Ballard Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Seattle, Washington.
- Location
- 820 Northwest 95th Street, Seattle, Washington 98117
- CMS Provider Number
- 505042
- Inspections on file
- 38
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Ballard Center during CMS and state inspections, most recent first.
The facility failed to complete thorough and timely investigations of alleged abuse and an unwitnessed fall. In one case, a cognitively intact resident’s alleged abuse by staff, reported by another resident, was not fully concluded until nearly a month later, and multiple resident interview forms lacked names and dates, listing only room numbers. In another case, a cognitively intact resident reported being called a derogatory name by a recreation staff member, and the investigation again used undated, unnamed interview forms. For a resident with a stroke, cognitive impairment, and total dependence for mobility who experienced an unwitnessed fall, the investigation did not include any staff interviews to determine circumstances before the fall. Nursing leadership acknowledged that interviews should be dated, identify residents by name, be completed within five working days, and that staff interviews are expected for fall investigations.
A resident without cognitive impairment reported that a recreation assistant called them a derogatory name, which the staff member claimed was a joke; the resident responded by calling the staff member a derogatory name in return. The facility’s investigation substantiated that the staff member had verbally abused the resident, but the incident was not entered on the required DSHS reporting log for the relevant period, despite the DON’s expectation that all incident investigations be logged within five days, resulting in a cited deficiency for failure to follow abuse reporting guidelines.
Three residents did not have timely or complete discharge care plans developed as required. For one resident, the discharge care plan was created only on the day of discharge, while two others had no documented discharge care plans at all. Staff interviews confirmed that the required care planning process was not followed, with both the Social Services and nursing departments acknowledging the deficiency.
Three residents who left the facility against medical advice did not receive complete discharge instructions, including discharge summaries or medication reconciliation. Documentation was missing or incomplete for each resident, and staff interviews revealed a lack of awareness about the requirement to provide these documents for AMA discharges.
A resident with a documented DNR order was given CPR after being found unresponsive, as staff did not verify the code status through the required documentation. Additionally, an LPN and a CNA were found to be working without current CPR certification, contrary to facility policy. Leadership confirmed that staff did not follow the expected process for verifying code status and that required CPR training was not up to date for all staff.
Two residents reported allegations of sexual abuse by staff, which were communicated to facility leadership but not reported to law enforcement as required by policy and guidelines. This failure to report placed the residents at risk and constituted a breach of abuse reporting requirements.
Two residents experienced ant infestations in their rooms, including one with ants found on a Foley catheter during hospital transfer and another with ants crawling on their body and bed. Housekeeping and visitors reported ant activity across multiple nursing units, and service requests documented repeated pest sightings, indicating the facility did not effectively implement its pest control policy.
A resident reported multiple concerns, including negligence and disrespectful language, to an outside agency. The facility failed to initiate a timely investigation, as required by their guidelines. Staff F submitted a report to the state agency but only conducted a care conference and completed grievance forms, without informing the Administrator or starting a formal investigation.
A facility failed to timely develop a care plan for a resident readmitted with lice. The resident was readmitted with orders for permethrin treatment, but the care plan was not initiated until 20 days later. This delay was confirmed by the Interim DON, acknowledging the care plan should have started upon readmission, increasing risk for further infestation.
A facility failed to maintain contact precautions for a resident with lice, as the required signage was removed from the resident's room. Despite ongoing symptoms and treatment orders, staff were not informed of the need for PPE. Interviews with staff, including an RN and Infection Preventionist, confirmed the oversight, highlighting a lapse in procedure adherence.
The facility did not conduct required reference checks for four staff members, including a CNA and RN Manager, before hiring them, violating its abuse policy. This oversight placed residents at risk for abuse and neglect, as the facility failed to adhere to its own procedures and legal requirements.
The facility failed to conduct annual performance evaluations for five CNAs, with some evaluations missing since 2015. This oversight, acknowledged by the DON and Administrator, risks resident care quality due to potential staff underqualification.
The facility failed to properly store medications in two medication carts, risking compromised or ineffective treatments for residents. Medication Cart 2 contained an opened vial of insulin past the discard date and a mix of creams and ointments for multiple residents, not properly separated. Medication Cart 3 also had improperly stored creams and ointments for different residents. Staff acknowledged some treatments were discontinued and needed discarding, and the DON emphasized the need for proper medication management.
The facility failed to provide residents with current food menus and alternatives that met their nutritional needs, including fresh fruits and vegetables. Several residents reported not receiving menus or being aware of alternative options like the Bistro menu. Staff acknowledged issues with menu distribution and communication, partly due to the resignation of the dietary manager. The facility's policy required nutrient analysis and menu posting, which was not consistently followed.
The facility failed to follow Contact Precautions for residents with infections, as staff frequently entered rooms without PPE, improperly disposed of PPE, and neglected hand hygiene protocols. These actions increased the risk of infection spread among residents and staff.
The facility failed to address grievances for two residents, one regarding a missing television remote control and the other concerning discharge planning to transfer closer to a family member. The grievances were not logged or resolved in a timely manner, leading to frustration and unmet care needs. The facility's grievance policy was not followed, resulting in unresolved issues impacting the residents' quality of life.
The facility failed to investigate resident-to-resident altercations involving three residents, leading to risks of repeated incidents and unidentified abuse. A resident reported verbal assault, another experienced a physical threat, and a third reported unwanted physical contact, but these incidents were not properly documented or investigated. Staff failed to notify the appropriate authorities and did not follow the facility's policy for handling such altercations.
A resident's MDS assessment was inaccurately completed by the facility, as the MDS Coordinator signed off on key sections before the end of the observation period. This premature completion failed to capture the resident's condition accurately, potentially leading to unmet care needs. The Director of Nursing confirmed the expectation for accurate MDS completion according to the RAI Manual.
The facility failed to complete accurate PASARR evaluations for two residents with mental health conditions, leading to a lack of appropriate assessments for their care needs. One resident with bipolar disorder did not receive a timely Level II PASARR after a planned discharge was delayed, while another resident with anxiety and major depressive disorder had an incomplete PASARR process, lacking a necessary Level II evaluation.
The facility failed to update care plans for three residents, leading to potential risks. A resident's care plan was delayed, lacking involvement from the resident or their representative. Two residents with unsafe smoking behaviors and oxygen use did not have updated care plans, posing safety risks. Staff interviews confirmed the absence of necessary care plan revisions.
A LTC facility failed to follow physician orders for three residents, leading to medication administration errors. An LPN administered incorrect dosages of Sertraline to a resident due to outdated information. Another resident received a multivitamin with minerals instead of the prescribed type due to a misunderstanding about available stock. Additionally, the facility did not document vital signs before administering Hydralazine to a resident, as required by the medication's parameters.
A resident's discharge plan was not aligned with their expressed goal to transfer closer to family, despite their cognitive function being intact. The facility failed to update the discharge care plan and did not involve the resident or their representative in the planning process, leading to dissatisfaction and unresolved grievances.
The facility failed to provide necessary ADL assistance and nail care for two residents. One resident, requiring substantial assistance, was not helped out of bed or given showers as scheduled. Another resident with diabetes did not receive proper nail care, despite documentation indicating otherwise. Staff interviews confirmed these deficiencies, highlighting unmet care needs and documentation inaccuracies.
A facility failed to consistently provide ROM services for a resident with limited upper extremity ROM. The care plan required splint application and ROM exercises, but there was no documentation of these interventions being performed. Observations showed the resident was not wearing splints, and staff interviews revealed a lack of consistent implementation of the care plan.
A facility failed to follow its smoking policy and care plan for a resident with unsafe smoking habits, who was observed smoking without supervision and did not surrender smoking materials. The resident's care plan was not updated, and nicotine patches were refused. Additionally, another resident's bed side rails were found to be loose, with maintenance only performed upon request. Staff interviews revealed non-compliance with facility policies, posing risks to resident safety.
The facility failed to adhere to physician orders for oxygen therapy for two residents, leading to deficiencies in care. One resident received higher oxygen flow rates than prescribed, while another did not receive routine oxygen therapy as ordered. Staff interviews revealed non-compliance with verifying and adjusting oxygen flow rates and improper storage of oxygen equipment.
The facility failed to implement comprehensive care plans for four residents, leading to unmet care needs. A resident with lymphedema was not provided with compression stockings as per their care plan. Another resident experienced significant weight gain without proper notification to healthcare providers. A third resident's range of motion interventions were not documented or implemented, and a fourth resident's care plan lacked a discharge plan. Staff interviews confirmed these deficiencies.
The facility failed to follow care plans and notify providers for three residents, leading to unmet care needs. A resident with lymphedema did not receive prescribed compression therapy, another experienced significant weight gain without timely provider notification, and a third resident's constipation care plan was not followed, resulting in prolonged periods without bowel movements.
The facility's assessment failed to include plans for maximizing direct care staff recruitment and retention, as required by its policy. The Facility Assessment Tool, updated in August 2024, did not address this aspect, and both the Administrator and Interim Administrator acknowledged the oversight during interviews.
The facility failed to serve food at the proper temperature in two nursing units, with meals being significantly below required standards. Residents reported the food as cold and flavorless, leading to dissatisfaction and potential nutritional risks. Staff acknowledged the issue, noting that the containers used did not maintain warmth.
A malfunctioning boiler in the facility's kitchen led to a lack of consistent hot water for dishwashing, resulting in meals being served in plastic containers. Staff had to use a makeshift method to obtain hot water, which was inefficient and time-consuming. The issue began when the boiler was turned off due to a leak, and despite repair attempts, the problem persisted, affecting meal quality for residents.
Incomplete and Untimely Abuse and Fall Incident Investigations
Penalty
Summary
The deficiency involves the facility’s failure to conduct thorough and timely investigations into alleged abuse and an unwitnessed fall, contrary to regulatory requirements and the facility’s own policies. The Nursing Home Guidelines (“Purple Book”) require that all alleged violations be thoroughly investigated, with results reported to the administrator and appropriate officials within five working days. The facility’s abuse policy also requires thorough investigations and interviews with other residents to whom the accused employee provides care or services. However, for multiple incidents involving three residents, investigations were either delayed beyond the five‑day requirement or lacked essential documentation such as interview dates, resident names, and staff interviews. For one resident with intact cognition, an incident investigation dated 02/16/2026 was initiated after another resident reported witnessing this resident being abused by a staff member. The investigation included an undated interview form in which the resident denied inappropriate touching and six additional interview forms that lacked resident names and dates, listing only room numbers. The summary and conclusion of this investigation were not completed until 03/17/2026, which was beyond the five working days allowed. The Assistant DON confirmed they did not conclude or summarize the investigation until almost a month after the allegation, and the DON stated that interviews should be dated and include resident names, and that investigations were expected to be completed within five working days. For another cognitively intact resident, an incident investigation dated 02/19/2026 documented that the resident complained a recreation staff member called them a derogatory name during a conversation, and that the staff member admitted to the communication issue, stating they were joking. The investigation concluded that the staff member did call the resident a derogatory name, and included five other interview forms that again lacked resident names and dates, listing only room numbers. The DON stated that all resident interviews should be dated and include resident names, noting that using only room numbers could make it difficult to identify who was interviewed if residents changed rooms or were discharged. In a separate unwitnessed fall incident for a resident with a stroke, cognitive impairment, and total dependence for transfers and mobility, the investigation documented that the roommate saw the resident get up from bed, move toward a chair, and stumble, with unclear documentation on where the resident landed or whether they hit their head. The investigation did not include any staff interviews. A RN, the LPN/Unit Manager who completed the investigation, and the DON all stated that staff interviews, particularly with the assigned nursing assistant and any staff who had contact with the resident prior to the fall, were expected and should have been included to complete the fall investigation.
Failure to Log Substantiated Verbal Abuse Incident on Facility Reporting Log
Penalty
Summary
The deficiency involves the facility’s failure to log an allegation of unprofessional conduct involving verbal abuse on the required reporting log. According to the Nursing Home Guidelines, The Purple Book, Sixth Edition, dated October 2015, allegations of staff-to-resident abuse must be entered on the facility’s Department of Social and Health Services reporting log within five days. Resident 3’s quarterly MDS assessment dated 02/10/2026 showed the resident had been readmitted on that date and did not have problems with memory or thinking. On 02/19/2026, an incident investigation form documented that Resident 3 complained a recreation assistant (Staff C) called them a derogatory name while they were speaking. Resident 3 reported that Staff C claimed the comment was made jokingly, but Resident 3 did not perceive it that way and responded by calling Staff C a derogatory name in retaliation. Further review of the incident investigation showed the allegation was substantiated when Staff C acknowledged calling Resident 3 a derogatory name. However, review of the facility’s incident log for the period 02/03/2026 to 02/28/2026 did not show that this substantiated verbal abuse incident from 02/19/2026 was entered on the log. During a joint record review and interview on 03/25/2026 at 4:50 PM, the Director of Nursing Services (Staff A) confirmed that the verbal abuse incident was not logged on the incident report log for that time frame and stated that all incident investigations were expected to be logged within five days of the incident. This failure to log the allegation and substantiated finding of verbal abuse was cited under WAC 388-97-0640(5)(a).
Failure to Develop and Implement Timely Discharge Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans addressing discharge needs for three out of five residents reviewed for discharge care planning. According to the facility's policy, a comprehensive care plan, including discharge planning, should be developed within seven days of completing the comprehensive MDS assessment. However, for one resident, the discharge care plan was initiated only on the day of discharge, and for two other residents, no discharge care plan was documented prior to or at the time of discharge. Review of the electronic health records confirmed the absence or late completion of these required care plans. Interviews with facility staff revealed that the interdisciplinary team was responsible for care plans based on medical needs, while the Social Services Department handled discharge care plans. The Social Services Director stated that discharge care plans were to be completed within 72 hours of admission, but acknowledged that for the residents in question, this was not done in a timely manner or at all. The Director of Nursing Services confirmed that discharge care plans should have been completed within seven days after the admission MDS assessment, but this requirement was not met for the affected residents.
Failure to Provide Discharge Summaries and Medication Reconciliation for Residents Leaving AMA
Penalty
Summary
The facility failed to provide appropriate discharge instructions, including a discharge summary or recapitulation of stay, for three residents who left the facility against medical advice (AMA). For each of these residents, documentation was incomplete or missing regarding their medical status, medication reconciliation, and other essential discharge information at the time of their departure. The facility's policy required that AMA discharges be processed in accordance with the resident's or representative's request for a safe and appropriate discharge, with applicable documentation completed, but this was not followed. One resident with diagnoses including type II diabetes, protein-calorie malnutrition, and dysphagia left the facility AMA without documentation of a discharge summary or medication reconciliation. The discharge plan documentation for this resident was incomplete, lacking information on home/community status, follow-up care, skin condition, diet, infections, assistance needs, therapy services, and medication changes. Another resident with type II diabetes and atrial fibrillation also left AMA, and similarly, there was no documentation of attempts to provide a discharge summary or medication reconciliation. The discharge plan documentation for this resident was also incomplete in several key areas. A third resident, with a history of falls and a healing fracture, left the facility AMA to a shelter, and there was no evidence of a completed discharge summary or discussion of medication reconciliation prior to discharge. Interviews with staff revealed a lack of awareness regarding the requirement to provide discharge summaries for residents leaving AMA, and record reviews confirmed the absence of completed discharge documentation for all three residents involved.
Failure to Honor Advance Directive and Maintain Staff CPR Certification
Penalty
Summary
The facility failed to verify and follow the code status for a resident and did not ensure that licensed nursing staff maintained current CPR certification. One resident, who had a documented advance directive and physician order for Do Not Resuscitate (DNR), was found unresponsive, without a pulse or breathing. Despite the resident's clear DNR status, staff initiated CPR and continued until paramedics arrived and took over, performing multiple rounds of CPR. Staff interviews revealed that the completed POLST form indicating the resident's DNR status was not available at the time of the emergency, and staff did not verify the code status through physician orders in the electronic health record before starting resuscitation efforts. Further review showed that the facility's policies required staff to inform residents of their right to execute advance directives and to maintain copies in the medical record. The policies also stated that CPR-certified staff would be available at all times and that licensed nursing staff must maintain current CPR certification. However, two staff members, an LPN and a CNA, were found to be working without current CPR certification. One staff member admitted their certification had lapsed, and another stated they had not received recent CPR training, with their last training occurring years prior. Interviews with facility leadership confirmed that staff were expected to verify code status using the POLST form or physician orders during emergencies, but in this case, the required documentation was not accessible, and the staff did not follow the expected verification process. The lack of current CPR certification among staff and the failure to honor the resident's advance directive were directly observed and confirmed by staff and leadership during the investigation.
Failure to Report Alleged Sexual Abuse to Law Enforcement
Penalty
Summary
The facility failed to report allegations of sexual abuse involving two residents to law enforcement, as required by both facility policy and state guidelines. One resident, who had intact cognition and required assistance with care, reported to a therapist that two male staff members engaged in inappropriate touching and made sexually suggestive comments during nighttime care. This allegation was communicated to the Director of Rehabilitation, who then informed the Administrator. In a separate incident, another resident with impaired cognition and in need of care assistance reported to a physical therapist that a staff member was sexually inappropriate during a bathroom visit. This allegation was also reported to the Administrator. Despite being made aware of both allegations, the Administrator did not report either incident to law enforcement. Interviews with facility staff, including the Director of Nursing Services, confirmed that the facility's policy and the referenced guidelines required immediate reporting of such allegations to law enforcement. The failure to report these incidents constituted a breach of the facility's abuse reporting policy and placed the residents at risk for further harm.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program as required by its own policy, resulting in multiple incidents involving ants in resident care areas. For one resident with paralysis and a Foley catheter, emergency medical transport staff observed ants on the catheter during a hospital transfer. Nursing progress notes confirmed the resident was located in the 200 nursing unit at the time. Another resident was found by a visitor to have ants crawling on their body and in their bed, with the visitor reporting similar observations to staff on two separate occasions. Service request forms documented additional ant sightings on the 400 and 500 nursing units, including ants on a call button cord and in resident rooms. Housekeeping staff reported seeing ants in the 200, 300, 400, and 500 nursing units and communicated these findings to both maintenance and the facility administrator. The administrator acknowledged that the current pest control service might be insufficient to address the ongoing ant problem. The facility's pest control policy, last revised in May 2008, requires an ongoing program to keep the building free of insects and rodents, but the documented incidents and staff interviews indicate that this policy was not effectively implemented.
Failure to Investigate Allegation of Neglect
Penalty
Summary
The facility failed to timely initiate and investigate an allegation of neglect for one resident, which placed the resident at risk for potential unidentified neglect and lack of protection from abuse or neglect. The facility's guidelines and policy require that all alleged incidents of abuse, neglect, and other related issues be thoroughly investigated and reported to the appropriate agencies. However, in this case, the facility did not adhere to these guidelines. The resident, who was cognitively intact, reported multiple concerns, including negligence, falls, and disrespectful language, to an outside agency. This information was communicated to the facility by the agency, but the necessary investigation was not initiated. Staff F, responsible for social services, received the report from the outside agency and submitted it to the state agency's online incident reporting line. However, Staff F only conducted a care conference with the resident and completed grievance forms, believing this was sufficient. The Director of Nursing Services at the time was informed, but the Administrator was not. Staff B, who was not present during the incident, acknowledged that an allegation of neglect should have been thoroughly investigated. Staff G, the Regional Nurse Consultant, confirmed that no investigation folder was found, and Staff A, the Administrator, stated that they were not informed of the allegation or involved in any investigation.
Delayed Care Plan for Lice Infestation
Penalty
Summary
The facility failed to develop a timely care plan for a resident who was readmitted with a lice infestation. The resident was readmitted on 03/04/2025 with orders for permethrin treatment for lice, but the care plan addressing the lice and necessary contact precautions was not initiated until 03/24/2025, 20 days after readmission. This delay in care planning was confirmed during an interview with the Interim Director of Nursing Services, who acknowledged that the care plan should have been started upon the resident's readmission. This oversight placed residents, staff, and visitors at increased risk for further infestation and unmet care needs.
Failure to Maintain Contact Precautions for Resident with Lice
Penalty
Summary
The facility failed to ensure that contact precautions signage was placed on the outside of a resident's room, who was being treated for lice infestation. The absence of this signage meant that staff and visitors were not informed of the need to wear personal protective equipment (PPE) such as gowns and gloves before entering the resident's room. This oversight was identified during a joint observation and interview with a registered nurse, who acknowledged the missing sign and the ongoing symptoms of lice infestation in the resident. The resident, who was cognitively intact, had been treated for lice at a hospital and readmitted to the facility with orders for further treatment. Despite this, the contact precautions sign was removed, and the resident continued to experience symptoms such as persistent itching. Interviews with various staff members, including an ARNP and the Infection Preventionist, confirmed that the resident should still be on contact precautions. The Interim Director of Nursing Services was unaware of why the sign was removed, indicating a lapse in communication or procedure adherence within the facility.
Failure to Conduct Reference Checks for New Hires
Penalty
Summary
The facility failed to implement its abuse policy and procedure by not conducting reference checks for four out of five staff members reviewed, which included a Certified Nursing Assistant, a Weekend Registered Nurse Manager, a Nursing Assistant Registered, and a Smoking Aide. The facility's policy, titled 'Abuse Prohibition Policy and Procedure,' mandates screening potential hires for a history of abuse, neglect, or mistreatment, including obtaining information from previous employers. However, the employee records for these staff members did not show that reference checks were conducted prior to their hire dates. Interviews with facility staff revealed that reference checks were not completed for these employees, despite the facility having a process in place since January 2023. The Administrator acknowledged that reference checks were expected as part of the hiring process and should have been completed. The failure to conduct these checks placed residents at risk for abuse, neglect, exploitation, and misappropriation of property, as the facility did not adhere to its own policy and state and federal requirements.
Failure to Conduct Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to complete the required annual performance evaluations for five Certified Nursing Assistants (CNAs), identified as Staff M, N, O, P, and Q. The facility's policy mandates that each employee's job performance be reviewed and evaluated at least annually. However, upon review of the personnel files, it was found that Staff M's last evaluation was in 2015, Staff N's in 2015, and Staff P's in 2022. No evaluations were found for Staff O and Q. Interviews with the Director of Nursing and the Senior President of Operations revealed a lack of awareness and oversight regarding the completion of these evaluations. The absence of current performance evaluations for these CNAs placed residents at risk of receiving care from potentially underqualified staff. The Director of Nursing and the Administrator both acknowledged the expectation for timely evaluations, yet the records provided by Human Resources confirmed the evaluations were either missing or outdated. This deficiency highlights a significant lapse in the facility's adherence to its own policies and regulatory requirements, potentially impacting the quality of care provided to residents.
Improper Storage of Medications in Medication Carts
Penalty
Summary
The facility failed to appropriately store drugs and biologics for two of the three medication carts reviewed, which placed residents at risk for receiving compromised or ineffective medications. During an observation and interview, it was found that Medication Cart 2 contained an opened vial of Humulin insulin that was dated 40 days from the date it was opened, exceeding the facility's policy of discarding multi-dose vials within 28 days. Additionally, the bottom drawer of the cart contained a box with various creams, ointments, and powders for multiple residents that were not properly stored or separated by resident. This included opened bottles and tubes of medications such as nystatin powder, triamcinolone, bacitracin, and Aspercream, some of which were unlabeled or intended for house supply. Similarly, Medication Cart 3 was found to have a box in the last drawer containing various creams, ointments, and powders for different residents, which were also not properly stored or separated. This included opened tubes and bottles of medications like triple antibiotic ointment, Halobetasol, nystatin, bacitracin, and clotrimazole cream. Staff members acknowledged that some of these treatments were discontinued and needed to be discarded. The Director of Nursing stated that discontinued medications should be sent back to the pharmacy and that expired or discontinued medications should be removed from the medication cart immediately. Treatment creams should not be mixed and should be separated in the medication cart.
Deficiency in Menu Provision and Nutritional Needs
Penalty
Summary
The facility failed to ensure that residents received current food menus and alternative menus that met their nutritional needs, including daily fresh fruits and vegetables. This deficiency was observed in five out of six residents reviewed for dining services. The facility's menus did not consistently offer fresh fruits and vegetables, and residents were not always provided with menus or informed of their food choices. The facility's policy required menus to be posted in resident care areas and to include nutrient analysis to meet nutritional needs, but this was not consistently followed. Several residents reported not receiving food menus or being aware of the Bistro menu, which offered alternative meal options. For instance, Resident 14 stated they did not receive a food menu and had to physically check the posted menu to know their meal options. They also reported not receiving fresh fruits or vegetables. Similarly, Resident 309 had an outdated menu and was unaware of the Bistro menu. Resident 89 mentioned inconsistency in receiving menus and noted that the fruit provided was mostly canned. Resident 55 also reported not receiving fresh fruits or vegetables. The facility's staff acknowledged issues with menu distribution and communication of available food options. Staff CC, the Regional Dietary Manager, mentioned that the menus were preloaded and based on resident preferences, but only a small percentage of residents returned filled menus. Staff OO, the Recreation Assistant, noted that the dietary manager had resigned, leading to a lapse in menu distribution. Staff PP, the Dietitian, confirmed that fresh fruits were available but not always served daily. The facility administrator, Staff A, expressed the expectation that residents should be aware of their meal choices and have access to fresh fruit daily.
Infection Control Lapses in Contact Precaution Practices
Penalty
Summary
The facility failed to adhere to Contact Precautions for four residents, leading to potential infection risks. Resident 51 had a wound infection requiring Contact Precautions, but there was no hazardous waste container in the room, leading staff to improperly dispose of PPE. Staff M, a CNA, admitted to taking the soiled gown to the utility room without bagging it due to the absence of a designated disposal bin. Staff MM, an RN, confirmed the lack of a disposal container and intended to find one, while the Infection Preventionist and Director of Nursing both emphasized the expectation for PPE disposal within the room. Resident 27 and Resident 64 were also on Contact Precautions due to wounds and MDROs, respectively. However, multiple staff members, including CNAs and RNs, entered their rooms without wearing the required PPE. Staff members admitted to not following the posted precaution signs, with some believing that brief room entry or lack of direct contact with residents exempted them from PPE use. This misunderstanding led to actions such as taking contaminated items out of precaution rooms, further increasing the risk of infection spread. Resident 93, with multiple wounds and a history of MDRO infection, was on Contact Precautions, yet staff failed to consistently wear PPE when entering the room. Staff X, a Maintenance Assistant, entered without PPE and touched various surfaces, while Staff LL, a CNA, also entered without proper attire. The facility's policies on hand hygiene and glove use were not followed by several staff members, including Staff DD, who handled medication without gloves, and Staff II, who did not sanitize an insulin pen before use. These lapses in infection control practices were acknowledged by staff and management, highlighting a systemic issue in adherence to established protocols.
Failure to Address Grievances for Missing Items and Discharge Planning
Penalty
Summary
The facility failed to properly address and resolve grievances for two residents, leading to frustration and unmet care needs. Resident 44, who was cognitively intact, reported a missing television remote control to a staff member, but the grievance was not logged or resolved, and the resident was not reimbursed for the replacement. The staff member responsible for handling the grievance was new and unaware of the reimbursement process, resulting in the grievance not being properly addressed. Resident 36, also cognitively intact, expressed a desire to transfer to another facility closer to a family member, CC2, but experienced issues with the facility not returning phone calls to CC2 regarding discharge planning. A grievance was filed by CC2 in December, but it was not addressed in a timely manner, and the resident's discharge care plan did not reflect their goal of transferring closer to CC2. The staff member responsible for addressing the grievance did not receive it until several weeks after it was filed, and there was no documentation of communication between social services and CC2 during the relevant period. The facility's grievance policy requires grievances to be logged, investigated, and resolved promptly, with notification to the person filing the grievance within 72 hours. However, in both cases, the grievances were not logged or resolved in a timely manner, and the facility's expectations for handling grievances were not met. The failure to address these grievances resulted in unresolved issues for the residents, impacting their quality of life.
Failure to Investigate Resident Altercations
Penalty
Summary
The facility failed to thoroughly investigate resident-to-resident altercations involving three residents, which placed them at risk for repeated incidents and unidentified abuse. Resident 44 reported being verbally assaulted by another resident, Resident 95, but the incident was not documented in the nursing progress notes or assessed for a change of condition. Staff S, who was involved in the incident, did not notify the Administrator or Director of Nursing and did not document the incident as a resident-to-resident altercation, as they believed altercations were only physical. Resident 55 experienced an incident where their roommate, Resident 39, threw a fork at them, but this was not documented in the nursing progress notes, grievance log, or incident log for August 2024. Although Resident 39 was transferred to another room, the altercation was not investigated until October 2024, and the appropriate authorities were not notified at the time of the incident. Staff EE and Staff T confirmed that the altercation was not documented or reported as required. Resident 46 reported an unwanted physical interaction with their previous roommate, Resident 95, which was considered sexual abuse. However, the investigation into this allegation was incomplete, lacking staff and additional resident interviews, and did not include a summary ruling out abuse. Staff A, the abuse coordinator, acknowledged the deficiency in the investigation process and the lack of documentation to support a thorough investigation.
Inaccurate MDS Assessment for a Resident
Penalty
Summary
The facility failed to accurately assess a resident, identified as Resident 36, using the Minimum Data Set (MDS) assessment tool. The deficiency was found in the completion of the Significant Change in Status Assessment (SCSA) for the resident, specifically in Sections L (Oral/Dental Status), N (Medications), O (Special Treatments, Procedures, and Programs), P (Restraints and Alarms), and Q (Participation in Assessment and Goal Setting). The MDS Coordinator, Staff D, signed off on these sections before the end of the observation period, which was from 10/15/2024 to 10/21/2024, thus failing to capture the resident's condition accurately during the entire look-back period. During interviews, Staff D acknowledged that the assessments were completed prematurely, and the Director of Nursing, Staff B, confirmed that the facility's expectation was for the MDS to be completed accurately according to the RAI Manual. This premature completion of the assessment placed the resident at risk for unidentified and/or unmet care needs, potentially affecting their quality of life. The report highlights the importance of adhering to the specified observation period to ensure accurate resident assessments.
Failure to Complete Accurate PASARR Evaluations
Penalty
Summary
The facility failed to ensure accurate Preadmission Screening and Resident Reviews (PASARR) for two residents, which is essential to determine if individuals with Serious Mental Illness (SMI) or Intellectual/Developmental Disabilities (ID/DD) are appropriately placed in nursing homes. Resident 103, diagnosed with bipolar disorder, was admitted with a Level I PASARR indicating an exempted hospital discharge. However, due to an inability to discharge the resident as planned, a Level II PASARR evaluation was required but not completed within the stipulated 30 days. The Social Services Director acknowledged the oversight and stated that the Level II PASARR would be sent out after the deficiency was identified. Resident 22, with diagnoses including anxiety and major depressive disorder, had a Level I PASARR indicating SMI indicators for mood and anxiety disorders, yet no Level II evaluation was conducted. The Social Services Director admitted that a Level II PASARR should have been initiated and attempted to rectify the situation by submitting a new Level I PASARR. However, the updated form was not found in the records, and the PASARR evaluator did not have a copy either. The Interim Administrator confirmed the expectation for timely PASARR reviews and submissions, highlighting the failure to correct and submit the necessary evaluations for Resident 22.
Failure to Update Care Plans for Smoking and Oxygen Use
Penalty
Summary
The facility failed to develop and revise comprehensive care plans for three residents, leading to potential risks for unmet care needs and negative outcomes. Resident 36's care plan was not completed within the required seven days following a Significant Change in Status Assessment (SCSA). Despite the resident's intact cognitive function, the care plan addressing various health concerns was delayed, and there was no documented involvement of the resident or their representative in the care planning process. Interviews revealed that the resident and their representative were not adequately informed or involved in the care planning. Resident 87, who was admitted with generalized muscle weakness and a history of falls, was identified as having unsafe smoking behaviors and was using oxygen therapy. However, the resident's care plan was not updated to address these smoking behaviors or the use of oxygen, which posed a significant safety risk. Staff interviews confirmed the absence of a care plan for these issues, despite the known hazards of smoking while using oxygen. Resident 91 was also involved in unsafe smoking behaviors, as observed by staff. Although a smoking evaluation was conducted, the resident's care plan was not revised to reflect these behaviors or the resident's refusal of nicotine patches for smoking cessation. The lack of timely updates to the care plan following the identification of these behaviors was acknowledged by staff, indicating a failure to adequately address and document the resident's needs and risks associated with smoking.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to adhere to physician orders and professional standards in medication administration for three residents, leading to potential medication errors and compromised care. For Resident 42, the Licensed Practical Nurse (LPN) did not verify the current medication order for Sertraline, resulting in the administration of an incorrect dosage. The LPN was observed preparing a 100 mg dose of Sertraline without confirming the updated order, which had changed from 125 mg to 100 mg daily. This oversight was due to the LPN's haste and reliance on outdated medication packaging, rather than checking the Medication Administration Record (MAR). Resident 43 experienced a similar issue with the administration of a multivitamin. The LPN administered a multivitamin with minerals instead of the prescribed multivitamin without minerals, due to a misunderstanding about the facility's available stock. The LPN admitted to not verifying the order against the available supply and relied on incorrect information from a coworker. The Director of Nursing (DON) later confirmed that the two types of multivitamins were not interchangeable and that the order should have been clarified. For Resident 46, the facility failed to follow the prescribed parameters for administering Hydralazine, a blood pressure medication. The MAR indicated that the medication should be withheld if the resident's systolic blood pressure was below 110 or their heart rate was below 60. However, the facility did not document vital signs before administering the evening dose of Hydralazine, as required. The Registered Nurse and DON both acknowledged the lack of documentation and the necessity of checking vital signs before each dose, highlighting a lapse in following medication administration protocols.
Failure in Resident-Centered Discharge Planning
Penalty
Summary
The facility failed to ensure an effective resident-centered discharge plan for one resident, identified as Resident 36, who was reviewed for discharge planning. The deficiency was identified through interviews and record reviews, revealing that the discharge care plan did not align with the resident's needs or the expressed goals of the resident's representative. Despite Resident 36's cognitive function being intact and their expressed desire to transfer to another facility closer to a family member, the discharge care plan was not updated to reflect this goal. Resident 36 had submitted a grievance expressing dissatisfaction with the facility's discharge planning process, stating that they were unhappy at the facility and wanted to be closer to a family member. The grievance was assigned to a social services assistant, who acknowledged the resident's desire to transfer but did not update the discharge care plan accordingly. Additionally, the resident and their family member reported issues with communication, as the facility did not return phone calls or involve them in the discharge planning process. Interviews with facility staff, including the social services assistant and the director of nursing, confirmed that the discharge care plan should have been updated to reflect the resident's stated goal. The facility's process for discharge planning was not followed, as the resident and their representative were not included in care conferences, and the discharge care plan did not include interventions to support the resident's goal of transferring to another facility closer to family.
Failure to Provide Necessary ADL Assistance and Nail Care
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADL) for two residents, leading to unmet care needs. Resident 8, who required substantial assistance with transfers and bathing, was observed to have remained in bed for several days without being offered the opportunity to get out of bed. Despite the expectation that residents be offered daily opportunities to get out of bed, staff interviews revealed that Resident 8 had not been assisted out of bed since returning from the hospital. Additionally, there was no documentation of Resident 8 receiving a shower from early December to early January, despite being scheduled for weekly showers. Resident 65, who had diabetes and required regular nail care, was found to have long, curving fingernails with brown discoloration, indicating a lack of proper nail care. Although the Medication Administration Record (MAR) indicated that nail care was provided, observations and interviews confirmed that Resident 65's nails had not been trimmed as required. Staff acknowledged that the MAR should not have been signed if the care was not performed. The facility's policy on ADLs, revised in March 2018, mandates that residents unable to perform ADLs independently receive necessary services to maintain hygiene and mobility. However, the facility's failure to adhere to this policy for Residents 8 and 65 resulted in deficiencies related to unmet care needs and documentation inaccuracies.
Failure to Provide Consistent ROM Services for a Resident
Penalty
Summary
The facility failed to consistently provide services to maintain or improve the range of motion (ROM) for Resident 17, who had limited ROM in their upper extremity. The resident's care plan, revised in April 2020, included interventions such as applying a right rigid resting splint for 3-4 hours and performing passive ROM (PROM) to the right upper extremity and active ROM (AROM) to the left upper extremity. However, there was no documentation in the resident's electronic health record indicating that these interventions were carried out. Observations on two separate occasions showed that Resident 17 was not wearing any splints. Interviews with staff revealed a lack of consistent implementation of the care plan. A Certified Nursing Assistant (CNA) acknowledged that they did not perform any ROM exercises for Resident 17 and noted that the resident had not been wearing splints recently. A Registered Nurse confirmed that nursing was responsible for applying splints but could not confirm consistent application. The Director of Nursing (DON) admitted that there was no restorative program in place and expected CNAs to perform exercises recommended by therapy. The DON also confirmed the absence of documentation for the application of splints and ROM exercises, indicating a failure to meet the resident's care needs as outlined in their care plan.
Deficiencies in Smoking Policy and Bed Safety Maintenance
Penalty
Summary
The facility failed to implement and follow its smoking assessment and care plan for Resident 91, who was not listed on the facility's smoking audit despite having a history of unsafe smoking habits. Resident 91 was observed smoking in the facility's entrance lot and did not surrender smoking materials to staff upon re-entering the facility. The resident's care plan was not updated to reflect smoking behaviors identified in a smoking evaluation, which indicated the need for supervised smoking due to unsafe habits. Additionally, the resident refused nicotine patches prescribed for smoking cessation, and there was no documentation of where the resident stored smoking materials, posing a potential hazard. The facility also failed to ensure that side rails were secured and maintained for Resident 34. Observations revealed that the side rails on Resident 34's bed were loose, and a registered nurse acknowledged the need for maintenance. The maintenance assistant confirmed that side rails were only checked if listed in a work order, and upon inspection, noted that the side rails were loose and required additional washers to tighten them. This lack of maintenance could lead to potential hazards associated with resident entrapment. Interviews with staff revealed a lack of adherence to facility policies regarding smoking materials and bed safety. Staff acknowledged the need for care plan updates and proper storage of smoking materials, as well as the requirement for side rails to be maintained and functioning properly. The deficiencies in both smoking policy implementation and bed safety maintenance placed residents at risk of harm.
Deficiencies in Oxygen Therapy Management for Two Residents
Penalty
Summary
The facility failed to provide respiratory care in accordance with accepted professional standards for two residents, leading to deficiencies in oxygen therapy management. Resident 22, who was cognitively intact and diagnosed with chronic obstructive pulmonary disease, was observed receiving oxygen at higher flow rates than prescribed. Despite physician orders for two to three liters per minute, observations showed Resident 22 receiving four and a half to five liters per minute. Staff interviews revealed a lack of adherence to checking and adjusting the oxygen flow as per the physician's orders, with staff admitting to not verifying the flow rate during their shifts. Resident 87, admitted with generalized muscle weakness and chronic pain syndrome, had a physician's order for oxygen therapy at two liters per minute every day and evening. However, observations indicated that the oxygen therapy was not administered as ordered, and there was no documentation of oxygen saturation readings since October 2024. Staff interviews confirmed that the oxygen therapy was not given routinely, contrary to the physician's order, and there was no instruction to administer it based on oxygen saturation levels. Additionally, the nasal cannula was improperly stored, being placed on personal belongings instead of in a bag. The facility's failure to follow physician orders for oxygen therapy and properly store oxygen equipment placed the residents at risk for respiratory infections and related complications. Staff interviews highlighted a lack of compliance with the facility's policy on oxygen administration, which requires verification of physician orders and proper storage of equipment. The Director of Nursing and other staff acknowledged the discrepancies and the expectation for staff to follow the physician's orders as written.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for four residents, leading to unmet care needs and potential complications. Resident 39, diagnosed with lymphedema, had a care plan that included the use of compression stockings to manage edema. However, multiple observations revealed that the resident was not wearing the stockings, and staff acknowledged their responsibility in failing to implement this aspect of the care plan. Resident 89 experienced a significant weight gain, indicating a nutritional risk. The care plan required notifying the dietitian and physician of such changes, but there was no documentation of this notification before the resident was sent to the emergency room for anasarca evaluation. Staff interviews confirmed that the weight gain was not reported to the nurse practitioner or physician as expected. Resident 17's care plan included interventions for limited range of motion, such as the use of splints and exercises. Observations and record reviews showed no documentation of these interventions being carried out, and staff interviews confirmed the lack of implementation. Additionally, Resident 99's comprehensive care plan lacked a discharge plan, which staff attributed to uncertainty about the resident's discharge destination. The Director of Nursing stated that discharge planning should begin at admission, but this was not reflected in the care plan.
Failure to Follow Care Plans and Notify Providers
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for three residents, leading to unmet care needs and potential complications. Resident 39, diagnosed with lymphedema, had orders for compression therapy to manage swelling in the lower extremities. However, multiple observations revealed that the resident was not wearing the prescribed compression Tubigrip, despite documentation indicating otherwise. Staff interviews confirmed that the compression therapy was not administered as ordered, and documentation was inaccurately completed, failing to reflect the actual care provided. Resident 89 experienced a significant weight gain of 26.2 pounds within a week, which was not reported to the medical provider in a timely manner. The resident expressed concerns about their condition and requested to be sent to the hospital, but staff did not notify the provider until after the resident's representative called 911. The provider was only informed of the weight gain and associated edema during a routine visit, highlighting a lapse in communication and failure to follow the facility's weight management policy. Resident 46's care plan for constipation was not followed, as the resident went several days without a bowel movement without receiving the prescribed PRN medications. Documentation of bowel movements was inconsistent, and staff interviews revealed that the bowel protocol was not initiated as required. The lack of documentation and failure to administer necessary medications resulted in prolonged periods without bowel movements, contrary to the resident's care plan and facility policy.
Facility Assessment Lacks Staff Recruitment and Retention Plan
Penalty
Summary
The facility failed to update its facility assessment to include plans for maximizing direct care staff recruitment and retention, which is necessary to competently care for residents during both day-to-day operations and emergencies. The facility's policy, dated December 2023, mandates an annual assessment to determine the resources needed to meet resident needs. However, the Facility Assessment Tool, last updated on August 14, 2024, did not address strategies for staff recruitment and retention. During interviews, both the Administrator and Interim Administrator acknowledged the omission, with Staff A admitting it was missed and Staff C confirming it should have been included.
Food Temperature and Palatability Deficiency
Penalty
Summary
The facility failed to ensure that food was served at the proper temperature for residents in two nursing units, specifically the 500 and 200 Units. During observations, it was noted that the temperatures of the meals served were significantly below the required standards. For instance, a chicken patty was served at 100 degrees Fahrenheit, whereas it should have been at least 135 degrees Fahrenheit. Similarly, other food items like stuffing and Brussel sprouts were also served at temperatures below the required 135 degrees Fahrenheit. Cold items such as banana pudding and milk were also not maintained at the appropriate cold temperature of 40 degrees Fahrenheit, being served at 58 and 57 degrees Fahrenheit, respectively. Staff members acknowledged the temperature discrepancies and noted that the plastic containers used for serving did not help in maintaining the food's warmth. Multiple residents expressed dissatisfaction with the food, describing it as cold, flavorless, and inedible. Residents without cognitive impairments reported that the food was consistently served cold and lacked taste, leading some to avoid eating the meals provided by the facility. Complaints about the food's temperature and palatability were frequent, with residents even resorting to leaving notes for the dietary staff. The Director of Nursing Services stated that the expectation was to serve food at the correct temperatures, which was not being met, thus placing residents at risk for decreased nutritional intake and a diminished quality of life.
Boiler Malfunction Affects Kitchen Operations
Penalty
Summary
The facility failed to maintain a functioning boiler that consistently supplied hot water to the kitchen sink, which is essential for dishwashing. This deficiency was observed during a survey on December 12, 2024, when it was noted that the kitchen staff had to use a makeshift method to obtain hot water. A small white sink with a white tube taped to the faucet was used to fill large pans with hot water, which were then transported to larger sinks for washing pots, pans, and meal trays. This process was time-consuming and inefficient, leading to the use of plastic food containers for serving meals to residents. The issue began on December 3, 2024, when the boiler stopped working, and the problem persisted despite attempts to repair it. Interviews with staff revealed that the boiler had been turned off by the city on December 3, 2024, due to a leak, and it was tagged to prevent use. Although a repair technician was on-site on December 4 and 5, 2024, and again on December 8, 2024, the boiler continued to malfunction, affecting the kitchen's operations and the quality of meals served to residents. The maintenance staff was aware of the situation and expressed concerns about the boiler's reliability. The facility administrator acknowledged the issue and expressed dissatisfaction with the delay in resolving the problem.
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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