Columbia Lutheran Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Seattle, Washington.
- Location
- 4700 Phinney Avenue North, Seattle, Washington 98103
- CMS Provider Number
- 505470
- Inspections on file
- 20
- Latest survey
- February 6, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Columbia Lutheran Home during CMS and state inspections, most recent first.
A resident with dementia and anxiety disorders was transferred to a hospital and later discharged based on verbal confirmation that he did not wish to return, but the facility failed to provide written discharge notification, including appeal rights and bed-hold information, to him and his designated representative. Although a transfer/discharge notice was completed and indicated the resident refused to sign, there was no documentation that it was mailed or otherwise given in writing to the representative, who had signed the admission paperwork as the legal decision maker. Multiple staff, including RCMs, Medical Records, and the DON, confirmed through EHR review and interviews that the facility’s process requiring written notice to both the resident and representative was not followed.
The facility failed to adhere to food safety standards, with expired and improperly handled food items found in kitchen and pantry areas. Staff were observed handling food without gloves, and meal trays were delivered with uncovered items due to a shortage of plastic wrap. These deficiencies were acknowledged by staff, including the Food Service Manager and Director of Nursing.
The facility failed to ensure proper hand hygiene and glove use during resident care and housekeeping, as well as during medication administration. Staff did not adhere to Enhanced Barrier Precautions or sanitize medical equipment between uses. A resident's urinary catheter bag was also improperly handled, increasing infection risk.
The facility failed to provide a system for residents and representatives to anonymously report grievances, affecting both floors. Staff interviews and observations revealed that grievances were collected in a non-anonymous manner, with no accessible grievance box available. The facility's policy and documentation did not include a method for anonymous reporting, and the administrator acknowledged the absence of such a system.
The facility failed to ensure accurate and timely PASARR evaluations for several residents, leading to deficiencies in identifying and addressing Serious Mental Illness (SMI) or intellectual disabilities. For example, a resident's PASARR Level I did not include all relevant diagnoses, and necessary Level II evaluations were delayed. Staff interviews revealed misunderstandings and inconsistencies in the review process, contributing to these issues.
Two residents in an LTC facility experienced deficiencies in care planning. One resident did not receive the prescribed nutritional supplement, Ensure, with breakfast as per their care plan. Another resident, with diabetes and ESRD, lacked a care plan for diabetic nail care and had inconsistent daily weight recordings. Staff interviews confirmed these oversights, highlighting a failure to follow comprehensive care plans.
The facility failed to conduct timely care plan meetings with two residents and/or their representatives, as required. One resident, who was cognitively intact, reported not having a recent care conference, and there was no documentation of care conferences being offered or held. Another resident was unaware of any care conferences, and the facility's records lacked documentation of their participation. Staff interviews revealed that care conferences were expected to be held with the MDS schedule, but there was no evidence to verify the residents' involvement.
A facility failed to ensure proper documentation of medication administration for a resident. A Registered Nurse signed the Medication Administration Record (MAR) before administering medications, contrary to the facility's policy requiring the MAR to be signed after administration. Interviews with the nurse, Unit Manager, and Director of Nursing confirmed the expectation of post-administration documentation, highlighting a risk for medication errors.
The facility failed to provide proper respiratory care for two residents. One resident's nebulizer equipment was not stored correctly, increasing infection risk, while another resident did not receive prescribed oxygen therapy. Staff acknowledged the expectations but did not adhere to protocols, leading to deficiencies in care.
The facility failed to ensure that a dietary staff member maintained a current food handler's permit, as required by policy. Staff EE's permit had expired, yet they continued to work in the kitchen on several occasions. This was confirmed by the Food Service Manager and the Administrator, who both acknowledged the expectation for staff to have up-to-date permits.
The facility failed to provide a resident with weekly menus, leading to dissatisfaction with meals, and did not deliver an ordered nutritional supplement to another resident due to a system oversight. Staff interviews revealed unclear responsibilities and process adherence issues in dietary services, impacting residents' nutritional needs and meal satisfaction.
A facility failed to accurately assess a resident's depression diagnosis using the MDS tool. The resident was admitted with depression and prescribed an antidepressant, but the Admission MDS did not reflect this diagnosis. The MDS Coordinator acknowledged the oversight, and the DON expected accurate MDS completion. This lapse could lead to unmet care needs.
The facility failed to provide two residents with information about COVID-19 vaccinations, including risks and benefits, and did not document their vaccination status. One resident expressed a desire for the vaccine but was not offered it due to admission after the vaccine clinic. The facility prioritized long-term residents for vaccination, leading to this deficiency.
A resident was observed self-administering eye drops without a documented assessment or physician's order, contrary to facility policy. Staff confirmed the absence of an order and acknowledged that the medication should not have been at the bedside. The facility's policy requires an IDT assessment for safe self-administration, which was not documented in the resident's records.
Failure to Provide Required Written Discharge Notice and Appeal Rights
Penalty
Summary
The deficiency involves the facility’s failure to provide required written notification of a discharge, including appeal rights and bed-hold information, to a resident and the resident’s representative. The resident had dementia with agitation and anxiety disorders and had a designated representative who signed the admission paperwork because the resident stated he could not sign. The resident was transferred to the hospital for medical evaluation, and a Notice of Transfer or Discharge was completed on the transfer date, indicating the resident refused to sign. However, there was no documentation that this notice was mailed or otherwise provided in writing to the resident’s representative, despite the representative being listed in the record. Subsequent nursing documentation showed that the Resident Care Manager (Staff B) contacted the resident by phone the day after the transfer and obtained verbal confirmation that the resident did not wish to return to the facility, and the resident was treated as discharged at that time. Staff B did not contact the resident’s representative to notify them of the discharge and confirmed there was no record that written notice or appeal rights were mailed to the representative. Joint record reviews with Medical Records (Staff D) and another Resident Care Manager (Staff C) confirmed that all documents were scanned into the EHR and that there was no documentation of written discharge notification to either the resident or the representative. The DON (Staff A) stated the expectation that written notifications of transfers and discharges be provided to residents and their representatives, but this did not occur for this resident, in violation of WAC 388-97-0120(2)(a-c).
Food Safety and Handling Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards of food safety, as evidenced by multiple observations of expired and improperly handled food items. In the kitchen's reach-in refrigerator, a gallon of fat-free milk was found past its use-by date, and in the walk-in refrigerator, grapes with mold were discovered. Staff D, the Food Service Manager, acknowledged these issues, stating that dietary staff were expected to label, date, and discard expired items. Similar issues were noted in the kitchen dry storage room, where unlabeled bags of cereal were found, and in the dining room pantry refrigerators, where expired yogurts and nutritional supplements were observed. In addition to expired food items, the facility also failed to maintain proper food handling practices. During meal service in the dining room, a Nursing Assistant Certified (NAC) was observed handling a banana with bare hands, contrary to the facility's policy requiring the use of gloves or utensils. Interviews with various staff members, including the Director of Nursing and Unit Manager, confirmed that the expectation was for nursing staff to use gloves or utensils when assisting residents with their meals. Furthermore, the facility did not ensure that food items were covered during meal tray delivery. Observations in the dining room and hallways showed multiple instances of uncovered cheesecakes being transported to resident rooms. Staff interviews revealed that the lack of coverage was due to a shortage of plastic wrap, which was later rectified. However, the initial failure to cover food items during transport was acknowledged by staff, including the Dietary Aide and Infection Control Nurse, who stated that all food items should be covered when being delivered to resident rooms.
Infection Control Deficiencies in Hand Hygiene and Equipment Sanitization
Penalty
Summary
The facility failed to ensure proper hand hygiene and glove use during resident care and housekeeping activities. Staff Y and Staff Z did not change gloves or perform hand hygiene after providing peri-care to a resident, and Staff K, a housekeeper, did not perform hand hygiene between glove changes while cleaning resident rooms. These actions were contrary to the facility's hand hygiene policy, which requires hand hygiene before and after glove use to prevent the spread of infection. Additionally, the facility did not ensure proper hand hygiene and sanitation of medication trays during medication administration. Staff U, a registered nurse, did not perform hand hygiene before preparing and administering medications to residents, and Staff V did not sanitize the medication tray before and after use. This was in violation of the facility's medication administration policy, which mandates hand hygiene prior to administering medications and sanitizing medication trays between uses. The facility also failed to adhere to Enhanced Barrier Precautions (EBP) and proper sanitization of medical equipment. Staff W did not wear the required personal protective equipment (PPE) while providing high-contact care to a resident on EBP, and both Staff W and Staff CC did not clean or disinfect shared medical equipment, such as a sit-to-stand lift and vital sign equipment, between resident uses. Furthermore, Resident 41's urinary catheter drainage bag was observed touching the floor without a barrier, which was not in line with the facility's expectations for catheter care.
Lack of Anonymous Grievance Reporting System
Penalty
Summary
The facility failed to establish a comprehensive system for residents and their representatives to anonymously report grievances, affecting both the first and second floors. The facility's policy, titled 'Grievance and Concerns,' indicated that residents should be informed of their right to voice grievances, including anonymously, but the policy was undated and lacked a clear system for anonymous reporting. The Resident Handbook and Grievance/Concern Form also did not document a method for filing grievances anonymously. Interviews with staff revealed inconsistencies and a lack of awareness regarding the process for anonymous grievance submission. On the first floor, the Unit Manager, Staff E, stated that grievances could be submitted in writing but acknowledged that the process was not anonymous, as completed forms were collected by staff and placed in a locked office. A joint observation confirmed the absence of an accessible grievance box. On the second floor, the Social Services staff, Staff H, confirmed the lack of an anonymous process and stated that grievances were similarly collected and stored in a locked office. The facility administrator, Staff A, admitted the absence of an anonymous grievance collection system and expressed an expectation for such a system to be in place.
Inaccurate and Delayed PASARR Evaluations
Penalty
Summary
The facility failed to ensure the accuracy and timely submission of Preadmission Screening and Resident Review (PASARR) forms for several residents, which is crucial for identifying individuals with Serious Mental Illness (SMI) or intellectual disabilities. This deficiency was observed in five residents, where their PASARR Level I forms did not accurately reflect their diagnoses, and necessary Level II evaluations were not conducted in a timely manner. For instance, Resident 2's PASARR Level I did not include their diagnoses of mood disorder, PTSD, and psychotic disorder, and the Level II referral was delayed by six months. Similarly, Resident 22's PASARR Level I failed to mark anxiety and recurrent depressive disorder, and incorrectly indicated that no Level II evaluation was needed. Resident 34's PASARR Level I did not include PTSD, and also incorrectly marked that no Level II evaluation was required. Staff responsible for reviewing these forms admitted to inaccuracies and misunderstandings regarding when a Level II evaluation should be indicated, particularly when residents appeared stable. Further issues were noted with Resident 63 and Resident 39, where their PASARR forms were either inaccurately completed or not updated to reflect the need for a Level II evaluation. Staff interviews revealed a lack of clarity and consistency in the process of reviewing and correcting PASARR forms, leading to these deficiencies. The Director of Nursing/Director of Social Services acknowledged the expectation for accurate and timely PASARR evaluations, which was not met in these cases.
Deficiencies in Care Planning for Nutritional and Diabetic Needs
Penalty
Summary
The facility failed to implement and develop comprehensive care plans for two residents, leading to deficiencies in their care. Resident 49, who was admitted to the facility, had a care plan intervention to receive oral nutritional supplements, specifically a strawberry Ensure with breakfast. However, observations and interviews revealed that the resident did not receive the Ensure as ordered on multiple occasions. Staff members, including a Nursing Assistant Certified and the Registered Dietitian, acknowledged the oversight and confirmed that the care plan was not being followed as expected. Resident 1, who was admitted with diagnoses including type two diabetes mellitus and End Stage Renal Disease, also experienced deficiencies in care planning. The resident's care plan lacked a person-centered plan for diabetic nail care, and their daily weight was not consistently recorded as ordered. Observations showed that the resident's fingernails were long and untrimmed, and interviews with staff confirmed that diabetic nail care should have been ordered and care planned. Additionally, the resident's daily weight was not consistently documented, despite being a care plan intervention. These deficiencies in care planning and implementation placed the residents at risk for unmet care needs and a diminished quality of life. The facility's policy required comprehensive person-centered care plans for each resident, but the failure to adhere to these plans resulted in the identified deficiencies.
Failure to Conduct Timely Care Plan Meetings
Penalty
Summary
The facility failed to conduct timely care plan meetings with residents and/or their representatives, specifically for two residents, identified as Resident 2 and Resident 22. Resident 2, who was cognitively intact, reported not having a recent care conference. A review of Resident 2's progress notes from September 24, 2024, to March 17, 2025, showed no documentation of care conferences being offered or held. The facility's Care Plan Review Signature Record for 2024 also lacked documentation of Resident 2's participation in care plan reviews. Resident 22 also reported being unaware of any care conferences. A review of Resident 22's progress notes from November 13, 2024, to March 19, 2025, showed no documentation of care conferences or care plan reviews with Resident 22 or their representative. The Care Plan Review Signature Records for 2024 and 2025 were signed by Social Services and the Dietician but lacked signatures from Resident 22 or their representative, indicating their absence from the meetings. Interviews with facility staff revealed that care conferences were expected to be held in conjunction with the MDS schedule and that residents were to be invited to participate. However, there was a lack of documentation to verify that Resident 22 or their representative attended or were invited to the care plan reviews. Staff acknowledged the absence of documentation and stated that Resident 22 should have been involved in their care plan review, but there was no evidence to support that this occurred.
Failure to Document Medication Administration Correctly
Penalty
Summary
The facility failed to ensure that staff documented medications in accordance with professional standards for one resident, identified as Resident 388, during a review of medication administration. The facility's policy on Medication Administration requires that medications be administered by licensed nurses as ordered by the physician and that the Medication Administration Record (MAR) be signed after medication administration. However, an observation on March 18, 2025, revealed that Staff U, a Registered Nurse, signed off medications in the MAR before administering them to Resident 388. In subsequent interviews, Staff U acknowledged the error, and both the Unit Manager and the Director of Nursing confirmed that the expectation was for medications to be signed off after administration. This failure placed the resident at risk for medication errors and negative outcomes.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care in accordance with accepted professional standards for two residents, leading to deficiencies in their care. Resident 22, diagnosed with Chronic Obstructive Pulmonary Disease (COPD) and acute and chronic respiratory failure with hypoxia, had a nebulizer mouthpiece that was consistently observed to be improperly stored on the bedside table instead of in a bag as per facility policy. Despite multiple observations and interviews with staff, the nebulizer equipment was not stored correctly, which could increase the risk of respiratory infections. Resident 9, diagnosed with moderate persistent asthma with acute exacerbation, had a physician's order for continuous oxygen therapy at two liters per minute via nasal cannula. However, observations revealed that Resident 9 was not using oxygen, and there were no oxygen supplies in their room. Interviews with staff indicated that Resident 9 had not used oxygen since being transferred to their current room, and staff failed to clarify the order with the physician despite the resident's reported normal oxygen levels and lack of breathing difficulties. The facility's staff, including the Licensed Practical Nurse, Unit Manager, and Director of Nursing, acknowledged the expectations for storing nebulizer equipment and following physician orders for oxygen therapy. However, the staff did not adhere to these protocols, resulting in a failure to provide appropriate respiratory care for the residents. The deficiency was identified through observations, interviews, and record reviews, highlighting the need for adherence to professional standards and physician orders in respiratory care management.
Expired Food Handler's Permit for Dietary Staff
Penalty
Summary
The facility failed to ensure that the required qualifications for dietary staff were up to date, specifically for one staff member, Staff EE. The facility's policy mandates that dietary staff must have the appropriate competencies and skill sets, including maintaining a current food handler's permit. However, a review revealed that Staff EE's food handler's permit had expired, and they continued to work in the kitchen on multiple occasions after the expiration date. This was confirmed during an interview and joint observation with Staff D, the Food Service Manager, who acknowledged that Staff EE should not have worked without a valid permit. The facility administrator, Staff A, also stated that they expected dietary staff to maintain current food handler's permits.
Failure to Provide Menus and Nutritional Supplements
Penalty
Summary
The facility failed to consistently provide weekly menus to Resident 33, which led to the resident not having access to their food choices and experiencing dissatisfaction with meals. Despite an initial introduction to the menu system by the Registered Dietitian, Resident 33 did not receive subsequent weekly menus, and there was a lack of clarity on where to find them. Interviews with various staff members revealed that the responsibility for distributing menus was unclear, and Resident 33 was not on the list of residents needing assistance with menu selections. This oversight resulted in Resident 33 not being able to make informed dietary choices. Additionally, the facility did not provide the ordered nutritional supplement, Ensure, to Resident 49 as per their dietary requirements. Although the supplement was documented in the resident's nutritional assessment and meal tickets, it was not delivered with the resident's breakfast meals. The failure was attributed to a missing label in the tray card system, which was not generated due to an unchecked box in the system. This oversight meant that the kitchen did not supply the supplement, and the nursing staff did not deliver it to Resident 49. The deficiencies in both cases highlight a breakdown in communication and process adherence within the facility's dietary services. Staff interviews indicated a lack of consistent procedures for distributing menus and ensuring dietary supplements were provided as ordered. These failures placed the residents at risk of unmet nutritional needs and dissatisfaction with their meals, impacting their overall quality of life.
Inaccurate MDS Assessment for Resident's Depression Diagnosis
Penalty
Summary
The facility failed to accurately assess a resident's condition using the Minimum Data Set (MDS) assessment tool, specifically in capturing the diagnosis of depression. The resident, who was admitted with a diagnosis of depression, was prescribed an antidepressant as per physician orders. However, the Admission MDS did not reflect this diagnosis in Section I, which is designated for active diagnoses. This discrepancy was identified during a joint record review with the MDS Coordinator, who acknowledged the oversight and noted that the resident was receiving medication for depression at the time of admission. The Director of Nursing expressed an expectation for MDS assessments to be completed accurately, indicating a lapse in the assessment process. The failure to accurately code the resident's depression diagnosis in the MDS could lead to unidentified or unmet care needs, potentially affecting the resident's quality of life. The report highlights the importance of ensuring that all participants in the assessment process have the requisite knowledge to complete accurate assessments, as outlined in the Long-Term Care Resident Assessment Instrument (RAI) User's Manual.
Failure to Educate and Document COVID-19 Vaccination for Residents
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were provided with information about COVID-19 vaccinations, including the risks, benefits, and potential side effects. This deficiency was identified for two residents, who were not documented as having been offered, accepted, or refused the 2024-2025 COVID-19 vaccine, nor were they provided with education about it. The lack of documentation and education placed these residents at risk for COVID-19 infection and denied them the right to make informed decisions regarding their health care. Resident 22, who was admitted to the facility after the vaccine clinic in October 2024, expressed a desire to receive the COVID-19 vaccination but had not been offered it. Resident 63, who was also not documented as having been offered the vaccine, reportedly did not want it when it was recently offered. The Director of Nursing stated that the facility's process was to offer COVID-19 immunizations during their vaccine clinic, prioritizing long-term residents first. However, due to limited vaccine availability, short-term residents like Residents 22 and 63 were not prioritized, leading to the deficiency.
Failure to Assess Resident for Safe Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was evaluated, assessed, and obtained a physician order for the safe self-administration of medications. This deficiency was identified for one resident who was observed self-administering eye drops without a documented interdisciplinary team (IDT) assessment or a physician's order. The facility's policy requires that residents may only self-administer medications after an IDT assessment determines it is safe, and the results are recorded in the resident's medical record. However, the resident's electronic health records did not show any completed documentation of such an assessment or a physician's order for self-administration. During multiple observations and interviews, the resident was seen with a bottle of eye drops on their bedside table, which they stated they self-administered. The staff, including a registered nurse and the unit manager, confirmed that there was no physician's order for the resident to self-administer the eye drops, and the medication should not have been at the bedside. The Director of Nursing also stated that they expected the staff to remove medications found at the bedside for safe storage and that the resident should have been assessed for the ability to safely self-administer their eye drops.
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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