habitual non-compliance or being unaware of the proper process. Further deficiencies were observed in hand hygiene practices among staff. Housekeeping and nursing staff were seen changing gloves between tasks or after leaving resident rooms without performing hand hygiene in between glove changes. Staff interviews confirmed that some were unaware of the requirement to clean hands before donning new gloves, while others acknowledged the expectation but failed to comply during observed instances. These lapses occurred during routine care activities, such as meal delivery, medication administration, and cleaning resident rooms. The facility's own policies, updated in June 2024, require adherence to CDC hand hygiene and PPE guidelines, which specify that PPE must be removed and hand hygiene performed before leaving a resident's environment. Despite these policies, observations and staff statements demonstrated inconsistent implementation, resulting in a failure to maintain effective infection prevention and control for residents, staff, and visitors.
Failure to Obtain Informed Consent Prior to Psychotropic Medication Administration
Penalty
Summary
The facility failed to obtain informed consent for the administration of a psychotropic medication prior to starting the medication regimen for one resident diagnosed with depression. According to the facility's policy, informed consent, which includes a discussion of the medication's risks and benefits, must be obtained from the resident or their representative before initiating psychotropic drugs such as antidepressants. Record review showed that the resident was prescribed and began receiving an antidepressant medication, but the informed consent form was not completed until several months after the medication was started. Interviews with facility staff, including a Charge RN and the Director of Nursing, confirmed that the expectation was for informed consent to be obtained and documented in the resident's electronic health record prior to the first dose of the medication. However, staff were unable to locate an informed consent form dated before the start of the antidepressant, and acknowledged that the required consent was not obtained prior to administration. This failure was identified through both record review and staff interviews.
Delayed Transfer of Discharged Resident's Personal Funds
Penalty
Summary
The facility failed to ensure that a discharged resident's personal funds were transferred to the resident or their representative/estate within the required timeframe. According to the facility's own Resident Trust Procedures, the balance in a resident's personal fund should be returned within one week of discharge. However, review of records showed that a resident who was discharged had a trust account balance of $622.23, which was not transferred until 283 days after discharge. The check to the resident's representative was dated significantly later than the discharge date, indicating a substantial delay in returning the funds. Interviews with the Finance Manager and the Administrator confirmed that the facility's process requires transferring trust balances within a week after discharge, and both acknowledged that the transfer in this case was late. The deficiency was identified through review of the trust account ledger, discharge records, and interviews, all of which confirmed that the resident's funds were not handled in accordance with facility policy or regulatory requirements.
Failure to Monitor for Adverse Side Effects of Psychotropic Medications
Penalty
Summary
The facility failed to ensure adequate monitoring for adverse side effects of psychotropic medications for two residents. One resident with an anxiety disorder was prescribed clonazepam, an antianxiety medication, but there was no documentation in the clinical record of monitoring for adverse side effects as required by facility policy. Multiple staff interviews confirmed that there was no order or documentation for monitoring, and staff acknowledged that such monitoring should have been in place. Another resident with a diagnosis of depression was prescribed and administered an antidepressant daily, but there was no evidence of monitoring for adverse side effects in the medication administration record or physician's orders. Staff interviews confirmed that monitoring for adverse side effects was expected to begin with the initial dose, but this was not documented or ordered. The lack of monitoring for both residents was contrary to the facility's policy on high-risk medication monitoring.
Failure to Complete SCSA After Resident's Significant Decline
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) for a resident who experienced a major decline in condition. The resident was initially admitted without a feeding tube and required substantial to moderate assistance with eating and mobility. Following an aspiration event, the resident was hospitalized, failed a swallow evaluation, and had a feeding tube placed, resulting in a transition to NPO status. Upon return to the facility, the resident's condition had changed significantly, including increased dependence for mobility and receiving the majority of nutrition via tube feeding. Despite these changes, review of the resident's records showed that no SCSA was completed after the decline, as required by the RAI Manual when a significant change in status occurs that is not expected to resolve within two weeks. Interviews with the MDS Coordinator and the Director of Nursing confirmed that an SCSA should have been completed for this resident's decline in condition, but it was not documented in the electronic health record.
Failure to Develop Comprehensive Care Plans for Anticoagulant Use and PTSD
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents with specific clinical needs. For one resident who was prescribed apixaban, an anticoagulant, the Medication Administration Record confirmed the medication was started, but the resident’s care plan did not include any reference to anticoagulant use or monitoring for its adverse side effects. Multiple staff interviews and joint record reviews confirmed that the care plan lacked this essential information, despite staff acknowledging that monitoring for side effects should have been included. Another resident with a diagnosis of Post Traumatic Stress Disorder (PTSD) did not have their history of trauma or identified triggers addressed in their care plan. The resident reported discomfort with certain situations due to past traumatic events, but the care plan did not document the PTSD diagnosis or specific interventions related to trauma-informed care. Staff interviews confirmed that the care plan did not reference triggers or trauma history, and staff stated that such information would be a relevant and expected addition.
Failure to Revise Care Plans for Resident Safety and Activity Preferences
Penalty
Summary
The facility failed to revise and update comprehensive care plans for two residents as required. For one resident, repeated refusals to wear a safety apron while smoking were observed and documented by staff, but this behavior was not reflected in the resident's care plan. Staff interviews confirmed that the refusal was ongoing and known to the care team, yet the care plan was not updated to address this behavior, despite expectations from nursing leadership that it should have been included. For another resident, the quarterly Minimum Data Set (MDS) assessment identified specific activity preferences, including being around animals, doing favorite activities, and going outside for fresh air. These preferences were marked as very important by the resident's representative. However, a review of the resident's activity care plan showed that these preferences were not incorporated. Staff involved in care planning acknowledged that the care plan did not reflect the resident's identified interests, and facility leadership confirmed that such preferences should be included.
Failure to Provide Individualized Activity Program Based on Resident Preferences
Penalty
Summary
The facility failed to provide an individualized and ongoing activity program that met the needs and preferences of a resident, as identified through comprehensive assessments and care planning. The resident's Minimum Data Set (MDS) assessments indicated several daily preferences, including listening to preferred music, keeping up with the news, going outside for fresh air, being around animals, and participating in favorite activities. However, these preferences were not incorporated into the resident's activity care plan. Observations over several days showed the resident remained in their room, primarily in bed with the TV on, and was not offered activities outside of their room. Interviews with staff confirmed that the resident was not escorted to group activities or provided with opportunities to participate in activities aligned with their stated preferences. Staff acknowledged that the resident could have been safely transported outside their room using a Geri-chair, but this was not done. Documentation also revealed that no activities outside the resident's room were provided during the month reviewed, and the activity care plan was not personalized to reflect the resident's interests and preferences as identified in the MDS assessments.
Failure to Assess and Care Plan for PTSD Triggers in Resident
Penalty
Summary
The facility failed to adequately assess and provide trauma-informed care for a resident diagnosed with Post Traumatic Stress Disorder (PTSD). Despite the facility's policy requiring staff to provide trauma-informed and culturally competent care, including working with residents and families to identify strengths and minimize triggers, the resident's comprehensive care plan did not document their history of trauma or identify specific triggers. The resident, who had experienced two separate traumatic events, reported discomfort with certain situations, but this information was not reflected in their care plan. Interviews with facility staff revealed that there was no specific assessment process in place to identify PTSD triggers for residents. The social worker confirmed that the initial social services assessment did not include discussions about triggers or PTSD-related concerns, and the care plan lacked any reference to PTSD or associated interventions. The Director of Nursing stated that residents with PTSD should receive trauma-informed care and have their triggers identified and included in their care plans, but this was not done for the resident in question.
Failure to Monitor for Adverse Effects of Anticoagulant Medication
Penalty
Summary
The facility failed to ensure adequate monitoring for a resident receiving an anticoagulant medication, apixaban, which was prescribed for pulmonary embolism and deep vein thrombosis. According to the facility's High-Alert Medication Monitoring Policy, residents on high-risk medications are to be routinely assessed for adverse side effects, with observations documented in the clinical record. However, review of the physician's order summary and the Medication Administration Records (MARs) for April and May 2025 showed that there was no order for monitoring adverse side effects related to anticoagulant use, nor was there documentation of such monitoring for the resident in question. Interviews with nursing staff, including a Registered Nurse, the Minimum Data Set Coordinator, and the Director of Nursing, confirmed that the resident had not been adequately monitored for adverse side effects from anticoagulant use. Staff acknowledged that there was no physician's order for monitoring, and the required monitoring was not performed or documented. This lack of monitoring was contrary to facility policy and was confirmed through both record review and staff interviews.
Failure to Assess Residents and Verify Staff Training in Paid Feeding Assistance Program
Penalty
Summary
The facility failed to ensure that residents receiving paid feeding assistance were properly assessed for appropriateness and that staff providing this assistance were adequately trained. One resident required one-person total assistance with eating and was observed being assisted by a recreation therapist, who claimed to have received paid feeding assistant training. However, the staff member was unable to provide a valid training certificate, and the facility could not locate documentation confirming completion of the required training. Another resident, who had documented swallowing difficulties and required thickened liquids, was also receiving paid feeding assistance. Review of the resident's records showed no documentation of an assessment to determine if they were appropriate for the paid feeding assistance program, despite facility policy requiring such an assessment for residents with complicated feeding problems, including swallowing difficulties. Interviews with facility staff revealed a lack of awareness regarding responsibility for completing these assessments, and the Director of Nursing confirmed that the resident did not meet the criteria for the program and that no assessment documentation existed. Facility policy stated that only residents without complicated feeding problems should be considered for the paid feeding assistant program and that only appropriately trained staff should provide this assistance. The lack of assessment and training documentation for both residents and staff led to the deficiency, as residents with special dietary needs and risks were assisted by staff whose qualifications could not be verified.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse in a timely manner to the State Agency, as required by their policy and federal law. A cognitively intact resident reported an allegation of sexual abuse by a visitor to a social worker, Staff B, on February 7, 2025. However, the facility did not report this allegation to the State Agency until February 10, 2025, three days after the initial report was made by the resident. This delay in reporting was contrary to the facility's policy, which mandates immediate reporting of such incidents. During interviews, Staff B acknowledged that the resident had informed them of the incident on February 7, 2025, and admitted that they should have reported it to the State Agency on the same day. The Assistant Director of Nursing, Staff A, also confirmed that they expected allegations of sexual abuse to be reported immediately. The failure to report the allegation promptly placed residents at risk for potential unidentified abuse and lack of protection from abuse.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to complete admission Minimum Data Set (MDS) assessments within the required 14 days of admission for two residents and did not complete annual MDS assessments within 14 days from the Assessment Reference Date (ARD) for another two residents. Specifically, Resident 1's admission MDS was completed 54 days late, and Resident 25's admission MDS was completed 105 days late. Additionally, Resident 27's annual MDS was completed 69 days late, and Resident 3's annual MDS was completed 88 days late. These delays were confirmed through interviews and record reviews with facility staff, who acknowledged the late completion of the assessments. The Resident Assessment Instrument (RAI) 3.0 User's Manual mandates that comprehensive assessments be completed within 14 days of admission and annually within 14 days from the ARD. The facility's failure to adhere to these timelines placed residents at risk for delayed and/or unmet care needs, potentially affecting their quality of life. Staff members, including the MDS Coordinator and the Assistant Director of Nursing, were aware of the expectations for timely MDS completion but did not meet these requirements for the residents in question.
Late Completion of MDS Assessments
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were conducted within the required timeframe of 14 days from the Assessment Reference Date (ARD) for eight residents. This deficiency was identified through interviews and record reviews, revealing that the MDS assessments for Residents 2, 5, 19, 6, 3, 22, 25, and 18 were completed late, ranging from 14 to 99 days past the ARD. Staff D, the MDS Coordinator, acknowledged during interviews that the assessments were not completed on time, despite following the Resident Assessment Instrument (RAI) manual guidelines. The report highlights specific instances of late MDS assessments for each resident. For example, Resident 2's quarterly MDS with an ARD of 01/02/2024 was completed 86 days late, and another with an ARD of 04/03/2024 was 21 days late. Similarly, Resident 5's assessments were 99 and 33 days late, respectively. Staff B, the Assistant Director of Nursing, confirmed the expectation for timely completion of MDS assessments, aligning with the RAI manual. The failure to complete these assessments on time placed residents at risk for delayed or unidentified care needs.
Expired Food Items Not Discarded
Penalty
Summary
The facility failed to adhere to professional standards of food safety by not discarding expired food items in the Kitchen Dry Foods Storage Area. During an observation and interview, it was found that there were four packages of small size tortillas and six packages of large size tortillas with expiration dates that had passed. The Food Services Manager, Staff L, acknowledged that these tortillas were expired and should have been discarded by their expiration date. Additionally, the Administrator, Staff A, confirmed the expectation that food items should be discarded by their expiration date and recognized that the expired tortillas should have been removed from the kitchen. This oversight placed residents at risk for foodborne illness, cross-contamination, and a diminished quality of life.
Deficiencies in Water Management and Infection Control Practices
Penalty
Summary
The facility failed to ensure its water management program included a flow diagram to assess or monitor the potential growth of Legionella or other waterborne pathogens. The facility's Water Management Policy, revised in November 2021, aimed to reduce the risk of healthcare-associated infections from water sources. However, the facility's Water Quality Management Plan, revised in March 2018, did not include a flow diagram of their building water systems. Staff R, the Facilities Manager, confirmed that the water management plan lacked a flow diagram, and Staff A, the Administrator, acknowledged not having seen one. Additionally, the facility did not adhere to Enhanced Barrier Precautions (EBP) for a resident with a history of Multidrug-Resistant Organism (MDRO). Resident 23's physician orders required EBP for high-contact care activities, including the use of gloves and gowns. However, multiple observations revealed the absence of EBP signage on Resident 23's door. Staff G, a Certified Nursing Assistant, and Staff F, a Registered Nurse, both confirmed the lack of EBP signage and the failure to use PPE during high-contact care. Staff B, the Assistant Director of Nursing, stated that residents on EBP should have signage and that staff should follow EBP protocols.
Failure to Inform Resident of Risks and Benefits of Transfer Pole
Penalty
Summary
The facility failed to inform a resident and/or their representative of the risks and benefits before the installation and use of a transfer pole. This deficiency was identified for one of the two residents reviewed for accidents, specifically Resident 27. The resident was admitted to the facility and was noted to be independent in certain movements according to the Minimum Data Set assessment. However, the care plan included the use of a transfer pole as a safety device, and there was no documentation in the electronic health record indicating that the resident had been informed of the risks and benefits associated with its use. Observations and interviews revealed that Resident 27 used the transfer pole daily for mobility purposes. Staff members, including a Certified Nursing Assistant, a Registered Nurse, and a Charge Nurse, confirmed the resident's use of the pole but indicated a lack of awareness or documentation regarding the need for consent. The Rehab Manager stated that verbal consent was obtained, but there was no written documentation to support this. The Assistant Director of Nursing acknowledged that the transfer pole was considered an assistive device and expected documentation of informed consent to be present.
Failure to Report Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse to the State Agency for two residents, which is a violation of federal law requiring all allegations of abuse or neglect to be reported. Resident 3 reported being hit by an unknown female staff member, but the investigation report did not show that this allegation was reported to the State Agency. Similarly, Resident 25's complaint of rough care by nurses was documented in the Resident Council Minutes, but there was no evidence that this was reported to the State Agency or investigated. The facility's policy on the prevention of abuse and neglect requires the Administrator On Call to investigate all alleged incidents and report them according to the State's Nursing Home Guidelines. However, the facility did not adhere to these guidelines, as evidenced by the lack of reporting for both Resident 3 and Resident 25's allegations. Staff members involved in the process, including the Administrator and the Director of Nursing, failed to report these incidents, citing reasons such as not considering the rough care as abuse or believing that the situation was being handled internally. Interviews with staff revealed a lack of clarity and consistency in the reporting process. Staff A, the Administrator, acknowledged that the allegations should have been reported to the State Agency. Staff B, the Assistant DON, stated that they did not report the allegations because they believed it was the Administrator's responsibility. This miscommunication and failure to follow established protocols resulted in the deficiency of not reporting potential abuse incidents to the appropriate authorities.
Failure to Investigate Allegation of Rough Care
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident, identified as Resident 25, who reported that nurses were rough during care. The facility's policy mandates that all allegations of abuse, neglect, or mistreatment must be thoroughly investigated, yet there was no documentation of an investigation or report to the State Agency regarding Resident 25's complaint. The incident was noted in the Resident Council Minutes, but it was not logged in the facility's incident reporting or grievance logs. Staff E, who facilitated the resident council meetings, reported the concern to Staff O, the Director of Nursing, but no further action was documented. Staff B, the Assistant Director of Nursing, was unaware of the allegation until informed by the administrator on a later date. The investigation report for Resident 25, dated several months after the initial complaint, lacked interviews with other residents and staff, and was described by Staff A as an abbreviated investigation. Staff B treated the complaint as a care issue rather than abuse, leading to a lack of thorough investigation and reporting. This oversight placed Resident 25 at risk for repeated incidents and diminished quality of life.
Failure to Provide Written Notification of Hospital Transfer
Penalty
Summary
The facility failed to provide a written notice of transfer or discharge to a resident and their representative, which is a requirement under the regulations. Specifically, Resident 10 was transferred to the hospital on two occasions, but there was no documentation indicating that written notification was provided to the resident or their representative. This lack of documentation was confirmed through interviews with various staff members, including a charge nurse, a social worker, the assistant director of nursing, and the administrator. Each of these staff members acknowledged that their practice was to notify residents and their representatives by phone, and they did not provide written documentation for hospital transfers. The deficiency was identified during a review of Resident 10's clinical records, which showed no evidence of written notification for hospitalizations on two specific dates. Staff members interviewed during the investigation consistently stated that it was not their policy to provide written notifications, and the administrator was uncertain about the requirement for written notices. This failure to provide written notification placed Resident 10 at risk of not being able to make an informed decision about their transfers or discharges.
Failure to Provide Bed-Hold Notice During Hospital Transfer
Penalty
Summary
The facility failed to provide a bed-hold notice to a resident, identified as Resident 10, at the time of their transfer to the hospital. According to the facility's policy, updated in January 2018, clinical staff are required to ask the resident to sign a copy of the bed-hold policy and provide them with a copy at the time of hospitalization. However, a review of Resident 10's electronic health record (EHR) revealed no documentation indicating that a bed-hold notice was given to the resident or their representative during their transfer to the hospital on 05/04/2024. Interviews with facility staff, including a charge nurse, a social worker, and the assistant director of nursing, confirmed the absence of the required documentation. Staff members acknowledged that a bed-hold notice should have been provided to Resident 10 and/or their representative at the time of hospitalization, as per the facility's policy. This oversight placed the resident at risk of not being informed about their right to hold their bed while hospitalized.
Inaccurate MDS Assessment for Tube Feeding and Falls
Penalty
Summary
The facility failed to accurately assess a resident's condition in their Minimum Data Set (MDS) assessment, specifically regarding tube feeding and fall incidents. The resident, who was admitted with multiple diagnoses including dysphagia, had their tube feeding discontinued in February 2024, yet the quarterly MDS with an Assessment Reference Date (ARD) of March 23, 2024, incorrectly coded the resident as receiving tube feeding. Observations and interviews confirmed that the resident was receiving nutrition and hydration orally, using adaptive utensils, and was assisted by staff during mealtimes. Additionally, the facility did not code fall incidents in the resident's quarterly MDS, despite records showing two near falls from a wheelchair on March 18, 2024. The MDS Coordinator acknowledged the errors, stating that the tube feeding should not have been coded and the falls should have been included. The Assistant Director of Nursing expressed an expectation for staff to complete MDS assessments accurately, highlighting the oversight in the resident's assessment.
Inaccurate PASRR Form for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure the Level 1 Pre-Admission Screening and Resident Review (PASRR) accurately reflected the current diagnosis for a resident, which placed the resident at risk for inappropriate placement and/or not receiving timely and necessary services to meet mental health care needs. The resident was admitted with diagnoses including anxiety and unspecified psychosis, yet the PASRR form did not mark any mental disorders. This discrepancy was identified during an interview and record review. Staff H, responsible for admissions, stated that the hospital was responsible for completing the PASRRs and that they would request the PASRR from the hospital social worker. If a PASRR was incorrect, Staff H would contact the social worker to correct it. However, in this case, Staff H was unaware of the inaccuracy in the PASRR form for the resident. The Assistant Director of Nursing expected the PASRR form to be completed accurately and for Admissions to follow up with the hospital for any incorrect PASRRs.
Failure to Provide Baseline Care Plans to Residents
Penalty
Summary
The facility failed to provide a copy of the baseline care plan to two residents, which is a requirement according to their policy. Resident 230 was admitted to the facility, and although the baseline care plan was reviewed with the resident and their representative by Staff K, there was no documentation in the Electronic Health Record (EHR) that a copy was provided. Staff K admitted to not offering or providing baseline care plans to residents or their representatives, only providing comprehensive care plans during care conference meetings. Similarly, Resident 29 was admitted to the facility, and the baseline care plan was reviewed with the resident by Staff V. However, there was no documentation in the EHR that a copy of the baseline care plan was offered or provided to Resident 29. Staff K confirmed the practice of not providing baseline care plans, which was contrary to the facility's policy as stated by Staff B, the Assistant Director of Nursing. This failure resulted in the residents not being informed of their initial plan for delivery of care services.
Failure to Develop Oxygen Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was receiving oxygen therapy, which was identified during a survey. The resident, admitted to the facility, had a physician's order for oxygen administration via nasal cannula as needed for comfort, starting on 04/06/2024. However, a review of the resident's care plan, printed on 05/14/2024, revealed the absence of a care plan addressing oxygen care and management. Interviews with facility staff, including a Registered Nurse, Charge Nurse, and the Assistant Director of Nursing, confirmed that the resident should have had an oxygen care plan in place when the oxygen treatment began. This oversight placed the resident at risk for unmet care needs and a diminished quality of life.
Failure to Revise Care Plans for Two Residents
Penalty
Summary
The facility failed to revise comprehensive care plans for two residents, leading to potential risks for unmet care needs. Resident 15, who was admitted to the facility, had a care plan indicating the use of full upper and lower dentures, with assistance required for placement and care. However, observations and interviews revealed that Resident 15 was not wearing dentures and had lost them. Staff members, including a Recreational Therapist and a Certified Nursing Assistant, confirmed that Resident 15 did not have dentures, and the care plan was incorrect. The Minimum Data Set Coordinator and the Assistant Director of Nursing acknowledged that the care plan should have been revised to reflect the resident's current status. Resident 25, also admitted to the facility, had a care plan indicating the use of enteral nutrition with a goal to tolerate a certain percentage of intake via tube feeding. However, physician orders and nursing progress notes showed that tube feeding was discontinued, and the tube was maintained only for medication administration. Observations and interviews confirmed that Resident 25 received food and water orally and used adaptive utensils with staff assistance during meals. The Minimum Data Set Coordinator confirmed that the care plan should have been updated to reflect the change from tube feeding to oral intake.
Failure to Assess Resident for Safe Use of Transfer Pole
Penalty
Summary
The facility failed to ensure an assessment was completed prior to the use of a transfer pole for a resident, which placed the resident at risk for accidents and injury. The resident, who was independent in certain movements according to their Minimum Data Set, used a transfer pole daily to assist with moving in and out of bed. However, there was no documentation in the resident's electronic health record indicating that an assessment for the safe use of the transfer pole had been conducted. Observations revealed that the transfer pole was unstable, and staff interviews confirmed that no formal assessment had been performed. Staff members, including a Certified Nursing Assistant and a Physical Medicine Aide, acknowledged the use of the transfer pole by the resident and noted its instability. The Rehab Manager, responsible for assessing residents for safety prior to the use of assistive devices, admitted that no formal assessment was conducted for the transfer pole. The Assistant Director of Nursing expected the Rehab department to perform such assessments and confirmed that there was no documentation of an assessment for the resident's use of the transfer pole.
Failure to Check Gastric Residual Volumes Before Tube Feeding
Penalty
Summary
The facility failed to ensure appropriate treatment and services related to tube feeding for a resident, identified as Resident 10, who was reviewed for tube feeding management. The deficiency was observed when a registered nurse, Staff U, connected Resident 10's feeding tube to their enteral formula without checking the gastric residual volumes (GRV) prior to the administration of the tube feeding. This action was contrary to the facility's policy, which requires checking the GRV to verify the appropriate placement of the feeding tube and to assess the resident's tolerance to the feeding. Resident 10 had a feeding tube as indicated in their significant change in status Minimum Data Set dated 04/16/2024, and their care plan, revised on 05/04/2024, included instructions to check the GRV. During interviews, both the Charge Nurse, Staff N, and the Assistant Director of Nursing, Staff B, confirmed that staff were expected to check the GRV each time before connecting residents to their enteral formula. The failure to adhere to this protocol placed Resident 10 at risk for medical complications and a diminished quality of life.
Failure to Conduct Timely AIMS Assessments for Residents on Antipsychotics
Penalty
Summary
The facility failed to conduct timely Abnormal Involuntary Movement Scale (AIMS) assessments for three residents receiving antipsychotic medications, which are necessary to monitor for tardive dyskinesia and other side effects. Resident 20, who was prescribed Quetiapine for restlessness and agitation, did not have an AIMS assessment completed prior to May 16, 2024, despite being admitted earlier. Staff acknowledged that the assessment should have been conducted quarterly, but it was not done. Similarly, Resident 6, who was taking Seroquel for anxiety related to dementia with behavioral disturbances, had not received an AIMS assessment since March 2023. The resident's records lacked documentation of monitoring for side effects related to tardive dyskinesia or Extrapyramidal Symptoms (EPS). Resident 3, prescribed Olanzapine for unspecified psychosis and neurocognitive disorder with Lewy Bodies, also did not have any AIMS assessments completed. Staff confirmed that these assessments were expected to be done quarterly but were not performed.
Failure to Document Pneumonia Vaccine Education
Penalty
Summary
The facility failed to ensure that residents received education regarding the potential risks and benefits of the pneumonia vaccine, specifically for two residents reviewed for immunizations. The facility's policy, reviewed in March 2023, mandates that each resident or their legal representative be provided with education about the benefits, potential side effects, and possible medical contraindications of the pneumococcal immunization. However, for Residents 3 and 20, there was no documentation in their Electronic Health Records (EHR) indicating that they were informed of these risks and benefits before receiving the pneumococcal vaccine on April 13, 2023. Interviews with facility staff revealed a lack of documentation regarding the provision of this information. On May 17, 2024, the Infection Preventionist, Staff C, confirmed the absence of documentation for Residents 3 and 20. Additionally, on May 20, 2024, the Assistant Director of Nursing, Staff B, stated that it was expected that residents be informed of the risks and benefits of pneumonia vaccinations and that there should be documentation of whether a resident received the vaccination or declined it. This oversight placed the residents and/or their representatives at risk of not being fully informed before making decisions about their pneumonia immunizations.
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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