Life Care Center Of Kirkland
Inspection history, citations, penalties and survey trends for this long-term care facility in Kirkland, Washington.
- Location
- 10101 Northeast 120th Street, Kirkland, Washington 98034
- CMS Provider Number
- 505334
- Inspections on file
- 32
- Latest survey
- March 23, 2026
- Citations (last 12 mo.)
- 30
Citation history
Health deficiencies cited at Life Care Center Of Kirkland during CMS and state inspections, most recent first.
A resident reported via a grievance that they remained in a wet brief for most of the day until late afternoon, and this concern was logged by the facility as alleged neglect. The resident later stated they had requested incontinence care multiple times and that a CNA said she was busy and needed to take a break before eventually apologizing. Despite facility policy and the Purple Book guidelines requiring that all alleged neglect be reported to proper authorities, the Assistant DON did not report the allegation to the State Agency, citing perceived inconsistencies between the written grievance and the resident’s follow-up statement and an undocumented belief that the resident was seen during routine rounds. The DON and Executive Director later acknowledged that the allegation met criteria for reporting and should have been reported.
A resident did not receive appropriate care for existing pressure ulcers, and the facility did not take adequate steps to prevent new ulcers from developing, as observed and documented by surveyors.
A resident with moderately impaired cognition reported missing money, and while the facility initiated an investigation and took immediate actions such as contacting police and searching the room, they failed to interview staff and other residents as required by policy. Multiple staff confirmed they were not interviewed, and facility leadership acknowledged the investigation was incomplete.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
The facility did not provide written summaries of baseline care plans to several residents or their representatives, as required by policy. Staff interviews and record reviews confirmed the absence of documentation or signatures indicating that these care plans were given or discussed, resulting in unmet procedural requirements for new admissions.
Staff did not use N95 masks correctly or receive timely fit-testing, with several staff wearing masks improperly and lacking training. Additionally, Enhanced Barrier Precautions were not followed for a resident with a PICC and wounds, as staff failed to use required PPE during high-contact care and no signage or PPE cart was present. Leadership confirmed these lapses occurred despite facility policies and recent infection outbreaks.
A resident with dementia and muscle weakness, dependent on staff for toileting, did not consistently receive or have documented assistance with toileting as required by their care plan. Staff interviews and chart reviews revealed multiple shifts where toileting care was either not provided or not documented, and the resident's representative reported inadequate care during one shift.
A facility failed to ensure a resident-centered discharge plan was in place, as required by their policy. The discharge planning process, which should begin upon admission, was not properly documented for a resident. The baseline care plan lacked a marked discharge plan, and the Initial Discharge Planning Evaluation form was left blank. Staff interviews confirmed that the discharge process was not adequately initiated, placing the resident at risk for unmet care needs.
A resident with intact cognition reported feeling neglected after not being changed for several hours, resulting in a soiled state. The incident was not reported to the State Agency within the required timeframe due to miscommunication among staff, placing the resident at risk for ongoing neglect.
A resident in an LTC facility reported neglect after being left unchanged for an extended period, resulting in them being soaked in urine and having a BM. The facility's investigation was incomplete, lacking statements from key staff and failing to remove the RN involved from duties, contrary to policy. Inconsistencies in staff accounts and missing documentation further compromised the investigation.
A resident with severe cognitive impairment and a history of elopement exited an LTC facility unnoticed, likely with a visitor, as alarms did not activate. Despite being identified as at risk, the resident's care plan interventions were insufficient, leading to the resident being found by police outside the facility.
The facility failed to develop comprehensive care plans for five residents, leading to unmet care needs. A resident with nutritional concerns and a pressure ulcer lacked appropriate care plans. Another resident using CPAP therapy did not have a care plan for its use. A resident on antiplatelet medication lacked monitoring for bleeding risks. A resident with communication difficulties had a care plan that was not effectively implemented. Lastly, a resident using oxygen therapy did not have a care plan for its use.
The facility failed to properly label and store medications, as observed in two medication carts. An opened insulin pen was found unlabeled in a plastic bag with a resident's name, and another cart contained an unlabeled insulin pen, expired heparin syringes, and an unlabeled nasal spray. Staff acknowledged these issues, highlighting lapses in medication labeling and storage practices, which placed residents at risk.
The facility failed to maintain food safety standards in the kitchen and Baker Dining Room. Unlabeled food items were found in storage, and staff did not perform hand hygiene between glove changes. Additionally, a CNA assisted a resident with their meal using bare hands, contrary to expected practices. The Dietary Manager, Infection Preventionist, and Executive Director acknowledged these lapses.
A resident with aphasia and dementia was found without an accessible call light, despite being dependent on staff for daily activities. Observations showed the call light was not within reach, and staff were unable to locate it. The resident was observed calling out for help without response from staff, highlighting a failure to ensure the call light was properly positioned.
A resident with moderately impaired cognition alleged that a staff member was stealing their medication and attempting to poison them. Despite the resident's report to the police and a handwritten statement given to facility staff, the allegations were not reported to the State Agency as required by the facility's policy. Several staff members were aware of the allegations, but they were not logged in the incident reporting log, indicating a failure in the facility's reporting procedures.
A resident with moderate cognitive impairment alleged that a nurse was stealing their medication and attempting to poison them. Despite the resident providing a written statement and reporting the incident to staff, no investigation was conducted. Interviews revealed that key staff members were either unaware of the allegations or failed to act, violating facility policy and state regulations.
A facility failed to provide a written transfer/discharge notice to a resident and their representative, as required by policy. The resident was hospitalized, but there was no documentation of the notice in their electronic health record. Interviews with staff revealed that the usual procedure was not followed, and the notice was not mailed as intended.
A resident experienced significant health changes, including a 6.83% weight loss and a new facility-acquired DTI, but the facility failed to complete the required SCSA MDS. The MDS Coordinator and DON acknowledged the oversight, which placed the resident at risk for delayed care planning.
A facility failed to complete a quarterly MDS assessment on time for a resident, as required by the RAI manual. The assessment, due within 14 days of the ARD, was completed 10 days late. The MDS Coordinator acknowledged the delay, and the DON confirmed the expectation for timely completion. This placed the resident at risk for delayed care needs.
The facility failed to accurately assess four residents using the MDS tool, leading to incorrect documentation of behavior changes, continence status, discharge status, and insulin administration. These inaccuracies were confirmed by staff during interviews and record reviews.
A facility failed to conduct a proper PASRR Level I and did not refer a resident with anxiety and depression for a Level II evaluation. The resident, who was admitted with generalized anxiety disorder, experienced a significant change in condition, but the necessary screenings and referrals were not completed, as confirmed by staff interviews.
The facility failed to clarify a physician's order for a resident with a feeding tube, leading to incorrect medication administration. Another resident's medication was signed off before administration, contrary to policy. Additionally, insulin injection sites were not documented for a resident with diabetes, violating best practices.
A resident with severe cognitive impairment and muscle weakness did not receive scheduled bathing and personal hygiene care as per their care plan. Observations showed the resident had long, untrimmed fingernails with debris, and documentation revealed missed bathing sessions without records of refusal. Staff interviews confirmed lapses in care and documentation, with the DON emphasizing the need for adherence to care plans.
A facility failed to manage enteral tube feeding properly for a resident with dysphagia and gastrostomy status, who relied on tube feeding for over 51% of their nutritional intake. Observations revealed multiple opened and undated syringes at the resident's bedside, contrary to the facility's policy of daily syringe changes and dating. Staff interviews confirmed the protocol was not followed, placing the resident at risk for infection.
A resident with anxiety, depression, and opioid dependence experienced a decline in cognition and behavior, yet the facility failed to conduct a social services assessment or provide necessary behavioral health services. Despite documented behavioral episodes and observations of the resident's distress, staff interviews revealed a lack of awareness and action regarding the need for psychological consultation or counseling.
The facility exceeded the acceptable medication error rate, reaching 6.45%, due to incorrect administration of medications to two residents. One resident received enteric-coated aspirin instead of chewable, and another received levothyroxine via g-tube instead of orally. Staff acknowledged the errors and the importance of following the correct medication orders.
The facility failed to follow Enhanced Barrier Precautions and proper hand hygiene practices, placing residents at risk. A resident with a feeding tube did not receive care with the required PPE, and staff did not consistently perform hand hygiene or use gloves correctly. These deficiencies were confirmed by staff interviews and observations.
The facility failed to maintain residents' dignity by not covering urinary catheter drainage bags for three residents. The bags were visible from the hallway and to visitors, and staff provided inconsistent information about the need for privacy covers.
A resident with moderately impaired cognition reported that a large man grabbed and squeezed their arm, causing a significant skin tear. Despite the facility's policy requiring such incidents to be reported, the Director of Nursing Services did not report the incident to the State Agency or law enforcement. The resident's representative and staff members attempted to follow up, but the incident remained unreported.
A resident with moderately impaired cognition reported being grabbed and squeezed by a large man, resulting in a skin tear. The facility failed to thoroughly investigate the allegation, did not interview relevant staff or the resident's representative, and did not report the incident to the state. The DNS did not consider the incident as abuse and did not conduct staff training on proper transfer techniques.
The facility failed to ensure proper skin care and treatments for three residents, resulting in undocumented and untreated skin tears. Staff did not follow protocols for notifying providers, completing thorough skin assessments, and obtaining treatment orders.
The facility failed to ensure urinary catheters were positioned off the floor for two residents, placing them at risk for infections. Staff confirmed that the drainage bags should be hooked on the bed frame, as per the facility's policy.
The facility failed to designate a qualified Infection Preventionist (IP) to oversee the infection prevention and control program. During a COVID-19 outbreak, 42 residents and 17 staff tested positive. The Executive Director confirmed that the interim IP was not certified, and the certified staff member was not acting as the IP. Infection control responsibilities were managed as a team effort.
The facility failed to ensure proper hand hygiene, disinfection of medical equipment, and appropriate use and disposal of PPE. Staff members were observed not following protocols, including not performing hand hygiene, not disinfecting vital sign equipment, and not changing N95 masks or disinfecting face shields after exiting COVID-19 isolation rooms. Additionally, 13 out of 18 staff members were not fit tested for N95 masks.
A facility failed to provide adequate nutritional care for a resident, resulting in significant weight loss. Despite policies for weekly reviews, the resident's weight loss was not discussed, and no nutritional supplements were ordered. The weight loss was not communicated to the medical provider, the resident, or their representative.
Failure to Report Alleged Neglect to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of neglect to the State Agency within the required timeframe. A grievance form dated 02/01/2026 documented that Resident 1 reported being left in a wet brief from morning until approximately 5:00 PM, and the February 2026 incident log recorded this concern as alleged neglect. The facility’s own policy on Abuse, Neglect and Exploitation required that all alleged violations of mistreatment, exploitation, neglect, or abuse, including injuries of unknown origin and misappropriation of resident property, be reported to proper authorities within prescribed timeframes, and the Nursing Home Guidelines (Purple Book) defined neglect as a pattern of conduct or inaction, or an act or omission, that fails to maintain a vulnerable adult’s physical or mental health or avoid harm. Resident 1 later stated in an interview that on weekends there were fewer staff members, that they needed to be changed, and that the CNA did not come the whole day despite being asked a couple of times; the resident reported that the CNA said she was busy and needed to take her break and later apologized. Staff C, the Assistant DON, acknowledged receiving the grievance, speaking with the resident, and documenting the incident as alleged neglect in the incident log, but did not report the allegation to the State Agency, citing inconsistency between the grievance form and the resident’s follow-up statement and the belief that the resident had been seen during a 2:30 PM round, for which there was no documentation. Staff B, the DON, and Staff A, the Executive Director, both stated that the allegation of neglect should have been reported to the State Agency, confirming that the required reporting did not occur.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that necessary interventions to manage existing pressure ulcers and prevent additional ones were not consistently carried out for affected residents.
Failure to Conduct Thorough Investigation of Missing Resident Property
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of missing money for one resident with moderately impaired cognition. According to the investigation report, a collateral contact reported that $1,000 was missing from the resident's wallet, which had not been checked for three months. Immediate actions taken included initiating an investigation, contacting the police, searching the resident's room, reviewing the belongings list, and reporting the incident to the state agency. However, the investigation report did not include interviews with other residents or staff members who may have had information about the incident. Multiple staff members, including certified nursing assistants and registered nurses who were assigned to the resident, confirmed in interviews that they were not interviewed regarding the missing money. The Assistant Director of Nursing acknowledged that, although the facility's policy and the Purple Book guidelines require thorough investigations—including interviews with staff and residents—these steps were not documented or completed. The Director of Nursing also confirmed that the investigation lacked evidence of such interviews, indicating the investigation was not thorough as required by facility policy and regulatory guidelines.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Provide Written Baseline Care Plan Summaries to Residents and Representatives
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan to residents and/or their representatives for four residents reviewed. Record reviews for each resident showed no evidence that a written summary of the baseline care plan was given or documented as received by the resident or their representative. Interviews with staff, including the Assistant Director of Nursing, Director of Nursing, Interim Executive Director, and Social Services Director, confirmed that there was no documentation or signatures indicating that the baseline care plans had been provided or discussed with the residents or their representatives. The facility's policy required staff to review the baseline care plan and physician orders with the resident or representative, provide copies, and obtain signatures, but these steps were not documented as completed for the residents in question. Collateral contacts and residents interviewed did not recall receiving a written summary of the baseline care plan. Nursing progress notes and assessments for each resident lacked evidence of the required documentation. Staff acknowledged the importance of the baseline care plan in informing both staff and residents or representatives about the care to be provided, but confirmed that the process was not followed or documented for the affected residents.
Failure to Ensure Proper N95 Mask Use, Fit-Testing, and Enhanced Barrier Precautions
Penalty
Summary
Staff failed to use N95 masks correctly and did not receive timely fit-testing, as observed with four staff members. Staff were seen wearing N95 masks with both straps below the ears, with twisted straps, or with only one strap, and some staff reported not being trained on proper mask application. Two staff members, including an agency occupational therapist and a physical therapy intern, confirmed they had not been fit-tested at the facility before using N95 masks, despite working directly with residents. The facility's own policy required fit-testing before use and annually, but this was not followed for these staff. Additionally, the facility did not ensure Enhanced Barrier Precautions (EBP) were followed for a resident with a peripherally inserted central catheter (PICC) and wounds. There was no EBP signage or PPE cart outside the resident's room, and a certified nursing assistant assisted the resident with a transfer without wearing a gown and gloves, resulting in direct contact between the staff's clothing and the resident's gown. The staff member later acknowledged missing the requirement to use PPE for this resident, and the order for EBP had been in place for several days prior to the observation. Interviews with facility leadership confirmed that the expected practices were not followed. The infection preventionist and director of nursing both stated that staff should be fit-tested before using N95 masks and that EBP signage and PPE should be present and used for residents requiring these precautions. The failures were identified during a period when the facility had recently experienced a COVID-19 outbreak affecting residents and staff.
Failure to Provide and Document Required Toileting Assistance
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADL), specifically toileting, for one resident who was dependent on staff for this care. The resident had diagnoses including dementia, muscle weakness, and required assistance with personal care. According to the resident's care plan and assessment, the resident was frequently incontinent of urine and dependent on staff for toileting hygiene and transfers. Documentation from the electronic charting system showed that toileting assistance was either not provided or not documented on multiple shifts over a one-week period. In several instances, the activity was marked as 'did not occur,' and on other shifts, there was no documentation of toileting assistance at all. Interviews with staff, including a CNA, Unit Care Coordinator, and DON, confirmed that the expectation was for residents to be offered toileting assistance at least every two hours and for this care to be documented at least once per shift. Staff acknowledged that documentation of 'activity did not occur' meant the care was not provided, and there was no evidence that the required assistance was given or properly documented on the specified dates. The resident's representative also reported an incident where the resident was changed only once in an eight-hour period, resulting in urine soaking through their briefs.
Failure to Initiate Resident-Centered Discharge Plan
Penalty
Summary
The facility failed to ensure a resident-centered discharge plan was in place for a resident reviewed for discharge planning. The facility's policy required that the discharge planning process begin upon or shortly after admission, with Social Services or Care Management associates completing the initial discharge plan evaluation form within 48 hours of admission. However, for the resident in question, the baseline care plan did not have the discharge plan marked, and the Initial Discharge Planning Evaluation form was left blank. Interviews with various staff members, including LPNs, Social Services, and the Assistant Director of Nursing, revealed that while the discharge process was supposed to start at admission, the necessary documentation was not completed for the resident. Staff D, responsible for filling out the initial discharge planning evaluation, admitted to not completing the form, acknowledging it was opened but not filled out. This oversight placed the resident at risk for unmet care needs and a diminished quality of life, as the discharge planning process was not properly initiated or documented.
Failure to Timely Report Allegation of Neglect
Penalty
Summary
The facility failed to report an allegation of neglect involving a resident in a timely manner to the State Agency. The resident, who had intact cognition, was admitted to the facility and reported feeling neglected after not being changed for an extended period. The incident occurred when the resident was left unchanged from 8:30 AM to 2:30 PM, resulting in the resident being found in a soiled state by a visitor. The visitor reported the situation to a registered nurse, but the nurse did not report it as an allegation of neglect, believing it did not sound like one. Other staff members, including a CNA, were aware of the situation but assumed it would be handled by the nurse they informed. The facility's policy required that allegations of neglect be reported within 24 hours if they did not result in serious bodily injury. However, the incident was not logged until several days later, and the staff involved did not report the situation to the State Agency within the required timeframe. The Executive Director confirmed that the staff should have reported the allegation within two hours, but the delay in reporting was due to a lack of communication among the staff members. This failure to report the incident promptly placed the resident at risk for potential ongoing neglect.
Failure to Investigate Allegation of Neglect
Penalty
Summary
The facility failed to thoroughly investigate an allegation of neglect involving a resident who was cognitively intact. The incident was reported on October 12, 2024, when the resident was found to have not been changed for an extended period, resulting in them being soaked in urine and having a bowel movement (BM). The investigation lacked statements from key staff members involved in the incident, including the Certified Nursing Assistant (CNA) who changed and showered the resident after the neglect was reported. Additionally, the Registered Nurse (RN) who continued to work with the resident after the allegation was not removed from their duties, contrary to the facility's policy. The facility's policy on abuse and neglect investigations requires prompt and thorough investigation, including interviews with all relevant parties and the removal of the alleged perpetrator from resident care areas. However, the investigation into this incident did not include statements from the staff who first responded to the situation or those who assisted with the resident's shower. Furthermore, the RN involved continued to work with the resident for several days following the report of neglect, which was against the policy that mandates suspension of the accused staff pending investigation. Interviews with staff revealed inconsistencies in the care provided to the resident. Staff D reported that the resident was visibly upset and had not been changed since the morning, while Staff E claimed the resident was checked on multiple times and did not report being wet. The Executive Director acknowledged the lack of documentation regarding regular checks on the resident and the omission of critical details in the investigation. This failure to conduct a comprehensive investigation placed the resident at risk for further neglect and compromised their quality of life.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision for a resident at risk for elopement, resulting in the resident leaving the facility unnoticed. The resident, who had severe cognitive impairment due to dementia, was known to wander and had a history of attempting to leave the facility. Despite being identified as at risk for elopement, the resident managed to exit the facility without triggering alarms, suggesting they left with a visitor. This incident occurred on September 10, 2024, when the resident was last seen by staff at 6:00 PM and was later found by police at 6:48 PM outside the facility. The resident's care plan, initiated in April 2023, acknowledged their tendency to wander and included goals to prevent them from leaving the facility unattended. However, the care plan interventions, such as offering walks, providing frequent safety checks, and reducing noise, were insufficient to prevent the elopement. On the day of the incident, the facility's reporting log indicated that the resident was exit-seeking multiple times, yet they were still able to leave the premises unnoticed. Interviews with facility staff, including the Director of Nursing and the Executive Director, confirmed the resident's risk for elopement and acknowledged the failure to prevent the resident from leaving unsupervised. The staff concluded that the resident likely exited with a visitor, as the alarms did not activate. Signage was placed on exit doors to remind visitors and staff to ensure residents do not leave with them, but this measure was not effective in preventing the incident.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for five residents, leading to unmet care needs and potential complications. Resident 9 was admitted with nutritional concerns and developed a pressure ulcer, yet their care plan lacked provisions for both nutrition and wound care. Despite being identified as at risk for nutritional issues, no care plan was initiated, and the pressure ulcer was not addressed in the care plan, as confirmed by multiple staff members. Resident 65, who required CPAP therapy for obstructive sleep apnea, did not have a care plan for CPAP use, despite using the device nightly. Staff interviews revealed an expectation for a care plan to be in place, but it was not documented. Similarly, Resident 68, who was on antiplatelet medication, lacked a care plan for monitoring bleeding risks, even though a pharmacy consultation recommended such monitoring. Resident 3, with communication difficulties due to aphasia and dementia, had a care plan that included using interpretation services and communication tools, but these were not effectively implemented. Staff were observed not utilizing available resources, and interpretation service information was not accessible in the resident's room. Lastly, Resident 54, who used oxygen therapy, did not have a care plan for its use, despite having the necessary equipment and a physician's order. Staff interviews confirmed the absence of a care plan for oxygen therapy.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to properly label and store medications and biologicals, as observed in two medication carts. During an inspection of the Cascade medication cart, an opened insulin lispro pen was found without a resident's name label, although it was placed in a plastic bag labeled with Resident 68's name. Staff FF, a Registered Nurse, acknowledged that the insulin pen should have been labeled with the resident's name. Similarly, the [NAME] medication cart contained an opened insulin lispro pen without a resident's name, two expired heparin syringes, and an unlabeled opened saline nasal spray. Staff L, another Registered Nurse, confirmed that the insulin pen should have been labeled and discarded, and acknowledged the expired heparin syringes and the infection risk posed by the unlabeled nasal spray. Interviews with facility staff, including the Licensed Practical Nurse Unit Care Coordinator and the Director of Nursing, revealed that there was an expectation for opened insulin pens to be labeled with residents' names and for expired medications to be removed from medication carts. The Director of Nursing also stated that nasal sprays should not be used for multiple residents and should be labeled with a resident's name if opened. These lapses in medication labeling and storage practices placed residents at risk of receiving compromised, incorrect, or ineffective medications.
Food Safety and Hygiene Deficiencies in Kitchen and Dining Room
Penalty
Summary
The facility failed to adhere to professional standards of food safety, as observed in both the kitchen and the Baker Dining Room. In the kitchen's dry storage room, five unlabeled bags of vanilla wafers were found in a bin labeled for Cheerios, and in the walk-in refrigerator, three trays of banana pudding were stored without labels or dates. Staff C, the Dietary Manager, acknowledged that these items should have been labeled with the name and date received, and expected food items to be labeled and dated. In terms of hand hygiene, Staff I, a cook, was observed not performing hand hygiene between glove changes while handling food and cleaning containers. Similarly, Staff J, another cook, did not perform hand hygiene between glove changes while preparing residents' lunch trays. Both staff members acknowledged that they should have performed hand hygiene after removing used gloves, and Staff C confirmed the expectation for staff to perform hand hygiene between glove use. In the Baker Dining Room, Staff K, a Restorative Certified Nursing Assistant, was seen assisting a resident with their meal by touching the resident's bread with bare hands, despite acknowledging that they were not supposed to do so. Staff K stated they had washed their hands before assisting the resident, but the Infection Preventionist and the Director of Nursing both stated that staff should use utensils or gloves when touching residents' food. The Executive Director also confirmed that staff should not touch residents' food with bare hands and that food items should be labeled correctly.
Resident's Call Light Not Accessible
Penalty
Summary
The facility failed to ensure that a call light was within reach for a resident, identified as Resident 3, which placed the resident at risk for delayed care and diminished quality of life. Resident 3, who was readmitted to the facility with diagnoses including aphasia, vascular dementia with psychotic disturbance, and unsteadiness on feet, was dependent on staff assistance for various activities of daily living. The resident's care plan indicated the need for a soft touch call light to be within reach, yet observations on multiple occasions revealed that the call light was not visible or accessible to the resident. Staff members, including the Activities Director and Registered Nurse Unit Care Coordinator, were unable to locate the call light, and it was noted that maintenance was in the process of obtaining a new one. Further observations showed that even after attempts to address the issue, the call light remained out of reach, clipped to the wrong side of the bed, and the resident was observed calling out for help without response from passing staff. Interviews with staff, including the Director of Nursing, confirmed awareness of the issue and the expectation that residents should have a call light or a soft touch call light if unable to use a standard one. Despite this, the resident continued to be without a properly positioned call light, as evidenced by multiple observations and staff interviews.
Failure to Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to report suspected allegations of abuse and/or neglect to the State Agency for one resident, which placed residents at risk for potential unidentified and ongoing abuse/neglect. The facility's policy requires reporting alleged violations related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown sources and misappropriation of resident property, to the proper authorities within a prescribed time frame. However, the facility did not adhere to this policy in the case of a resident who alleged that a staff member was stealing their medication and attempting to poison them. The resident, who had moderately impaired cognition, reported these allegations to the police and provided a handwritten statement to the facility staff. Despite the resident's report and the awareness of several staff members, including the Activities Director and the Director of Social Services, the allegations were not logged in the facility's incident reporting log for the relevant months, nor were they reported to the State Agency. The Executive Director and the Director of Nursing were unaware of the allegations, indicating a breakdown in communication and reporting procedures within the facility.
Failure to Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse and/or neglect for a resident, which placed the resident at risk for unidentified abuse and/or neglect. The resident, who was moderately cognitively impaired, reported that a registered nurse was stealing their medication and attempting to poison them. The resident provided a handwritten statement detailing these allegations, which was given to the Activities Director and subsequently reported to the Executive Director. Despite these reports, no investigation was conducted into the allegations. Interviews with various staff members revealed a lack of awareness and action regarding the resident's allegations. The Director of Social Services was aware of the resident's call to 911 to report the alleged poisoning but did not ensure an investigation was conducted. The Director of Nursing was unaware of the allegations, and the Executive Director only knew of a report regarding medication refusal, not the full extent of the allegations. This lack of communication and failure to investigate violated the facility's policy and state regulations, as no incident investigation was completed.
Failure to Provide Written Transfer/Discharge Notice
Penalty
Summary
The facility failed to provide a written transfer or discharge notice to a resident and their representative, which is a requirement under their policy. This deficiency was identified during a review of the case of a resident who was hospitalized. The facility's policy, revised in August 2024, mandates that residents and their representatives be notified in writing about transfers or discharges, including the reasons for such moves, in a language and manner they understand. However, the review of the resident's electronic health record, including assessments and nursing progress notes, did not show any documentation that a written notice was provided. Interviews with facility staff revealed gaps in the process of issuing transfer or discharge notices. The Director of Social Services mentioned that the usual procedure involves filling out a notice form and mailing it to the resident's address. However, they could not find any documentation confirming that this was done for the resident in question. The Executive Director also acknowledged that residents should receive a copy of the written notice. This oversight placed the resident at risk of not being able to make informed decisions regarding their transfer or discharge.
Failure to Complete SCSA MDS for Resident with Significant Health Changes
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) for a resident who experienced significant changes in their health status. According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, a SCSA is required when a resident undergoes a major decline or improvement affecting more than one area of their health. In this case, the resident experienced a 6.83% weight loss in less than 30 days and developed a new facility-acquired Deep Tissue Injury (DTI) on their left buttock, both of which are conditions that necessitate a SCSA. Despite these significant changes, the facility did not complete the required SCSA MDS for the resident. During interviews, both the MDS Coordinator and the Director of Nursing acknowledged that the SCSA MDS should have been completed in accordance with the RAI manual guidelines. The failure to conduct this assessment placed the resident at risk for delayed care planning and unmet care needs.
Delayed MDS Assessment for a Resident
Penalty
Summary
The facility failed to complete a quarterly Minimum Data Set (MDS) assessment within the required timeframe for one resident, identified as Resident 32. According to the Resident Assessment Instrument (RAI) 3.0 User's Manual, a quarterly assessment is considered timely if completed within 14 days after the Assessment Reference Date (ARD). For Resident 32, the ARD was 10/08/2023, but the MDS was not completed until 11/01/2023, making it 10 days late. During an interview and record review, the MDS Coordinator, Staff G, acknowledged the delay and confirmed that the assessment should have been completed within the specified timeframe. The Director of Nursing, Staff B, also stated that the expectation was for the quarterly MDS to be completed on time. This delay in completing the assessment placed the resident at risk for delayed and/or unidentified care needs.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to accurately assess four residents using the Minimum Data Set (MDS) assessment tool, which is crucial for identifying and meeting residents' care needs. Resident 11's significant change of status MDS was incorrectly coded as N/A for a change in behavior, despite having a prior MDS assessment. This error was acknowledged by the MDS Coordinator, who admitted it was a coding mistake. The Director of Nursing also confirmed the expectation for accurate coding. Resident 3's annual MDS inaccurately reflected their bladder and bowel continence status. The MDS was marked as frequently incontinent, while the resident was actually always incontinent and dependent. Both the MDS Coordinator and the Director of Nursing confirmed the inaccuracy during joint record reviews and interviews. Resident 95's discharge status was incorrectly recorded as discharged to a short-term general hospital, while nursing progress notes indicated the resident was discharged home with home health services. Additionally, Resident 8's annual MDS inaccurately recorded the number of days insulin injections were received as zero, despite daily administration documented in the Medication Administration Record. These inaccuracies were confirmed by the MDS Coordinator and the Director of Nursing.
Failure to Conduct Proper PASRR Evaluations
Penalty
Summary
The facility failed to ensure that a Level I Pre-Admission Screening and Resident Review (PASRR) was properly conducted for a resident with a diagnosis of generalized anxiety disorder. The resident was admitted to the facility with this diagnosis, and the Level I PASRR dated 05/17/2024 indicated an anxiety disorder but did not include a referral for a Level II evaluation. This oversight meant that the necessary comprehensive evaluation to confirm the diagnosis and determine the appropriateness of the resident's placement was not conducted. Additionally, the facility did not complete a new PASRR Level I when the resident experienced a significant change in condition, as evidenced by a significant change in status Minimum Data Set (MDS). The resident was discharged to the hospital and readmitted with additional diagnoses of depression and anxiety, for which they were receiving medication. Despite these changes, no new PASRR Level I was completed, and no referral for a Level II evaluation was made, as confirmed by the Director of Social Services and the Executive Director during interviews.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to clarify a physician's order for a resident with a feeding tube, leading to the incorrect administration of medication. Resident 55, who had a feeding tube for supplemental nutrition, was prescribed levothyroxine to be given by mouth. However, the medication was crushed and administered via the g-tube by an LPN, contrary to the physician's order. The staff member acknowledged the discrepancy and admitted that the order should have been clarified to reflect the correct route of administration. Another deficiency was observed in the documentation of medication administration for Resident 2. An LPN was seen signing off on the Medication Administration Record (MAR) before actually administering the medications. This practice was contrary to the facility's policy, which requires staff to document medication administration only after the medication has been given to the resident. The LPN admitted to signing the MAR prematurely, which was confirmed by the Unit Care Coordinator and the Director of Nursing, who both stated that the MAR should be signed as medications are administered. Additionally, the facility failed to document insulin injection sites for Resident 3, who was receiving daily insulin injections for type 2 diabetes. The MAR for several months, including September 2024, lacked documentation of the injection sites, which is necessary to prevent complications such as hard lumps or fatty deposits. Staff members, including an RN Unit Care Coordinator and the Director of Nursing, confirmed the absence of documentation and acknowledged that best practices for insulin administration were not followed.
Failure to Provide Scheduled Bathing and Hygiene Care
Penalty
Summary
The facility failed to consistently provide bathing, shower, and personal hygiene care according to the care plan for a resident with severe cognitive impairment and muscle weakness, who required substantial assistance with personal hygiene. The resident was observed multiple times with long, untrimmed fingernails and brown debris underneath them, indicating a lack of proper hygiene care. The resident's care plan specified the need for a sponge bath when a full bath or shower could not be tolerated, and the resident was scheduled for bathing twice a week. However, documentation showed that the resident received bathing only once in July and had no documented bathing in August, with no records of the resident refusing care. Interviews with staff revealed that the responsibility for providing showers and fingernail care lay with the shower aides, and any refusal of care should have been reported and documented. Staff members, including a CNA and an RN Unit Care Coordinator, acknowledged the oversight in care and documentation, noting that the resident's showers were incorrectly documented as "activity did not occur." The Director of Nursing confirmed the expectation that care should be provided according to the care plan and that refusals should be documented and addressed, emphasizing the need for the resident's fingernails to be kept short and clean.
Failure in Enteral Tube Feeding Management
Penalty
Summary
The facility failed to ensure proper management of enteral tube feeding for a resident, identified as Resident 55, who was receiving more than 51% of their nutritional intake through tube feeding due to conditions including dysphagia and gastrostomy status. The deficiency was identified through observations, interviews, and record reviews, which revealed that the facility did not adhere to its policy of changing and dating tube feeding syringes daily. Specifically, the Treatment Administration Record for August and September 2024 lacked documentation of daily syringe changes for Resident 55. During observations, multiple opened syringes were found at Resident 55's bedside, some dated several days prior and others undated, indicating they were not replaced daily as required. Interviews with staff, including a Registered Nurse and the Director of Nursing, confirmed that the facility's protocol was to change syringes every 24 hours and to date them upon opening. The failure to follow these procedures placed Resident 55 at risk for infection and related complications.
Failure to Provide Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident with a history of generalized anxiety disorder, depression, and opioid dependence. Upon readmission, the resident experienced a decline in cognition and overall medical condition, as noted in the Minimum Data Set (MDS) assessment. Despite these changes, the facility did not complete a social services assessment for the resident's change in condition. The Care Area Assessment (CAA) indicated the resident had inattention, disorganized thinking, confusion, and occasional agitation, along with little interest or pleasure in activities and verbal behavioral symptoms directed towards others. The Medication Administration Record (MAR) documented behavioral episodes for six out of eight days in August, including crying, isolation, and anxious behavior. Observations and interviews revealed that the resident was often found lying in bed with closed blinds and no lights, expressing a desire to be left alone and wanting to go home. Staff interviews indicated a lack of awareness and action regarding the resident's need for behavioral health services. The Activity Director noted the resident's long history of disinterest and refusal of activities, while the Registered Nurse Unit Care Coordinator was unaware of any referral for behavioral health services. The Director of Social Services acknowledged the resident's symptoms could indicate depression but confirmed no referral or services were provided. The Director of Nursing and Executive Director both expressed expectations that the resident should have been referred for psychological consultation or counseling, which did not occur.
Medication Error Rate Exceeds 5% Due to Incorrect Administration
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a rate of 6.45% during a medication pass observation. This deficiency involved two residents. For Resident 2, the error occurred when an LPN administered an enteric-coated aspirin instead of the prescribed chewable aspirin. The LPN acknowledged the mistake during a joint record review, stating that they should have given the chewable form as ordered. The Unit Care Coordinator confirmed the expectation that medication orders should match what is administered to residents. For Resident 55, the error involved the administration of levothyroxine via a g-tube instead of by mouth as prescribed. The LPN responsible for this administration expressed confusion over the order, expecting it to specify the g-tube route given the resident's feeding tube. The Unit Care Coordinator reiterated the importance of following the correct route as per the medication order. The Director of Nursing also emphasized the necessity of adhering to the prescribed form and route of medication administration.
Infection Control Deficiencies in PPE and Hand Hygiene Practices
Penalty
Summary
The facility failed to adhere to Enhanced Barrier Precautions (EBP) and proper hand hygiene practices, which are critical for infection control. Specifically, for Resident 55, who had a feeding tube and was on EBP, Staff AA, an LPN, did not wear the required personal protective equipment (PPE) such as a gown and mask while administering medications via the feeding tube. This oversight was acknowledged by Staff AA and confirmed by Staff F, the Assistant Director of Nursing/Infection Preventionist, who stated that PPE should be worn during high-contact care involving indwelling medical devices like feeding tubes. Additionally, the facility did not ensure proper hand hygiene and glove use among its staff. Staff EE, an LPN, failed to perform hand hygiene before and after entering resident rooms and before and after glove use, as observed during blood sugar checks and medication administration. Similarly, Staff M, a Certified Nursing Assistant, did not remove gloves after handling trash and used them inappropriately in the hallway, contrary to the facility's expectations. These lapses in infection control practices were confirmed through interviews with various staff members, including the Director of Nursing, who emphasized the importance of hand hygiene and proper glove use.
Failure to Cover Urinary Catheter Drainage Bags
Penalty
Summary
The facility failed to maintain and promote residents' dignity by not covering urinary catheter drainage bags for three residents. Resident 4's catheter drainage bag was observed with amber-colored urine and visible from the hallway without a privacy bag. Staff C, a Registered Nurse, confirmed that the drainage bag should be covered. Resident 5's catheter drainage bag was also visible to their roommate and a visitor, and it was not covered. Staff D, an LPN, incorrectly stated that the drainage bag did not need to be covered. Resident 6's catheter drainage bag was visible from the hallway and not covered when they were out of their room in a wheelchair. Resident 6 confirmed that their catheter bag was not covered, and Staff G, the Unit Care Coordinator, and Staff B, the Director of Nursing, both stated that catheter drainage bags should be covered for dignity.
Failure to Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to the State Agency and/or law enforcement. The resident, who was usually understood but had moderately impaired cognition, was found with a significant skin tear on their right forearm. The resident reported that a large man had grabbed and squeezed their arm, causing the injury. Despite this, the incident was not reported to the appropriate authorities as required by the facility's policy. The Director of Nursing Services (DNS) was informed of the incident but did not consider it an alleged violation or abuse due to the location of the wound and did not report it. The resident's representative also attempted to follow up on the incident by contacting the DNS but received no response. Staff members who were aware of the incident and the resident's account of the event reported it to the DNS, who assured them that it would be investigated. However, the DNS did not report the incident to the State Agency or law enforcement. The facility's administrator later acknowledged that the incident should have been reported to the appropriate agencies.
Failure to Investigate Allegation of Abuse
Penalty
Summary
The facility failed to ensure an allegation of abuse was thoroughly investigated for one resident. The resident, who was usually understood but had moderately impaired cognition, reported that a large man grabbed and squeezed their arm, causing a skin tear. The facility's investigative report concluded that the injury likely occurred during a transfer from a wheelchair to a bed, but there was no documentation of interviews with relevant staff or the resident's representative, nor was there evidence of staff training on proper transfer techniques. The Director of Nursing Services (DNS) did not consider the incident as an alleged violation or abuse and did not report it to the state or conduct a thorough investigation. The resident's representative reported the incident to the DNS and requested a copy of the incident report but received no response. Staff members confirmed that the resident had mentioned being grabbed by a large man, and one staff member identified another staff member who fit the description. Despite this, the DNS did not take appropriate action to investigate the allegation or educate staff on proper transfer techniques. The facility administrator acknowledged that the incident should have been reported and investigated.
Failure to Ensure Proper Skin Care and Treatment
Penalty
Summary
The facility failed to ensure residents received skin care and treatments in accordance with professional standards of practice for three residents reviewed for skin conditions. Resident 1 had a skin tear on the right forearm that was not documented with measurements in the skin assessment, and there was no physician's treatment order for the skin tear. Resident 2 had a skin tear on the right knee, but there was no treatment order written for it, even though the skin tear was resolved. Resident 3 had a skin tear on the left buttock, but the dressing was incorrectly placed on the right buttock, and there was no physician's order for the left buttock skin tear. Staff E and Staff F confirmed these deficiencies during joint record reviews and interviews. The Director of Nursing (DNS) stated that staff were expected to notify the provider, DNS, and the resident's representative when new skin issues were found, complete a thorough skin assessment, and obtain treatment orders. However, this protocol was not followed for Residents 1, 2, and 3. The lack of proper documentation, assessment, and treatment orders for the skin tears placed the residents at risk for not receiving the necessary skin care treatment, unmet care needs, and a diminished quality of life.
Failure to Properly Position Urinary Catheters
Penalty
Summary
The facility failed to ensure urinary catheters were positioned off the floor for two residents, which placed them at risk for urinary tract and bladder infections. Resident 4 was observed with their urinary drainage bag lying flat on the floor while sitting on the edge of their bed. Staff C, a Registered Nurse, confirmed that the drainage bag should be hooked on the bed frame and off the floor. Similarly, Resident 5 was observed in bed with their drainage bag lying flat on the floor. Staff D, a Licensed Practical Nurse, also confirmed that the drainage bag should be off the floor. The facility's policy on Indwelling Urinary Catheter Management, reviewed on 08/24/2023, specifies that the collecting bag should always be kept below the level of the bladder and should not rest on the floor. Despite this policy, both residents' catheter bags were found on the floor during observations. Staff G, the Unit Care Coordinator, and Staff B, the Director of Nursing Services, both acknowledged that the urinary catheter drainage bags should be off the floor, indicating a lapse in adherence to the facility's policy and proper catheter care protocols.
Failure to Designate a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified staff person to serve as an Infection Preventionist (IP) to oversee the infection prevention and control program. This deficiency was identified during a review of the facility's records and interviews with staff. The facility document titled 'Care List for Positive Individuals' showed that 42 residents and 17 staff had tested positive for COVID-19 between 03/18/2024 and 04/01/2024. On 04/03/2024, the Executive Director (Staff A) confirmed that the facility did not have a certified IP, and that Staff B was serving as the interim IP without certification. Staff B also confirmed their lack of certification. Staff C, who was certified, stated they were not acting as the IP but were assisting with infection control tasks as directed by Staff B. Staff A reiterated that the infection control responsibilities were being managed as a team effort, with no single certified IP designated.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by one of the staff members, identified as Staff E. Staff E was observed exiting a COVID-19 isolation room with soiled linen and entering a non-isolation room without performing hand hygiene. This action was against the facility's hand hygiene policy, which mandates hand hygiene before and after contact with residents and contaminated surfaces. Staff E admitted to not sanitizing their hands before entering the non-isolation room, acknowledging the lapse in protocol. The facility also failed to appropriately disinfect medical equipment. Staff E was observed using vital sign equipment in a COVID-19 isolation room and exiting without disinfecting the equipment. According to the facility's policy, non-critical reusable patient care equipment should be cleaned daily and before and after reuse with an EPA-registered hospital disinfectant. Staff E admitted to not disinfecting the equipment and stated they were informed of the correct procedure only on the day of the observation. Additionally, the facility did not ensure the proper use and disinfection or disposal of personal protective equipment (PPE). Staff E and Staff F were observed exiting COVID-19 isolation rooms multiple times without changing their N95 masks or disinfecting their face shields. Staff F admitted to wearing the same N95 mask all day and only changing it if a resident seemed sicker. The facility's policy requires staff to remove and discard disposable respirators and disinfect or discard face shields after exiting isolation rooms. Furthermore, the facility failed to ensure that 13 out of 18 staff members were fit tested for N95 masks, which is required before staff can wear tight-fitting respirators. Staff E, who tested positive for COVID-19, had not been fit tested prior to the observation date, and several other staff members either had no fit testing documentation or had expired fit testing documentation.
Failure to Provide Adequate Nutritional Care
Penalty
Summary
The facility failed to provide adequate nutritional care and services for a resident, leading to significant weight loss. The resident, who was at risk for malnutrition due to dysphagia, was readmitted to the facility and initially showed no weight loss. However, subsequent records indicated a significant weight loss of 16.5 lbs. (9.9%) within a month. Despite the facility's policy to conduct weekly meetings to review residents at risk, the resident's weight loss was not discussed, and no nutritional supplements were ordered. The resident's weight dropped from 166.3 lbs. to 149.8 lbs. within a short period, and this was not communicated to the medical provider, the resident, or their representative. Interviews with staff revealed that the registered dietician was not informed of the resident's weight loss, and the weight loss was not addressed in the weekly meetings. The resident care manager confirmed the weight loss and acknowledged that it was not communicated appropriately. The facility administrator stated that the process for monitoring weights and updating nutritional assessments was not followed, leading to a lack of intervention and notification regarding the resident's significant weight loss.
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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