Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Kin On Health Care Center during CMS and state inspections, most recent first.
A resident with dementia, mobility issues, and osteoporosis was transferred by staff without the use of a gait belt, contrary to the care plan and facility policy. During the transfer, the resident experienced pain and was later diagnosed with a fractured clavicle. Staff interviews confirmed the gait belt was not used due to the urgency of the situation, and leadership acknowledged the expectation to follow care plans.
Two residents with cognitive impairment were exposed to dangerously hot water due to staff providing water from an auxiliary spout in the nurse's lounge, with temperatures far exceeding the safe limit. One resident suffered second-degree burns after spilling the hot water, while another was observed accessing the hot water unsupervised. Staff were unaware of the required safety protocols and did not monitor water temperatures, leading to serious injury and risk.
The facility did not thoroughly investigate or document several incidents involving injuries of unknown source and abuse allegations. In multiple cases, residents were found with unexplained injuries such as fractures and bruising, but investigations lacked required interviews and did not include conclusions ruling out abuse. Staff confirmed that investigative procedures and documentation were incomplete or missing.
The facility did not ensure that the attending physician reviewed residents' care and completed timely progress notes for all residents seen. The Medical Director failed to document or upload progress notes in the electronic health record for several weeks, despite expectations from staff that such documentation should be completed promptly after each visit. This resulted in a lack of timely and complete physician oversight for all residents reviewed.
A resident was found with large bruises on the chest and torso, and was unable to explain the cause of the injuries. The incident was documented by nursing staff and logged internally, but was not reported to the state agency as required by policy and regulation. Both the DON and Administrator confirmed the event should have been reported.
Facility staff failed to maintain resident dignity by not knocking or introducing themselves before entering rooms. An LPN was observed entering multiple rooms without following protocol, contrary to the facility's policy on resident rights. Interviews with staff confirmed the expectation to knock and introduce themselves, highlighting a lapse in maintaining residents' personal space and dignity.
The facility did not include recertification and complaint survey results in the survey result binder for two of the three years reviewed, and failed to post notices of survey report availability in prominent areas. The Administrator acknowledged the missing documents and lack of postings.
The facility failed to develop and implement comprehensive care plans for the use of bed rails for seven residents, despite physician orders and observations of their use. Staff interviews confirmed the absence of care plans, placing residents at risk for unmet care needs.
The facility failed to update care plans for four residents, including one with dementia and another with dental issues. Two residents had discharge goals not reflected in their care plans. Staff interviews confirmed the need for revisions.
The facility failed to assess the risks and benefits of bed rail use for several residents, contrary to its policy. Observations showed residents with bed rails in use without documented assessments, placing them at risk. Staff interviews confirmed the absence of assessments and a lack of adherence to policy requirements.
The facility did not accurately complete the daily nurse staffing form with actual hours worked after the start of each shift for several days. Despite policy requirements, the forms were not updated until the end of shifts, leaving residents uninformed about current staffing levels. Interviews revealed that the Personnel Coordinator and DON were responsible for updates, but the process was not followed as required.
The facility failed to ensure proper medication management for four residents, leading to potential medication errors. A resident received methotrexate without clarifying a physician's order, another's medication was not documented, and two residents were not properly identified before medication administration. Staff acknowledged these oversights, which were against the facility's policies.
The facility failed to monitor and document refrigerator temperatures for vaccine storage in the Station 2 Medication Room, with multiple missing checks over several months. Additionally, expired medical supplies were found in the Station 2 Clean Utility Room, which should have been discarded. Staff acknowledged these oversights, which were against facility policy and CDC guidelines.
The facility failed to maintain the correct concentration of sanitizing solution for food preparation surfaces, as observed during a survey. The solution was found below the required 50 ppm, and there was no log to track changes or tests. Staff confirmed the deficiency, acknowledging the absence of a log and the need to follow policy, placing residents at risk for foodborne illnesses.
The facility failed to report an influenza outbreak and did not adhere to proper infection control practices. Multiple residents tested positive for Influenza A, but the outbreak was not reported as required. Staff failed to perform hand hygiene during resident care and did not use barriers during medication administration. Additionally, staff did not follow proper PPE protocols for residents on droplet/contact isolation, increasing the risk of infection spread.
A resident reported a missing lower denture, but the facility failed to log or investigate the grievance, contrary to its policy. The resident, who was cognitively intact, did not receive a resolution, and the Social Services Director acknowledged the oversight. The Administrator confirmed that grievances should be resolved within five days, highlighting a lapse in the grievance process.
The facility failed to investigate injuries of unknown source and falls for two residents, leading to a deficiency in incident management. A resident with cognitive impairment had a bruise on their forehead that was not logged or investigated, while another resident experienced a fall outside the facility that was not documented or investigated. The facility's policy required all incidents to be logged and investigated, but this was not followed in these cases.
A facility failed to accurately assess two residents' conditions in their MDS assessments. One resident's broken denture was not documented, despite observations and a dental consult note indicating the issue. Another resident's GDR attempt for antipsychotic medication was not recorded, and the date of clinically contraindicated GDR was inaccurately documented. Staff acknowledged these errors, highlighting a gap in the facility's assessment process.
A resident with depression was admitted to the facility without a correct PASARR form, which failed to indicate the need for a Level II evaluation. The social worker and Social Services Director acknowledged the oversight, and the facility administrator expected accurate PASARR completion.
A LTC facility failed to provide adequate supervision for a resident with a history of stroke during meals, despite care plans and physician orders requiring 1 to 1 supervision for aspiration precautions. Additionally, the facility did not ensure bed rails were properly secured for another resident, as the enabler was found to be loose and not initially reported to maintenance. These deficiencies posed risks for accidents and injuries.
A facility failed to ensure monthly pharmacy recommendations were followed for a resident, leading to a lapse in addressing a psychotropic dose reduction. The DON acknowledged the oversight, noting that the process of reviewing and signing recommendations did not always occur as expected, resulting in the deficiency.
A resident with intact cognition reported financial exploitation by a family member, with over three thousand dollars missing from their account and an ATM card unaccounted for. Despite reports to Adult Protective Services, the police, and the facility, no investigation was conducted, violating facility policy and guidelines.
A resident with severe cognitive impairment exhibited increased urinary frequency and had multiple positive urine analyses indicating a UTI. Despite these findings, the UTI was not treated promptly, and the physician did not document the rationale for this decision. The facility's policy on antibiotic stewardship was not followed, and staff interviews revealed that the resident's symptoms met the criteria for a UTI, which should have been treated.
The facility failed to investigate bruises of unknown origin for four residents, contrary to its policy requiring immediate investigation of such incidents. Despite observations and staff acknowledgment of the bruises, no incident reports or investigations were initiated, leaving the residents at risk for unidentified abuse.
Failure to Use Gait Belt During Transfer Results in Resident Injury
Penalty
Summary
Staff failed to follow the established plan of care and facility policy requiring the use of a gait belt during transfers for a resident with dementia, difficulty walking, and osteoporosis. The resident's care plan specifically indicated the use of a gait belt when additional assistance was needed due to weakness. On the night of the incident, staff attempted to assist the resident, who was found attempting to transfer themselves, and subsequently became too weak to bear weight. Staff members transferred the resident from the floor to a wheelchair and then to bed without using a gait belt, despite facility policy and care plan directives. During the transfer, the resident experienced pain and later was found to have sustained a left clavicle fracture, as confirmed by hospital records. Staff interviews revealed that the gait belt was not used because they felt the situation required immediate action, and they did not retrieve the device. The Director of Nursing and Administrator both stated that staff were expected to follow the care plan and use the gait belt as required. The failure to use the gait belt during the transfer directly resulted in harm to the resident.
Unsafe Hot Water Access and Inadequate Supervision Result in Resident Injury
Penalty
Summary
The facility failed to ensure safe water temperatures and adequate supervision to prevent accidents, resulting in serious harm to two residents. One resident, who had hemiplegia and cognitive impairment, was provided with hot water directly from a nurse's lounge auxiliary spout, which was measured at temperatures significantly above the safe limit of 120°F. The resident attempted to drink the water, spilled it on themselves, and sustained second-degree burns to the neck, chest, and abdomen. Staff interviews revealed that the hot water was routinely provided to this resident without checking or mixing the temperature, and staff were unaware of the actual temperature or the policy requirements. Another resident, with Alzheimer's disease and cognitive impairment, was observed entering the nurse's lounge unsupervised and accessing the same hot water auxiliary spout. This resident filled a metal container with hot water and resisted staff attempts to intervene, leaving the lounge with the hot water. Staff acknowledged that this resident had a history of entering nourishment areas to obtain hot water or use the microwave, often without supervision, and that residents were not permitted in the nurse's lounge. However, staff did not consistently prevent access or monitor the water temperature. Record reviews and staff interviews confirmed that the facility's policy required hot liquids to be served at safe temperatures, with water provided by dietary staff and not exceeding 120°F. Despite this, staff frequently used the nurse's lounge hot water spout, did not log or check temperatures, and were unaware of the risks. The lack of supervision and failure to adhere to safety protocols directly led to one resident's injury and placed another at risk of harm.
Removal Plan
- Remove the hot water auxiliary spout in the nurse's lounge
- Lock door to the nurse's lounge and require key access to nourishment rooms
- Provide training to staff
- Complete hot liquids evaluations for all residents
- Revise hot liquids safety policy
Failure to Thoroughly Investigate Injuries of Unknown Source and Abuse Allegations
Penalty
Summary
The facility failed to ensure that injuries of unknown source and abuse allegations were thoroughly investigated for four out of five residents reviewed. According to the facility's own policy and state guidelines, all substantial injuries of unknown source, as well as all alleged incidents of abuse, neglect, or mistreatment, must be thoroughly investigated and documented. However, the records showed that investigations were either incomplete, lacked documentation, or did not include required interviews and conclusions to rule out abuse. For one resident, an allegation of rough treatment by staff was reported, but there was no initial written documentation of an investigation, and the investigation report was only completed after surveyor inquiry. Another resident was found with a fractured ankle of unknown origin, but the investigation did not include interviews with other residents or a documented conclusion ruling out abuse. A third resident was discovered with significant bruising on the torso, but the investigation lacked staff and resident interviews and did not document a conclusion. The fourth resident, who had cognitive deficits, was found with a dislocated shoulder and fractured arm, but again, the investigation did not include interviews or a documented conclusion regarding abuse. Staff interviews confirmed that the required investigative steps, such as interviewing witnesses or other residents and documenting conclusions, were not consistently followed. In several cases, staff acknowledged that investigations were incomplete or that documentation was missing. The lack of thorough investigations and documentation for injuries of unknown source and abuse allegations was observed across multiple incidents and residents.
Failure to Ensure Timely Physician Progress Notes and Care Review
Penalty
Summary
The facility failed to ensure that the attending physician reviewed the total program of care, including treatments and medications, and completed timely progress notes for all 38 residents reviewed. The Medical Director, who was responsible for seeing approximately 40 residents, did not document or upload progress notes in the electronic health record for any of the residents he visited over a period of several weeks. Staff interviews confirmed that while other providers uploaded their notes within 24 to 48 hours, the Medical Director did not follow this practice, and no progress notes from him were available in the system for the specified timeframe. Staff members, including the CEO, DON, and medical records personnel, all stated that they expected timely documentation of resident visits and care, but acknowledged that this was not occurring for the Medical Director’s visits. The Medical Director stated that his process was to provide handwritten documentation after seeing residents and to upload progress notes every four to six weeks, but also indicated that it was not possible to include a full review of the care program, medications, and treatments in his handwritten notes. The lack of timely and complete documentation was confirmed by multiple staff members and through joint record reviews, which showed no progress notes had been uploaded by the Medical Director during the review period. This deficiency was reported to the state agency due to concerns about the Medical Director’s fulfillment of his medical duties.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report a significant injury of unknown origin for one resident, as required by both state regulations and the facility's own policies. A Certified Nursing Assistant notified a Registered Nurse that the resident had bruising on the upper torso. The RN documented a large green-yellow bruise on the chest between the breasts and another purple bruise on the left side of the torso next to the left breast. The resident was unable to explain how the injuries occurred and exhibited discomfort and pain during movement and touch. According to the facility's policy and state guidelines, such injuries—especially those in areas not generally vulnerable to trauma—must be reported to the state agency. Despite logging the incident in the facility's March incident log, the event was not reported to the state agency. Both the Interim Director of Nursing and the Interim Administrator acknowledged during interviews that the incident met the criteria for mandatory reporting and should have been reported according to the guidelines outlined in the Purple Book and facility policy. The failure to report the injury constituted a deficiency in the facility's abuse, neglect, and injury reporting procedures.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility staff failed to uphold the residents' rights to dignity and respect by not knocking or introducing themselves before entering resident rooms. This deficiency was observed in four out of eleven rooms reviewed for dignity. Specifically, Staff R, an LPN, was seen entering rooms multiple times without knocking or identifying themselves to the residents. These actions were contrary to the facility's policy on resident rights, which emphasizes treating residents with respect and dignity. Interviews with facility staff, including Staff R, the Resident Care Manager, the Director of Nursing, and the Administrator, confirmed the expectation that staff should knock and introduce themselves before entering a resident's room. Staff R acknowledged the failure to do so, citing that some residents were sleeping, but admitted that they should have followed the proper protocol. The Resident Care Manager and other senior staff reiterated that a resident's room is considered their personal private space, and staff are expected to respect this by knocking and introducing themselves.
Failure to Maintain and Display Survey Results
Penalty
Summary
The facility failed to ensure that the survey result binder included the recertification and complaint survey results that resulted in citations for two of the three years reviewed (2022 and 2024). This omission was identified during a review of the State Survey/Inspection Report binder, which did not contain the necessary recertification and complaint surveys and associated plans of corrections dated 09/28/2022, 08/01/2024, and 12/23/2024. Staff A, the Administrator responsible for maintaining the binder, acknowledged the absence of these documents and confirmed that they should have been included. Additionally, the facility did not post notices of the availability of survey reports in prominent and accessible areas, such as the facility entrance, lobby, hallway by the main dining room, and bulletin board by the Social Services office. During an observation, it was noted that there was no posting of the availability of state survey results in these areas. Staff A initially claimed that such postings were present but later admitted that they were not, acknowledging that they should have been displayed.
Failure to Implement Care Plans for Bed Rail Use
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for the use of bed rails for seven residents. These residents included those with cognitive impairments and those who relied on bed rails for repositioning and transfers. Despite having physician orders for bed rails, the care plans for these residents did not reflect the use of these devices, which is a requirement according to the facility's policy. Observations and interviews revealed that residents were using bed rails for assistance, yet their care plans did not document this usage. For instance, Resident 43 and Resident 78 were observed using side rails for repositioning and transfers, but their care plans lacked documentation of this need. Staff interviews confirmed the absence of care plans for bed rail use, despite audits being conducted to address this issue. The Director of Nursing and other staff members acknowledged the expectation that care plans should include the use of bed rails. However, the care plans for residents such as Resident 1, Resident 9, Resident 80, Resident 3, and Resident 85 did not include this information, even though these residents had orders for bed rails and were observed using them. This oversight placed residents at risk for unmet care needs and diminished quality of life.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility failed to revise comprehensive care plans for four residents, which placed them at risk for unmet care needs and diminished quality of life. Resident 76, who was diagnosed with dementia, did not have their care plan updated to reflect this diagnosis. Instead, the care plan addressed an altered thought process related to encephalopathy, which was classified as a historical diagnosis. Staff interviews confirmed that the care plan should have been revised to address the resident's dementia. Resident 1 had a broken upper denture and a missing lower denture, yet their dental care plan had not been updated since 2021 to reflect these changes. Observations showed the resident wearing the broken denture, and staff interviews confirmed that the care plan should have been revised to address the resident's current dental status. Residents 492 and 58 had discharge goals that were not reflected in their care plans. Resident 492's care plan did not include their goal to return home after rehabilitation, despite this being determined in IDT meetings. Similarly, Resident 58's care plan did not reflect their or their representative's goal for discharge to the community. Staff interviews confirmed that these discharge goals should have been included in the residents' care plans.
Failure to Assess Bed Rail Use Risks
Penalty
Summary
The facility failed to comprehensively assess residents for the use of bed rails, which is a critical safety measure. The report highlights that for 7 out of 8 residents reviewed, there was no documented assessment of the risks and benefits associated with bed rail use. This lack of assessment is contrary to the facility's policy, which mandates a person-centered approach and a thorough evaluation of alternatives before bed rails are used. The absence of these assessments placed residents at risk for potential injury and unmet care needs. For Resident 1, who was cognitively intact, observations showed bed rails attached to both sides of the bed, yet no assessment was documented in the Electronic Health Record (EHR). Similarly, Resident 9, who was moderately impaired cognitively, had half bed rails in the raised position without any documented assessment. Staff interviews confirmed the absence of assessments and highlighted a misunderstanding or neglect of the facility's policy requirements. Other residents, including those with varying levels of cognitive impairment, such as Residents 80, 3, 43, 78, and 85, also had bed rails or enabler bars in use without documented assessments. Staff interviews revealed a lack of awareness or adherence to the policy requiring risk and benefit assessments and education for residents or their representatives. This systemic failure to conduct and document necessary assessments and education underscores a significant deficiency in the facility's compliance with safety protocols.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure the daily nurse staffing form was accurately completed with actual hours worked after the start of each shift for five out of seven days reviewed. The facility's policy required that the nurse staffing form be posted daily, reflecting the total number and actual hours worked by licensed and unlicensed nursing staff per shift, including any staff absences due to call-outs and illness. However, observations on multiple dates showed that the posted staffing forms did not include the actual hours worked for each shift that had started. Interviews with facility staff revealed that the Personnel Coordinator was responsible for updating the daily nurse staffing form, but was off work on certain days, during which the Director of Nursing was supposed to update the postings. Despite this, the actual working hours were not updated until the end of the shift, contrary to the facility's policy. Both the Director of Nursing and the Administrator acknowledged that the staffing forms should have been updated with actual hours worked at the beginning of each shift, but this was not done, leading to a deficiency in accurately informing residents and their representatives of current staffing levels.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper medication management for four residents, leading to potential medication errors and negative outcomes. For Resident 39, the facility did not clarify a physician's order regarding the administration of methotrexate while the resident was on antibiotics, resulting in the administration of both medications without proper verification. Staff U, a registered nurse, acknowledged the oversight and admitted to not clarifying the order with the physician before administering methotrexate. Resident 14's medication administration was not properly documented. Staff T, a registered nurse, administered a fluticasone inhaler but failed to record it in the electronic medication administration record (e-MAR). This lack of documentation was acknowledged by Staff T, who admitted to forgetting to mark the medication as given, despite having administered it during a blood glucose check. For Residents 49 and 6, the facility did not adhere to proper resident identification protocols before medication administration. Staff I, a registered nurse, failed to use available identification methods, such as photos or identification bands, to confirm the residents' identities. This was particularly concerning for Resident 6, who did not have an identification band and could not verbally confirm their identity. Staff I admitted to not using the pictures available in the medication cart for identification, which was against the facility's policy.
Deficiencies in Vaccine Storage and Expired Medical Supplies Management
Penalty
Summary
The facility failed to ensure proper monitoring and documentation of refrigerator temperatures for the safe storage of vaccines in the Station 2 Medication Room. The temperature log for the refrigerator showed multiple missing checks during both day and night shifts across several months, contrary to the facility's policy and CDC guidelines which require daily monitoring and documentation. Staff E, the Resident Care Manager, acknowledged the missing entries and stated that the expectation was for staff to monitor and document the temperatures as directed. Additionally, the facility did not remove or discard expired medical supplies in the Station 2 Clean Utility Room. During an observation, expired items such as Central Line Trays, BD Culture Swabs, and Intermittent Urinary Catheters were found. Staff E confirmed that these items should have been discarded and stated that the utility room was checked monthly to ensure expired items were removed. The Director of Nursing, Staff B, reiterated the expectation for staff to check refrigerator temperatures twice daily and to discard expired medical supplies.
Improper Sanitizing Solution Concentration in Kitchen
Penalty
Summary
The facility failed to maintain the correct concentration of sanitizing solution used for cleaning food preparation surfaces in the kitchen, as observed during a survey. Staff N, a Dietary Aid, tested the sanitizing solution in two red buckets and found the concentration to be below the required 50 parts per million (ppm). The facility's policy, as well as the Washington State Food Worker Manual, requires that sanitizing solutions be maintained within a range of 50 ppm to 100 ppm and be changed every two hours or when they become dirty or cloudy. However, there was no record or log maintained to track when the sanitizing solution was last changed or tested, leading to the deficiency. Interviews with Staff N and Staff O, the Dietary Manager, confirmed that the sanitizing solution was used for cleaning work surfaces and should be changed every two hours. Both staff members acknowledged the absence of a log to document the timing of changes and tests of the sanitizing solution. Staff A, the Administrator, also stated that the facility was expected to follow its policy and maintain a log for the sanitizing solution. This oversight placed residents at risk for foodborne illnesses due to potential contamination of food preparation surfaces.
Failure in Infection Control and Outbreak Reporting
Penalty
Summary
The facility failed to report a communicable disease outbreak, specifically an influenza outbreak, as required by their policy and the guidelines outlined in the Nursing Home Guidelines The Purple Book. The outbreak involved multiple residents testing positive for Influenza A and respiratory syncytial virus over the course of January and February 2025. Despite the facility's policy mandating timely reporting of such outbreaks, the Infection Preventionist, Staff C, acknowledged that the outbreak had not been reported to the appropriate authorities, which was a clear deviation from the established guidelines. In addition to the reporting failure, the facility did not adhere to proper infection control practices during resident care and medication administration. For instance, during the care of Resident 65, a CNA failed to perform hand hygiene between changing gloves, which is a critical step in preventing the spread of infections. Similarly, during medication administration for Resident 6, a nurse did not use a barrier between the medication and the bedside table, potentially leading to contamination. These lapses in infection control practices were acknowledged by the staff involved, indicating a lack of adherence to the facility's policies. Furthermore, the facility did not ensure proper use of Transmission-Based Precautions (TBP) for residents on droplet/contact isolation. Staff members were observed entering and exiting rooms of residents with Influenza A without wearing the required PPE, such as face shields or goggles, and without changing masks after exiting the rooms. These actions were contrary to the facility's infection control policies and the signage posted outside the residents' rooms, which clearly outlined the necessary precautions. The staff involved admitted to not following the proper procedures, highlighting a significant gap in the facility's infection prevention and control program.
Failure to Address Resident Grievance for Missing Denture
Penalty
Summary
The facility failed to initiate and resolve a grievance for a resident who reported a missing personal item, specifically a lower denture. The resident, who was cognitively intact, reported the missing denture to the facility, but no grievance was logged, and no investigation was completed. The facility's policy requires the Grievance Official to oversee the grievance process, including receiving, tracking, and investigating grievances, and issuing written decisions. However, in this case, the grievance was not documented or investigated, despite the resident's report and the Social Worker's awareness of the issue. Interviews with the Social Services Director/Grievance Official and the Administrator revealed that the grievance process was not followed. The Social Services Director acknowledged awareness of the missing denture but could not find a completed grievance form. The Administrator stated that grievances should be tracked, logged, and resolved within five days, indicating that the facility's procedures were not adhered to in this instance. This oversight placed the resident at risk for feelings of frustration and unmet care needs.
Failure to Investigate Injuries and Falls
Penalty
Summary
The facility failed to thoroughly investigate injuries of unknown source and falls for two residents, which placed them at risk for repeated incidents and unidentified abuse. Resident 81, who had cognitive impairment and was diagnosed with Non-Alzheimer's Dementia, was found with a bruise on their forehead. Despite the bruise being in an area not generally vulnerable to trauma and the resident's inability to explain its cause, the incident was not logged or investigated as required by the facility's policy. Staff members acknowledged the bruise but did not consider it a substantial injury, and no incident report was filed. Resident 65 experienced a fall while at a nephrology appointment outside the facility. The fall was reported by the resident's representative, but the facility did not log or investigate the incident. Staff members recognized that the facility was responsible for the resident's safety, even when outside the facility, and acknowledged that an investigation should have been conducted to determine the factors contributing to the fall and to prevent future occurrences. The facility's policy on incidents and accidents required that all incidents, whether occurring inside or outside the facility, be logged and investigated. However, in both cases, the facility failed to adhere to its policy, resulting in a lack of documentation and investigation for the incidents involving Residents 81 and 65. This oversight highlights a deficiency in the facility's incident management and reporting processes.
Inaccurate MDS Assessments for Oral/Dental Status and Medication Management
Penalty
Summary
The facility failed to accurately assess the oral/dental status of Resident 1, as evidenced by the discrepancies in the Minimum Data Set (MDS) assessments. Despite observations showing Resident 1 wearing a broken upper denture with missing teeth, the MDS assessments did not reflect this condition. The dental consult note from June 2024 indicated a loose or ill-fitting upper denture, yet the MDS assessments from October 2024 and January 2025 did not mark the oral/dental status as broken or loosely fitting. Staff F, the MDS Coordinator, admitted to completing the assessments based on the resident's response rather than the dental consult note, leading to inaccurate documentation. For Resident 57, the facility failed to accurately document the Gradual Dose Reduction (GDR) attempts for antipsychotic medication in the MDS. The resident was on olanzapine, and the MDS indicated no GDR attempt, despite a documented dose reduction in April 2024. Furthermore, the MDS inaccurately recorded the date of clinically contraindicated GDR. Staff F acknowledged the errors, stating that the GDR attempt should have been marked as attempted, and the date of contraindication should have been recorded as May 6, 2024, based on the progress notes. These inaccuracies in the MDS assessments for both residents highlight a failure in the facility's assessment process, potentially leading to unidentified and unmet care needs. The Director of Nursing expressed an expectation for accurate assessments, indicating a gap between expected and actual practices in the facility's assessment procedures.
Inaccurate PASARR Form Leads to Missing Level II Referral
Penalty
Summary
The facility failed to ensure the accuracy of the Preadmission Screening and Resident Review (PASARR) form for a resident with a diagnosis of depression. The PASARR form, dated 12/30/2024, incorrectly indicated that no Level II evaluation was required, despite the presence of a mood disorder. This oversight was identified during a joint record review and interview with the facility's social worker, who acknowledged that the PASARR was not accurate and that a Level II referral should have been in place. The facility's policy requires the Social Services Director or designee to track each resident's PASARR screening status and make necessary referrals. However, the social worker and the Social Services Director both confirmed that the PASARR for the resident in question was not reviewed or corrected, resulting in the absence of a necessary Level II referral. The facility administrator also stated that they expected staff to ensure PASARRs were filled out accurately and corrected upon admission if needed.
Inadequate Supervision and Equipment Maintenance in LTC Facility
Penalty
Summary
The facility failed to provide adequate supervision and assistance during meals for Resident 65, who had a history of a stroke and required 1 to 1 supervision assist for aspiration precautions. Despite having a care plan and physician orders indicating the need for strict supervision during meals, observations showed that Resident 65 was left unsupervised on multiple occasions while eating. Staff members, including a Licensed Practical Nurse and the Director of Nursing, acknowledged that the resident should have been supervised according to the care plan, but the supervision was not consistently provided. Additionally, the facility did not ensure that bed rails were properly secured for Resident 3, who used an enabler to assist with transfers. Observations revealed that the enabler was loose and moved when pushed, which was confirmed by the resident and staff. Although a Certified Nursing Assistant tightened the screw of the enabler, it was not initially reported to maintenance for further inspection, as expected by the facility's policy. These deficiencies in supervision and equipment maintenance placed the residents at risk for accidents and injuries. The facility's policies and care plans were not adequately followed, leading to potential hazards for the residents involved.
Failure to Follow Up on Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that monthly pharmacy recommendations were followed up for a resident reviewed for unnecessary medications. The facility's policy required staff to act upon all recommendations according to procedures for addressing medication regimen review irregularities. However, for one resident, there was no documentation of a pharmacy recommendation being addressed, specifically regarding a psychotropic gradual dose reduction for Trazadone and Olanzapine. The physician or prescriber response was not completed, indicating a lapse in the follow-up process. During an interview, the Director of Nursing (Staff B) acknowledged that they and the medical records department were responsible for overseeing the pharmacy drug regimen review documents. Staff B stated that the pharmacy recommendations were printed and placed in a binder for the provider to review and sign. However, it was noted that this process did not always occur as expected, and the recommendation for the resident in question was missing. Staff B mentioned that if the provider did not come to the facility, the recommendations would be faxed, but this did not happen in this case, leading to the deficiency.
Failure to Investigate Financial Exploitation Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of financial exploitation involving a resident. The resident, who had intact cognition, was informed by their Collateral Contact (CC1) that a family member had been taking money from their account without their knowledge. This was discovered through a review of the resident's bank statement, which showed over three thousand dollars missing, and the resident's ATM card was also reported missing. The incident was reported to Adult Protective Services and the facility administrator by the social worker, and CC1 also reported it to the police and the facility. Despite these reports, a review of the facility's incident reporting log for November and December 2024 showed no investigation was conducted regarding the allegation. The facility's administrator acknowledged awareness of the allegation but cited a miscommunication as the reason for the lack of investigation. This oversight was in violation of the facility's policy and the Nursing Home Guidelines, which require immediate and thorough investigation of all alleged incidents of abuse, neglect, or exploitation.
Failure to Treat UTI in Resident with Positive Lab Results
Penalty
Summary
The facility failed to provide care and services consistent with professional standards of practice in managing signs and symptoms of a urinary tract infection (UTI) for a resident. The resident, who had severe cognitive impairment, exhibited increased urinary frequency and had multiple positive urine analyses indicating the presence of Escherichia coli, a common causative agent of UTIs. Despite these findings, the resident's UTI was not treated promptly, and there was a lack of documentation explaining the rationale for not treating the infection. The facility's policy on antibiotic stewardship, which follows the CDC's NHSN Surveillance Definitions and McGeer criteria, was not adhered to by the physician responsible for the resident's care. The physician expressed distrust in the laboratory results and stated that they only treat UTIs if the resident has a fever, dysuria, and acidic urine pH. However, the physician did not document their rationale for not treating the UTI, despite the resident's symptoms and positive laboratory results. Interviews with facility staff, including the Infection Preventionist and Director of Nursing, revealed that the resident's symptoms and positive laboratory results met the criteria for a UTI and should have been treated. The Director of Nursing and Administrator both expected the physician to document the rationale for not treating the infection within 24 hours, which was not done. This lack of documentation and treatment placed the resident at risk of unmet care needs and medical complications.
Failure to Investigate Bruises of Unknown Origin
Penalty
Summary
The facility failed to investigate possible allegations of abuse for four residents, each of whom had bruises of unknown origin. The facility's policy on abuse, neglect, and exploitation, dated September 7, 2023, mandates that any physical marks such as bruises or injuries of unknown source should trigger an immediate investigation. However, the facility did not log or investigate the bruises found on Residents 1, 2, 3, and 4, as evidenced by the absence of these incidents in the July 2024 Incident Log. Observations and interviews confirmed the presence of bruises on these residents, and staff members acknowledged that no investigations were initiated to determine the root cause of these injuries. Resident 1 had bruises on the left upper and lower arm, Resident 2 had a bruise on the left upper arm, Resident 3 had multiple bruises on the left wrist and arm, and Resident 4 had a discoloration on the arm. Despite these findings, the facility did not follow its policy to start an incident report, conduct assessments, notify family and providers, or interview residents and staff to determine the cause of the bruises. The Director of Nursing and the Administrator both stated that investigations should have been conducted immediately, but this was not done, leaving the residents at risk for unidentified abuse and a diminished quality of life.
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Nursing homes near Seattle
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Caroline Kline Galland Home | 1.3 mi | ★★★★★ | 27 | 0 |
| Washington Care Center | 1.6 mi | ★★★★★ | 30 | 0 |
| Transitional Care Of Seattle | 3.1 mi | ★★★★★ | 49 | 0 |
| Covenant Shores Health Center | 3.8 mi | ★★★★★ | 25 | 0 |
| Seattle Medical Post Acute Care | 3.9 mi | ★★★★★ | 71 | 0 |
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