Lakeland Village Nursing Facility
Inspection history, citations, penalties and survey trends for this long-term care facility in Medical Lake, Washington.
- Location
- State Highway 902 & Salnave Road, Medical Lake, Washington 99022
- CMS Provider Number
- 50A263
- Inspections on file
- 39
- Latest survey
- December 15, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Lakeland Village Nursing Facility during CMS and state inspections, most recent first.
A resident with profound intellectual disability and PICA ingested an exam glove after gloves were left accessible in a bathroom drawer and a nearby trash can. Despite a care plan requiring 1:1 supervision, staff interviews and observations confirmed that the resident could easily access hazardous items, and no changes were made to storage practices following the incident.
A resident with intellectual disability and dementia did not receive a physician-ordered Epsom salt foot soak for a toe infection, despite documentation by an LPN indicating it was completed. Multiple staff accounts and facility investigation determined the treatment was not performed as ordered, resulting in a failure to provide necessary medical care.
A resident with cognitive impairment and high care needs experienced a fall and head injury, which was witnessed by staff. Despite facility policy, staff did not complete an incident report or notify a nurse for assessment, following instructions from a manager. No documentation or report of the incident was found in facility records, resulting in a failure to report the event to proper authorities.
The facility failed to protect two residents from abuse. A cognitively impaired resident was reportedly abused by an RN, resulting in a red mark on their chest. Another resident, unable to direct their own care, was assaulted by a fellow resident due to inadequate supervision when a staff member left their post for a lunch break.
Two residents with severe cognitive impairment were left in urine-soaked clothing, leading to skin issues. Despite care plans requiring frequent checks, staff failed to change the residents promptly, resulting in skin excoriation and moisture-associated rash. Staff interviews confirmed awareness of the residents' conditions but inaction in providing timely care.
The facility failed to test modified fluid consistencies for residents at risk of aspiration, leading to coughing incidents. Staff did not verify thickened fluids using recommended methods, relying instead on visual assessment. Additionally, food storage and preparation practices were inadequate, with improper labeling and temperature monitoring, and dishwasher temperatures were below required levels. Staff also neglected to wear hair nets over facial hair, risking contamination.
The facility failed to review infection control policies annually, maintain proper hand hygiene, and implement transmission-based precautions. Observations revealed outdated policies, inadequate hand hygiene practices, and improper handling of soiled laundry. A resident with a feeding tube did not have appropriate signage for enhanced barrier precautions, and staff were observed not following proper PPE protocols.
The facility failed to ensure all staff involved in food preparation had valid food handler's cards, with staff in six out of seven cottages preparing food without these certifications. Additionally, one dietary staff member had an expired card. This oversight posed a potential risk for unsafe food handling practices, placing residents at risk for foodborne illnesses.
A resident with a psychotic disorder was prescribed and received Duloxetine, a psychotropic medication, without documented informed consent. The facility did not ensure that the resident or their representative was informed of the medication's risks and benefits prior to administration, as confirmed by the DON.
The facility failed to transmit MDS assessments for two residents with severe cognitive impairments to CMS within the required timeframe. The assessments were completed but not accepted due to unknown reasons, as confirmed by a CMRN and the DON.
A facility failed to prevent and manage pressure ulcers for a resident, leading to a worsening condition. The resident was found sitting on multiple layers, including a Hoyer sling, which increased pressure risk. Staff interviews revealed a lack of understanding about proper pressure relief management, contributing to the deficiency.
The facility failed to report an allegation of potential abuse to the State Agency within the required timeframe. A CNA reported overhearing a staff member yelling at a resident, but the incident was not reported until several hours later, exceeding the two-hour reporting requirement. The DON acknowledged the delay, which violated state regulations.
A resident with bipolar disorder and intellectual disability was verbally abused by an LPN, who yelled at them to wake up and take medication. The incident was reported by a nursing assistant, but the LPN continued to work with the resident without immediate protective measures. The resident was not assessed for psychological harm until the following day, highlighting a deficiency in the facility's response.
A resident with intellectual and mental health disorders was neglected in a facility, as they were left in a soaked incontinence brief for hours and only given fruit for breakfast. Despite being dependent on staff for toileting and meal setup, the resident was not assisted out of bed until late morning, leading to emotional distress and a diminished quality of life.
A resident with intellectual and mental health disorders was allegedly neglected by a lead Nursing Assistant. The incident was reported internally by staff but not to the State Agency within the required two-hour window, as staff were unaware of the reporting timeline. This delay in reporting placed residents at risk.
The facility failed to promptly investigate allegations of neglect involving two residents with significant medical and physical needs. Concerns were initially reported by nursing staff, but the facility's response was delayed, allowing the alleged perpetrator to continue working with the residents for several days. This inaction placed the residents at risk for continued neglect.
Failure to Prevent Ingestion of Hazardous Items by Resident with PICA
Penalty
Summary
The facility failed to consistently implement interventions to prevent a resident with profound intellectual disability and PICA from ingesting non-food items, specifically an exam glove. The resident's care plan indicated a need for 1:1 staff supervision at all times to prevent ingestion of unsafe items, as the resident was known to be very sly and able to obtain items that were not digestible. Despite this, observations and interviews revealed that nitrile exam gloves were stored in an easily accessible drawer in the resident's bathroom and that a small trash can containing used gloves and paper towels was within reach in the resident's room. Staff confirmed that the resident had good hand dexterity, could move quickly, and would attempt to grab items within their vicinity. On one occasion, a nursing assistant discovered an intact nitrile exam glove in the resident's ileostomy stool pouch, indicating that the resident had ingested the glove. Further review of the facility's investigation and staff interviews confirmed that no changes had been made to the storage of gloves or the trash can following the incident. The staff responsible for 1:1 supervision stated that they were required to remain within arm's reach and maintain constant eyesight of the resident, acknowledging the resident's ability to quickly access and ingest items. The facility was unable to determine exactly how or when the ingestion occurred, but the presence of accessible gloves and inadequate environmental controls contributed to the deficiency.
Failure to Provide Ordered Medical Treatment for Resident's Toe Infection
Penalty
Summary
A resident with moderate intellectual disability and dementia was admitted to the facility and developed a discolored and tender right great toe. The facility physician was notified, and a verbal order was given to start Epsom salt soaks for the affected toe. The order was later updated to continue the soaks and add an antibiotic due to signs of infection, including erythema and open drainage. Documentation in the medication administration record indicated that the foot soak was completed as ordered on the evening shift; however, multiple staff statements and facility investigation revealed that the treatment was not actually performed during that shift. Further review showed that the resident was present in common areas during the time the soak was supposed to occur, and staff who were present did not witness the treatment being provided. Additionally, a nursing assistant noted that the bandage on the resident's toe appeared used and dry, inconsistent with a recent soak. The facility's investigation concluded that it was more likely than not that the ordered foot soak was not completed as documented, resulting in a failure to provide medical care as ordered and a possible diminished quality of life for the resident.
Failure to Timely Report and Document Resident Fall
Penalty
Summary
The facility failed to ensure timely reporting and documentation of an allegation of neglect involving a cognitively impaired resident with moderate intellectual disabilities and schizoaffective disorder, who required maximum assistance for activities of daily living. Multiple staff members witnessed or were informed of the resident falling out of bed and hitting their head, but did not follow established procedures for reporting and responding to such incidents. Staff B and Staff C both observed or were aware of the fall, but were instructed by Staff E, an Attendant Counselor Manager, not to complete an incident report, despite facility policy requiring incident reporting and nurse assessment before moving the resident. Staff B and Staff C did not escalate their concerns or report the incident further, citing fear of reprisal and uncertainty about the process. Staff E, upon being informed of the resident being on the floor, did not believe the incident was reportable and did not ensure a nurse assessment or incident report was completed. Staff D, another manager, was later informed of the incident but also did not report it to higher authorities. Review of facility records confirmed there was no documentation or incident report regarding the resident's fall and head injury during the relevant period. This lack of timely reporting and documentation resulted in a failure to notify proper authorities and ensure appropriate follow-up for the resident.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in potential physical and psychological harm. Resident 1, who was cognitively impaired and required one-to-one supervision, was reportedly subjected to physical abuse by a registered nurse (RN). Witnesses observed the RN pushing on Resident 1's chest while attempting to administer medication, resulting in a red mark on the resident's chest. This incident was corroborated by multiple staff members who confirmed the presence of the mark and the actions of the RN. Resident 2, who was unable to direct their own care and dependent on staff for most activities of daily living, was left unsupervised, leading to an assault by another resident. Staff members witnessed Resident 3 hitting Resident 2, resulting in a reddened area and scratches on Resident 2's neck. The incident occurred because a staff member left their post for a lunch break without ensuring another staff member was present to monitor the residents, contrary to the facility's staffing expectations.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for two residents, leading to potential skin injury and decreased quality of life. Resident 1, with severe cognitive impairment and dependent on staff for daily activities, was found with red and bleeding skin on the buttocks after being left in urine-soaked clothing. Staff interviews revealed that Resident 1 was not changed for several hours, despite being aware of the resident's wet condition. The care plan required frequent toileting assistance, but this was not adhered to, resulting in skin excoriation. Resident 2, also with severe cognitive impairment and dependent on staff, was found in urine-soaked clothing and wheelchair pad. The resident had a moisture-associated rash, which was documented in nursing progress notes. Staff interviews indicated that Resident 2 was not changed for an extended period, despite the care plan's requirement for frequent checks and changes to prevent skin breakdown. Staff acknowledged awareness of the resident's wet condition but failed to act promptly. The deficiency was identified through interviews and record reviews, highlighting a lapse in professional standards of practice. Both residents were at risk of skin injury due to prolonged exposure to moisture, and the facility's failure to adhere to care plans and timely incontinence care contributed to the residents' compromised skin integrity.
Failure to Ensure Safe Food and Fluid Consistency Practices
Penalty
Summary
The facility failed to test modified fluid consistencies after preparation and before serving to vulnerable residents at risk for aspiration. This deficiency was observed in three of nine sampled residents who required specific liquid consistencies due to swallowing difficulties. The facility's policy followed the International Dysphagia Standardization Initiative (IDDSI) for texture descriptions and terminology, but staff did not consistently verify the accuracy of thickened fluids before serving them to residents. For instance, Resident 8, who required extremely thick liquids, was served fluids that were not tested for consistency, leading to coughing during meals. Staff relied on visual assessment rather than using the IDDSI flow test or other recommended methods to ensure the correct consistency. Additionally, the facility failed to ensure that foods were stored and prepared in a safe manner, which placed residents at risk for foodborne illness. Observations revealed that food items in the main kitchen and various cottages were not properly labeled with dates, and refrigerator and freezer temperatures were not consistently monitored or documented. In some cases, temperature probes were not correctly placed, leading to inaccurate readings. The facility's policy required food to be labeled with preparation and use-by dates to prevent bacterial growth, but this was not consistently followed. The facility also failed to maintain the required dishwasher temperatures, which are necessary to kill bacteria and ensure sanitary conditions. The dishwasher logs showed multiple instances where the final rinse temperature did not reach the required 180 degrees Fahrenheit. Furthermore, staff working in the kitchen were observed not wearing hair nets over facial hair, which is necessary to prevent contamination. These deficiencies in food storage, preparation, and sanitation practices compromised the safety and quality of life for all residents in the facility.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to its infection prevention and control program, as evidenced by several deficiencies observed during the survey. The facility did not review its infection control policies annually as required, with the Antibiotic Stewardship Program and Infection Prevention and Control Program policies last reviewed in August 2022. Additionally, the facility's handling and washing of soiled laundry policy was outdated, and staff were not consistently wearing appropriate personal protective equipment (PPE) when handling soiled laundry. Observations in the laundry rooms revealed a lack of organization and separation between clean and dirty areas, with clean clothes left uncovered and exposed to potential contamination. Hand hygiene practices were also found to be inadequate. Staff members were observed failing to perform hand hygiene at critical moments, such as before and after resident contact, after touching potentially contaminated surfaces, and before donning gloves. Specific instances included staff serving food, checking temperatures, and assisting residents without washing hands or using hand sanitizer. These lapses in hand hygiene increased the risk of cross-contamination and the spread of infections among residents and staff. The facility also failed to implement proper transmission-based precautions for residents at risk of multidrug-resistant organisms (MDROs). For example, Resident 14, who had a feeding tube and required assistance with all activities of daily living, did not have appropriate signage indicating the need for enhanced barrier precautions. Staff were observed exiting the resident's room wearing gowns and gloves, which were not removed before leaving the room, and there was a lack of clear instructions for staff regarding the precautions to be taken. This oversight in implementing enhanced barrier precautions could lead to the transmission of MDROs within the facility.
Deficiency in Food Safety Certification for Staff
Penalty
Summary
The facility failed to ensure that all staff involved in food preparation had valid food handler's cards, which are necessary certifications indicating completion of food safety training. In six out of seven cottages, staff were observed preparing and cooking food without these cards. Specifically, staff in the Ponderosa and Rosewood Cottages were found to be handling uncooked, pasteurized eggs. Interviews with various staff members, including Attendant Counselor Managers and a Licensed Practical Nurse, revealed that while staff received food service training, they were not required to obtain the state-issued food handler's card. The Director of Nursing and the Administrator acknowledged the presence of raw eggs in the cottages and the necessity for staff preparing food to have food handler's cards. Additionally, within the dietary department, one of the 24 dietary staff members, identified as Staff C, was found to have an expired food handler's card. Despite this, Staff C was observed preparing food in the main kitchen. The Dietary Manager confirmed that a current Washington State Food Handler's card was required for all kitchen staff and acknowledged the lapse in Staff C's certification. This oversight in maintaining up-to-date food safety certifications for staff involved in food preparation posed a potential risk for unsafe food handling practices, thereby placing residents at risk for foodborne illnesses.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was informed of the potential risks associated with the use of psychotropic medications. Resident 72, who had a diagnosis of a psychotic disorder, was prescribed and received the psychotropic medication Duloxetine daily. However, there was no documentation or informed consent form completed to indicate that the risks and benefits of taking this medication were discussed with the resident or their representative prior to administration. This oversight was confirmed by the Director of Nursing, who acknowledged that informed consents for psychotropic medications should be completed before the resident receives the medication.
Failure to Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to encode and transmit resident assessment data to the Centers for Medicare & Medicaid Services (CMS) within the required timeframe for two residents. Resident 12, who has idiopathic hydrocephalus and autistic disorder, had a quarterly assessment completed on 07/20/2024, but the status was not accepted by CMS. Similarly, Resident 60, diagnosed with tuberous sclerosis and mental disorders, had an annual assessment completed on 07/20/2024, which also was not accepted. Both residents have severe cognitive impairments and require substantial assistance with activities of daily living. Staff R, a Case Manager Registered Nurse, acknowledged that the assessments for both residents were completed but not accepted by CMS. The assessments were reportedly compressed into a batch file and sent to CMS on 07/22/2024, but for unknown reasons, they were lost and not accepted. Staff R and the Director of Nursing confirmed that the MDS assessments should have been submitted within the required timeframe, but there was no documentation to show that the assessments were accepted by CMS.
Failure to Implement Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to implement appropriate interventions to prevent and heal pressure ulcers for a resident, identified as Resident 32. The resident was at risk for skin breakdown, and the care plan instructed staff to assist with activities of daily living, ensure an anti-pressure mattress was in place, and assist with turning and repositioning. However, the care plan did not document that Resident 32 had a pressure ulcer. Upon returning from the hospital, the resident was found to have a red and blanchable area on the coccyx, which was incorrectly identified as a pressure ulcer. Subsequent assessments documented changes in the condition of the wound, including it becoming open and increasing in size. Observations noted that the resident was sitting on multiple layers, including a Hoyer sling and cloth pad, which increased the risk of pressure. Interviews with staff confirmed that the Hoyer sling was not removed after transferring the resident to a wheelchair, which interfered with pressure relief and potentially delayed wound healing. Staff interviews revealed a lack of understanding regarding the proper management of pressure relief. The Director of Nursing acknowledged that residents should not sit or lay on cloth pads or Hoyer lift slings as it reduces the effectiveness of pressure-relieving cushions and mattresses, potentially worsening pressure ulcers. This deficiency placed other residents at risk for developing pressure ulcers and unmet care needs.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of potential abuse immediately to the State Agency as required, involving one of the three sampled residents. On August 6, 2024, at 7:25 AM, the Attendant Counselor Manager, Staff B, received an email from a Certified Nursing Assistant, Staff C, who reported overhearing Staff D yelling at a resident on August 5, 2024, at approximately 4:30 AM. However, the facility did not report this incident to the State Survey Agency until August 6, 2024, at 12:13 PM, exceeding the required two-hour reporting timeframe. During an interview on September 11, 2024, the Director of Nursing, Staff A, acknowledged the delay in reporting the possible abuse, which is a violation of the Washington Administrative Code (WAC) 388-97-0640 (5)(a).
Failure to Protect and Monitor Resident After Verbal Abuse Allegation
Penalty
Summary
The facility failed to protect, assess, and monitor a resident after an allegation of verbal abuse. The incident involved a resident with Rapid Cycle Type 2 Bipolar Disorder and Moderate Intellectual Disability. On the night shift, a nursing assistant overheard an LPN yelling at the resident to wake up and take medication, which left the resident appearing upset. The nursing assistant reported the incident to their supervisor via email the following morning. Despite the report, the LPN continued to work with the resident the next night, and no immediate protective measures were taken. The resident was not assessed for psychological harm until the morning after the second shift, and a nursing assessment for physical injury was conducted later that day. The delay in addressing the situation and monitoring the resident for potential harm constituted a deficiency in the facility's response to the abuse allegation.
Neglect of Resident's Incontinence Care and Meal Provision
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect, as evidenced by the lack of timely incontinence care and inadequate provision of a morning meal. The resident, who had a history of moderate intellectual disability, schizoaffective disorder, and bipolar disorder, was dependent on staff for toileting and meal setup. On the morning of the incident, the resident was found by a nursing assistant to be incontinent of urine, with their incontinence brief soaked and leaking onto the bed. Despite notifying another staff member, the resident remained in bed without care for several hours. Witness statements revealed that the resident was not assisted out of bed until late morning, by which time they were soaked in urine and visibly upset. The resident's breakfast was left uneaten, and when they were finally brought to the dining table, they were only given a portion of fruit instead of a full meal. Staff members reported that the resident appeared sad and emotional due to the neglectful care they received. The facility's administration was informed of the situation, but initial actions were insufficient to address the neglect. The administrator later acknowledged that the incident should have been investigated more thoroughly at the time it occurred. The failure to provide timely incontinence care and an adequate meal resulted in emotional distress and a diminished quality of life for the resident.
Failure to Timely Report Alleged Neglect
Penalty
Summary
The facility failed to report allegations of potential abuse and/or neglect to the State Survey Agency within the required two-hour window, as mandated by state law. This deficiency involved a long-term resident who had recently moved to the nursing facility portion due to increased medical and physical needs. The resident had a history of moderate intellectual disability, schizoaffective disorder, and bipolar disorder with severe manic episodes and psychotic symptoms. On the morning of June 7, 2024, three Nursing Assistants alleged that the resident had been neglected by a lead Nursing Assistant. These concerns were communicated to a Registered Nurse Case Manager and subsequently to the Developmental Disability Administrator by lunchtime. However, the facility did not report the neglect allegation to the State Agency until later that evening, well beyond the two-hour reporting requirement. Interviews with the involved staff revealed a lack of awareness regarding the necessity to report such allegations within the specified timeframe. Staff members believed that others would report the incident, indicating a breakdown in communication and understanding of the reporting protocol. This delay in reporting placed residents at risk for abuse and/or neglect.
Delayed Investigation into Alleged Neglect
Penalty
Summary
The facility failed to conduct a timely and thorough investigation into allegations of neglect involving two residents. Resident 1, who had a history of moderate intellectual disability, schizoaffective disorder, and bipolar disorder, was largely wheelchair-bound and dependent on staff for care. Resident 2, diagnosed with Down Syndrome, Alzheimer's Disease, and Spastic Cerebral Palsy, was also wheelchair-bound and reliant on staff. On June 7, 2024, concerns about possible neglect of Resident 1 were reported by Nursing Assistants to a Registered Nurse Case Manager, who then informed the Developmental Disability Administrator. However, the Administrator only spoke to the alleged perpetrator, an Assistant Lead Nursing Assistant, and did not take further action to protect Resident 1 or investigate the report until June 10, 2024. During this period, the alleged perpetrator continued to work with both residents, and no protective measures were implemented. It was not until June 10, 2024, that the incident was reported again by a Lead Nursing Assistant, who also expressed concerns about possible neglect of Resident 2. The facility's Administrator acknowledged that the investigation did not begin until three days after the initial report and that the alleged perpetrator was not removed from resident care until June 11, 2024. This delay in response and failure to protect the residents placed them at risk for diminished quality of life and continued possible neglect.
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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