Josephine Caring Community
Inspection history, citations, penalties and survey trends for this long-term care facility in Stanwood, Washington.
- Location
- 9901 272nd Place Northwest, Stanwood, Washington 98292
- CMS Provider Number
- 505465
- Inspections on file
- 28
- Latest survey
- January 22, 2026
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Josephine Caring Community during CMS and state inspections, most recent first.
The facility failed to honor resident bathing preferences and schedules for three residents whose care plans specified twice-weekly showers. One resident with post-stroke hemiplegia and moderate cognitive impairment had documented gaps of up to ten days between showers, with no record of re-offering a shower after a refusal and repeated observations of disheveled appearance. Another cognitively intact resident dependent on staff for showers reported preferring two showers per week but stated they barely received one weekly, with documentation showing extended intervals between showers. A third resident who required substantial assistance for bathing reported going eight days without a shower and being told by family they smelled of urine, despite a care plan for twice-weekly showers. Staff interviews confirmed that bathing preferences were obtained and documented, and that NACs were expected to chart showers and refusals in the EMR, but actual practice did not consistently follow these preferences.
Two residents did not receive appropriate care related to skin treatment, positioning, and meal assistance. One resident with Parkinson’s disease, ataxia, and dermatitis had a painful rash on the feet and toes; staff applied Triamcinolone ointment for months without cleaning the feet beforehand, and the order lacked a defined application site and end date, with no documented monitoring of the skin condition on the MAR or TAR. Another resident with stroke-related hemiplegia, existing PIs on the ankle and heel, and documented need for substantial/maximal assistance and heel-floating was repeatedly observed in bed with heels and an injured ankle resting directly on the mattress and in poor alignment. The same resident, who required supervision or touching assistance with meals, was observed multiple times with an untouched lunch tray and no staff present to assist, despite staff stating they rely on Kardex and nurse communication to guide individualized care.
A resident experienced a significant weight loss due to the facility's failure to accurately obtain and monitor weights, recognize weight loss, and provide necessary assistance during meals. The resident, with a history of malnutrition and advanced dementia, was often left without support during meals, leading to inadequate nutritional intake. Staff inconsistencies in recording and reviewing weights contributed to the oversight of the resident's declining health.
The facility was observed serving uncovered cold foods, including fruit cups and desserts, across multiple units, leading to unsanitary food service practices. The Dietary Manager confirmed that dessert bowls and small cups of condiments were not covered, contributing to the deficiency.
The facility failed to maintain complete and accurate medical records for several residents, including missing weights, shower documentation, and consents for restraints. Additionally, consultant provider notes for wound care and podiatry were not included in the records. Staff interviews revealed issues with documentation processes, leading to delays and omissions in the residents' medical records.
The facility failed to create comprehensive care plans for residents with specific medical needs, including congestive heart failure, hypertension, stroke-related conditions, dementia, dysphagia, and chronic diarrhea. Care plans lacked necessary interventions and guidelines, such as wheelchair positioning and monitoring for weight loss. Staff responsible for updating care plans acknowledged these omissions.
Two residents in an LTC facility did not receive adequate assistance with ADLs. One resident, dependent on staff for bathing, was not offered showers as per their care plan due to staffing shortages. Another resident, requiring assistance with meals, was left unattended, resulting in poor meal consumption. Staff interviews revealed issues with staffing and adherence to care plans.
A resident with severe cognitive impairment and multiple health issues was discharged from physical therapy with a recommendation for restorative nursing services, which were not provided due to a communication breakdown among staff. Despite the resident's willingness to participate in exercises, there was no documentation of restorative care being offered, placing the resident at risk of losing the progress made during therapy.
A resident with severe cognitive impairment was prescribed Quetiapine Fumarate as needed for agitation, but the facility failed to conduct the required 14-day reviews to assess the necessity and rationale for its continued use. Interviews with staff confirmed the absence of documentation for necessary assessments, placing the resident at risk for unnecessary medication use.
Failure to Honor Resident Bathing Preferences and Schedules
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ stated bathing preferences and schedules, as required for resident choice and self-determination. For Resident 2, who had a history of stroke with right-sided hemiplegia and hemiparesis, the quarterly MDS documented moderate cognitive impairment and dependence on staff for bathing and shower transfers. The resident’s preference care plan indicated a desire for showers twice a week before breakfast. However, v2 documentation showed inconsistent intervals between showers, including gaps of seven, eight, nine, and ten days between showers, and there was no documentation that a shower was re-offered after a refusal on one date. Observations over two days showed the resident repeatedly lying in bed in a hospital gown with disheveled hair. Resident 3, a long-term care resident with no cognitive impairment and dependent on staff for showers, had a care plan preference for two showers per week. Documentation for November and December showed some weeks where the interval between showers extended to six or seven days. In late December, showers were documented on two dates only. In January, the v2 report showed showers on three dates with seven and eight days between some showers. During an interview and observation, the resident, seated in a wheelchair and dressed, stated a preference for twice-weekly showers and reported they “barely get one a week.” Resident 4, also a long-term care resident, had an annual MDS indicating they could make their needs known and required substantial assistance for bathing. Their preference care plan documented a preference for two showers per week. In an interview, the resident reported they were bathed on Tuesdays and Fridays but stated it had been eight days since their last shower. The resident also reported that during a recent doctor’s appointment, a family member told them they smelled like urine, which the resident described as embarrassing, noting their limitations from using a wheelchair. Staff interviews confirmed that resident bathing preferences were obtained on admission and placed on care plans, and that NACs and shower aides were expected to document showers and refusals in the EMR and notify licensed nurses of refusals, but the documented shower frequencies did not consistently align with the residents’ stated preferences.
Failure to Provide Ordered Skin Care, Positioning, and Meal Assistance for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate skin care and treatment according to physician orders and resident needs for a resident with Parkinson’s disease, cerebellar ataxia, dementia, and muscle weakness. The resident, who had no documented cognitive impairment on a recent MDS, reported to a collateral contact that a rash on their toes and feet had worsened and was painful, and that staff did not clean their feet before applying prescribed ointment. The collateral contact observed the resident’s toes and feet as red, discolored, and with skin breakdown. The resident’s care plan documented chronic dermatitis to the lower extremities and later a fungal rash to both toes, and there was a long-standing order for Triamcinolone 0.1% ointment to be applied twice daily for rash, but the order lacked a specific application site and end date. Review of the MAR and TAR over several months showed no documentation of monitoring the skin condition of the feet/toes or cleaning the skin prior to ointment application. Nursing staff confirmed the ointment was applied to both feet and that the feet had not been cleaned prior to application until a specific date, and the DON acknowledged the order lacked a specific site and end date and could not clearly describe expectations for documenting and monitoring skin issues. The deficiency also involves the facility’s failure to follow care plan interventions for positioning and pressure injury prevention for a resident with a history of stroke, right-sided hemiplegia/hemiparesis, and existing pressure injuries to the right outer ankle and left heel. The resident’s MDS documented moderate cognitive impairment, a need for substantial/maximal assistance with bed mobility, supervision or touching assistance with meals, and risk for pressure ulcers. The care plan directed staff to provide substantial/maximal assistance with two staff for bed mobility and to float the resident’s heels when in bed as they allowed. Multiple observations showed the resident in bed with heels and feet lying directly on the mattress surface, including times when the lower legs were uncovered and when a pillow under the calves still left one heel resting directly on the bed. At another time, the resident was positioned on their side with their torso leaning toward the edge of the bed, knees hanging over the mattress edge, and the right outer ankle lying directly on the mattress. In addition, the facility failed to ensure appropriate assistance with meals for this same resident, who required supervision or touching assistance and only occasional monitoring and cueing after setup. Surveyors observed an untouched lunch tray on the overbed table within reach of the resident on multiple occasions over several hours, with no staff present to assist or supervise. Later observations showed the resident in the same position with the lunch tray still untouched, and when asked, the resident inaccurately reported having eaten lunch. Nursing assistants interviewed described relying on Kardex information in the closet or EMR and communication from licensed nurses or nurse managers for care directions, but the observed lack of meal assistance and positioning did not align with the resident’s documented needs and care plan requirements.
Failure to Monitor and Address Resident's Nutritional Needs
Penalty
Summary
The facility failed to consistently and accurately obtain weights, recognize significant weight loss, and provide consistent assistance with eating and cueing for Resident 33, who was reviewed for nutrition. Resident 33 experienced a significant 14.6% weight loss over a period of approximately six weeks. The facility's policy required weekly weights for new admissions, but there was a discrepancy in the recorded weights, and the facility did not document or address this discrepancy. The initial weight recorded at the facility was 140 lbs., which was inconsistent with the hospital's weight of 114 lbs. prior to admission. This discrepancy was not reviewed or corrected until much later. Observations revealed that Resident 33 was not receiving adequate assistance during meals. On multiple occasions, the resident was left alone with their meal tray, and staff did not provide necessary cueing or encouragement to eat. The resident, who had a history of protein calorie malnutrition, fractured hip, fractured left arm, and advanced dementia, struggled to consume meals independently. The resident's meal intake records showed that they consumed 50% or more of their meals only 31 times out of 137 meals, indicating a lack of adequate nutritional intake. Interviews with staff revealed inconsistencies in the process of obtaining and recording weights. Weights were recorded on worksheets by shower aides, but these were not entered into the electronic medical record or reviewed by nurses. The facility's Director of Nursing and Assistant Director of Nursing were unaware of the weight loss and the inaccuracies in weight documentation. The facility's failure to accurately monitor and address Resident 33's nutritional needs and weight loss was a significant deficiency, as it placed the resident at risk for further decline in health and quality of life.
Unsanitary Food Service Practices
Penalty
Summary
The facility failed to transport and serve food in a sanitary manner across three units: East, West, and North. Observations revealed that trays with uncovered cold foods, such as mandarin oranges, fruit cups with melon, apricots, and desserts like cake with whipped cream, were served to residents. These incidents occurred on multiple occasions, with specific observations noted on July 8th, 9th, 10th, and 15th, 2024. During an interview, the Dietary Manager, identified as Staff T, admitted that dessert bowls and small cups of condiments were not covered, which contributed to the deficiency.
Incomplete and Inaccurate Medical Records in LTC Facility
Penalty
Summary
The facility failed to maintain complete, accurate, and accessible medical records for several residents, leading to potential risks for medical complications and unmet care needs. For Resident 33, the facility did not document weights consistently, with only one weight recorded in the clinical record over a period of time. Similarly, Resident 49's records showed only three showers documented over two months, despite additional showers being noted on handwritten worksheets that were not part of the official medical record. This lack of systematic organization and accessibility of records was acknowledged by the Assistant Director of Nursing, who admitted that the worksheets were not considered part of the medical record. Resident 92's records were incomplete regarding the use of a tilt n space wheelchair, classified as a restraint, as there was no documentation of a Physical Restraint Informed Consent form at the time of the survey. Additionally, there were multiple missing entries for meal tray monitoring, which were supposed to be documented by CNAs. The consent form was eventually found, but it was dated two weeks after the restraint was initiated, indicating a delay in obtaining necessary consents. Staff interviews revealed that the documentation process was not being followed correctly, leading to these omissions. For Residents 78 and 103, the facility failed to include consultant provider notes in their medical records. Resident 78's records lacked documentation from an outside wound clinic, despite the resident attending weekly appointments. Similarly, Resident 103's records did not contain podiatry notes, even though the resident had been seen by a podiatrist for an infection. Staff interviews indicated that documentation was not being scanned into the electronic medical record in a timely manner, with case managers holding onto documents before they were scanned, leading to significant delays in record updates.
Deficiencies in Resident Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for several residents, leading to deficiencies in meeting their specific needs and preferences. Resident 7, who was admitted with congestive heart failure and hypertension, did not have a care plan addressing these conditions. Staff F, an LPN/Case Manager, confirmed the absence of a care plan for these diagnoses. Similarly, Resident 87, who used a tilt n space wheelchair due to stroke-related conditions, lacked a care plan detailing proper wheelchair positioning. Staff M, responsible for updating the care plan, acknowledged this omission. Resident 92, diagnosed with dementia, dysphagia, and muscle weakness, also used a tilt n space wheelchair and was at risk for weight loss. However, their care plan did not include guidelines for wheelchair positioning or monitoring for weight loss. Staff M admitted that these interventions were missing from the care plan. Additionally, Resident 73, who had been experiencing chronic diarrhea for 17 weeks, did not have a care plan addressing this issue despite a diagnosis of functional diarrhea and a referral to a GI physician. Staff B, the Director of Nursing, indicated that case managers were responsible for care plan updates, yet these deficiencies persisted.
Deficiencies in ADL Assistance for Two Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for two residents, leading to deficiencies in care. Resident 10, who was dependent on staff for bathing due to dementia and weakness, did not receive the preferred number of showers per week. Despite having a care plan that required substantial assistance for bathing, the resident was only offered showers five times over a period of six weeks, with no refusals documented. Interviews with staff revealed that the shower aide was often reassigned to other duties due to staffing shortages, resulting in the resident not receiving the necessary care. Resident 33, who required supervision and setup assistance with eating due to advanced dementia and physical impairments, was not provided with the necessary assistance during meals. Documentation showed that the resident consumed less than 50% of their meals in most instances, with only eight meals documented as having received partial or extensive assistance. Observations confirmed that the resident was left unattended during meals, struggling to eat without staff intervention. Interviews with staff indicated a lack of awareness and adherence to the care plan, which required cueing and assistance during meals. The deficiencies in care for both residents were attributed to inadequate staffing and a lack of adherence to established care plans. Staff interviews highlighted issues with staffing call-offs and the reassignment of shower aides, which contributed to the failure to meet the residents' care needs. The facility's policies on providing assistance with ADLs were not consistently followed, resulting in unmet care needs and a diminished quality of life for the affected residents.
Failure to Provide Restorative Nursing Services
Penalty
Summary
The facility failed to provide appropriate services and assistance to maintain or improve mobility and range of motion for a resident, identified as Resident 107, who was reviewed for the restorative nursing program. The facility's policy on the Restorative Nursing Program, dated 12/27/2023, indicated that residents should receive maintenance and restorative services to maintain and improve their abilities to the highest practicable level. Resident 107, who was admitted with multiple facial fractures, iron deficiency anemia, and essential tremors, was discharged from physical therapy on 06/11/2024 with a recommendation for restorative nursing services to maintain the abilities gained during therapy. However, a review of the resident's clinical record from 06/10/2024 to 07/11/2024 showed no documentation of receiving or refusing such services. Interviews conducted with facility staff revealed a breakdown in communication regarding the recommendation for restorative nursing care. Staff R, a CNA, noted that Resident 107 required more care than appeared necessary, while Staff M, an LPN and Restorative Program Manager, stated they had not received a recommendation for restorative care for the resident. CC1, a Physical Therapy Assistant, confirmed they had recommended restorative services for Resident 107 but acknowledged that the resident was not currently receiving the program. Additionally, Resident 107 expressed willingness to engage in exercises and walking with staff, indicating a missed opportunity to maintain their mobility and range of motion.
Failure to Review PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications, specifically regarding the extended use of a PRN anti-psychotic medication without proper assessment and documentation. The resident, who had severe cognitive impairment due to Alzheimer's disease and dementia, was prescribed Quetiapine Fumarate 25 mg every four hours as needed for agitation. This medication was initially prescribed by hospice. However, the facility did not conduct the required 14-day reviews to assess the necessity and rationale for the continued use of this PRN medication, nor was there any documentation of a stop date or duration of use. Interviews with facility staff, including a Registered Nurse/Case Manager and the Director of Nursing Services, revealed that the PRN medication had not been reviewed as required. The staff confirmed the absence of documentation for the necessary assessments and rationale for the medication's continued use. This oversight placed the resident at risk for medication-related complications and receiving unnecessary psychotropic medication, as there was no documented justification for the extended use of the anti-psychotic medication.
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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