Above 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 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 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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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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 Seattle
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Queen Anne Healthcare | 1.3 mi | ★★★★★ | 18 | 0 |
| Hearthstone, The | 1.4 mi | — | 0 | 0 |
| Ballard Center | 2.6 mi | ★★★★★ | 12 | 0 |
| Mirabella | 3.2 mi | ★★★★★ | 2 | 0 |
| Bailey-boushay House | 3.6 mi | ★★★★★ | 0 | 0 |
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