Average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Life Care Center Of Kennewick during CMS and state inspections, most recent first.
Surveyors found that staff did not consistently follow contact and droplet precaution requirements for residents with RSV. PPE carts contained instructions directing staff to reuse single-use face shields across multiple RSV-positive rooms, and multiple shields were observed hanging on carts for reuse. An NA entered an isolation room to deliver meal trays wearing only a mask and, at times, a gown, without gloves or eye protection, and re-entered the room without donning full PPE or changing their mask between residents. Another NA moved directly from one isolation room to a neighboring isolation room while wearing the same gown, gloves, mask, and eye protection, using soiled gloves to open the second room’s door and not changing the mask afterward. The IP and DON described policies requiring full PPE and single-use disposal of face shields but acknowledged that goggles and face shields were being reused and that staff did not follow established infection control procedures.
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.
PASARR screenings were not accurately completed or followed through for multiple residents with SMI/ID/DD indicators. Several residents admitted with diagnoses such as anxiety, depression, bipolar disorder, dementia, and Fragile X had Level I PASARRs showing positive SMI findings, but Level II evaluations were missing, incorrectly marked as not needed, or not updated when needed. Staff reported there was no formal tracking system for PASARR forms and that the Level II referral process had broken down.
A resident with hemiplegia, aphasia, bipolar disorder, and moderate cognitive impairment had a dirty wheelchair and flies observed in the room on multiple occasions. Staff reported the resident ate in the room, dropped food at times, and that the night shift was responsible for washing wheelchairs but was not following the schedule; staff also said flies had been present for months and the resident had been given a fly swatter.
Psychotropic meds were not monitored using individualized, resident-specific targeted behaviors for three residents. One resident with depression and anxiety, another with depression and anxiety, and a third with dementia, affective disorder, restlessness, and agitation all had psychotropic orders, but the MARs used generic behavior monitoring such as loss of interest, withdraw, or restless rather than behaviors tied to each resident’s condition and treatment goals. Staff and the DON stated the monitoring was not individualized and that generic checklists were being used across residents.
A resident with dementia and severe cognitive impairment was receiving Risperidone for dementia without behavioral disturbance. After a pharmacy review questioned the indication, an ARNP changed the medication order to bipolar disorder without performing a mental health evaluation, and the resident’s diagnosis list was not updated. The record also showed no monitoring for behaviors related to bipolar disorder, and the DON stated the standard of practice was not followed.
A resident admitted with cellulitis, muscle weakness, and difficulty walking did not receive a physician-ordered PT eval and tx in a timely manner. The resident’s initial PT eval and tx plan was completed five days after admission, rather than within the facility’s expected 24 to 48 hours. Staff stated the delay occurred because the facility did not have enough therapists at the time.
Failure to document or provide influenza immunization for one resident. A cognitively intact resident with anxiety, depression, and necrotizing fasciitis had no record of flu vaccine consent, refusal, administration, or education. Staff stated the resident was not offered the vaccine on admission because admission occurred outside flu season, and they were unsure why the resident was not offered it later when other residents were approached for consents.
Pest Control Program Failed to Address Flies in Resident Room: A resident with hemiplegia, aphasia, and moderate cognitive impairment was observed in a room where flies were repeatedly present, including flies landing on the resident and surrounding items. Staff interviews showed the issue had been present for months, but reports were not consistently recognized or followed up, and a fly swatter was left in the room.
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 Proper PPE Use and Isolation Practices for RSV Contact/Droplet Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to management of Respiratory Syncytial Virus (RSV) under contact and droplet precautions. CDC guidance and facility policies required appropriate PPE use, including gowns, gloves, masks, and eye protection, as well as universal masking and single-use disposal of certain PPE such as Arlington Scientific face shields. During a tour, surveyors observed PPE carts on two halls with written instructions directing staff to use one face shield per shift and to reuse the same shield in two or more RSV-positive rooms, despite manufacturer instructions that the face shields were single-use and should be disposed of after use. Multiple face shields were seen hanging from a PPE cart, including one labeled with a staff member’s name, and another shield lying on top of the cart, indicating reuse. Surveyors observed specific staff interactions with residents on contact/droplet precautions that did not comply with required infection control measures. One NA (Staff B) delivered meal trays to a room under contact and droplet precautions while wearing only a face mask and gown, without gloves or eye protection, and rearranged items on a bedside table and set up a meal. After removing the gown and performing hand hygiene at the doorway, Staff B then re-entered the same room to deliver a second meal tray without donning a gown, gloves, or eye protection and did not change their face mask between residents. In an interview, Staff B stated that their usual process for isolation rooms included gown, gloves, and goggles, but they did not wear gloves when passing meal trays because they were handling food and beverages, and they acknowledged they should have donned a gown before taking the second tray. Staff B also reported that the face shields hanging on the PPE cart were intended for staff reuse and that their goggles were reused by placing them on top of their head. Another NA (Staff D) was observed donning a gown, gloves, eye protection, and face mask before entering a contact/droplet precaution room to deliver a meal tray. After providing meal setup and exiting the room, Staff D, still wearing the same PPE, accepted another meal tray and opened the door to a neighboring contact/droplet precaution room using the same soiled gloves, then delivered the tray. Staff D removed their gown and gloves after leaving the second room, pushed their goggles to the top of their head, performed hand hygiene, and did not change their face mask. In an interview, Staff D stated they should have removed the gown after leaving the first room and put on a clean gown before entering the second room, and acknowledged that going from room to room without changing PPE could spread germs. The Infection Preventionist (Staff E) described the expected process for entering and exiting contact/droplet precaution rooms, including full PPE and changing masks upon exit, but reported that goggles were single use, the facility had run out of them, and they were reusing limited face shields without realizing they were single-use. The DON (Staff A) confirmed that face shields were not reusable and that staff did not follow the facility’s infection control and PPE use processes. This deficiency was cited as a repeat from a prior survey.
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.
PASARR screenings and Level II referrals were not completed or tracked for residents with positive SMI findings
Penalty
Summary
The facility failed to ensure PASARR screenings for residents with serious mental illness or intellectual/developmental disabilities were accurately completed before admission and updated when new SMIs were identified, and failed to ensure required Level II referrals were completed for residents with positive Level I PASARR findings. Review of the facility policy showed applicants were to have a Level I PASARR prior to admission, with a Level II evaluation required when the Level I identified SMI/ID/DD, including when such conditions were diagnosed after admission. Resident 9 was admitted with anxiety and major depressive disorder, and the comprehensive assessment showed impaired cognition, depression, and an anxiety disorder. The PASARR dated 08/15/2025 showed no SMI and no Level II evaluation required. Resident 43 was admitted with anxiety and depression, and the assessment showed intact cognition, depression, and an anxiety disorder. The PASARR dated 05/06/2025 showed a positive SMI for a mood disorder, but it was marked exempt from Level II due to a physician certification for less than a 30-day stay, and no Level II evaluation had been completed as of 11/19/2025. Resident 78 was admitted with bipolar disorder, anxiety, and depression, and the PASARR dated 07/24/2024 showed a positive SMI for a mood disorder and anxiety disorder, but no Level II evaluation was required. Resident 31 was admitted with dementia, affective disorder, restlessness, and agitation, and the assessment showed severe cognitive impairment and dependence for multiple ADLs. The PASARR Level I dated 09/09/2025 showed a positive screening for SMI due to affective disorder requiring Level II, but the form was marked no Level II indicated and no completed Level II was documented. Resident 6 was admitted with anxiety, bipolar disorder, and Fragile X Chromosome, and the assessment showed moderately impaired cognition and substantial assistance needs for toileting transfers and dressing. Two PASARR Level I reviews showed positive SMI screenings for bipolar and anxiety disorders requiring Level II, but no Level II evaluation was documented. Resident 58 was admitted with anxiety and depression, was cognitively intact, and had a PASARR Level I review showing positive SMI screening for mood and anxiety disorders requiring Level II, with no Level II documentation. Staff stated there was no formal tracking system for PASARR forms, that PASARR information was only documented in a chart note and reviewed annually, and that there had been a breakdown in the Level II referral process.
Resident Room Had Flies and Dirty Wheelchair
Penalty
Summary
The facility failed to promote a dignified living experience for one resident who had right-sided hemiplegia, aphasia, bipolar disorder, and needed assistance with grooming, dressing, toileting, transfers, and mobility. The resident’s comprehensive assessment showed moderate cognitive impairment. Facility policy required all wheelchairs to be cleaned and inspected for proper operation at least quarterly, but the resident’s wheelchair was observed to be dirty with dried white, yellow, and brown particles on the frame, wheels, foot pedals, and brakes, and staff could not determine when it had last been washed. During observations, multiple flies were seen in the resident’s room on several occasions, including flies hovering near the resident, landing on the resident’s leg, overbed table, and wheelchair armrest. The resident stated there were flies in the room often, had used a fly swatter, and said the dirty wheelchair had not been washed recently and that it bothered them to have a dirty wheelchair and flies in the room. Staff interviews indicated flies had been present in the room for months, the resident dropped food at times when eating in the room, and the night shift staff were responsible for washing wheelchairs but were not following the wheelchair washing schedule. The maintenance director also recalled being told about flies in the room previously and giving the resident a fly swatter, but did not return to check whether the flies were gone.
Psychotropic meds not monitored with individualized targeted behaviors
Penalty
Summary
The facility failed to ensure psychotropic medications were monitored for effectiveness using individualized, resident-specific targeted behaviors for three residents reviewed for unnecessary medications. The deficiency involved Resident 9, Resident 43, and Resident 31, whose records showed psychotropic medication use but whose monitoring documentation used generic behaviors rather than behaviors tied to each resident’s diagnosis, symptoms, or intended therapeutic effect. The report cited WAC 388-97-1060(3)(k)(i) and stated the failure placed residents at an increased risk for experiencing medication-related adverse side effects and unmet care needs. Resident 9 was admitted with diagnoses including anxiety and major depressive disorder, and the assessment showed impaired cognition, depression, and an anxiety disorder. During an observation and interview, Resident 9 was lying in bed watching television and stated they were sad at times related to vision problems, needed people to talk to when feeling down, and wanted staff to call family because family made them happy. The MARs showed an order for sertraline for major depressive disorder, and the care plan addressed mood problems and risk for self-harm, but the MARs only showed monitoring for loss of interest and did not identify or monitor individualized targeted behaviors for the medication. Resident 43 was admitted with anxiety and depression, and the assessment showed intact cognition, depression, and an anxiety disorder. During observation and interview, Resident 43 was lying in bed eating a snack and watching television and stated they were depressed and sad at times, liked to go outside, feel fresh air, and call their children, and said those things helped when they were in the pits. The MARs showed bupropion for depression, and the care plan addressed mood problems and risk for self-harm, but the MARs only showed monitoring for withdraw and did not identify or monitor individualized targeted behaviors. Resident 31 was admitted with dementia, affective disorder, restlessness, and agitation, and the assessment showed severe cognitive impairment and need for assistance with grooming, dressing, incontinent care, bathing, and mobility. Physician orders showed sertraline for depression and risperidone for bipolar disorder, but the MARs monitored restless and withdraw, and the care plan listed antipsychotic use related to dementia with monitoring for behaviors and side effects without specific individualized behaviors.
New mental health diagnosis added without evaluation
Penalty
Summary
The facility failed to follow professional standards of practice when it added a new mental health diagnosis for Resident 31 without a documented mental health evaluation. Resident 31 was admitted with diagnoses of dementia and affective disorder and was receiving Risperidone 1 mg twice daily for dementia without behavioral disturbance. The comprehensive assessment showed severe cognitive impairment and dependence on staff for grooming, dressing, incontinent care, bathing, and mobility. Provider progress notes from the admission period showed the resident was evaluated to establish care and review medications, but there were no changes to the medication regimen or diagnosis list. A pharmacist consultation report in October 2025 recommended clarifying the indication for Risperidone because the listed diagnosis of dementia without behavioral disturbance was not appropriate. Staff L, ARNP, wrote bipolar on the report and initialed it, and a physician order was then entered for Risperidone 1 mg twice daily for bipolar disorder. However, the resident’s diagnosis list was not updated, and the medical record later showed no monitoring for behaviors related to bipolar disorder. During interview, Staff L stated they had not evaluated Resident 31 specifically for mental health before adding bipolar disorder, and Staff B, DON, stated the standard of practice was to obtain a mental health evaluation before adding a new mental health diagnosis, which did not occur for Resident 31.
Delayed PT Evaluation and Treatment Order
Penalty
Summary
The facility failed to ensure a physician-ordered PT evaluation and treatment were provided in a timely manner for Resident 34. Resident 34 was admitted with diagnoses including cellulitis of the right lower leg, muscle weakness, and difficulty walking. The comprehensive assessment dated 10/08/2025 showed the resident required moderate to maximum assistance from one staff member for activities of daily living and had moderately impaired cognition. A physician order dated 09/12/2025 directed PT evaluation and treatment, but the resident did not receive the initial PT evaluation and treatment plan until 09/17/2025, five days after admission to the facility. During interviews, the Director of Rehab Services stated the evaluation was completed on 09/17/2025 and that there were not enough staff at the time of admission to complete new admission evaluations. The Director of Nursing Services stated the facility expectation was for PT evaluations to be completed within 48 hours of admission, unless the resident was admitted on Friday, in which case the evaluation would be completed the following Monday. The Administrator also stated PT evaluations should be completed within 24 to 48 hours of admission and that completing a PT evaluation five days after a new admission was not acceptable.
Failure to Document or Provide Influenza Immunization
Penalty
Summary
The facility failed to offer and/or provide an influenza immunization for 1 of 5 residents reviewed for immunizations and infection control. The resident was admitted with diagnoses including anxiety, depression, and necrotizing fasciitis, and the comprehensive assessment showed the resident was cognitively intact and required assistance from one to two staff members for activities of daily living, including setup assistance for eating and oral hygiene. The facility policy stated residents were to be offered influenza immunization between October 1 and March 31 each year unless medically contraindicated or already immunized during that period, and the medical record was to include documentation of education, receipt, or refusal. Review of the resident’s medical record showed no documentation of consent or refusal for the annual influenza immunization, no record that the immunization had been administered, and no documentation that education had been provided. The Infection Preventionist stated the resident was not offered the immunization upon admission because the resident was admitted in July and was unsure why the resident was not offered it in September when all residents were offered it. The DON stated the immunization was offered to all residents on admission and during respiratory season, that consents were obtained from all LTC residents prior to the start of influenza season, and that the resident was missed because they were in and out of the hospital when consents were obtained.
Pest Control Program Failed to Address Flies in Resident Room
Penalty
Summary
The facility failed to maintain an effective pest control program to prevent or address flies in resident areas. Review of the facility policy showed the pest control program was to provide frequent treatments, staff were to monitor the environment for potential concerns, and pest control problems were to be reported promptly to the Director of Maintenance. However, survey observations found flies in Resident 73's room on multiple occasions, including two flies near the resident's feet and on the windowsill, and later four flies flying around the resident and landing on the resident's right leg, overbed table, and wheelchair. A fly swatter and a dead fly were also observed on the resident's overbed table. Resident 73 was admitted with right-sided hemiplegia and aphasia and, on the comprehensive assessment, was documented to have moderate cognitive impairment and to require assistance from one to two staff members for grooming, dressing, toileting, transfers, and mobility. During interviews, the contracted pest control vendor stated they had not received complaints about flies, Staff I stated they were not aware of flies in resident rooms, and Staff J stated Resident 73's room had flies since July 2025. The Administrator stated they were surprised to learn the resident had been dealing with flies for that length of time, and the Maintenance Director stated they were aware of flies in the room in about September and had likely given the resident a fly swatter, but had not followed up to determine whether the flies were gone.
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.
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Illustrative
What surveyors actually found near you
We read the 22 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Kennewick
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Regency Canyon Lakes Rehab And Nursing Center | 1.6 mi | ★★★★★ | 0 | 0 |
| Avalon Health & Rehabilitation Center - Pasco | 3.2 mi | ★★★★★ | 12 | 0 |
| Life Care Center Of Richland | 7.8 mi | ★★★★★ | 10 | 0 |
| Richland Post Acute | 9.5 mi | ★★★★★ | 0 | 0 |
| Regency Hermiston Nursing & Rehab Center | 26.5 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.