Life Care Center Of Kennewick
Inspection history, citations, penalties and survey trends for this long-term care facility in Kennewick, Washington.
- Location
- 1508 West Seventh Avenue, Kennewick, Washington 99336
- CMS Provider Number
- 505080
- Inspections on file
- 46
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 38
Citation history
Health deficiencies cited at Life Care Center Of Kennewick during CMS and state inspections, most recent first.
The facility failed to follow its abuse-prevention and unsafe wandering policies when a cognitively impaired resident with dementia and severe agitation repeatedly wandered into other residents’ rooms, was difficult to redirect, and engaged in inappropriate contact. Staff documented and observed ongoing wandering into rooms, residents’ discomfort and fear, and one incident in which a resident’s breast was grabbed at a nurse’s station, as well as another incident where a resident with PTSD reported the wandering resident sat on their bed, pulled up their blanket, and looked at their legs. A third resident reported multiple unwanted room entries and feeling so unsafe they contacted police. Staff acknowledged that these events scared residents, but some did not recognize them as suspected abuse or report them, and the DON and Administrator later stated that the initial investigation and implementation of abuse prohibition policies were not done correctly, resulting in a failure to identify, protect, and prevent abuse as required by facility policy and regulation.
A resident with dementia, malnutrition, and post–hip dislocation aftercare did not receive timely access to medical records through their representative. The facility’s policy required records for current residents to be provided within two working days, but the representative’s verbal and written requests were not fulfilled until nine days after the authorization form was submitted. The Medical Records Director described time frames and processes that did not align with the written policy, and the Administrator reported being unsure of the regulations governing record requests, resulting in noncompliance with regulatory requirements for access to records.
Two residents were involved in a sexual altercation at the nursing station when a cognitively impaired resident with Alzheimer’s disease, dependent for ADLs, walked up and grabbed the left breast of another resident with intact cognition who used a wheelchair and had diabetes, COPD, and heart failure. An LPN witnessed the incident, removed the aggressor, and assisted them back to their hall. The resident who was touched reported feeling angry and violated and stated the contact was unwanted. The DON confirmed the contact was non-consensual, demonstrating a failure to prevent resident-to-resident sexual abuse despite an existing abuse-prevention policy.
A nurse/unit care coordinator entered and exited a room on contact precautions for a resident with diarrhea suspected of C. diff multiple times without donning gown and gloves or performing hand hygiene with soap and water, while interacting with both residents in the room and handling a meal tray that was then taken into the hallway near the kitchen. Facility policy and posted signage required gown, gloves, and soap-and-water handwashing for all staff entering the room, and the IP, interim DON, and administrator all confirmed these expectations. This was cited as a repeat deficiency under WAC 388-97-1320(1)(c)(2)(a).
The facility failed to follow its own abuse-prevention and screening policies and state guidelines by allowing an agency nurse serving as Interim DON to work unsupervised with residents without a completed criminal background check. Facility guidelines required all staff, including agency staff, to have a Washington State BGC completed and reviewed for disqualifying history before starting work. The Interim DON began working independently with residents without returning the BGC authorization form, and the accounting clerk, who had repeatedly provided the form, did not notify the administrator that the BGC was incomplete. The administrator stated they were unaware the Interim DON was working without a valid BGC and confirmed that the established process required completion and review of the BGC prior to the start date.
Surveyors found that several residents' medical records were incomplete, missing provider progress notes, hospice visit documentation, and up-to-date emergency contact information. Staff interviews revealed a significant backlog in scanning documents and difficulties accessing provider notes, with only one staff member able to retrieve records from an external system. The facility was not following its own policies for maintaining complete and accessible health records.
A resident with multiple complex conditions was admitted to hospice care, but the facility failed to designate an IDT member to coordinate with hospice, did not maintain required documentation such as physician orders and hospice plans of care, and lacked clear communication between facility and hospice staff regarding wound care and service responsibilities. Staff interviews revealed confusion about roles and processes, resulting in inconsistent documentation and coordination of hospice services.
A resident with severe cognitive impairment was discharged to another facility without the resident's representative being notified. An LPN assumed the representative had been informed, but this was not confirmed, and the representative only learned of the transfer upon arriving at the facility. The DON acknowledged that the required notification process for residents with altered mental status was not followed.
A resident with a history of brain injury, stroke, and high fall risk was left unsupervised in a wheelchair by a newly hired NA, despite care plan interventions requiring supervision. The NA did not review the Kardex for updated care directives, resulting in the resident being found on the floor.
A resident with intellectual and mental health conditions requested medication from an LPN, who, after being struck with a soda bottle by the resident, told the resident they had committed assault and would go to jail. This statement caused the resident significant distress, leading to their elopement from the facility. The incident was later recognized as verbal abuse according to state and facility policy.
A resident with a history of stroke and heart failure had their family member's visitation restricted to limited weekday hours after a verbal altercation with a nursing assistant. Despite multiple witness accounts indicating no physical threat, the facility imposed the restriction without a thorough investigation or interviewing all witnesses, leaving the resident visibly upset and fearful of further retaliation.
The facility did not report allegations of abuse and neglect to the State Agency for two residents with cognitive impairments. In one case, a resident reported feeling intentionally assaulted by another resident's representative, but the incident was not reported or logged appropriately. In another case, a resident expressed emotional distress and feelings of helplessness due to a staff member's behavior, but the grievance was not recognized or reported as potential abuse or neglect. Facility leadership was unaware of these incidents, resulting in a failure to investigate or report as required.
The facility failed to ensure proper infection control measures, with staff improperly removing PPE and not adhering to COVID-19 testing protocols. Observations showed staff mishandling N95 masks and goggles, and eating in hallways without masks. Additionally, residents were not tested every three days as required, leading to delayed identification of COVID-19 cases. Interviews revealed a lack of training and awareness among staff regarding PPE and testing procedures.
A resident in an LTC facility did not receive their prescribed Oxycodone due to a delay in ordering and lack of access to the Omnicell by agency staff. The resident was given medication from another resident's supply, leading to their transfer to the ER for pain management. The facility's Director of Nursing authorized this practice, and the pharmacy confirmed that temporary access codes could have been provided.
A resident in a LTC facility was injured during a transfer using a Hoyer Lift due to improper sling attachment. The sling used was incompatible with the lift, and staff failed to follow the facility's policy requiring two staff members and adherence to manufacturer's guidelines. The resident fell, sustaining a hematoma and abrasion, and was transferred to the emergency room.
A resident with a history of stroke and muscle weakness fell from a mechanical lift due to improper securing of the sling, resulting in facial injuries. The incident was not reported to the State Agency as required, despite the facility's policy mandating immediate reporting of serious bodily injuries. The report was eventually made after the resident's family raised concerns.
The facility failed to safely apply and justify the use of four-point restraints on two residents, leading to immediate jeopardy. A resident with severe intellectual disabilities was observed with a loose restraint, risking strangulation, while another with cerebral palsy had straps incorrectly positioned. Medical records lacked necessary documentation, and staff were untrained in proper restraint use.
A resident suffered a burn from hot food served at an unsafe temperature, and cleaning agents were found unsecured in shower rooms and on PPE carts, posing risks to residents. Staff interviews revealed a lack of procedures for reheating food and securing hazardous materials.
The facility failed to implement restorative nursing services for two residents, leading to a deficiency in maintaining or improving their range of motion. One resident, with muscle weakness, had no restorative program despite needing therapy services, and was unable to bend their right knee. Another resident, with rhabdomyolysis and Parkinson's, lacked a restorative program and was not using a prescribed splint due to its unavailability. The facility's limitation of only ten residents on restorative programs resulted in a waiting list, which was not communicated to therapy staff.
The facility failed to ensure proper dialysis care coordination for two residents, resulting in incomplete pre/post dialysis communication forms and lack of follow-up with the dialysis center. This led to missing documentation on residents' conditions and weights post-treatment, compromising continuity of care.
A resident, admitted with stroke, malnutrition, and depression, required assistance for oral care and was edentulous. Despite expressing a desire for dentures, the resident had not seen a dentist since admission. A referral to a denturist was made but not scheduled, contrary to the facility's process of completing referrals within one month. The administrator expected referrals to be completed sooner than four months.
The facility failed to maintain essential equipment, including a washing machine and a kitchen exhaust fan, in working condition. The washing machine had been out of service for a month, leading to laundry shortages, while the kitchen exhaust fan's malfunction resulted in chemical fume accumulation. Delays in repair approvals and lack of regular inspections contributed to these issues.
A resident with a history of urinary retention experienced prolonged bladder pain due to delayed assessment and intervention by facility staff. Despite complaints of pain and inability to urinate, the necessary bladder scan and catheterization were not performed promptly. Staff B, an agency LPN, failed to operate the bladder scanner and did not notify the physician, resulting in significant discomfort for the resident. The resident was eventually catheterized, revealing excessive urine retention.
A resident experienced severe urinary retention and pain due to delayed medical intervention in a facility. Despite repeated complaints and visible distress, staff failed to perform timely assessments or notify the on-call physician. The resident was eventually catheterized, but the incident was not reported to the State Agency as required, resulting in a deficiency.
A resident experienced prolonged bladder pain due to urinary retention, with no timely intervention from staff. Despite complaints and reports to the LPN and unit care coordinator, necessary assessments and interventions were delayed. The resident was eventually catheterized, relieving over 1200 ml of urine. The facility failed to investigate the incident or take immediate corrective action, resulting in a repeat deficiency.
A resident with a history of spinal stenosis and urinary retention experienced significant distress due to a nurse's failure to perform a bladder scan and notify a physician, despite clear instructions. The nurse, unfamiliar with the equipment, did not assess the resident, leading to a delay in catheterization and relief. The nurse's personnel file lacked documentation of necessary competencies, contributing to the deficiency.
A resident with multiple diagnoses experienced repeated leg injuries while using a motorized wheelchair due to inadequate supervision and insufficient interventions. Despite being assessed and approved to use the wheelchair, the resident had multiple accidents, resulting in severe injuries. Staff were unaware of restrictions on the resident's wheelchair use, and the facility's padding of the bed frame was insufficient, leaving hazardous areas exposed.
Failure to Implement Abuse-Prevention and Wandering Policies for Resident-to-Resident Incidents
Penalty
Summary
The deficiency involves the facility’s failure to implement its written abuse-prevention and unsafe wandering policies to identify, protect, and prevent abuse related to one resident’s repeated entry into other residents’ rooms and inappropriate contact. The facility had policies stating it would implement interventions to mitigate unsafe wandering, including wandering into other residents’ rooms, and that it would identify, assess, care plan, and monitor residents with behaviors that may lead to conflict, as well as ensure ongoing safety and protection for alleged victims and other residents. Despite these policies, Resident 1, who had dementia with severe agitation, anxiety, depression, severe cognitive impairment, and dependence on staff for ADLs, was repeatedly documented as wandering freely through the halls and into other residents’ rooms over multiple days. Progress notes described Resident 1 entering many rooms, being difficult to redirect, and causing other residents to feel uncomfortable or upset, with some residents requesting physical barriers such as stop sign barricades across their doorways. Staff interviews confirmed that Resident 1 frequently wandered and entered other residents’ rooms, and that the primary response was to redirect them back to their hall or room. Staff reported that Resident 1 had grabbed other residents’ belongings and that barricades were placed across some doorways to try to prevent entry. The Activities Director stated that Resident 1 constantly wandered into rooms, that these incidents upset some residents, and that female residents were more concerned due to feeling more vulnerable and Resident 1’s tall, dominant appearance. The Activities Director also described an incident in which Resident 1 followed them, placed hands on their forearms, and stated, “you are not going to like what I am about to do,” requiring assistance from other staff to move Resident 1 away. Other staff, including NAs and a maintenance assistant, acknowledged that Resident 1’s presence in rooms scared residents, but some did not recognize these events as suspected abuse and did not report residents’ fear to nursing or management. Multiple residents described specific incidents involving Resident 1 that were not effectively addressed under the abuse-prevention policy. One resident with intact cognition, diabetes, COPD, and heart failure reported that Resident 1 approached them at a nurse’s station, grabbed their left breast after a greeting, and had to be escorted away by staff. Another resident with PTSD, anxiety, and depression, who required assistance with ADLs and had intact cognition, reported that Resident 1 entered their room on more than one occasion, sat on their bed, pulled up their blanket, and looked at their legs, which made them feel scared, especially given their history of sexual trauma. A third resident with heart failure, anxiety, depression, and intact cognition stated that Resident 1 entered their room multiple times, refused to leave when asked, and made them feel unsafe and afraid to the point that they called the police. Staff interviews indicated that Resident 1 was “very difficult to watch,” that one-to-one supervision was believed necessary by some staff, and that management had been informed of residents’ fears. The DON and Administrator later acknowledged that the initial investigation into a resident-to-resident altercation involving Resident 1 was not completed correctly and that the correct process for implementing abuse prohibition policies had not been followed, resulting in a failure to identify and protect residents from potential abuse and psychosocial harm as required by facility policy and WAC 388-97-0640(1)(2)(6)(b).
Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
The facility failed to provide timely access to medical records and to maintain a medical records policy consistent with regulatory requirements. The facility’s undated policy, “Release of Resident Medical Records,” stated that records for active residents must be provided within two working days and records for non-active residents within 15 days. Resident 5, who had diagnoses including aftercare for right hip dislocation, dementia, and malnutrition, had a comprehensive assessment dated 11/03/2025 indicating a need for partial to dependent assistance with ADLs and moderately impaired cognition. The resident’s representative reported requesting the resident’s records, but the facility did not provide them as requested. Record review showed the representative emailed a request for the resident’s records on 02/04/2026, and an Authorization for Release of Information form was completed and provided to the facility on an unspecified date. The facility did not provide the records until 02/21/2026, nine days after receiving the authorization form, despite the representative having verbally requested the records prior to 01/29/2026. During interviews, the Medical Records Director stated that for current residents the facility had two days to provide records and for former residents 30 days, and that the process began when the release form was returned. The Administrator stated they were unsure of the regulations for record requests. These practices were inconsistent with the facility’s own policy and with applicable regulations, resulting in a failure to provide records within two working days for this resident.
Failure to Prevent Resident-to-Resident Sexual Contact at Nursing Station
Penalty
Summary
The facility failed to prevent a resident-to-resident sexual altercation, contrary to its Abuse-Prevention policy, which required prevention and prohibition of all types of abuse and protocols to prevent sexual abuse. Resident 1, who had Alzheimer's disease with severe impaired cognition and was dependent on one to two staff for ADLs, was involved in an incident with Resident 2, who had intact cognition, diabetes, COPD, heart failure, and required supervision or was dependent for ADLs while using a wheelchair for ambulation. The facility’s investigation report documented that on 02/04/2026, Resident 1 walked up to Resident 2 at the Team 3 nursing station and grabbed Resident 2’s left breast. Staff and resident interviews further described the event. Staff L, an LPN, stated they were present when Resident 2 spoke to Resident 1, after which Resident 1 reached out and squeezed Resident 2’s left breast; Staff L then removed Resident 1 from the situation and assisted them back to their hall and into a chair. Resident 2 reported that while at the nurse’s station, Resident 1 reached out and grabbed their left breast, and that they responded by telling Resident 1 not to do that and not to touch their breast, pushing Resident 1’s hand away. Resident 2 stated they felt angry and violated during the altercation. The DON later confirmed that Resident 2 did not have intent for Resident 1 to touch them and that the contact was unwanted, constituting an abusive incident under the facility’s abuse-prevention requirements and WAC 388-97-0640(1).
Failure to Follow Contact Precautions for Suspected C. diff Room
Penalty
Summary
The deficiency involves the facility’s failure to consistently implement its infection prevention and control measures for contact precautions in a room under investigation for Clostridioides difficile (C. diff). The facility’s Transmission-based Precautions and Isolation Procedures policy required staff to don appropriate PPE, including gown and gloves, before or upon entering a room on contact precautions and to perform hand hygiene prior to leaving the room. A contact precaution sign posted on a resident room door instructed everyone to clean their hands with soap and water before entering and leaving the room, and to put on gloves and a gown before room entry and discard them before room exit. One resident in the bed near the window in that room had complaints of diarrhea and was suspected of having C. diff, and the contact precaution signage had been posted for that reason. During observation, a Registered Nurse/Unit Care Coordinator (Staff D) entered this contact precaution room without washing hands or donning a gown and gloves, spoke with the resident in the bed near the window who reported dizziness and diarrhea, then spoke with the resident in the bed closest to the door, and exited the room without performing hand hygiene with soap and water. Staff D then obtained a straw from the medication cart, re-entered the same room again without hand hygiene or PPE, unwrapped the straw for the resident closest to the door, picked up that resident’s breakfast tray, exited the room with the tray, and placed it on a tray cart in the hall near the kitchen. Staff D then proceeded toward the employee lounge, stating they needed to wash their hands, and entered the lounge without having washed their hands with soap and water during the entire observation. In interviews, Staff D acknowledged the posted precautions applied to all staff and that they should have followed the instructions. The Infection Preventionist, the Interim DON, and the Administrator each stated that contact precautions required gown and gloves before room entry, removal of PPE before exit, and handwashing with soap and water when C. diff was suspected, and that all staff were expected to follow the posted precaution signs. The report states this is a repeat deficiency under WAC 388-97-1320(1)(c)(2)(a) from prior Statements of Deficiencies.
Failure to Complete Required Background Check Before Allowing Interim DON Unsupervised Access
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policies and state guidelines for screening staff through criminal background checks (BGCs) before allowing them unsupervised access to residents. The facility’s guidelines, including the Nursing Home Guidelines “The Purple Book” and the policy titled “Abuse - Screening of Employees and Residents,” require that all staff, including agency-contracted staff, who have unsupervised access to vulnerable adults must have a criminal history BGC completed within 72 hours of hire and prior to starting work, and must be free of disqualifying criminal history. Record review showed that Staff B, an agency nurse contracted to serve as the Interim DON, began working unsupervised with residents on 12/04/2025 without a completed BGC. Staff B’s BGC was not completed until 01/21/2026, 48 days after they began working unsupervised with residents. During interviews, the Accounting Clerk (Staff C) stated that the process for potential new hires included obtaining a BGC prior to the first day of work to ensure the applicant was not a danger to residents, and that they had repeatedly provided the Washington State BGC authorization form to Staff B, but Staff B had not returned it. Staff C also stated they did not inform the Administrator (Staff A) that the BGC had not been completed. Staff A stated that the purpose of the BGC was to ensure there were no disqualifying events that would hinder employment or put residents at risk for abuse and neglect, and that the process required completion and review of the Washington State BGC prior to the hire or start date. Staff A reported they were not aware that Staff B was working without a valid BGC.
Incomplete and Disorganized Medical Records for Multiple Residents
Penalty
Summary
The facility failed to maintain complete, accurate, readily accessible, and systematically organized medical records for four out of nine residents reviewed. For one resident with dementia, malnutrition, and diabetes who was receiving hospice care, hospice visit notes were missing for several weeks despite ongoing weekly visits, and there were no facility provider progress or visit notes in the medical record. Another resident with diverticulitis, heart failure, and muscle weakness had no facility provider physician progress or visit notes, and their emergency contact information was missing from the demographic section of the medical record, even though it was available on the admission referral. A third resident with encephalitis, severe intellectual disabilities, and dysphagia had no recent facility provider progress or visit notes, with the last note dated over a year prior. A fourth resident with respiratory failure, heart failure, and diabetes also had no documentation of a facility provider visit or progress note. Staff interviews revealed that the process for scanning and organizing medical records was significantly delayed, with a backlog of about six months, and that staff had difficulty accessing provider notes, which were stored in a separate system only accessible by the Medical Records Director. Staff acknowledged that the facility was not following its own policies for health information management, which required that records be complete and accessible. The lack of timely scanning and integration of documents, as well as incomplete demographic information, contributed to the deficiencies in maintaining accurate and accessible medical records for residents.
Failure to Coordinate and Document Hospice Services for Resident
Penalty
Summary
The facility failed to designate an interdisciplinary team (IDT) member responsible for coordinating care and communication with hospice services for a resident receiving end-of-life care. Despite facility policy requiring a written agreement with the hospice provider, including a coordinated plan of care and clear assignment of responsibilities, there was no documentation of a designated IDT contact or evidence that the facility implemented the required agreement. The medical record lacked essential documents such as a physician's order to admit the resident to hospice, physician certification of terminal illness, the hospice election form, and a coordinated plan of care outlining the division of services between the facility and hospice. The resident in question had multiple complex diagnoses, including dementia, moderate protein-calorie malnutrition, and diabetes, and was dependent on staff for activities of daily living with severely impaired cognition. The resident was admitted to hospice services, but the facility's records did not reflect the necessary documentation or coordination. Nursing progress notes indicated that hospice was involved and provided medications, but there was no consistent documentation of hospice visits, services provided, or updated plans of care after certain dates. Wound care was being provided by both the facility's wound care provider and hospice, but there was no clear communication or coordination between the two, leading to overlapping and potentially conflicting care orders. Interviews with facility staff and the hospice case manager revealed a lack of awareness regarding the roles and responsibilities for hospice coordination. Staff were unaware of the requirement for a designated IDT contact, did not consistently receive or document hospice plans of care, and were unclear about the process for communication and documentation of hospice visits and orders. The hospice case manager was not informed about the facility's wound care provider's involvement, and facility staff did not know about the specialized wound care program offered by hospice. The process for enrolling residents in hospice and ongoing communication was described as broken and inconsistent, with missing documentation and unclear lines of responsibility.
Failure to Notify Resident Representative of Discharge
Penalty
Summary
The facility failed to notify the resident's representative (RR) of a discharge for a resident with severely impaired cognition. The resident, who had diagnoses including follow-up care for a surgical procedure, heart failure, and dementia, was admitted with a cognitive assessment indicating severe impairment. According to the medical record, the resident was discharged to another facility, and the discharge documentation was signed by the resident. Staff A, an LPN, facilitated the discharge and assumed the RR had been notified, but did not confirm this. Later, the RR arrived at the facility and was informed by Staff A that the resident had already been transferred, leading to the RR expressing upset at not having been notified. Staff B, the DON, confirmed that the facility's process requires notification of representatives for residents with altered mental status, which was not followed in this case. The RR also verified during a telephone interview that they had not been notified of the transfer.
Failure to Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
Staff failed to implement fall prevention interventions as outlined in the care plan for a resident with a history of brain injury, stroke, and previous falls. The resident was assessed as high risk for falls and required substantial assistance for activities of daily living, with severe cognitive impairment. The care plan included interventions such as anticipating needs, keeping the call light within reach, using a mechanical lift for transfers, and ensuring the resident remained in supervised areas while in a wheelchair. Despite these documented interventions, a newly hired nursing assistant left the resident unsupervised in their wheelchair, resulting in the resident being found on the floor in their room. The facility's investigation identified the root cause as the failure of the new staff member to review the resident's Kardex for updated care directives, despite having completed orientation and training on reviewing care plans and Kardexes. This lapse led to the resident not receiving the required supervision as specified in their care plan.
Failure to Protect Resident from Verbal Abuse by LPN
Penalty
Summary
A resident with Fragile X syndrome, bipolar disorder, and anxiety disorder, who required partial assistance for dressing and had some memory and decision-making difficulties, requested medication from an LPN. The LPN informed the resident they would have to wait due to another resident's medical emergency. The resident then retrieved a partial bottle of soda from their room and threw it at the LPN's head. In response, the LPN told the resident that they had committed assault and were going to jail. Following this exchange, the resident left the facility to get some air and subsequently eloped. The facility's investigation documented that the resident was focused on the LPN's statement about assault and the possibility of going to jail, which led to their departure. The resident's representative reported that the resident was frantic and afraid of incarceration after the incident. Initially, the facility administrator did not consider the incident to be verbal abuse, but later acknowledged it as such after reviewing additional information. The report references state and facility policies defining verbal abuse as threatening language or statements made within hearing distance of residents.
Failure to Protect Resident Visitation Rights Following Staff-Visitor Altercation
Penalty
Summary
The facility failed to honor a resident's right to receive visitors of their choosing by indefinitely restricting the visitation hours of the resident's immediate family member. The resident, who had a history of stroke with left-sided deficit and heart failure, was cognitively intact and dependent on staff for activities of daily living. The restriction was imposed following an incident involving a nursing assistant and the resident's representative (RR), during which a verbal altercation occurred in the hallway. Multiple witnesses, including staff and a collateral contact, described the event as a heated exchange, but none reported any physical threat or danger posed by the RR to the staff member involved. Prior to the incident, the RR had regularly visited the resident, often twice daily, and had expressed concerns about late dinners. The resident reported that the nursing assistant had previously threatened that the RR's visitation could be revoked if complaints continued. After the hallway incident, the administrator restricted the RR's visitation to weekdays during business hours, with no weekend visits, without conducting a thorough investigation or interviewing all available witnesses. The resident was visibly upset by the restriction, expressing feelings of fear, insecurity, and reluctance to voice further concerns due to fear of retaliation. Staff interviews revealed inconsistent follow-up and lack of documentation regarding the incident and the imposed visitation restriction. The administrator confirmed the visitation limits were set to protect staff, despite the staff member involved no longer being employed at the facility. Other staff and witnesses indicated that the RR had not posed a physical threat, and the collateral contact who witnessed the event was not interviewed as part of the facility's response. The facility did not provide evidence of a formal investigation or adequate assessment of the resident's psychosocial well-being following the restriction.
Failure to Timely Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to report allegations of abuse and/or neglect to the State Agency for two residents who were reviewed for grievances. According to facility policy, all alleged violations of abuse, neglect, exploitation, or mistreatment must be reported within specified timeframes depending on the severity. However, in the case of one resident with bipolar disorder and epilepsy, who was assessed as having moderately impaired cognition and significant behavioral issues, an incident occurred where the resident reported feeling intentionally assaulted by another resident's representative. The nursing assistant who received this report did not notify the State Agency, and the incident was not logged as an allegation of assault, but rather as a skin issue. Facility administration was unaware of the allegation until after the fact, and the administrator acknowledged missing the relevant information in the incident statement. In another case, a resident with a right hip fracture and bipolar disorder, also with moderately impaired cognition and requiring substantial assistance, reported to a staff member that a nursing assistant was rude, unhelpful, and made the resident feel helpless and depressed. The grievance, written by the assistant rehab director, described the resident crying and expressing emotional distress due to the staff member's behavior. This grievance was not entered into the facility's grievance log, nor was it reported as an incident. The nursing assistant involved did not report the resident's emotional state or any change in condition, and only apologized after learning of the complaint from another staff member. Interviews with facility leadership revealed that the administrator and assistant director of nursing were unaware of the grievances and did not recognize them as potential abuse or neglect, resulting in a failure to initiate investigations or report the allegations as required. The facility's actions and omissions in both cases led to a lack of timely reporting and investigation of potential abuse or neglect, as required by policy and regulation.
Infection Control and Testing Deficiencies
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures, specifically in the use of personal protective equipment (PPE) by staff members. Observations revealed that Staff D, E, and F did not follow the correct procedures for removing PPE, which included improper handling of N95 masks and goggles. Staff D was observed tearing the elastic straps of their N95 mask and touching the front of the mask with bare hands, while Staff E removed their goggles and mask simultaneously, contrary to guidelines. Staff F was seen pulling down their mask to eat in a hallway, which is against infection control protocols. These actions indicate a lack of proper training and adherence to PPE guidelines, increasing the risk of COVID-19 transmission. The facility also failed to conduct COVID-19 testing every three days as directed by the Local Health Jurisdiction. Resident 1, who was admitted with conditions such as Parkinson's disease and muscle weakness, did not receive testing for six days and later tested positive for COVID-19. Similarly, Resident 2, with chronic obstructive pulmonary disease and heart failure, also went six days without testing before a positive result. Resident 3, who required supervision for activities of daily living, was not tested until five days after an outbreak was identified, and subsequent testing did not adhere to the three-day interval. These lapses in testing protocols contributed to the spread of COVID-19 within the facility. Interviews with staff revealed a lack of awareness and confusion regarding the proper procedures for PPE removal and COVID-19 testing. The Infection Preventionist acknowledged the incorrect practices but noted that staff preferred quicker methods, such as tearing off mask straps. The Director of Nursing Services admitted to not being aware of the improper PPE use and the oversight in testing new admissions. This lack of communication and training among staff members led to the deficiencies observed in infection control and testing protocols.
Failure to Ensure Timely Medication Administration
Penalty
Summary
The facility failed to ensure proper medication administration for a resident who required narcotic pain medication. The resident's Oxycodone supply was not ordered in a timely manner, leading to a shortage. Agency staff and newly hired staff did not have authorization codes to access the Omnicell, an emergency dispensing machine for medications. As a result, the resident's prescribed narcotic was unavailable, and the staff resorted to administering medication from another resident's supply, which is against acceptable standards of practice. The resident, who had heart and lung problems and diabetes, was on narcotic pain medication for pain management. The last dose of the resident's prescribed Oxycodone was administered on December 25, 2024, and the next supply did not arrive until late on December 27, 2024. During this period, the resident was given Oxycodone from another resident's supply on two occasions. The resident experienced excruciating pain and requested to be transferred to the emergency room (ER) for pain management, as the pharmacy had not yet delivered the medication. Interviews with staff revealed that the Director of Nursing authorized the borrowing of medication from other residents, and the agency staff did not feel comfortable with this instruction. The consulting pharmacy confirmed that temporary authorization codes could have been provided for the Omnicell, and management should have anticipated the need for such codes during the holiday schedule. The resident was eventually transferred to the ER, and their Oxycodone supply arrived shortly after their transfer.
Improper Use of Mechanical Lift Leads to Resident Injury
Penalty
Summary
The facility failed to identify avoidable accident hazards during a mechanical lift transfer, resulting in harm to a resident. The incident involved Resident 1, who was dependent on two staff members for transfers and had an intact cognition. During a transfer using a Hoyer Lift, the sling was not properly hooked, causing the resident to fall and sustain a hematoma and abrasion to the forehead, necessitating a transfer to the emergency room. The investigation revealed that the sling used was not compatible with the Hoyer Lift, as per the manufacturer's guidelines, which recommend using genuine Hoyer parts. Staff B, who was responsible for hooking the sling, did not wait for the second staff member before proceeding with the transfer. Staff C, who assisted in the transfer, did not double-check the straps, and both staff members assured the resident they were secure, despite the sling being improperly attached. Interviews with staff indicated a lack of training on the specific sling used, which was donated and not part of the standard equipment. Staff A, the Director of Nursing Services, acknowledged that the staff did not receive training on the particular sling before its use. The facility's policy required two staff members for transfers and adherence to manufacturer's guidelines, which were not followed in this case, leading to the resident's fall and subsequent injuries.
Failure to Report Resident Fall with Injury
Penalty
Summary
The facility failed to report a fall with significant injury to the State Agency as required. This incident involved a resident who was admitted with diagnoses including a stroke with left arm paralysis, muscle weakness, and heart failure. The resident was dependent on two staff members for bed mobility and transfers. During a transfer using a mechanical lift, the resident fell out of the sling because staff did not appropriately secure it. The resident sustained injuries to the face, including a hematoma on the left forehead, extending to the eye and lower face, with the left eye almost swollen shut. Despite these injuries, the Director of Nursing Services did not report the incident to the State Agency, citing the absence of significant injury, fractures, or head trauma. The incident was eventually reported after the resident's family expressed concerns about the lack of reporting. The facility's policy required that alleged violations resulting in serious bodily injury be reported immediately, but not later than two hours after the allegation was made. This failure to report in a timely manner placed residents at risk for harm and diminished protection and oversight from the State Agency.
Improper Use of Four-Point Restraints on Residents
Penalty
Summary
The facility failed to ensure the safe application and medical justification for the use of four-point restraints on two residents, leading to an immediate jeopardy situation. Resident 1, who has severe intellectual disabilities and encephalitis, was observed with a four-point restraint that was improperly applied, with significant looseness that increased the risk of strangulation. The resident's medical records lacked justification for the restraint's use, and there were no documented assessments or care plans addressing the restraint's application, duration, or necessity. Similarly, Resident 5, diagnosed with cerebral palsy and epilepsy, was observed with a loosely applied four-point restraint, with straps incorrectly positioned across the upper arms instead of over the shoulders. The medical records for Resident 5 also lacked necessary documentation, including a physician's order specifying the type of restraint and its medical justification. The care plan did not provide guidance for the restraint's use, and no assessments were conducted to evaluate its necessity or effectiveness. Interviews with staff revealed a lack of training and awareness regarding the proper application and monitoring of the restraints. Staff members admitted to not having received training on the new wheelchair and restraint system, and there was no evidence of ongoing evaluations or attempts to use less restrictive alternatives. The facility's failure to follow its own policies and procedures for restraint use placed both residents at significant risk of harm.
Unsafe Food Temperatures and Unsecured Cleaning Agents
Penalty
Summary
The facility failed to ensure food was served at a safe temperature, resulting in injury to a resident. During an observation, a nursing assistant served a meal to a resident without checking the temperature, leading to the resident burning their mouth on hot mashed potatoes. The cook had reheated the food in a microwave to 165 degrees Fahrenheit, exceeding the facility's policy of not serving food above 150 degrees Fahrenheit. The nursing assistant did not alert the resident to the hot temperature, and the resident experienced pain and a burning sensation in their mouth. Additionally, the facility did not maintain resident safety in two shower rooms and on personal protection equipment (PPE) carts. Observations revealed that cleaning agents, which are hazardous if ingested or come into contact with skin or eyes, were left unsecured in the shower rooms and on PPE carts. The shower room doors were unlocked, and cleaning solutions and wipes were accessible to residents, posing a risk of harm. Interviews with staff confirmed the lack of a process for ensuring food safety and securing hazardous materials. The cook and nursing assistant acknowledged the absence of procedures for reheating food and securing cleaning agents. The Director of Nursing stated that all cleaning agents should be stored securely to prevent resident access, highlighting the facility's failure to adhere to safety protocols.
Failure to Implement Restorative Nursing Services
Penalty
Summary
The facility failed to implement restorative nursing services programs, including the consistent use of braces and splints, for two residents, leading to a deficiency in maintaining or improving their range of motion (ROM). Resident 22, who was admitted with muscle weakness and required assistance with personal care, had no restorative nursing programs in place despite needing therapy services to maintain or attain their highest level of function. Observations revealed that Resident 22 was unable to bend their right knee and expressed a desire for assistance with exercises, which they were not receiving. Similarly, Resident 31, diagnosed with rhabdomyolysis, muscle weakness, and Parkinson's disease, also lacked a restorative nursing program. Although their care plan included an intervention to encourage the use of a resting right-hand splint, the resident was not wearing it due to its unavailability. Resident 31 expressed a desire to continue therapy, which had been stopped without their knowledge. Staff interviews confirmed the absence of the splint and glove and revealed a lack of awareness about the limited availability of restorative nursing program positions. The facility's administrator acknowledged that only ten residents could be on a restorative nursing program at a time, resulting in a waiting list for others in need. This limitation was not communicated to the therapy staff, who expected all residents to be on a restorative program unless medically unsafe. The deficiency placed the residents at risk for loss of ROM, deconditioning, and contractures, as the facility did not ensure the implementation of necessary restorative nursing services.
Deficiency in Dialysis Care Coordination
Penalty
Summary
The facility failed to ensure dialysis services met professional standards of care for two residents requiring such services. For Resident 9, the facility did not maintain complete pre/post dialysis communication forms, with five instances of incomplete documentation noted. The forms lacked information about the resident's condition at the dialysis center and their weight after treatment. Despite the facility's policy requiring communication and documentation, there were no recorded attempts by the nursing staff to contact the dialysis center to obtain the missing information. Similarly, for Resident 44, the facility did not complete pre-assessments on two occasions before sending the resident to the dialysis center, and one post-dialysis form was returned incomplete without follow-up documentation. Interviews with staff revealed that the expected process was not consistently followed, as the pre/post dialysis communication forms were not always completed or followed up on when returned incomplete. This lack of coordination and documentation between the facility and the dialysis center compromised the continuity of care for these residents.
Failure to Coordinate Denture Services for Resident
Penalty
Summary
The facility failed to coordinate a referral for denture services for a resident, identified as Resident 33, who was reviewed for dental services. Resident 33 was admitted to the facility with diagnoses including a stroke, malnutrition, and depression. The comprehensive assessment indicated that the resident required setup/cleanup assistance for oral care and had intact cognition. The care plan noted that Resident 33 was edentulous and included interventions for coordinating dental care and transportation. Despite these plans, Resident 33 expressed during interviews that they had not seen a dentist since admission and desired dentures to improve their ability to eat. Staff Q, a Social Services Assistant, acknowledged that although a referral to a denturist was made in April 2024, the appointment had not been scheduled, contrary to the facility's process of completing referrals within one month. The facility administrator expected dental referrals to be completed sooner than four months.
Deficiencies in Equipment Maintenance
Penalty
Summary
The facility failed to maintain essential equipment in working condition, specifically a washing machine (Washer 2) and a kitchen exhaust fan. Washer 2 had been out of service for about a month, as reported by the Laundry Assistant, who indicated that the machine would not drain water properly, necessitating repeated rinse and spin cycles. The Maintenance Director acknowledged the issue but stated that the part needed for repair had not been ordered due to awaiting administrative approval. This delay was compounded by a lack of follow-up with the outside vendor responsible for the repairs. As a result, the facility faced challenges in managing laundry effectively, leading to shortages of clean clothing and linens for residents. Additionally, the kitchen's janitor closet exhaust fan was found to be non-functional, resulting in the accumulation of chemical fumes. The Food Service Director was unaware of the fan's malfunction and stated that the kitchen staff were not responsible for its inspection. The Maintenance Director also confirmed the lack of regular inspections for the exhaust fan. The Administrator acknowledged the potential health risks posed by the non-functioning fan, which could lead to inhalation of chemical fumes by staff and residents.
Failure to Provide Timely Care for Urinary Retention
Penalty
Summary
The facility failed to provide timely care and services for a resident experiencing urinary retention, resulting in prolonged bladder pain. The resident, who had a history of spinal stenosis, diabetes, and urinary retention, was admitted to the facility following a laminectomy surgery. Despite the resident's complaints of bladder pain and inability to urinate, the necessary assessments and interventions were delayed. The resident reported not urinating during specific shifts and expressed significant discomfort, yet the staff did not promptly address the issue. Staff C, a Registered Nurse/Unit Care Coordinator, instructed Staff B, an agency LPN, to perform a bladder scan and notify the on-call physician if catheterization was needed. However, Staff B did not perform the bladder scan in a timely manner and failed to notify the physician. Staff B admitted to not knowing how to operate the bladder scanner and did not seek assistance until much later. The resident's condition was reported multiple times by nursing assistants, but Staff B prioritized other tasks and only administered pain medication, which was ineffective in alleviating the resident's pain. The delay in performing the bladder scan and catheterization resulted in the resident experiencing severe pain throughout the night. The bladder scan was eventually performed with assistance from another LPN, revealing a significant amount of urine retention. The resident was not catheterized until several hours after the initial complaint, leading to the removal of over 1200 ml of urine, far exceeding normal bladder capacity. The facility's failure to adhere to its alert charting policy and provide timely care resulted in harm to the resident.
Failure to Timely Report Neglect Incident
Penalty
Summary
The facility failed to report an incident of neglect involving a resident to the State Agency in a timely manner. The resident, who had no cognitive impairments and required assistance with turning in bed, transfers, and dressing, experienced urinary retention and severe abdominal pain over an extended period. Despite the resident's repeated complaints and visible distress, the necessary medical intervention was delayed, and the incident was not reported as required by the facility's policy and state regulations. The resident was admitted with conditions including spinal stenosis, diabetes, and urinary retention. After a hospitalization and surgery, the resident returned to the facility and soon experienced a significant issue with urinary retention. The resident reported not urinating for an extended period and experiencing severe abdominal pain, yet the staff failed to perform timely assessments or interventions. The resident's condition was not adequately monitored, and the necessary medical procedures were delayed, resulting in significant discomfort and distress. Staff members, including a Nursing Assistant and an LPN, were aware of the resident's condition but did not take appropriate action to address the issue promptly. The resident was eventually catheterized, relieving over 1200 ml of urine, but this occurred many hours after the initial complaints. The facility's failure to report this incident of neglect to the State Agency as required by their policy and state law was noted as a deficiency.
Failure to Investigate and Address Resident's Urinary Retention
Penalty
Summary
The facility failed to thoroughly investigate an incident of neglect involving a resident who experienced prolonged bladder pain due to urinary retention. The resident, who had no cognitive impairments and required assistance with turning in bed, transfers, and dressing, reported not urinating during specific shifts and experiencing severe abdominal pain. Despite the resident's complaints and the nursing assistant's reports to the licensed practical nurse (LPN) and registered nurse/unit care coordinator, the necessary assessments and interventions were delayed. The LPN, identified as Staff B, did not perform a bladder scan or notify the on-call physician as instructed by the unit care coordinator, Staff C. The resident continued to experience pain and distress throughout the night, with no action taken until the morning shift. The resident was eventually catheterized by another LPN, Staff G, who relieved the resident of over 1200 milliliters of urine, significantly exceeding normal bladder capacity. The facility's failure to conduct an investigation into the incident and take immediate corrective action was noted. The progress notes indicated a lack of monitoring and assessment by Staff B, despite the resident's change in condition. The delay in treatment and the resident's prolonged pain were not addressed in a timely manner, leading to a repeat deficiency from a previous statement of deficiencies.
Failure to Ensure Nurse Competency in Resident Care
Penalty
Summary
The facility failed to ensure that a Licensed Nurse, identified as Staff B, demonstrated competency in caring for a resident, referred to as Resident 1, who was experiencing a change in condition. Resident 1, who had a history of spinal stenosis, diabetes, and urinary retention, was admitted to the facility following a laminectomy surgery. On the night of June 8, 2024, Resident 1 reported to staff that they had not urinated and were experiencing bladder pain. Despite instructions from Staff C to perform a bladder scan and notify the on-call physician if necessary, Staff B did not carry out these tasks. Staff B, who was unfamiliar with the operation of the bladder scanner, failed to perform an assessment or take appropriate action despite multiple reports from nursing assistants about Resident 1's condition. The resident continued to experience significant discomfort and distress throughout the night, with no intervention from Staff B. It was not until the morning shift that another staff member, Staff G, was called to catheterize Resident 1, relieving them of over 1200 ml of urine. The review of Staff B's personnel file revealed a lack of documented competencies and skills necessary to safely perform care, contributing to the deficiency. The absence of proper evaluation and training for Staff B placed Resident 1 at risk for clinical complications, as evidenced by the delay in addressing the resident's urinary retention and associated pain.
Inadequate Supervision and Interventions for Resident Using Motorized Wheelchair
Penalty
Summary
The facility failed to provide adequate supervision and implement appropriate interventions to prevent avoidable accidents for a resident using a motorized wheelchair. The resident, who had diagnoses including cervical disc displacement, rheumatoid arthritis, anxiety, and muscle weakness, experienced multiple accidents resulting in leg wounds while using their motorized wheelchair. Despite being assessed and approved to use the wheelchair, the resident had accidents on three separate occasions, causing significant injuries that required hospital visits and sutures. The facility's progress notes documented the accidents and the injuries sustained by the resident. The first accident occurred when the resident caught their arm on the wheelchair and drove into their bed, causing a skin tear and bruising. Subsequent accidents involved the resident bumping their legs on the bed frame, resulting in severe lacerations and significant bleeding. Despite these incidents, the facility's interventions, such as padding the bed rails, were insufficient and not thoroughly implemented, leaving parts of the bed frame exposed and hazardous. Interviews with staff and the resident revealed a lack of consistent communication and education regarding the resident's use of the motorized wheelchair. Staff members were unaware of the resident's restrictions on using the wheelchair in their room without assistance. Additionally, the padding on the bed frame was not adequately applied, leaving exposed areas that contributed to the resident's injuries. The facility's failure to provide adequate supervision and implement effective interventions placed the resident at risk for further accidents and injuries.
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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