Benson Heights Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Kent, Washington.
- Location
- 22410 Benson Road Se, Kent, Washington 98031
- CMS Provider Number
- 505519
- Inspections on file
- 22
- Latest survey
- July 22, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Benson Heights Rehabilitation Center during CMS and state inspections, most recent first.
The facility's kitchen failed to maintain sanitary conditions, as observed by the lack of logs for sanitizing solution concentration and refrigerator temperatures. Additionally, improper handling of paper towels and inadequate cleaning practices were noted during lunch preparations, posing a risk of contamination.
The facility failed to provide proper written transfer notifications to residents and their representatives, as evidenced by four cases where forms were either improperly signed or missing. This deficiency involved residents being transferred to hospitals without receiving the necessary documentation to inform them of their rights and appeal procedures.
The facility failed to obtain informed consent for the use of bed rails and bed placement against walls for three residents, despite their medical conditions and care plans indicating the need for such arrangements. Staff E confirmed that consent was not obtained, which is necessary to ensure residents are informed and involved in their care decisions.
The facility failed to complete Level II PASRR evaluations for four residents, including those with severe memory impairment, depression, schizophrenia, PTSD, and significant behavioral issues. Despite indications from Level I screenings, the necessary evaluations were not documented, placing residents at risk for unmet mental health care needs. The Social Services Director acknowledged the oversight and the importance of these evaluations.
The facility failed to develop and implement comprehensive care plans for six residents, leading to potential risks for unmet care needs. A resident on anticonvulsant medication lacked a care plan for its use, while another with a urinary catheter and pressure ulcers did not have individualized Enhanced Barrier Precautions. Three residents had beds against the wall without documentation, and a resident with hearing difficulties lacked a care plan for communication. Additionally, a resident's care plan for seizure medication and antibiotics lacked monitoring details.
The facility failed to obtain and implement physician orders for several residents, leading to potential risks and unmet needs. A resident's bed was placed against the wall without a physician order, and another resident's oxygen tubing was not changed weekly as required. Conflicting orders for a pain medication patch lacked clarity, and a swallow evaluation for a resident at risk of aspiration was delayed. These deficiencies compromised resident safety and care quality.
The facility failed to implement skin breakdown interventions for a resident with severe memory impairment by not using a Therapy Carrot as ordered, and lacked documentation for its application. Additionally, another resident with heart failure and edema was not monitored daily for weight as required, with only weekly checks being conducted, despite the presence of pitting edema.
The facility failed to conduct safety assessments for three residents with beds against the wall, did not secure hazardous materials in an unlocked utility room, and inadequately supervised a resident with a history of PTSD and substance abuse during a leave of absence. The resident left unaccompanied despite a physician order requiring accompaniment, and the care plan lacked necessary interventions.
The facility failed to provide adequate respiratory care for two residents, leading to deficiencies in oxygen administration and equipment maintenance. One resident with respiratory failure was not monitored according to physician's orders, with low oxygen levels not reported or documented. Another resident's oxygen tubing was not changed weekly as required, increasing infection risk.
The facility failed to provide appropriate pain management for two residents. One resident received incorrect dosages of PRN pain medication, leading to inadequate pain relief. Another resident, on a scheduled pain regimen, was not monitored for side effects despite complaints of sedation. Staff interviews confirmed these deficiencies, highlighting a lack of adherence to prescribed medication parameters and monitoring protocols.
The facility failed to provide necessary social services for two residents with pressure ulcers, leading to a deficiency in care. One resident, with dementia and muscle weakness, refused care, including repositioning, contributing to worsening skin conditions and weight loss. The social services department was unaware of these refusals. Another resident also refused care, and their care plan did not involve social workers, contributing to continued resistance. The DON acknowledged the challenges but did not indicate effective measures to address refusals.
A resident received an antibiotic for 23 days instead of the prescribed 14 days due to a transcription error by the Unit Manager, leading to unnecessary medication administration. The resident, who required a CPAP machine, was at risk of adverse side effects from the prolonged antibiotic use.
A facility failed to provide a resident with the required carbohydrate-controlled, renal diet, despite the resident's complex medical conditions. The Dining Services Director was unaware of the dietary order and struggled to provide the necessary menus, leading to the resident receiving meals that did not meet their nutritional needs. The dietician emphasized the importance of following the correct menus, which were not adhered to by the dietary staff.
Sanitation and Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to ensure that food and drinks served to residents were prepared and distributed under sanitary conditions. During an inspection of the facility kitchen, it was observed that there was no log documenting that the kitchen's sanitizing solution was at an effective concentration. Staff S, the Dining Services Director, was unable to locate the log and confirmed that the sanitizer had not been checked since the shift change over three hours prior. Additionally, the refrigerator logs showed that temperatures had not been recorded for two consecutive days, indicating a lapse in monitoring the refrigeration conditions. Further observations during lunch preparations revealed that the paper towel dispenser was empty, and a roll of paper towels was placed on the counter, with the loose part resting against a can opener. The roll was dotted with drips of water, suggesting improper handling. Staff U, a Dietary Aide, used a piece of paper towel from the roll to wipe down a cart without using sanitizer or washing hands before or after the task, and then returned to food preparation. Staff S acknowledged that the paper towel dispenser should have been refilled and that sanitizer should be used for cleaning surfaces, with gloves only used when handling ready-to-eat foods.
Failure to Provide Proper Transfer Notifications
Penalty
Summary
The facility failed to provide required written notices to residents and their representatives at the time of transfer or discharge, as evidenced by the cases of four residents. Resident 22 was discharged to an acute care hospital without a properly signed transfer notification form, as it only contained the signature of a registered nurse and not the resident's or a witness's signature. The unit manager confirmed that the notification should have been witnessed and provided to the resident or their representative to ensure understanding of their rights. Similarly, Resident 63 was discharged without a properly signed transfer notification form, which only had the staff's signature and not the resident's or representative's. The staff involved believed that the social service staff was responsible for sending the notice to the representative, indicating a lack of clarity in the process. Resident 82's case was further complicated by the absence of a written transfer notification in the health records, with staff unable to locate it in the medical records or scanning bin. The social service director emphasized the importance of providing a written copy to inform residents or representatives about their rights and appeal procedures. Resident 20, who had no memory impairment and a history of medical issues, was transferred to the hospital twice without proper written notifications. Both instances lacked the resident's signature and a witness signature, with only the staff's signature present. The facility administrator stated that nurses were responsible for completing the notification form, while social services were tasked with ensuring the form was provided to the resident or their representative. This deficiency highlights a systemic issue in the facility's process for handling transfer notifications.
Failure to Obtain Informed Consent for Bed Rail and Bed Placement
Penalty
Summary
The facility failed to ensure that residents were provided informed consent for the use of bed rails and the placement of beds against walls, affecting three residents. Resident 63, who had no memory impairment and was diagnosed with general muscle weakness and mobility issues, had a bed rail installed without consent. The care plan indicated the use of an assist rail for bed mobility, but consent was not obtained, as confirmed by Staff E, the Unit Manager. Similarly, Resident 4, who had no memory impairment and was diagnosed with morbid obesity and a history of stroke, had their bed placed against the wall without consent. The care plan did not identify this arrangement, and Staff E acknowledged the oversight. Resident 70, diagnosed with lack of coordination and general muscle weakness, also had their bed placed against the wall without consent, which was not documented in their care plan. Staff E confirmed that consent should have been obtained for these arrangements to ensure residents were informed and involved in their care decisions.
Failure to Complete Level II PASRR Evaluations
Penalty
Summary
The facility failed to ensure that Level II Preadmission Screening and Resident Review (PASRR) evaluations were completed and incorporated into the care plans for four residents who required them. Resident 61, who was admitted with severe memory impairment and multiple mental health diagnoses, had three Level I PASRR screenings indicating the need for Level II services, but no Level II evaluation was on file. Similarly, Resident 22, diagnosed with depression and schizophrenia, had a Level I PASRR indicating the need for a Level II evaluation, but no such evaluation was documented. Staff D, the Social Services Director, acknowledged the absence of these evaluations and noted the importance of obtaining consultant recommendations for mental health care. Resident 82, with diagnoses including depression and PTSD, also required a Level II PASRR as indicated by a Level I screening, but no documentation of the evaluation was found. Resident 20, who exhibited significant behavioral issues, had a Level I PASRR indicating the need for a Level II evaluation, but this was not completed due to the resident's frequent discharges and admissions. Staff D stated that the hospital should have completed the referral before admission and emphasized the importance of the Level II PASRR in determining the necessary level of care. The lack of completed Level II evaluations for these residents placed them at risk for unmet mental health care needs.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for six residents, leading to potential risks for unmet care needs and negative health outcomes. Resident 34, who had a history of stroke and was on anticonvulsant medication for a seizure disorder, did not have a care plan addressing the use of this medication. The Director of Nursing acknowledged the oversight, noting that a care plan should have been developed to address the anticonvulsant use. Resident 10, diagnosed with difficulty voiding urine and dementia, had a urinary catheter and multiple pressure ulcers. However, the care plan did not reflect the need for Enhanced Barrier Precautions specific to the resident's condition, such as the presence of pressure ulcers and catheter use. The Director of Nursing confirmed that the care plan needed to be individualized to address these specific needs. Residents 4, 63, and 70 had their beds positioned against the wall for safety, but there were no care plans documenting this arrangement. Additionally, Resident 70, who had difficulty hearing, did not have a care plan addressing their hearing impairment. Resident 38's care plan for seizure medication lacked details on monitoring for side effects and drug toxicity, and their antibiotic treatment for respiratory illness was not adequately documented in the care plan. The Unit Manager and Director of Nursing both acknowledged these deficiencies, emphasizing the importance of including medication monitoring in the care plans.
Failure to Obtain and Implement Physician Orders
Penalty
Summary
The facility failed to ensure physician orders were obtained, clarified, and implemented for several residents, leading to potential risks and unmet needs. For Resident 4, the right side of the bed was placed against the wall without a physician order, which was acknowledged by Staff E as necessary to ensure an appropriate plan of care. Similarly, Resident 22's left side of the bed was against the wall without a physician order, and their oxygen tubing was not changed weekly as per facility policy due to the absence of a physician order. Staff F confirmed the importance of having these orders to prevent infection and ensure a physician-guided plan of care. Resident 63 also had their bed placed against the wall without a physician order, which Staff E noted was important for ensuring an appropriate care plan. Resident 71's bed was similarly positioned without a physician order, and Staff E reiterated the need for such an order. Additionally, Resident 34 had conflicting physician orders for a pain medication patch, lacking clarity on the strength of the medication, which Staff B stated should have been clarified. Resident 38, who had a history of stroke and difficulty swallowing, required a swallow evaluation due to the risk of aspiration. Although a physician order for the evaluation was made, it was not completed within the expected timeframe. Staff F and Staff B acknowledged the delay and the need for specific feeding instructions in the care plan, which were pending the evaluation. These deficiencies highlight the facility's failure to adhere to professional standards of practice, potentially compromising resident safety and care quality.
Failure to Implement Skin and Weight Monitoring Interventions
Penalty
Summary
The facility failed to implement skin breakdown interventions for Resident 61, who had severe memory impairment and required total assistance with daily routines. Despite a physician's order to use a Therapy Carrot for hand positioning to prevent skin breakdown, observations on multiple occasions revealed that the Therapy Carrot was not in place. Additionally, there was no documentation available for nursing staff to record the application and duration of the Therapy Carrot use, as confirmed by the Director of Nursing. This lack of documentation and implementation of the ordered intervention placed Resident 61 at risk for skin breakdown. The facility also failed to provide adequate weight monitoring for Resident 82, who had diagnoses of heart failure and edema and was receiving diuretic medication. The care plan required daily weight monitoring to manage edema and prevent complications such as cardiac overload. However, the Unit Manager admitted that Resident 82's weight was only being monitored weekly instead of daily. Observations confirmed the presence of pitting edema in Resident 82's lower extremities, indicating a failure to adhere to the care plan and monitor the resident's condition effectively.
Failure to Conduct Safety Assessments and Supervise Resident Leave
Penalty
Summary
The facility failed to ensure safety assessments were completed for three residents whose beds were placed against the wall. Resident 4, who had no memory impairment and diagnoses including morbid obesity and a history of stroke, did not have a safety assessment completed for their bed's right side against the wall. Similarly, Resident 63, with diagnoses of general muscle weakness and unsteadiness, and Resident 70, with lack of coordination and general muscle weakness, also lacked safety assessments for their beds placed against the wall. Staff interviews confirmed that these assessments were not conducted, which was necessary to ensure resident safety. Additionally, the facility did not secure hazardous materials in the North Utility Room, which was found unlocked with razors, hygiene supplies, and disinfectant cleaners stored in open cabinets. Staff acknowledged that the room should have been locked to prevent resident access to potentially dangerous items. This oversight posed a risk to resident safety, as these materials were accessible to vulnerable individuals. Furthermore, the facility failed to supervise a resident with a history of post-traumatic stress disorder and substance abuse during a leave of absence. Resident 90, who had a physician order requiring accompaniment when leaving the facility, left unaccompanied and admitted to misleading staff about having permission. The care plan did not include interventions for unaccompanied leave, and staff were unaware of the physician's order, which was potentially due to the resident's medical condition requiring a PICC line for antibiotic administration.
Deficiencies in Oxygen Administration and Equipment Maintenance
Penalty
Summary
The facility failed to provide adequate respiratory care for two residents, leading to deficiencies in oxygen administration and equipment maintenance. Resident 38, who had respiratory failure and low blood oxygen levels, was not monitored according to the physician's orders. Despite orders to monitor blood oxygen levels every shift and notify the provider of low levels, documentation showed that Resident 38's oxygen levels were at or below 90% on multiple occasions without any notification to the provider or adjustments to the care plan. Interviews with staff confirmed that the provider should have been notified, and the low oxygen levels should have been documented in the resident's progress notes. Resident 22, who had respiratory failure and chronic obstructive pulmonary disease, was dependent on supplemental oxygen. The facility's policy required weekly changes of oxygen tubing to prevent respiratory infections. However, observations revealed that Resident 22's oxygen tubing had not been changed according to this policy, as the tubing was dated beyond the weekly change requirement. Staff acknowledged the oversight and the importance of adhering to the policy to prevent infections.
Inadequate Pain Management and Monitoring in LTC Facility
Penalty
Summary
The facility failed to provide appropriate pain management for two residents, leading to deficiencies in care. For one resident with a history of stroke and chronic nerve pain, the facility did not adhere to the prescribed parameters for administering PRN pain medication. On multiple occasions, the resident received incorrect dosages of pain medication, either too high or too low, based on their reported pain levels. This inconsistency in following the physician's orders resulted in the resident experiencing inadequate pain relief, as confirmed by the resident's own report of persistent pain and the staff's acknowledgment of the issue. Another resident, who was on a scheduled pain medication regimen for conditions such as low back pain and arthritis, was not monitored for side effects of the medication. Despite the resident's complaints of excessive sedation and observations of lethargy, there was no physician order to monitor for these side effects. Staff interviews confirmed the lack of monitoring and the importance of ensuring the resident was not experiencing adverse effects from the medication. These failures in pain management practices placed the residents at risk for untreated pain and potential medication side effects.
Failure to Provide Medically-Related Social Services for Residents with Pressure Ulcers
Penalty
Summary
The facility failed to provide medically-related social services to two residents with pressure ulcers, leading to a deficiency in care. Resident 10, who had conditions such as dementia and muscle weakness, refused care on multiple occasions, including turning and repositioning, which are critical for pressure ulcer management. Despite having a care plan that involved both nurses and social workers to address these behaviors, the social services department was unaware of Resident 10's refusals. This lack of coordination and awareness contributed to the resident's worsening skin condition and significant weight loss. Similarly, Resident 21, who also had dementia and other health issues, refused care and repositioning, which are essential for preventing and managing pressure ulcers. The care plan for Resident 21 did not involve social workers in encouraging participation in care, which may have contributed to the resident's continued resistance to care. The Director of Nursing acknowledged the challenges posed by the residents' refusals but did not indicate any proactive measures taken to address these refusals effectively. The Social Services Director was aware of some behavioral issues but not the specific refusals of care, indicating a gap in communication and intervention strategies.
Antibiotic Administration Error for a Resident
Penalty
Summary
The facility failed to ensure that Resident 63's drug regimen was free from unnecessary medications, specifically concerning the administration of an antibiotic. Resident 63, who had no memory impairment and required a CPAP machine while sleeping, was prescribed a 14-day course of antibiotics for a sinus infection starting on January 15, 2025. However, due to a transcription error, the antibiotic was administered for a total of 23 days, exceeding the physician's order by nine days. The error occurred when Staff E, the Unit Manager, revised the antibiotic order on January 24, 2025, inadvertently restarting the 14-day course. This mistake led to the antibiotic being administered for an excessive duration. Staff C, the Infection Preventionist, confirmed that the antibiotic should have been given for only 14 days. The prolonged administration of the antibiotic placed Resident 63 at risk of experiencing avoidable adverse side effects and other potential negative health outcomes.
Failure to Provide Specialized Diets for Residents
Penalty
Summary
The facility failed to provide specialized diets required by residents, specifically for one resident who was assessed to need a carbohydrate-controlled, renal diet due to complex medical conditions including stage-3 kidney disease, diabetes mellitus, and morbid obesity. Despite the dietary order indicating the need for a specific diet, the resident expressed concerns about the facility not meeting their nutritional needs, citing an example of being served too many carbohydrates at breakfast. This indicates a lack of adherence to dietary requirements, which could lead to unmet nutritional needs and other negative health outcomes for the resident. The Dining Services Director, Staff S, was unable to provide the necessary therapeutic diet menus and was unaware of the resident's dietary order for a renal diet. During meal preparation, it was observed that the dietary staff did not have access to the correct menus, and the instructions provided did not specify the composition of meal trays for different dietary needs. Staff S took 44 minutes to access and print the required menus, and even then, the necessary food items, such as sliced carrots, were not available. The dietician, Staff T, confirmed the importance of following the break-out menus to ensure residents receive the nutrition they require, highlighting a significant lapse in the facility's dietary management.
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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