Everett Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Everett, Washington.
- Location
- 1919 112th Street Southwest, Everett, Washington 98204
- CMS Provider Number
- 505491
- Inspections on file
- 44
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Everett Center during CMS and state inspections, most recent first.
The facility did not provide required written bed hold notices to residents or their representatives during hospital transfers, with staff often marking 'refused' without documenting who was contacted or when, and some staff were unaware of the bed hold policy. In several cases, residents or their families reported not being informed about the bed hold option, and documentation was incomplete or inaccurate.
The facility failed to provide adequate staffing to meet resident needs, resulting in delayed call light responses and untimely medication administration. Residents and family members reported long wait times, particularly on weekends, leading to unmet care needs and frustration. Despite in-service training efforts, staffing shortages and high dependency needs persisted, contributing to repeated citations.
The facility failed to conduct thorough investigations for several residents, including incidents of falls, pressure injuries, and allegations of abuse. Investigations lacked critical details such as medication information, witness statements, and predisposing factors. Allegations of neglect, such as rough handling and delayed care, were not adequately addressed, compromising resident safety and care quality.
The facility failed to complete timely and comprehensive Resident Assessment Instruments (RAIs) for several residents, impacting individualized care plans. CAAs lacked necessary information, and MDS assessments were not completed within required timeframes. Staff interviews revealed a lack of awareness regarding assessment deadlines and documentation requirements.
The facility did not develop or communicate baseline care plans with essential healthcare information within 48 hours of admission for several residents. Key needs such as communication methods and dietary requirements were not documented, and residents or their representatives were not informed of the initial care plan in a timely manner. Care conferences were delayed, and written copies of care plans were not provided, resulting in incomplete documentation and inconsistent care processes.
The facility did not act on pharmacist medication regimen review (MRR) recommendations within the required timeframe, resulting in delayed completion of assessments and medication changes for several residents. For example, a resident on antipsychotic medication did not receive a timely AIMS assessment, and multiple residents experienced delays in discontinuation or clarification of anticoagulant medications. Staff and leadership were unaware of these delays, which were not in accordance with facility policy.
Surveyors found expired medications in multiple medication carts, incomplete temperature monitoring for medication refrigerators, and improper storage of controlled substances that were not in permanently affixed, locked compartments. Additionally, a resident with no cognitive impairment was observed self-administering medications at bedside without an assessment, physician order, or care plan for self-medication, contrary to facility policy.
The facility failed to maintain complete and accurate medical records for several residents, including missing documentation of medication monitoring, incomplete assessments after falls, and lack of restorative care notes. Staff interviews confirmed that required documentation was not consistently entered into the electronic health record, leading to gaps in resident care records.
A facility failed to assist three residents with routine ADLs, including repositioning and transferring. One resident was not transferred to a wheelchair as required, while two others were not repositioned according to their care plans. Staff interviews revealed inconsistencies in following care plans, with some staff citing time constraints. Observations showed residents lying in bed for extended periods without repositioning, contrary to facility standards.
A resident in a vegetative state was repeatedly exposed to loud, sexually explicit audio and video from their roommate's laptop, with the content audible from the hallway. Multiple staff members noticed the situation but did not intervene or update care plans, and leadership was unaware until the survey. The facility failed to uphold the resident's right to a dignified and respectful environment.
Three residents with significant medical and communication needs were repeatedly found without accessible call lights, despite facility policy and staff expectations. Observations and interviews showed that call lights were left out of reach, sometimes purposefully, and staff did not consistently correct this, even after entering residents' rooms. Family members and residents reported ongoing issues, and administration was unaware of the problem until informed by surveyors.
The facility did not complete or update required PASRR assessments for two residents with mental health conditions who remained in the facility beyond the exempted hospital discharge period. Both residents continued to receive psychotropic medications without the necessary Level II PASRR referrals or evaluations, and required documentation was incomplete or missing.
The facility did not update care plans for three residents to reflect their current needs and preferences. One resident with a swallowing disorder and mental health diagnoses had concerns about medication administration and feeding tube handling that were not addressed in their care plan. Another resident, who was severely cognitively impaired, fell from their wheelchair after staff failed to remove a Hoyer sling post-transfer, with the care plan lacking instructions for sling removal. These omissions resulted in care plans that did not accurately guide staff in meeting residents' needs.
A nurse prepared and attempted to administer medications to a resident with cognitive impairment, but after the resident refused, the medications were left unlabelled and later given to another nurse to administer without proper oversight. Additionally, blood pressure readings were not documented before administering antihypertensive medications to another resident, despite physician orders. Staff interviews confirmed inconsistent adherence to medication administration policies and monitoring requirements.
A resident with severe cognitive impairment was not assisted by staff to participate in activities as outlined in their care plan. Despite documented preferences for social engagement and sensory stimulation, the resident was repeatedly observed alone in their room, not participating in group activities, and not provided with planned sensory items or assistance. The Activities Director confirmed that the resident had not been included in activities or received room visits during the week due to staff being too busy.
A resident with a midline IV was found with an old, non-intact dressing and visible discoloration at the insertion site. Staff had not performed required dressing changes or IV flushes, and the IV remained in place despite a physician's order to discontinue it. Facility policies for vascular access device care were not followed, and staff were unaware of the necessary care steps.
A resident with communication and swallowing difficulties did not receive timely social services due to the social worker's extended absence and lack of effective coverage. The initial social work assessment and care conference were delayed, and there was no documentation regarding advance directives or efforts to inform the resident about their care plan.
Sharps containers in a medication cart, shower room, and resident room were observed to be filled above the full line, with items such as insulin pens, lancets, and razors present above the limit. Staff interviews revealed confusion about who was responsible for replacing the containers, with conflicting statements from an RN, IP nurse, Resident Care Manager, and DON. The containers remained overfilled during the survey period.
The facility failed to complete required PASRR evaluations for three residents with mental disorders, including a resident with severe major depressive disorder and another with bipolar disorder. Despite indications for Level II evaluations, there was a lack of documentation and follow-up communication with PASRR evaluators, leading to deficiencies in ensuring appropriate care and services.
The facility failed to assist residents with activities of daily living, including grooming, repositioning, and oral care. A resident was observed with unkempt hair and facial hair, while others were not repositioned as required, leading to potential risks of skin breakdown. Two residents reported not receiving oral care, with no supplies found in their rooms, despite staff expectations for daily hygiene assistance.
The facility failed to adhere to professional standards in medication management and lab testing for several residents. A resident with cardiac issues received blood pressure medications despite a low heart rate, and another with hypotension was given Midodrine outside prescribed parameters. Additionally, a resident missed an insulin dose during dialysis, and another experienced a delayed referral to a GI specialist. These deficiencies indicate significant lapses in care coordination and adherence to medical orders.
A facility failed to maintain a medication error rate below five percent, resulting in a 15% error rate. An RN administered a liquid multivitamin instead of a tablet, and an LPN left medications at a resident's bedside, contrary to policy. Neither resident was on a self-medication program, highlighting protocol breaches.
The facility failed to secure and properly administer medications, with several residents found with unattended medications despite not being on self-medication programs. Staff interviews revealed a lack of adherence to medication policies, and the narcotic reconciliation process was disorganized, risking errors. The DNS acknowledged these issues, noting a pharmacy switch contributed to the disorganized reconciliation.
The facility failed to report potential abuse and neglect for three residents. A resident with cognitive impairment had concerns about care that were dismissed without investigation. Another resident with a traumatic brain injury suffered bruising from a blood pressure cuff, but no report or investigation was made. A third resident reported verbal abuse involving racial slurs, but no formal investigation or report was conducted.
The facility failed to thoroughly investigate allegations of abuse and neglect for two residents, compromising their safety and quality of life. A resident with cognitive impairment reported rough handling by a staff member, but the investigation had inconsistencies. Another resident reported racial slurs from a roommate, but no formal investigation was conducted. The facility's policy requires thorough investigations, which were not completed in these cases.
A resident with a physician's order for supplemental oxygen was found using undated oxygen equipment, and the facility failed to maintain, change, or document the oxygen tubing and nasal cannula as per standards. Staff interviews revealed inconsistencies in monitoring and maintaining the resident's oxygen therapy, leading to a deficiency in care.
A resident was prescribed an antidepressant without a documented diagnosis of depression, and the facility failed to monitor behaviors or adverse effects. Staff interviews confirmed the lack of necessary documentation and monitoring for the psychotropic medication, placing the resident at risk for unnecessary medication use.
Failure to Provide Proper Bed Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide written bed hold notices to residents or their representatives at the time of transfer to the hospital for three of four sampled residents reviewed for hospitalization. For one resident, documentation showed that the bed hold notice was signed by a staff member, but there was no time recorded, and the section for the resident or representative was marked as 'refused' without specifying who refused or the date and time of contact. Another resident, who was cognitively intact, denied being offered a bed hold notice, and their family member confirmed not being contacted. Staff interviews revealed a lack of understanding of the bed hold policy, with some staff unaware of the requirement and others indicating that they would mark 'refused' if unable to reach the resident or representative, without documenting attempts or details of contact. For a third resident, who was cognitively impaired, multiple hospital transfers were documented, but there was no evidence that the representative was provided with written information about the bed hold policy or their decisions. Bed hold notices for this resident were signed by staff, with 'refused' written in the resident or representative section, again without documentation of who refused or when contact was attempted. Staff confirmed that they did not document the details of their attempts to contact representatives and acknowledged that the documentation should have reflected unsuccessful contact attempts rather than refusals.
Staffing Deficiencies Lead to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient qualified staff to meet the needs of its residents, as evidenced by observations, interviews, and record reviews. The facility's assessment indicated that 5-7 nurses and 5-10 Nursing Assistant Certified (NACs) were required to care for an average census of 70 to 75 residents, many of whom had complex medical needs such as tracheostomies and ventilators. However, staffing patterns showed variances, with some shifts having fewer staff than needed, particularly on weekends. This resulted in delayed responses to call lights, untimely medication administration, and inadequate supervision of NACs, leading to unmet care needs and negative outcomes for residents. Interviews with residents and family members revealed consistent concerns about long wait times for call light responses, with some residents waiting over an hour for assistance. Residents reported feeling frustrated and vulnerable due to the delays, and some were forced to perform activities of daily living independently despite needing assistance. Family members echoed these concerns, noting that weekends were particularly problematic, with staff being slow to respond and residents being left in soiled conditions for extended periods. The facility's grievance log and Quality Assurance Performance Improvement (QAPI) documents further highlighted the ongoing staffing issues. Multiple grievances were filed regarding call light response times, and the facility had implemented in-service training to address these concerns. Despite these efforts, the facility continued to struggle with staffing shortages, high employee turnover, and a population with high dependency needs, contributing to the repeated citation for insufficient staffing.
Inadequate Investigations and Documentation in Resident Care
Penalty
Summary
The facility failed to conduct thorough investigations for several residents, leading to potential risks for repeat incidents and unmet care needs. For Resident 71, the investigations into multiple falls were incomplete, lacking details such as medication information, predisposing situational factors, and witness statements. Additionally, there were allegations of abuse and neglect, including rough handling by staff, delayed incontinent care, and call lights being placed out of reach. These concerns were not thoroughly investigated, and the facility's response to grievances was inadequate. Resident 78 experienced a fall after a shower, but the investigation did not include statements from the staff who provided care shortly before the incident, nor did it address the removal of safety equipment like the helmet and neck brace. The investigation also failed to clarify the time of the fall or whether the resident's leg brace was on, leaving gaps in understanding the circumstances leading to the fall. For Resident 58, the investigation into new pressure injuries was insufficient, as it did not collect evidence to demonstrate that the wounds were unavoidable or rule out neglect. Similarly, the investigation into a skin tear for Resident 73 did not determine the cause or implement interventions to prevent future occurrences. These deficiencies highlight a pattern of inadequate investigation and documentation, potentially compromising resident safety and care quality.
Deficiency in Timely and Comprehensive Resident Assessments
Penalty
Summary
The facility failed to complete the Resident Assessment Instrument (RAI) within the required timeframes and did not provide comprehensive summaries of the Care Area Assessments (CAAs) for nine residents. This deficiency was identified through interviews and record reviews, revealing that the CAAs lacked necessary information such as current goals, preferences, strengths, or needs for specific care areas. The absence of this information hindered the development of individualized care plans for the residents. For Resident 71, the CAAs were incomplete, missing comprehensive summaries or analyses necessary for updating the care plan. Similarly, Resident 78's CAAs were blank except for auto-populated information, lacking the required analysis. Resident 58's CAAs for pressure ulcers, feeding tube, and nutrition were also incomplete, with no documentation of complications or risk factors. Resident 66's CAAs did not include input from the resident or family, nor did they document risk factors or necessary interventions. Resident 73's pressure ulcer CAA was similarly incomplete, lacking documentation of complications or risk factors. Additionally, the facility failed to complete comprehensive admission MDS assessments within the required 14-day timeframe for Residents 67, 80, and 334. Resident 13's annual comprehensive assessment was incomplete and overdue. Interviews with staff revealed a lack of awareness regarding the deadlines for MDS assessments and a failure to document risk factors or analyses in the CAAs. The Director of Nursing acknowledged the expectation for timely completion of MDS assessments.
Failure to Develop and Communicate Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement baseline care plans that included the minimum necessary healthcare information within 48 hours of admission for five residents. Specifically, the baseline care plans did not address critical aspects such as communication needs, dietary requirements, and did not ensure that residents or their representatives were informed of the initial plan for care and services. For example, one resident with aphasia and dysphagia used pen and paper to communicate and required nectar thick liquids, but these needs were not documented in the care plan or Kardex. Staff relied on observation and verbal handoff rather than documented guidance, leading to gaps in care delivery. Additionally, the facility did not provide documentation that residents or their representatives were informed of the baseline care plan within the required 48-hour timeframe. In several cases, care conferences and discussions about goals of care occurred several days after admission, with some meetings delayed up to fourteen days. There was also no evidence that written copies of the baseline care plan were provided to residents or their representatives, and staff interviews confirmed that this was not standard practice. The lack of timely and comprehensive baseline care plans, as well as the failure to communicate these plans to residents and their representatives, was observed across multiple cases. Staff interviews revealed inconsistent processes for obtaining and sharing information about new admissions, and documentation in the electronic health record was incomplete or missing regarding communication of care plans. These deficiencies were found to be in violation of facility policy and regulatory requirements.
Delayed Implementation of Pharmacist Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to act on the consultant pharmacist's monthly medication regimen review (MRR) recommendations in a timely manner, as required by their own policies and procedures. Specifically, for one resident with schizoaffective disorder, major depression, and panic disorder, the pharmacist recommended completion of an Abnormal Involuntary Movement Scale (AIMS) assessment due to ongoing antipsychotic medication use. Although the provider agreed to the recommendation, the assessment was not completed within the required timeframe, with the last documented AIMS assessment occurring more than six months prior to the recommendation. Staff interviews revealed a lack of awareness and follow-up regarding the overdue assessment. Additionally, a review of the November MRR revealed that out of 93 provider recommendations, the majority were not addressed until 47 to 64 days after the initial report, well beyond the facility's policy of acting within 30 days. Several residents had recommendations related to the clarification or discontinuation of injectable anticoagulant medications, such as heparin and enoxaparin, which were not implemented until 51 to 60 days after the recommendations were made. Documentation showed that providers agreed to the recommendations, but the actual changes in medication orders were delayed. Interviews with facility leadership, including the Director of Nursing Services and the Administrator, indicated that they were unaware of the delays in implementing the MRR recommendations for the month in question. The facility's policy required that MRR reports be available within 48 hours and that recommendations be acted upon within 30 days, but this standard was not met for multiple residents and recommendations during the review period.
Expired Medications, Improper Storage, and Unassessed Self-Administration
Penalty
Summary
The facility failed to ensure proper management and storage of drugs and biologicals, as evidenced by multiple expired medications found in three out of five medication carts. During observations and interviews, staff discovered expired bottles of Iron, Omeprazole, Saline Nasal Spray, and Naloxone HCl in various medication carts. Staff members acknowledged that nurses were responsible for checking for expired medications, but some believed the pharmacist was primarily responsible for these checks. The facility policy required immediate removal and disposal of outdated or discontinued medications, which was not consistently followed. Temperature monitoring for medication refrigerators was also deficient. In two out of three refrigerators storing medications, daily temperature logs were incomplete or missing for several days, and in one case, temperature checks were only performed once daily instead of the required twice daily when vaccines were present. Staff interviews confirmed that the responsibility for temperature checks was not consistently executed according to policy, and there was confusion regarding the proper storage location for certain vaccines. Controlled substances were not stored in compliance with facility policy or regulatory requirements. In both medication rooms, controlled medications such as Lorazepam were found in containers that were not permanently affixed inside the refrigerators, and in one case, a plastic container was secured only with a zip tie, which staff considered a lock. Staff were unaware that controlled substances required a separately locked, permanently affixed compartment. Additionally, a resident was found to have medications at bedside without being assessed for a self-medication program, lacking both a physician order and care plan, despite facility policy requiring evaluation and documentation for self-administration. The resident had no cognitive impairment and was observed using the medications independently, but no assessment or care plan was present in the clinical record.
Incomplete and Inaccurate Medical Record Documentation for Multiple Residents
Penalty
Summary
The facility failed to ensure that residents' medical records were complete, accurate, accessible, and systematically organized for four out of five residents reviewed for unnecessary medication. This included incomplete assessments, missing documentation of restorative care, and incomplete records related to resident incidents. For example, documentation for anticoagulant monitoring was inconsistent, with several instances where required follow-up notes were missing after staff indicated a potential issue by marking 'N' on monitoring forms. Additionally, blood pressure and heart rate measurements were not consistently recorded before administering certain medications, as required. For one resident, there were multiple falls documented, but the facility did not complete or document assessments every shift for 72 hours following each fall, as expected. Progress notes were missing or incomplete for several shifts after these incidents, and there was a lack of documentation related to the monitoring of side effects for anticoagulant medications, even when monitoring forms indicated a need for further assessment. Another resident's records showed similar gaps in documentation after a fall, with missing shift assessments and unclear or incomplete progress notes regarding the incident and the resident's condition. In another case, a resident's allegation against a staff member was not promptly or thoroughly documented in the electronic health record. The alert charting system was not used consistently, and late entries were made without clear indication of the dates they referred to. Additionally, for a resident on a restorative program, there was no documentation of evaluations or progress notes in the electronic health record, despite weekly meetings to discuss the resident's needs. Staff interviews confirmed that documentation practices did not align with facility policy or expectations.
Failure to Assist Residents with ADLs in LTC Facility
Penalty
Summary
The facility failed to assist three residents, identified as Residents 52, 67, and 28, with routine activities of daily living (ADLs), specifically in repositioning and transferring them out of bed. Resident 52, who was in a persistent vegetative state and dependent on a ventilator, was observed not being transferred to a wheelchair as required by their care plan. Despite the care plan and medication administration record indicating the need for daily mobilization, documentation showed multiple days where Resident 52 was not transferred. Interviews with staff revealed inconsistencies in following the care plan, with some staff admitting to not transferring the resident due to time constraints or only doing so on specific days like Bingo Day. Resident 67, also in a persistent vegetative state and dependent on a ventilator, was observed lying on their back for extended periods without being repositioned as required by their care plan. The care plan directed staff to reposition the resident every one to two hours, but observations and interviews indicated that this was not consistently done. Staff interviews confirmed that the resident was dependent on two staff members for bed mobility, yet the required repositioning was not documented or observed during the survey period. Similarly, Resident 28, with a diagnosis of a persistent vegetative state and ventilator dependency, was observed lying on their back with elevated heels for extended periods without repositioning. The care plan and Kardex directed repositioning every two to three hours, but observations showed that staff did not enter the resident's room for significant periods. The Director of Nursing confirmed the facility's standard practice of repositioning every two to three hours, yet this was not adhered to, as evidenced by the observations and lack of documentation.
Failure to Ensure Resident Dignity Due to Exposure to Explicit Content
Penalty
Summary
The facility failed to maintain a dignified environment for a resident who was in a vegetative state and fully dependent on staff for care. The resident was placed in a shared room with another resident who frequently watched and listened to pornography at a high volume on their laptop. The sexually explicit audio was loud enough to be heard from the hallway, and several staff members were observed to notice the noise but did not intervene or address the situation. Staff interviews revealed that the roommate regularly watched pornography loudly due to being hard of hearing and had previously refused to use headphones. Staff also indicated that the roommate could become aggressive if interrupted, leading them to avoid intervening directly and instead notify a nurse. Despite being aware of the situation, staff did not document any interventions or care plan updates for either resident regarding this issue. The care plans for both residents lacked documentation about the exposure to pornography or any measures to address it. Leadership, including the Resident Care Manager, DON, and Administrator, were not aware of the ongoing situation until it was brought to their attention during the survey. Staff acknowledged that a reasonable person would not want to be exposed to such content in their living environment. The facility's failure to address the situation resulted in a violation of the resident's right to dignity and a respectful environment, as outlined in facility policy and CMS guidance.
Failure to Ensure Call Lights Within Reach for Multiple Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for three residents, as required by its own policy and regulatory standards. Multiple observations and interviews revealed that call lights were repeatedly left out of reach for residents with significant medical needs, including one resident with hemiplegia, depression, anxiety, and PTSD, another with a traumatic brain injury and multiple fractures, and a third with glaucoma, dementia, and limited English proficiency. In several instances, call lights were found clipped to the mattress, hanging on the wall, or wrapped under the bed, making them inaccessible to the residents. Interviews with residents and their family members indicated that staff sometimes purposefully moved call lights out of reach, particularly for residents who frequently used them. One resident and their spouse expressed concern about possible retribution for reporting this issue. Family members reported consistently finding the call light out of reach during visits, and one resident reportedly crawled out of bed to seek help, resulting in a fall, when the call light was not accessible. Staff interviews confirmed that the expectation was for call lights to always be within reach, and staff were observed entering and leaving rooms without correcting the placement of call lights. Despite these expectations, staff and administration were unaware of the ongoing issue until it was brought to their attention. The facility's failure to ensure call lights were accessible placed residents at risk for delayed care and other negative outcomes.
Failure to Complete and Update PASRR Assessments for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that Pre-Admission Screening and Resident Review (PASRR) assessments were accurately completed and updated for two residents with mental health diagnoses. For one resident with major depressive disorder, anxiety disorder, and PTSD, the Level 1 PASRR was marked as an exempted hospital discharge, indicating no Level II evaluation was needed unless the resident stayed beyond 30 days. Despite the resident remaining in the facility for 48 days and receiving multiple psychotropic medications, there was no evidence of a Level II PASRR referral or evaluation as required. Another resident with mild cognitive impairment and bipolar disorder also had a Level 1 PASRR marked as an exempted hospital discharge, but key sections were left blank and the form was not signed by a physician as required. The resident remained in the facility for 38 days without a Level II PASRR referral, despite the requirement to complete one if the resident's stay exceeded 30 days. The responsible staff member acknowledged that the PASRR should have been completed but had not yet contacted the PASRR coordinator. The facility's policy assigns responsibility for PASRR coordination and updates to Social Services, including prompt notification to state authorities after significant changes in a resident's mental or physical condition. However, the records and staff interviews confirmed that these procedures were not followed for the two residents, resulting in incomplete or missing PASRR evaluations beyond the allowed exemption period.
Failure to Review and Revise Care Plans for Resident Needs
Penalty
Summary
The facility failed to review and revise care plans for three residents, resulting in care plans that did not accurately reflect the residents' current conditions and needs. For one resident with a swallowing disorder, major depressive disorder, anxiety disorder, and PTSD, the care plan was not updated to include the resident's preferences regarding medication administration and handling of their feeding tube, despite the resident expressing concerns about being given medications while not awake and not being informed about the medications being administered. The resident's preferences were not reflected in the care plan, even after the issue was brought to the attention of nursing staff and the Director of Nursing Services. Another resident, who was severely cognitively impaired, experienced a fall from their wheelchair after sliding forward due to a Hoyer sling being left under them following a transfer. Staff interviews revealed inconsistent practices regarding the removal of the sling, and the care plan did not include instructions for removing the Hoyer sling after transfers. The omission was confirmed during record review and staff interviews, and the care plan was only revised to include this instruction after the incident. These failures to review and revise care plans as required placed residents at risk for unmet care needs.
Failure to Follow Professional Standards in Medication Administration and Monitoring
Penalty
Summary
A deficiency was identified when a registered nurse (RN) prepared a resident's morning medications, including controlled substances and other prescribed drugs, and attempted to administer them. The resident, who had moderate cognitive impairment and diagnoses including diabetes, osteoarthritis, and Alzheimer's disease, refused the medications and asked the nurse to leave the room. The nurse placed the unlabelled and uncovered medicine cup containing the medications on top of the medication cart. Later, the RN handed the same cup to another nurse, who attempted to administer the medications to the resident without the original nurse present to observe the administration or confirm ingestion. Facility staff interviews revealed inconsistent understanding and application of the facility's medication administration policy, which requires the nurse who prepares the medication to administer it and mandates disposal of refused medications. Another deficiency was found regarding the administration of antihypertensive medications to a resident with hypertension. The resident's medication orders specified that blood pressure should be checked and medications held if systolic blood pressure was less than 100. However, review of the medication administration record (MAR) and vital signs documentation showed that blood pressures were not recorded at multiple required times before medication administration. Interviews with nursing staff confirmed that blood pressures should have been checked and documented prior to giving antihypertensive medications, but no records could be found for the specified dates and times. The facility's failure to follow professional standards of medication administration, including proper documentation, preparation, and administration procedures, as well as failure to adhere to physician orders for monitoring blood pressure prior to antihypertensive medication administration, resulted in deficiencies. These actions did not meet the facility's own policies or regulatory requirements, as confirmed by staff interviews and record reviews.
Failure to Assist Resident with Activities as Outlined in Care Plan
Penalty
Summary
The facility failed to ensure that a resident with severe cognitive impairment received assistance with activities as outlined in their care plan. The resident's care plan specified that they should be assisted to activities, helped to sit at the nurse station, and provided with sensory items, as well as opportunities to watch TV and listen to music. Despite these directives, multiple observations over several days showed the resident repeatedly left alone in their room, often with the TV turned off, and not engaged in any activities. During times when group activities such as BINGO and painting were occurring in the dining room, the resident remained in their room and was not assisted to participate. Interviews and record reviews confirmed that the resident enjoyed being around people and exploring their environment, and that staff were aware of these preferences. However, the Activities Director acknowledged that the resident had not been taken to any activities or received room visits during the week in question, citing being too busy and organizational lapses. This lack of engagement and failure to follow the care plan resulted in the resident being isolated and not provided with meaningful activities as required by facility policy.
Failure to Maintain and Discontinue Midline IV as Ordered
Penalty
Summary
A deficiency occurred when a resident with a persistent vegetative state and ventilator dependence did not receive appropriate care for a midline IV catheter. The resident's midline IV, placed in the right arm, was observed with a discolored dressing, curled edges exposing the insertion site, and visible discoloration (purple and red) around the site. The dressing was dated nearly a month prior, and the catheter tubing and connector contained a brown substance. Staff interviews revealed that the dressing had not been changed as required, and there were no orders or documentation for IV flushes or dressing changes. The IV had not been flushed, and the dressing was not intact, contrary to facility policy and professional standards. Further review of the resident's records showed that there was a physician's order to discontinue the midline IV over two weeks prior to the observation, but the IV remained in place. Staff were unaware of when the dressing was last changed and confirmed that the IV should have been removed according to the order. The facility's policies required sterile dressings to be maintained and vascular access devices to be flushed routinely, but these were not followed. This deficiency was also noted as a repeat from a previous statement of deficiencies.
Failure to Provide Timely Social Services and Care Conference
Penalty
Summary
The facility failed to provide medically related social services to help a resident achieve the highest practicable physical, mental, and psychosocial well-being. A resident with aphasia, dysphagia, and a history of stroke was admitted and was cognitively intact but had unclear speech. Upon review, there was no documentation in the resident's chart regarding advance directives, nor evidence that the resident had been asked about them. The initial social work assessment was completed nine days after admission, and the care conference was not scheduled within the required 72 hours, but instead was set for 14 days after admission. Interviews with staff revealed that the social worker was on extended leave at the time of the resident's admission, and no effective plan was implemented to ensure continuous social service coverage. Other staff members, such as the business office manager, MDS nurse, and receptionist, attempted to cover social work duties, but there was no documentation of efforts to set up the care conference or follow up on advance directives. The resident reported not knowing their plan of care and not having had a care conference prior to the scheduled date.
Failure to Replace Full Sharps Containers in Multiple Facility Locations
Penalty
Summary
Surveyors observed that sharps containers in multiple locations, including a medication cart, a shower room, and a resident room at Station 2, were filled above the designated full line. Specific observations noted that insulin pens, lancets, and blue disposable razors were present above the full line in these containers. These conditions persisted over several days, as evidenced by repeated observations, with the contents remaining above the full line and, in one case, the container not being properly affixed to its stand. Interviews with staff revealed confusion regarding responsibility for replacing full sharps containers. A registered nurse was unsure who was responsible and initially believed it was the Infection Preventionist (IP) nurse, while the IP nurse stated that floor nurses were responsible for replacement. The Resident Care Manager and Director of Nursing Services both indicated that nurses were responsible for replacing full containers, with the IP nurse tasked with monitoring them. Despite these stated responsibilities, the containers remained overfilled during the survey period.
Failure to Complete PASRR Evaluations for Residents with Mental Disorders
Penalty
Summary
The facility failed to adhere to the Preadmission Screening and Resident Review (PASRR) process for three residents, which is a federal requirement to ensure individuals with mental disorders or intellectual disabilities receive appropriate care and services. Resident 15, who was readmitted with severe major depressive disorder, anxiety disorder, and panic disorder, had an updated Level I PASRR indicating a need for a Level II evaluation. However, no Level II evaluation was completed, and there was a lack of documented follow-up communication with the PASRR evaluator. Staff F, the Social Services Director, acknowledged the absence of documentation and stated that communication with the PASRR Coordinator had occurred but was not recorded. Resident 13, diagnosed with bipolar disorder, also required a Level II evaluation as indicated by a Level I PASRR. However, the clinical record lacked this evaluation and any follow-up documentation. Staff F believed a PASRR invalidation existed due to a past Level II evaluation but could not find it in the record. Similarly, Resident 5, with diagnoses including anxiety and depression, required a Level II evaluation as per their PASRR, but there was no documentation of validation or communication with the PASRR validator. Staff F confirmed that a new PASRR was submitted in June, but no further follow-up was conducted.
Deficiencies in ADL Assistance and Hygiene Care
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for five residents, leading to deficiencies in personal hygiene, grooming, and repositioning. Resident 3, who was comatose and dependent on staff for all care, was observed multiple times with unkempt hair and facial hair, indicating a lack of grooming. Despite the care plan directing staff to turn and reposition the resident every two hours, observations showed the resident remained on their back for extended periods, and family members reported insufficient attention from staff. Resident 15, who was cognitively intact and dependent on staff for personal hygiene, was observed repeatedly on their back, contrary to the care plan's directive for repositioning every two to three hours. The resident reported not being turned unless they specifically requested it, highlighting a failure in routine care. Similarly, Resident 122, who had a stage IV pressure ulcer and was dependent on staff for all care, was consistently observed on their back, despite care plan instructions for frequent repositioning. Residents 62 and 53 experienced deficiencies in oral care. Resident 62, who was cognitively intact and dependent on staff for ADLs, was observed with unclean teeth and reported not having their teeth brushed. No oral care supplies were found in their room. Resident 53 also reported not receiving assistance with oral care since admission, and no supplies were present in their room. Staff interviews confirmed that oral care was expected daily, yet it was not provided, indicating a systemic issue in meeting residents' hygiene needs.
Deficiencies in Medication Management and Lab Testing
Penalty
Summary
The facility failed to provide treatment and care according to professional standards for several residents, leading to potential adverse health events. Resident 60, who had a history of anemia and cardiac issues, was administered blood pressure medications despite a heart rate below the prescribed threshold. Additionally, there were lapses in laboratory testing and reporting, with missing results for critical tests that were supposed to be conducted, leading to a delay in identifying a gastrointestinal hemorrhage. Resident 15, admitted with hypotension, received Midodrine outside of the prescribed parameters, as the medication was administered even when the systolic blood pressure was above the threshold. This indicates a failure to adhere to medication administration guidelines, potentially compromising the resident's health. Resident 53, with chronic kidney disease and diabetes, missed an insulin dose while at dialysis, and there was no coordination with the dialysis center to ensure insulin administration. Furthermore, Resident 66, who experienced diarrhea after tube feedings, had a delayed referral to a gastrointestinal specialist, which was not scheduled until 47 days after the order was given. These deficiencies highlight significant lapses in medication management, lab testing, and specialist referrals.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a 15% error rate during medication administration by two licensed nurses. Specifically, Staff R, an RN, administered a liquid multivitamin to a resident through a gastrostomy tube instead of the prescribed tablet form, citing the unavailability of the tablet. Additionally, Staff R documented the administration of eye cleansing wipes, which were not used at the time, and left them in the resident's room for later use by a nursing assistant. This action was not in accordance with the resident's medication administration record, which specified a multivitamin in tablet form. Staff E, an LPN, dispensed medications to another resident, who stated they would take them later, and left the medications at the bedside. This was against the facility's policy, as confirmed by Staff C, the unit manager, and Staff B, the Director of Nursing Services, who stated that medications should not be left at the bedside unless the resident is on a self-medication program, which neither resident was. The facility's failure to adhere to proper medication administration protocols placed residents at risk for adverse events and decreased quality of care.
Medication Security and Administration Deficiencies
Penalty
Summary
The facility failed to ensure the security and proper administration of medications and biologicals on two units, leading to unauthorized access and potential medication errors. Observations revealed that Resident 54, who was not on a self-medication program, was found with pills on their pudding without a nurse present. Similarly, Resident 24 had OcuSoft eyelid cleansing pads left in their room by a nurse, and Resident 35 was observed with pills left on their bedside table. Resident 41 also had pills left unattended on their bedside table, despite not being on a self-medication program. None of these residents had assessments or care plans indicating they were capable of self-administering medications. Interviews with staff highlighted a lack of awareness and adherence to the facility's medication administration policies. Staff D, an LPN, was unaware of any self-medication programs on Unit 2 and speculated that nurses might have left medications for alert and oriented residents. Staff C, another LPN, confirmed that medications should not be left at the bedside, and the Director of Nursing Services (DNS) expressed concern over the recurring issue of medications being left unattended. Additionally, the facility's process for narcotic reconciliation was found to be disorganized and potentially inaccurate. During a shift change, Staff J and Staff S, both RNs, conducted a narcotic count using multiple books in a disorganized manner, leading to confusion and the potential for errors. The DNS acknowledged the issue, noting that the facility had switched pharmacies, resulting in some medications being recorded in old books, which contributed to the disorganized reconciliation process.
Failure to Report Alleged Abuse and Neglect
Penalty
Summary
The facility failed to immediately report potential abuse and/or neglect to the state agency for three residents, which placed them at risk for unidentified mistreatment. Resident 19, who had cognitive impairment, had concerns raised by their responsible party regarding hydration, oral care, and positioning. These concerns were dismissed by the facility's administrator, and no grievance or investigation was initiated. The facility's grievance logs and state incident reporting log showed no entries related to Resident 19's potential neglect. Resident 61, with a traumatic brain injury, experienced bruising on their arm due to a blood pressure cuff being left on too tight. Despite the visible injury and the family being informed, the facility did not log the incident in the state reporting log or conduct an investigation to rule out abuse or neglect. The Director of Nursing Services was aware of the discoloration but had not been informed of the incident involving the blood pressure cuff until later. Resident 62, diagnosed with anxiety disorder, depression, and spinal stenosis, reported being verbally abused by their roommate, including the use of racial slurs. Although the incident was reported to the mental health provider and discussed with the Director of Nursing Services, no formal investigation was conducted, and the allegation was not reported to the state agency. The facility's social services director was aware of the situation but did not report it, and the resident declined an offer to move rooms.
Incomplete Investigations of Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse and neglect for two residents, which placed them at risk for unidentified abuse or neglect. Resident 41, who had a history of stroke, diabetes, and cognitive impairment, reported being handled roughly by a staff member, causing arm pain. The facility suspended the alleged staff member and initiated an investigation, but there were inconsistencies in the documentation. Staff M, a registered nurse, claimed not to have provided physical care to Resident 41, yet documented applying antifungal cream on the day of the alleged abuse. Additionally, an earlier fall incident involving Resident 41 lacked witness or staff statements and did not confirm if care plan interventions were in place. Resident 62, diagnosed with anxiety disorder, depression, and spinal stenosis, reported being called derogatory names and racial slurs by their roommate. Despite these serious allegations, the facility did not conduct a formal investigation. The incident report noted that Resident 62 had a history of bipolar disorder and schizophrenia and was sometimes confused. Although Resident 62 was offered a room change, which they declined, there was no written or verbal statement from the roommate included in the investigation. The facility's policy on abuse prevention mandates that investigations be initiated within 24 hours of an allegation, including interviews and documentation. However, the investigations for both residents were incomplete, lacking necessary documentation and statements. This failure to adhere to policy and thoroughly investigate the allegations compromised the residents' safety and quality of life.
Deficiency in Respiratory Care for Resident
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident by not maintaining, changing, or dating oxygen tubing and nasal cannula as per professional standards. Resident 11, who was admitted with diagnoses including high blood pressure, chronic pain, and muscle weakness, had a physician's order for supplemental oxygen as needed to maintain oxygen saturation above 90%. However, there was no documentation or indication of when the oxygen equipment should be changed or replaced. Observations revealed that Resident 11 was using undated oxygen equipment, and the care plan lacked focus or interventions related to oxygen use. Interviews with staff revealed inconsistencies in the monitoring and maintenance of Resident 11's oxygen therapy. Staff O, an LPN, stated that checking oxygen saturation was not required during the day shift and deferred the responsibility of changing oxygen tubing to respiratory therapy. However, the respiratory therapist, CC 5, was unsure about the tracking of equipment changes. Additionally, the Director of Nursing Services confirmed that Resident 11 used oxygen as needed, but there was no clear process in place to ensure compliance with the physician's orders. This lack of coordination and documentation led to the deficiency in providing appropriate respiratory care.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications, specifically an antidepressant, as required. The resident, who was admitted with diagnoses including metabolic encephalopathy and dementia, was prescribed Sertraline HCl for dementia with behavioral disturbance. However, there was no documented diagnosis of depression in the resident's medical record. Additionally, the facility did not have any orders for monitoring depressive behaviors, symptom management, interventions to prevent, or adverse side effects related to the antidepressant medication. Interviews with facility staff revealed that the care plan and physician orders, which are supposed to guide resident care, did not include necessary information for monitoring the resident's use of the antidepressant. Staff members, including an LPN and the Director of Nursing Services, acknowledged the lack of documentation and monitoring for the resident's psychotropic medication. The deficiency was identified as a failure to ensure appropriate indication for the medication and to monitor and document behaviors and symptoms, placing the resident at risk for adverse side effects and unnecessary medication use.
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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