Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bothell Health Care during CMS and state inspections, most recent first.
Failure to follow a care planned Hoyer transfer led to an assisted fall during a shower-room transfer. A resident with a recent fall history was supposed to receive a mechanical lift and 2-person extensive assist, but one CNA relied on the resident’s statement and attempted the transfer without the required support. The resident fell, sustained a distal fibula fracture, and was sent to the ER.
A resident with generalized muscle weakness, impaired mobility, and moderately impaired cognition, who was dependent on staff for showering and considered bathing very important, was care planned and scheduled to receive two baths/showers per week. Review of the Kardex and EHR showed that multiple scheduled showers over several months were not provided, with only two refusals documented, despite the DON later stating the resident had refused multiple times without documentation. The Resident Care Manager and DON confirmed that staff were expected to follow the bathing schedule and document and report refusals, but this did not consistently occur, resulting in a failure to provide necessary ADL services for personal hygiene.
A resident with a medical condition requiring a restricted-calorie diabetic diet was served both a cherry tart and a fruit cup at lunch, exceeding the prescribed caloric intake. Dietary and nursing staff confirmed that only the fruit cup should have been provided, and records showed the planned menu surpassed the ordered calorie limit. The resident reported regularly receiving both items and consuming them.
The facility failed to assess and secure self-administered medications for four residents, leading to potential risks. A resident had an albuterol inhaler without a self-medication order, another had multiple medications unsecured, a third had Chinese herbs and cream without assessment, and a fourth had nasal spray and cream without a physician's order. Staff confirmed the lack of assessments and unsecured storage, contrary to facility policy.
The facility did not include the website address of the Washington State Long-Term Care Ombudsman on posted contact information in four areas. Observations confirmed the omission, despite facility documents stating residents' rights to such information. The administrator acknowledged the missing website address.
The facility did not maintain a homelike environment by serving meals on trays in residents' rooms and posting medical information signage. Staff had differing views on the impact of these practices, with some residents expressing a preference for changes.
The facility failed to ensure proper medication administration and handling, including premature signing of MARs, touching medications with bare hands, improper insulin administration, and not verifying feeding tube placement. These actions were against the facility's policies and placed residents at risk.
The facility failed to maintain food safety standards in the Walk-In Refrigerator and on a shelf below the steamer table, with improperly labeled and spoiled food items. Additionally, a dishwasher was observed without a beard net, despite having a beard, indicating a lapse in hygiene protocols. These deficiencies were acknowledged by the Dietary Manager and Administrator, highlighting risks of foodborne illness and cross-contamination.
The facility failed to document glucometer control testing readings accurately for five residents. The MARs only showed a check mark or plus symbol, without recording the exact reading numbers for low and high control tests. This oversight was confirmed by the DON, who stated that the results were not documented in the MARs, placing residents at risk of medical complications.
The facility failed to maintain an effective infection prevention and control program, leading to several deficiencies. There was no comprehensive water management program for Legionella, and staff were observed touching medications with bare hands, not performing proper hand hygiene, and failing to disinfect glucometers and insulin pens. Additionally, staff did not adhere to Enhanced Barrier Precautions and Transmission-Based Precautions, and sharps containers were not replaced when full.
The facility failed to follow manufacturer guidelines for disinfecting glucometers in Wing 300, using non-validated Mycolio wipes and alcohol wipes instead of recommended products. This was confirmed by staff interviews and observations, placing residents at risk of inaccurate blood sugar readings.
The facility failed to maintain dignity during meal assistance for a resident. Two CNAs were observed standing while assisting a resident with meals, contrary to the facility's expectations that staff should be seated and at eye level. This failure was confirmed by the Director of Nursing and the Administrator, and it placed the resident at risk for diminished self-worth.
A resident was administered the psychotropic medication Nuplazid without prior consent, contrary to the facility's protocols. The medication was given to address symptoms of Parkinson's psychosis, but consent was not documented until over a year later. This oversight was confirmed during a review with the Resident Care Manager.
A facility failed to document an advance directive for a resident, despite the resident stating they had one and a designated DPOA. Staff were unable to find the document in the EHR or physical records, risking the resident's healthcare preferences not being honored.
The facility failed to issue the required SNF ABN and NOMNC to two residents, which are necessary to inform them of the end of their Medicare coverage and potential financial liability. One resident did not receive either notice, while another did not receive the SNF ABN. Staff interviews confirmed the oversight, placing residents at risk of not being fully informed and losing their right to an appeals process.
A facility failed to transmit a resident's MDS assessment to CMS within the required timeframe. The discharge MDS, completed on November 18, 2024, was not submitted as required, which was confirmed by the MDS Nurse and the DON. This oversight placed residents at risk for unmet care needs and diminished quality of life.
The facility failed to accurately complete PASARR Level I forms and necessary Level II referrals for residents with SMI or ID. One resident's depression and delusional disorder were not marked on the PASARR form, and another resident with Parkinson's psychosis did not receive a Level II referral. Additionally, a resident with an exempted hospital discharge stayed over 30 days without a completed PASARR screening.
A facility failed to provide a resident with dementia culturally relevant activities as per their care plan. The resident, who preferred activities in Mandarin, was not given access to Chinese-language media or reading materials. Staff interviews revealed a lack of implementation of the care plan, with reasons cited including the presence of the resident's family and the ongoing COVID situation.
A facility failed to ensure consistent communication and documentation of hospice care for a resident receiving hospice services. Despite a policy requiring communication and documentation, hospice visit notes were missing from the resident's EHR. Staff confirmed that communication with hospice was mainly verbal, and the Director of Nursing acknowledged the lack of written documentation, placing the resident at risk of unmet care needs.
The facility failed to provide trauma-informed care for residents with PTSD. A resident with PTSD did not have a documented history of trauma or identified triggers in their care plan, despite a positive trauma assessment. Another resident, a retired police officer, lacked a trauma-informed care assessment, and a third resident with a malignant neoplasm also did not have an assessment. Staff acknowledged these oversights.
The facility failed to monitor anticoagulant use for two residents on apixaban for A-Fib, as required by their medication management policy. Staff interviews revealed that monitoring for side effects was not consistently documented, leading to a deficiency in medication management.
The facility failed to label and store medications properly in one of its medication storage refrigerators. A multi-dose vial of Tubersol was found without an open date, contrary to the facility's policy and manufacturer's recommendations. This oversight was confirmed by the DON, highlighting a risk of compromised medication for residents.
The facility failed to ensure CNAs received required dementia management training upon hire, as shown by the lack of documentation for two staff members. Despite the facility's policy mandating compliance with training regulations, records revealed that Staff U and Staff V did not complete the necessary training. The Infection Preventionist/Staff Development Coordinator confirmed the oversight, and the Director of Nursing expected the training to be completed upon hire, placing residents at risk for potential negative outcomes.
The facility's assessment was not updated to include specific staffing needs for each resident unit and shift, nor did it identify contracts with third-party services like hospice and hemodialysis. This omission was confirmed by the administrator during a review, placing residents at risk for unmet care needs.
A resident with dementia and moderate cognitive impairment was scheduled for a fistula gram procedure, but the LTC facility failed to inform the resident's DPOA about the need for consent. This oversight led to the cancellation of the procedure as the clinic could not obtain the necessary consent. Interviews revealed a lack of communication and coordination among staff regarding the resident's medical appointment.
Failure to Follow Care Planned Hoyer Transfer
Penalty
Summary
The facility failed to provide supervision and use the care planned mechanical lift and two-person assistance for a resident during a transfer, resulting in an assisted fall in the shower room. The resident had a history of falls, and the admission MDS showed a fall in the month before admission. The resident’s ADL care plan, initiated before the incident, showed that the resident required a Hoyer lift for transfers, and the therapy care guide showed mechanical lift use with two-person extensive assistance. On the day of the incident, the resident was in the shower room with one CNA. The resident stated that only one person was helping with the transfer from the wheelchair to standing, and that while standing to be dried and dressed, the resident felt unstable, said they were sliding, and could not get back to the wheelchair. The CNA stated that she asked the resident’s aide about transfer status, was told extensive assistance, and also asked the resident, who said one person could assist. The CNA stated she did not follow the care plan, later learned the resident needed a Hoyer, and acknowledged that she was wrong. Staff who reviewed the event stated that the resident was a Hoyer transfer with two-person assistance at the time of the fall and that staff should not change transfer status based on what the resident said. The facility’s investigation report showed the resident had a witnessed assisted fall in the shower room, the physician was notified of radiology results, and the resident was sent to the emergency room. Radiology showed an acute fracture of the right distal fibula, and hospital records showed a displaced distal fibular shaft fracture with placement in a three-way splint.
Failure to Provide Scheduled Bathing and Document Care Refusals
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary ADL services, specifically scheduled bathing, to a resident who was dependent on staff for showering. The resident was admitted with generalized muscle weakness and had an ADL care plan initiated that identified self-care performance deficits related to weakness, pain, and impaired mobility. The care plan and facility task schedule specified that the resident was to receive two baths/showers per week, on Tuesdays and Saturdays. A quarterly MDS assessment documented that the resident had moderately impaired cognition, was dependent on staff for showering/bathing, and that showering/bathing was very important to them. In an interview, the resident reported not receiving baths/showers consistently and stated it had been three weeks since their last shower. Record review of the Kardex and the facility’s electronic health record showed multiple missed showers between early December and early March on numerous scheduled dates, despite the established twice-weekly bathing schedule. The records also showed only two documented refusals of showers on two specific dates, while the DON later stated the resident had refused bath/shower multiple times without documentation. The Resident Care Manager and the DON both stated that staff were expected to provide showers/baths as scheduled and, when residents refused care, to offer it at another time, document the refusal, and report it. The documented pattern of missed showers, combined with incomplete documentation of refusals, demonstrated that the facility did not consistently follow the resident’s care plan and bathing schedule as required by policy and regulation.
Failure to Provide Ordered Therapeutic Diet to Resident
Penalty
Summary
The facility failed to ensure that a therapeutic diet was provided as ordered for a resident with a diagnosis of a syndrome causing excessive appetite and overeating. The resident was prescribed a diabetic diet limited to 2,000 calories per day, with specific instructions to substitute fruit for dessert. However, review of dietary records and direct observation revealed that the resident's lunch tray included both a cherry tart dessert and a mixed fruit cup, and the resident consumed both items. The planned diabetic menu for the day also exceeded the prescribed caloric limit by 220 calories. Interviews with dietary and nursing staff confirmed that the resident should not have received the cherry tart and that only the fruit cup was appropriate for their diet. Staff acknowledged difficulties in redirecting the resident from requesting extra portions and confirmed that the dietary orders were not followed as prescribed. The resident reported routinely receiving both a dessert and fruit at lunch and expressed difficulty in losing weight, despite efforts to comply with dietary restrictions.
Failure to Assess and Secure Self-Administered Medications
Penalty
Summary
The facility failed to ensure that residents were properly evaluated and assessed for self-medication administration, did not receive physician orders for self-medication, and were not educated on storing medications in a lockable storage unit. This deficiency was observed in four residents. Resident 50 had an albuterol inhaler in their room without a self-medication order or assessment. Resident 7 had multiple oral medications and eye drops in an unlocked drawer and was taking medications without supervision, despite not having a self-medication assessment for oral medications. Resident 76 had Chinese herbs and a cream in their room without a self-medication assessment, and Resident 90 had Afrin nasal spray and hydrocortisone cream without a physician's order or self-medication assessment. The facility's policy required all medications to be stored in locked compartments, but this was not adhered to for the residents involved. Staff E, the Resident Care Manager, confirmed the lack of self-medication assessments for these residents and acknowledged that medications should be stored in a locked drawer, which was not the case. The Director of Nursing stated that residents on self-medication administration should have a self-medication assessment and store their medications in a locked drawer, which was not followed, placing residents at risk for medication errors and related complications.
Ombudsman Website Address Not Posted
Penalty
Summary
The facility failed to provide the website address of the Washington State Long-Term Care Ombudsman on the posted contact information in four areas: the 100-Wing, 400-Wing, across the conference room, and the library. This omission was identified through observations conducted on multiple dates and times. The facility's documents, including the Admission Agreement and Resident Handbook, indicated that residents have the right to be informed of their rights and provided with contact information for state and local advocacy organizations, including the Long-Term Care Ombudsman. However, the posted information did not include the website address, as confirmed by the facility's administrator during an interview.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to provide a homelike environment for residents, as evidenced by the serving of meals on trays in residents' rooms and the posting of medical information signage in residents' rooms. Observations showed that two residents were served their meals on trays, which staff acknowledged was not homelike. Staff interviews revealed a lack of consensus on whether serving meals on trays in residents' rooms affected the homelike environment, with some staff believing it did not make a difference unless residents had a preference. Additionally, medical information signage was posted in the rooms of two residents, which was not aligned with creating a homelike environment. One resident expressed a desire to have the sign removed, while another was unaware of the sign's presence. Staff interviews indicated that the signs were intended as visual reminders for staff, and there was a belief that they did not detract from the homelike environment. However, the presence of these signs was noted as a failure to maintain a homelike setting, as required by the facility's guidelines.
Medication Administration and Handling Deficiencies
Penalty
Summary
The facility failed to ensure that staff documented medications in accordance with professional standards of practice for three residents. Staff L, a registered nurse, signed the Medication Administration Record (MAR) for three residents before actually administering their medications. This premature signing was based on the assumption that the residents would take their medications as usual, which is against the facility's policy that requires signing the MAR only after medication administration. Staff D, the Resident Care Manager, confirmed that the MAR should be signed post-administration. Additionally, the facility did not adhere to proper medication handling protocols. Staff L was observed picking up a Vitamin D tablet with bare hands after it fell on the medication cart surface and then administering it to a resident. This action was contrary to the facility's policy, which mandates disposing of medications that have been contaminated and not touching them with bare hands. Staff D acknowledged that the medication should have been disposed of and replaced with a new one. The facility also failed to follow proper procedures for insulin administration and feeding tube verification. Staff K did not clean the insulin pen rubber seals with alcohol wipes before attaching the needle and did not pinch the skin before injecting insulin for two residents. Furthermore, Staff G did not verify the placement of a feeding tube before administering medications to a resident, contrary to the facility's policy. Staff B, the Director of Nursing, confirmed the expectations for these procedures, indicating that the staff did not comply with the established protocols.
Food Safety and Hygiene Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards of food safety in their handling and storage of food items, as observed in the Walk-In Refrigerator and on the shelf below the steamer table. During an inspection, it was found that a half package of cheese lacked an open date, a package of provolone cheese was missing a use by date, and an opened bag of iceberg lettuce contained brownish leaves, indicating spoilage. Additionally, a container of baking powder had an unreadable open date and was past its expiration date, while opened jugs of honey and a bottle of red wine vinegar were not labeled with open or use by dates. These lapses in food safety practices were acknowledged by Staff O, the Dietary Manager, who confirmed the items should have been properly labeled and the spoiled lettuce discarded. Furthermore, the facility did not ensure that all kitchen staff adhered to proper hygiene standards, as evidenced by Staff W, a dishwasher, who was observed washing dishes without a beard net, despite having a beard. Staff O admitted that there was no specific policy regarding beard nets, and Staff A, the Administrator, stated that they expected kitchen staff to wear beard nets if they had long beards. This oversight in enforcing hygiene protocols placed residents at risk for foodborne illnesses and cross-contamination.
Inaccurate Documentation of Glucometer Control Testing
Penalty
Summary
The facility failed to accurately document glucometer control testing readings for five residents, which included Residents 20, 19, 92, 24, and 47. The facility's policy required glucometer control testing to be performed every night shift, with results compared to the range printed on the test strip bottle. However, the Medication Administration Records (MAR) for these residents only showed a check mark or a plus symbol to indicate that the test was performed and within range, without documenting the exact reading numbers for the low and high control tests. This lack of documentation was confirmed during a joint record review and interview with Staff B, the Director of Nursing. The facility's policy on glucometer cleaning and control testing, revised in April 2025, did not specify the exact reading numbers for the low and high solution control tests. During an interview and observation, Staff B confirmed that the results of the low- and high-level reading numbers were not documented in the residents' MARs. The glucometer system used, Evencare G2, had specific ranges for low (35 to 65) and high (160 to 216) readings, but these were not recorded in the MARs. This oversight in documentation placed the residents at risk of medical complications, unmet care needs, and diminished quality of life.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, leading to several deficiencies. The facility did not have a comprehensive water management program to assess the potential growth of Legionella or other waterborne pathogens in the decorative water fountain. The last documented Legionella risk assessment was completed in 2023, and there was no control test documentation for the water fountain after 2020. This oversight could potentially increase the risk of Legionella transmission among residents, staff, and visitors. During medication administration, a registered nurse was observed touching a Vitamin D tablet with bare hands after it fell on the medication cart, which is against the facility's policy. This incident involved a resident who was administered the contaminated tablet. Additionally, staff failed to perform proper hand hygiene and disinfection of glucometers between residents, as observed with three residents during blood glucose monitoring. Insulin pens were also not cleaned prior to administration for two residents, which could lead to cross-contamination and infection. The facility did not adhere to Enhanced Barrier Precautions and Transmission-Based Precautions. Staff were observed not wearing appropriate PPE, such as gowns and N95 masks, when required, and failed to perform hand hygiene when entering and exiting rooms of residents on isolation precautions. Furthermore, sharps containers were not replaced when full, posing a risk of injury and infection. These deficiencies indicate a lack of adherence to infection control protocols, increasing the risk of infection transmission within the facility.
Improper Glucometer Disinfection Practices
Penalty
Summary
The facility failed to maintain proper disinfection procedures for glucometers in Wing 300, as per the manufacturer's recommendations. Observations revealed that Staff K, a Registered Nurse, cleaned glucometers with alcohol wipes after checking the blood sugar levels of Residents 20, 92, and 19, which is not in accordance with the manufacturer's guidelines. The facility's policy, revised in April 2025, incorrectly instructed staff to use Mycolio disinfectant wipes, which are not validated by the manufacturer for use with EVENCARE G2 glucometers. This discrepancy was confirmed by Staff C, the Infection Preventionist, and Staff D, the Resident Care Manager, who both acknowledged the inappropriate cleaning practices. Further investigation showed that the facility's documentation and cleaning practices were inconsistent with the manufacturer's instructions. The Director of Nursing, Staff B, confirmed that the EVENCARE G2 glucometer manufacturer's guide did not list Mycolio as a validated disinfectant. Additionally, the facility's records did not document the reading numbers of glucometer control tests in the residents' Medication Administration Records (MARs), only indicating results within range with a plus symbol. This lack of proper documentation and adherence to manufacturer guidelines placed residents at risk of inaccurate blood sugar readings and potential negative outcomes.
Failure to Maintain Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure that staff provided care and services in a manner that maintained and promoted dignity while assisting a resident with meals. Specifically, two Certified Nursing Assistants (CNAs), Staff Z and Staff AA, were observed standing while assisting Resident 70 with their meals. Staff Z was observed standing while assisting Resident 70, who was seated in a wheelchair, and acknowledged that sitting would be better to prevent residents from feeling rushed. Staff AA was also observed standing while assisting Resident 70, who was in bed, and stated that the bed was too high to sit down. Interviews with the Director of Nursing and the Administrator confirmed that staff were expected to be seated and at eye level when assisting residents with meals. The facility's Resident Handbook included a bill of rights stating that residents have the right to be treated with respect and dignity. The failure to adhere to these expectations placed Resident 70 at risk for diminished self-worth and overall well-being.
Failure to Obtain Consent for Psychotropic Medication
Penalty
Summary
The facility failed to inform a resident and/or their representative before administering a psychotropic medication, Nuplazid, which is used to treat symptoms such as delusions and hallucinations associated with Parkinson's psychosis. The resident, identified as Resident 34, was started on Nuplazid on September 21, 2023, without obtaining the necessary consent. This oversight was discovered during a review of the Electronic Health Record (EHR), which showed that consent for the medication was not documented until October 9, 2024, over a year after the medication was first administered. The facility's documents, including the Admission Agreement and Resident Handbook, emphasize the resident's right to be informed about the risks and benefits of treatments and to make health care decisions. However, these protocols were not followed in the case of Resident 34. During an interview and joint record review with Staff E, the Resident Care Manager, it was confirmed that the consent for Nuplazid was not completed in 2023, and the first dose was administered on September 22, 2023, without prior consent. This failure placed the resident at risk of not being fully informed about their treatment options.
Failure to Document Advance Directive for a Resident
Penalty
Summary
The facility failed to ensure that an advance directive was obtained and completed for one of the residents reviewed for advance directives. The resident, identified as Resident 70, was capable of making their own decisions with support from their daughters. However, the facility's records, including the Social Service History & Initial Assessment and the comprehensive care plan, did not indicate whether Resident 70 had a Durable Power of Attorney (DPOA) for health care or if they chose not to execute an advance directive document. Interviews with the resident revealed that they had an advance directive and a relative designated as their DPOA. Despite the resident's statement, the facility's staff, including the Social Services Assistant, Unit Manager, and Social Services Director, were unable to locate any documentation of the advance directive in the resident's Electronic Health Records (EHR) or in the physical records kept at the nursing station. The Administrator expressed an expectation that residents should have advance directives, but the facility's failure to document and maintain this information placed the resident at risk of not having their healthcare preferences honored.
Failure to Provide Required Medicare Coverage Notices
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility (SNF) Advanced Beneficiary Notice of Non-coverage (SNF ABN) and Notification of Medicare Non-Coverage (NOMNC) to two residents, which are necessary to inform them of the end of their Medicare coverage and their potential financial liability. Resident 25 received Medicare Part A Skilled Services from January 20, 2025, to February 22, 2025, but there was no documentation that an SNF ABN or NOMNC was provided two days before the last covered day. Similarly, Resident 73, who received Medicare Part A skilled services from November 14, 2024, to February 25, 2025, did not receive an SNF ABN, and there was no documentation of such notice in their Electronic Health Record (EHR). Interviews with facility staff confirmed the oversight, with Staff M, a Social Services Assistant, acknowledging that the SNF ABN was not provided for Residents 25 and 73, and the NOMNC was not provided for Resident 25. The facility's administrator, Staff A, also confirmed the expectation that these notices should have been provided before the end of the residents' Medicare coverage. This failure placed the residents at risk of not being fully informed and losing their right to an appeals process.
Failure to Transmit MDS Assessment Timely
Penalty
Summary
The facility failed to transmit the Minimum Data Set (MDS) assessment for one resident to the Centers for Medicare & Medicaid Services (CMS) within the required timeframe. Specifically, the discharge MDS for Resident 69, completed on November 18, 2024, was not submitted to CMS as required. According to the guidelines, comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date, and all other MDS assessments must be submitted within 14 days of the MDS Completion Date. This oversight was identified during a joint record review and interview with the MDS Nurse, who acknowledged that the MDS was completed but not transmitted. The Director of Nursing confirmed the expectation that MDS assessments should be completed and transmitted in a timely manner. The failure to transmit Resident 69's discharge MDS by the deadline of December 2, 2024, was acknowledged by the staff involved. This lapse placed the residents at risk for unmet care needs and diminished quality of life, as timely submission of MDS data is crucial for ensuring appropriate care planning and resource allocation.
Failure to Complete Accurate PASARR Screenings and Referrals
Penalty
Summary
The facility failed to ensure accurate completion of the Preadmission Screening and Resident Review (PASARR) Level I forms and necessary referrals for Level II evaluations for residents with serious mental illness (SMI) or intellectual disabilities (ID). Resident 55 was admitted with a diagnosis of depression, which was not marked on the Level I PASARR form. Additionally, a new diagnosis of delusional disorder was not updated on the form, and no Level II referral was made. Staff N, the Social Services Director, acknowledged these omissions during a joint record review and interview. Resident 34's PASARR Level I was completed without a referral for Level II, despite the resident having diagnoses of Parkinson's psychosis, delusions, and visual hallucinations. The psychiatric progress note indicated the resident was on antipsychotic medication. Staff M, the Social Services Assistant, did not complete a new Level I PASARR or a referral for Level II, believing the resident did not qualify due to the absence of suicidal ideations. Staff A, the Administrator, also did not expect a new PASARR to be completed for Resident 34. Resident 2 was admitted with an exempted hospital discharge and remained in the facility for over 30 days without a completed Level I PASARR screening. Staff M stated that they usually send a completed PASARR screening before the 30th day if a resident is expected to stay longer. However, no Level I PASARR screening or Level II referral was completed before Resident 2's hospital discharge. Staff A confirmed that the screening should have been done for residents staying more than 30 days.
Failure to Provide Culturally Relevant Activities for Resident
Penalty
Summary
The facility failed to implement and provide an activity plan for a resident diagnosed with dementia, who preferred activities such as reading and keeping up with the news in their native language, Mandarin. The resident's care plan, initiated in December 2024, indicated that they enjoyed independent activities like reading and watching Chinese news programs. However, observations on multiple occasions in March 2025 showed that the resident was not provided with any reading materials or access to Chinese-language media, as their TV was not on and there were no culturally relevant materials in their room. Interviews with staff and the resident's relative revealed that the resident was not offered activities aligning with their cultural background and interests. Staff Y, a CNA who spoke Mandarin, admitted to not providing the resident with Chinese reading materials or setting their TV to Chinese channels, citing the presence of the resident's family as a reason. The Activity Director, Staff P, acknowledged not providing activities as per the care plan, attributing the lapse to the ongoing COVID situation. The facility administrator confirmed the expectation that staff should have implemented the care plan and provided appropriate activities to the resident.
Failure in Communication and Documentation of Hospice Services
Penalty
Summary
The facility failed to ensure consistent communication and collaboration of care between the facility and hospice care for Resident 15, who was receiving hospice services. The facility's policy required maintaining communication with hospice and documenting all interventions. However, a review of Resident 15's medical records revealed a lack of documentation of hospice care visit notes, despite the hospice referral being made in January 2025. Interviews with facility staff, including a Licensed Practical Nurse and the Resident Care Manager, confirmed that communication with hospice staff was primarily verbal or by phone, and hospice visit notes were not uploaded into the resident's Electronic Health Record (EHR). The Director of Nursing acknowledged that there should have been both verbal and written communication to coordinate care between the facility and hospice. The absence of hospice visit notes in Resident 15's EHR was confirmed, indicating a failure to adhere to the facility's policy on coordination of hospice services. This deficiency placed Resident 15 at risk of not receiving necessary hospice care services, leading to unmet care needs and a diminished quality of life.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for residents diagnosed with PTSD, as required by their policy. Resident 8, who was diagnosed with PTSD, did not have a documented history of trauma or identified triggers in their care plan. Despite a positive trauma assessment indicating PTSD, the facility did not complete a trigger assessment or update the care plan to include strategies for managing PTSD. Staff N, the Social Service Director, acknowledged the oversight and confirmed that the care plan should have been updated to address Resident 8's triggers. Additionally, Resident 34, a retired police officer, did not have a trauma-informed care assessment in their Electronic Health Record, despite the potential for trauma-related issues due to their previous occupation. Staff M, the Social Services Assistant, confirmed the absence of such an assessment. Similarly, Resident 76, diagnosed with a malignant neoplasm of the frontal lobe, also lacked a trauma-informed care assessment. Staff N admitted that no assessment was found in Resident 76's records, and Staff A, the Administrator, expressed the expectation that trauma-informed care assessments should be completed for all residents.
Failure to Monitor Anticoagulant Use in Residents
Penalty
Summary
The facility failed to adequately monitor the use of anticoagulant medications for two residents, leading to a deficiency in medication management. Resident 55, who was admitted to the facility and prescribed apixaban for atrial fibrillation, did not have documented monitoring for anticoagulant use from January to March 2025. Interviews with staff revealed that monitoring for adverse side effects should have been initiated when the medication was first ordered, but this was not done. The Director of Nursing confirmed that monitoring is required to ensure resident safety and appropriate intervention if complications arise. Similarly, Resident 45, who was also prescribed apixaban for atrial fibrillation, was not monitored for anticoagulant use as per the March 2025 Medication Administration Record. Staff interviews indicated that monitoring was only documented if symptoms were observed, which led to a lack of consistent documentation. The Director of Nursing acknowledged that monitoring entails documentation and that there should have been continuous monitoring for side effects. The deficiency was identified as a failure to adhere to the facility's policy on medication monitoring, placing residents at risk for receiving unnecessary medications and related complications.
Failure to Label and Store Medications Properly
Penalty
Summary
The facility failed to appropriately label and store drugs and biologicals in one of the two refrigerators designated for medication storage, specifically Medication Storage A. During an observation and interview, it was found that a multi-dose vial of Tubersol, used for tuberculosis diagnosis, was present in the refrigerator without an open date marked on it. According to the package insert for Tubersol, an open multi-dose vial should be discarded after 30 days. The absence of an open date on the vial made it impossible to determine how long it had been in use, which is a violation of the facility's medication storage policy. The facility's policy, revised in May 2024, mandates that all medications be stored according to the manufacturer's recommendations, ensuring proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. The Director of Nursing confirmed that without the open date, the facility could not ascertain when the vial was opened, thus failing to comply with the policy. This oversight placed residents at risk of receiving compromised and ineffective medications.
Failure to Provide Dementia Training for CNAs
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) had the required dementia management training upon hire, as evidenced by the lack of documentation for two staff members, Staff U and Staff V. The facility's policy, revised in September 2024, mandates compliance with state and federal regulations regarding the training and continuing education of nurse aides. However, a review of the employee records showed that Staff U, hired on July 9, 2024, and Staff V, hired on April 23, 2024, did not have documentation of completing the required dementia management training. During an interview and joint record review, Staff C, the Infection Preventionist/Staff Development Coordinator, confirmed that dementia management training is provided upon hire and annually through an online platform, Relias. However, the review of the online training records revealed that Staff U and Staff V had not completed their dementia management training. Staff C acknowledged this oversight, and Staff B, the Director of Nursing, stated that they expected the training to be completed upon hire. This deficiency placed residents at risk for potential negative outcomes and unmet care needs.
Facility Assessment Lacks Staffing and Service Agreements
Penalty
Summary
The facility failed to update its facility-wide assessment to include specific staffing needs for each resident unit and shift, as well as to identify contracts or agreements with third-party services such as hospice and hemodialysis. This oversight was identified during an interview and joint record review with the facility's administrator, who confirmed that the updated assessment did not document these critical elements. The absence of this information in the facility assessment placed residents at risk for unmet care needs and a diminished quality of life.
Failure to Inform DPOA Leads to Procedure Cancellation
Penalty
Summary
The facility failed to provide timely information about a medical appointment for a resident with moderate cognitive impairment, leading to the cancellation of a necessary medical procedure. The resident, who was diagnosed with dementia and required supervision in decision-making, was scheduled for a fistula gram procedure. However, the facility did not notify the resident's Durable Power of Attorney (DPOA) about the need for their presence or consent at the appointment. As a result, the clinic was unable to proceed with the procedure due to the lack of consent from the DPOA. Interviews with facility staff revealed a lack of communication and coordination regarding the resident's medical appointment. The Unit Coordinator acknowledged their responsibility to coordinate appointments but failed to inform the DPOA about the necessity of their availability for consent. The Director of Nursing Services mistakenly believed the resident was capable of making independent decisions, despite the care plan indicating the need for supervision. The facility administrator expected collaboration with the resident's representative for arranging appointments, but this expectation was not met, leading to the deficiency.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Bothell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fircrest Nursing Facility | 3 mi | ★★★★★ | 25 | 0 |
| Alderwood Post Acute & Rehabilitation | 3.1 mi | ★★★★★ | 61 | 0 |
| Lynnwood Post Acute Rehabilitation Center | 4.1 mi | ★★★★★ | 1 | 0 |
| Edmonds Post Acute | 4.3 mi | ★★★★★ | 60 | 0 |
| Pine Ridge Post Acute | 4.8 mi | ★★★★★ | 18 | 0 |
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