Life Care Center Of Puyallup
Inspection history, citations, penalties and survey trends for this long-term care facility in Puyallup, Washington.
- Location
- 511 10th Avenue Southeast, Puyallup, Washington 98372
- CMS Provider Number
- 505324
- Inspections on file
- 34
- Latest survey
- April 10, 2026
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Life Care Center Of Puyallup during CMS and state inspections, most recent first.
A resident's allegation of neglect, including being left in soiled briefs, developing open sores, receiving incorrect skin treatment, and having stroke-like symptoms ignored, was not reported to the State Agency as required. The administrator received the complaint but did not log or report the incident.
A resident with diabetes and heart disease, admitted after a surgical amputation, had provider orders for CRP and ESR blood tests following wound care for a dehisced surgical site. The facility transcribed the orders but did not complete the lab work until 40 days later due to lack of a phlebotomist and limited nursing staff trained in blood draws, resulting in the resident's lab work being missed.
A resident with a Stage 4 pressure ulcer did not have weekly wound assessments documented in a timely manner. Instead, several weeks of wound documentation were entered into the electronic medical record retrospectively, and the DNS could not provide consistent source data for these entries.
Two residents with documented urinary incontinence did not have this condition addressed in their care plans until late or not at all, despite assessments indicating the need. The DON confirmed that care plans should have been implemented promptly based on assessment findings.
The facility did not consistently monitor or assess the skin impairments of two residents with pressure injuries and moisture-associated skin damage. Despite initial identification and documentation, there were no ongoing measurements, treatment or monitoring orders, or follow-up assessments to track the status or healing of these wounds, as confirmed by the DON.
Two residents admitted with significant skin impairments, including a sutured leg laceration and multiple bruises, did not receive timely treatment or monitoring orders as required. Orders for wound care and monitoring were delayed by 11 and 14 days, respectively, despite facility expectations for immediate assessment and provider notification.
A resident with hemiplegia and mobility issues reported to an SLP that a staff member refused to provide their bed remote and pushed them, but the allegation was only documented on a grievance form and not immediately reported. The incident was not logged or reported to the State Agency until over a day later, exceeding required reporting timeframes.
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in their care. One resident with a pressure ulcer lacked a care plan focus area for the ulcer, while another resident's care plan inaccurately reflected their diet and NPO status. Facility staff confirmed these issues did not meet expectations.
The facility failed to follow professional standards of care for several residents, including improper medication administration and inadequate monitoring. A resident did not receive orthostatic blood pressure monitoring, and their medication was administered outside prescribed parameters. Another resident had a foley catheter of the incorrect size, and two residents did not have complete orthostatic blood pressure monitoring or required tests for medication side effects. Staff interviews confirmed these actions did not meet expectations.
The facility failed to provide necessary grooming services for two residents, leading to deficiencies in personal hygiene. One resident, with a right humerus fracture and diabetes, was not assisted with shaving despite expressing a desire for it. Another resident, with rheumatoid arthritis and heart failure, had long, thick toenails and was not referred to a podiatrist as needed. Staff interviews revealed confusion about responsibilities and unmet expectations for care.
A facility failed to ensure proper care for a resident with a fractured humerus by not applying a PRN sling as ordered, and did not consistently monitor or document bowel movements for two residents, leading to missed administration of constipation medication. Staff interviews revealed lapses in following care protocols and documentation procedures.
A resident at high risk for falls did not have fall mats in place as required by their care plan, despite previous falls and multiple diagnoses including stroke and dementia. Staff interviews revealed the mats were removed due to being frayed, and new ones were ordered, but not yet in place.
A resident with diabetes, paraplegia, and anxiety experienced inadequate pain management due to the facility's failure to provide clear parameters for PRN pain medications. The resident reported that the pain relief was insufficient, and staff confirmed the lack of guidance on medication administration. This deficiency risked the resident's quality of life.
The facility failed to maintain safe and functional wheelchairs for two residents, resulting in cracked and torn armrests that were not logged for maintenance. Despite residents' ability to communicate their needs, the issues were not addressed, and staff interviews confirmed the need for repairs.
The facility failed to make survey results easily accessible to residents and did not post notices about their availability in prominent areas. Two cognitively alert residents were unaware of the survey results' location. The binder was found in a conference room, with no notices throughout resident areas. Staff interviews revealed inconsistent knowledge about the binder's location.
The facility failed to provide written transfer notices to three residents, who were only informed verbally about their hospital transfers. An LPN confirmed the lack of written notices, and the Administrator acknowledged the expectation for written documentation, which was not met.
Failure to Report Allegation of Neglect
Penalty
Summary
The facility failed to report an allegation of neglect involving one resident, as required by regulation. A public complaint was sent to the State Agency alleging that the resident was left in soiled adult diapers for extended periods, developed open sores in the groin area, received incorrect treatment for skin impairments, and experienced symptoms such as left arm numbness, tingling, nausea, and vomiting, which were reportedly ignored by staff. The complaint was copied to the facility administrator via email. However, a review of the facility's incident report logs showed that the allegation was not logged or reported to the State Agency. During an interview, the administrator confirmed receipt of the complaint but acknowledged that the allegations were not reported to the State Agency.
Failure to Timely Complete Ordered Laboratory Tests
Penalty
Summary
The facility failed to follow provider orders for laboratory blood work for one resident who was admitted after a surgical amputation of toes and had diagnoses including diabetes and heart disease. The resident had an order for blood tests (CRP and ESR) to be drawn at the facility following a visit to an outpatient wound care center for treatment of a dehisced surgical foot wound. Although the physician's order for these labs was transcribed into the facility's records, the tests were not performed until 40 days after the order was written. According to the Director of Nursing Services, the delay occurred because the facility did not have a phlebotomist at the time and only two nurses were trained to draw blood, resulting in the resident's lab work being missed.
Failure to Maintain Timely and Accurate Wound Documentation
Penalty
Summary
The facility failed to maintain accurate and timely wound monitoring records for a resident with a Stage 4 pressure ulcer. The resident was admitted with a significant wound over the sacrum, with exposed bone and specific measurements documented at admission. Although the facility had a process in place for weekly wound documentation using a Wound Observation Tool, records showed that several weeks of wound assessments were not entered into the electronic medical record on a weekly basis as required. Instead, multiple weeks of documentation were entered retrospectively, well after the assessments should have been completed. During interviews, the Director of Nursing Services (DNS) acknowledged that the weekly wound documentation was not completed as scheduled and admitted to being behind in documentation. When asked to provide the original source data for the wound documentation, the DNS was unable to produce records consistent with what was entered into the electronic medical record. This lapse resulted in incomplete and potentially inaccurate clinical information being available to the interdisciplinary team.
Failure to Develop Comprehensive Care Plans for Urinary Incontinence
Penalty
Summary
The facility failed to develop and implement comprehensive care plans addressing urinary incontinence for two residents. For the first resident, who was admitted with diagnoses including hip fracture with surgical repair, weakness, difficulty walking, and a need for assistance with personal care, the admission MDS indicated that the resident was always incontinent of bowel and bladder. However, review of the comprehensive care plan showed that incontinence was not listed, and there were no goals or interventions documented to address this need. For the second resident, who was admitted with dementia, overactive bladder, and a need for assistance with personal care, the admission MDS and facility documentation indicated frequent bladder incontinence. Despite this, the comprehensive care plan did not include incontinence until the date of discharge. During an interview, the DNS confirmed that care plans for incontinence should have been in place as soon as the need was identified through assessments.
Failure to Monitor and Assess Pressure Injuries and Skin Impairments
Penalty
Summary
The facility failed to routinely monitor and assess the status of skin impairments for two residents who were at risk for pressure injuries. One resident was admitted with a hip fracture, weakness, and impaired mobility, and was identified as having a stage 1 pressure injury over the sacrum. Although the care plan noted the risk for pressure-related skin injury, there were no documented measurements of the injury, no treatment or monitoring orders, and no follow-up documentation to indicate whether the injury was monitored, worsened, or improved after admission. Another resident, admitted with dementia, generalized muscle weakness, and incontinence, was identified as having moisture-associated skin damage and a small open area in the gluteal cleft. Initial documentation included measurements of the wound, but subsequent records lacked ongoing measurements or descriptions of the wound's status. There was no further documentation after the initial assessment to show that the open area was monitored or that its condition was tracked over time. The Director of Nursing Services confirmed that monitoring orders and weekly assessments should have been in place for both residents.
Failure to Implement Timely Skin Impairment Treatment and Monitoring Orders
Penalty
Summary
The facility failed to implement treatment and monitoring orders for skin impairments for two residents upon admission. For one resident, who was admitted with a right lower leg laceration that had been sutured in the hospital, the facility did not initiate any treatment or monitoring orders for the wound until 11 days after admission, despite hospital discharge instructions to follow current wound care recommendations. The resident's initial assessment documented the presence of a significant laceration with 15 stitches, but this was not followed by timely care orders. Another resident was admitted with multiple medical diagnoses and was noted during the nursing admission evaluation to have a large bruise on the right upper shoulder and bruises on both arms. However, no treatment or monitoring orders for these bruises were implemented until 14 days after admission. The Director of Nursing Services confirmed that the expectation was for a full-body skin assessment upon admission and prompt communication with a medical provider for any skin impairments, which did not occur in these cases.
Failure to Timely Identify and Report Alleged Abuse
Penalty
Summary
A resident with hemiplegia, muscle weakness, and difficulty walking was admitted to the facility and required assistance with personal care. On the morning of 04/21/2025, the resident reported to a Speech Language Pathologist (SLP) that a staff member had refused to give them their bed remote control and pushed them on the shoulder the previous night, expressing that the staff member appeared angry. The SLP relayed the allegation to their supervisor and documented it on a grievance form, which was then placed in a grievance box near the social services office. The facility's incident report log showed that the allegation of abuse was not logged until 04/22/2025, and the State Agency was notified approximately 33 hours after the resident initially reported the incident. The Director of Nursing Services (DNS) stated they were unaware of the delay, and the Administrator acknowledged that the allegation should have been reported to the State Agency within 2 hours, rather than being handled solely through the grievance process. This delay in identifying and reporting the abuse allegation resulted in a failure to meet required reporting timeframes.
Deficiencies in Care Planning for Two Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, which led to deficiencies in their care. Resident 10, who was admitted with paraplegia, diabetes, and a pressure ulcer, did not have a care plan focus area for the pressure ulcer. Despite receiving treatment from facility staff and an outside wound provider, the care plan lacked specific interventions for the pressure ulcer. Interviews with facility staff, including a Licensed Practical Nurse/Unit Care Coordinator and the Director of Nursing Services, confirmed that the absence of a care plan focus area for the pressure ulcer did not meet the facility's expectations. Resident 80, admitted with hydrocephalus, dysphagia, and respiratory failure, also experienced a deficiency in care planning. The resident's care plan inaccurately reflected a diet intervention of nothing by mouth (NPO), despite having a provider's order for a regular diet with puree texture. The resident was observed with a feeding pump machine and reported receiving tube feeding at night. The Director of Nursing Services acknowledged that the care plan was not updated to reflect the current diet and NPO status, which did not meet the facility's expectations.
Deficiencies in Monitoring and Medication Administration
Penalty
Summary
The facility failed to adhere to professional standards of care for several residents, leading to deficiencies in monitoring and medication administration. Resident 1, diagnosed with Crohn's disease, autism, and dementia, did not receive orthostatic blood pressure monitoring as ordered, and their medication, midodrine, was administered outside the prescribed parameters multiple times over several months. Staff interviews confirmed that these actions did not meet the facility's expectations for following provider orders. Resident 75, who had a history of stroke, muscle weakness, and neurogenic bladder, was found to have a foley catheter of the incorrect size, contrary to the provider's orders. The resident's family had expressed concerns about the appearance of the resident's urine and reported abdominal pain, which was documented by a licensed nurse. However, the catheter was changed to a smaller size than ordered, and staff were unaware of this discrepancy until it was pointed out during an interview. Resident 72, with anxiety and psychotic disorders, did not have complete orthostatic blood pressure monitoring documented as required by their provider's orders. The MARs for several months showed incomplete or missing documentation of blood pressure readings in different positions. Similarly, Resident 6, who was on quetiapine, did not have the required AIMS test completed to monitor for adverse side effects, and there was no documentation of orthostatic blood pressures. Staff interviews confirmed that these monitoring processes were not conducted as expected.
Deficiencies in Grooming Services for Residents
Penalty
Summary
The facility failed to provide necessary grooming services for two residents, leading to deficiencies in personal hygiene. Resident 49, who was admitted with a right humerus fracture, diabetes, and depression, expressed a desire to shave but was not offered assistance by the facility. Observations showed that Resident 49 had facial hair about an inch long, indicating a lack of grooming. The care plan for Resident 49 required one staff assistance with personal hygiene but did not include specific instructions for shaving. Interviews with staff revealed confusion about responsibilities for shaving, with CNAs providing conflicting accounts of who should assist Resident 49. Resident 61, admitted with rheumatoid arthritis, respiratory failure, and heart failure, required substantial assistance with personal hygiene due to impairments in both upper and lower extremities. Observations showed Resident 61 had long, thick toenails and had requested to see a podiatrist, but their name was not on the referral list. Staff interviews confirmed that Resident 61's toenails should have been trimmed by a podiatrist, but this had not occurred, failing to meet the facility's expectations for care.
Deficiencies in Resident Care and Bowel Management
Penalty
Summary
The facility failed to ensure necessary interventions were in place for a resident with a history of a fractured humerus. Resident 75, who had multiple diagnoses including stroke and dementia, was observed without a sling or proper arm positioning despite a provider's order for a PRN sling for comfort when out of bed. The order was not transcribed into the medication administration record (MAR) until several days later, leading to a lack of proper care and positioning for the resident. Staff interviews revealed that the resident's daughter wanted the sling applied, but the resident frequently refused, resulting in a change to a PRN order that was not properly documented. Additionally, the facility failed to consistently monitor and document bowel movements and implement the bowel program for two residents. Resident 6 and Resident 49 both experienced multiple days without bowel movements, yet the prescribed constipation medication was not administered as per the provider's orders. Interviews with staff indicated that the system was supposed to flag when there were no documented bowel movements, but the protocol was not followed, leading to a lack of necessary interventions for these residents.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that fall mats were in place to minimize the risk of injury during a fall for one resident, identified as Resident 75, who was at high risk for falls. The resident had multiple diagnoses, including stroke, muscle weakness, cancer, dementia, anxiety, and depression, and was dependent on staff for assistance with activities of daily living. Despite the care plan indicating that the bed should be in the lowest position and floor mats should be placed at the side of the bed while the resident slept, these interventions were not observed during the survey. The resident had previously experienced falls on two occasions, and the fall scene investigation reports did not document the presence of fall mats. Interviews with facility staff revealed that the fall mats were not in place due to them being frayed and awaiting replacement. Staff members, including a Licensed Practical Nurse and a Certified Nurse Aide, acknowledged the absence of fall mats and the requirement for them as per the resident's care plan. The Director of Nursing Services confirmed that the mats had been removed earlier, and the Administrator stated that the expectation was for the interventions in the care plan to be implemented. This oversight placed the resident at risk for potential injury and negative outcomes.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide adequate pain management for a resident, identified as Resident 3, who was admitted with diagnoses including diabetes, paraplegia, and anxiety. Resident 3 reported that the pain medication provided by the facility staff sometimes did not control their pain effectively. When Resident 3 requested additional pain medication, they were informed by the staff that they could not receive more at that time. The review of Resident 3's medication administration records for January and February 2025 revealed that the resident was prescribed two over-the-counter (OTC) pain medications and one narcotic pain medication, all on an as-needed (PRN) basis. However, there were no parameters set for the nursing staff to determine which medication to administer based on the resident's pain level. Interviews with facility staff, including a Licensed Practical Nurse/Unit Care Coordinator and the Director of Nursing Services, confirmed that the PRN pain medications lacked specific parameters to guide nursing staff in medication administration. The Director of Nursing Services acknowledged that the absence of pain scale parameters for PRN medications did not meet the facility's expectations. This deficiency in pain management placed Resident 3 at risk of experiencing uncontrolled pain and a diminished quality of life.
Wheelchair Maintenance Deficiency
Penalty
Summary
The facility failed to maintain a safe and functional environment for residents, as evidenced by the condition of wheelchairs used by two residents. Resident 21's wheelchair had a left armrest with cracked and torn vinyl, exposing an uncleanable surface. Despite the resident's ability to communicate their needs, the issue was not addressed by the staff, and the problem was not logged in the maintenance binder from early January to late February. Staff interviews confirmed the armrest's condition and acknowledged that it should have been repaired or replaced. Similarly, Resident 72's wheelchair had a right armrest with cracked and torn vinyl and a left armrest that was unstable. The resident had informed staff about these issues, but they were not logged in the maintenance binder. Staff interviews corroborated the resident's account and identified the need for repairs. The facility's administrator confirmed that the process for logging equipment issues was not followed, and the condition of the wheelchairs did not meet the facility's expectations.
Survey Results Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that survey results were posted in a location easily accessible to all residents and did not provide notices regarding the availability of these survey reports in prominent areas. This deficiency was identified during a group interview with two cognitively alert residents who were unaware of the survey results' availability or location. Observations revealed that the binder labeled 'State Survey Results' was placed on a small corner table in the conference room on the 100-hall, while the facility had four hallways where residents resided. There were no notices about the binder's availability or location throughout the resident-occupied areas. Interviews with staff members, including an LPN, a receptionist, and the administrator, indicated a lack of consistent knowledge about the binder's location, with the administrator confirming its placement in the conference room but acknowledging the absence of additional signage informing residents or visitors of its location.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written notification of the reason for transfer to the hospital to three residents, placing them at risk of not knowing their rights regarding transfer and discharge. Resident 21, who was admitted with heart failure, kidney failure, and diabetes, was transferred to the hospital twice without receiving written notice. Similarly, Resident 54, with heart failure, diabetes, and respiratory failure, was transferred once without written notification. Resident 72, with heart failure and diabetes, was also transferred twice without receiving written notice. In each case, the residents or their representatives were only informed verbally. During interviews, Staff C, an LPN/Unit Care Coordinator, confirmed that the residents or their representatives did not receive written notices for the hospital transfers. Staff A, the Administrator, stated that the expectation was for nurses to complete an interact transfer form and provide a written Nursing Home Transfer or Discharge Notice form to the resident and/or their responsible party. However, this procedure was not followed, as evidenced by the lack of documentation in the residents' electronic health records.
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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