Linden Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Toppenish, Washington.
- Location
- 802 West Third Avenue, Toppenish, Washington 98948
- CMS Provider Number
- 505096
- Inspections on file
- 32
- Latest survey
- November 21, 2025
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Linden Post Acute during CMS and state inspections, most recent first.
A resident with Parkinson's Disease and reduced mobility left the facility without notice, and staff were unaware of their whereabouts. The incident was not documented in the incident log, and the state agency was not notified as required. Social Services attempted to contact the resident and notified law enforcement, but did not log the event or inform the state agency.
Three resident rooms were found with significant wall damage, exposed sharp metal, peeling paint, and splintered closet doors, with maintenance logs showing no record of inspection or repair. The Maintenance Director and Administrator were unaware of the issues, despite facility policy requiring regular inspections.
The facility failed to ensure a safe environment for a resident who required a smoking apron due to dexterity issues, as they were not provided with the necessary protective equipment during smoking times. Additionally, compressed oxygen cylinders were left unsecured in a storage room, and toxic cleaning chemicals were accessible to residents in two hallways, increasing the risk of accidents and injuries.
The facility failed to provide appetizing and palatable food to several residents, including those with diabetes and dysphagia, leading to dissatisfaction and potential nutritional inadequacy. Delays in meal service and inadequate equipment for maintaining food temperatures were observed, with staff acknowledging the need for better communication and adherence to meal service times.
The facility failed to ensure proper sanitation of food preparation surfaces, appropriate labeling of open foods, and cleanliness of food delivery carts, risking foodborne illnesses. Expired test strips were used for sanitizing solutions, and open foods were improperly labeled and stored. Food delivery carts were dirty, with visible debris and rusty wheels. The dietary manager and administrator acknowledged training issues in food safety.
Two residents with severe cognitive impairments and additional disabilities experienced significant delays in receiving meal assistance, compromising their dignity. One resident, who is legally blind, waited 16 and 17 minutes on separate occasions for help, while another resident, who is deaf, waited 30 and 31 minutes. Delays were due to staff being occupied with other duties, as confirmed by the facility's administrator.
The facility failed to properly review and validate PASARR screenings for two residents with serious mental illness (SMI), leading to a deficiency. One resident was admitted with PTSD and depression without a Level II referral, while another had an incorrect initial PASARR screening that was not followed by a necessary Level II referral. These oversights placed the residents at risk of not receiving appropriate care.
The facility failed to effectively plan and document discharge processes for two residents, leading to unsafe discharges. One resident, admitted with heart failure and dehydration, was discharged AMA without a documented plan, despite expressing a desire to return to the community. Another resident, with cellulitis and paraplegia, left AMA with a PICC line in place, without notifying the provider or authorities, posing a risk of infection.
A resident with type two diabetes mellitus received insulin therapy based on unconfirmed blood glucose readings from a FreeStyle Libre 2 sensor, contrary to manufacturer's guidelines. Facility staff were unaware of the need to confirm sensor readings with a fingerstick glucose device within the first 12 hours after changing the sensor, leading to potential health risks due to incorrect insulin dosing.
A facility failed to identify and utilize an implanted bladder stimulator device for a resident with urinary incontinence. The resident, who was cognitively intact, reported not having the remote to control the device and had not seen a urologist since admission. Staff interviews revealed a lack of awareness about the device, and the care plan did not document its presence or any related interventions.
A resident with PTSD and a history of military service was not provided with trauma-informed care at the facility. Despite being able to communicate their needs, the resident's known triggers, such as being startled by loud noises, were not identified or documented in their care plan. Staff interviews confirmed awareness of the resident's condition, but no specific interventions were implemented to prevent re-traumatization.
A facility failed to maintain a medication error rate below five percent, resulting in a 7.41 percent error rate. Two residents were affected: one received insulin without proper pen priming, and another was nearly given expired medication. Staff involved were unaware of the insulin pen priming requirement and assumed new medications were not expired.
The facility failed to properly dispose of kitchen refuse, leading to unsanitary conditions with flies observed on plates and trash bags left outside attracting pests. Staff interviews revealed that trash was not taken to the dumpster immediately as required.
A facility failed to ensure a resident with severe cognitive impairment understood a binding arbitration agreement, which waived their right to a jury trial. The resident, admitted with congestive heart failure and bipolar disorder, had a BIMS score indicating severe cognitive impairment. Despite this, the resident signed the agreement without a power of attorney or legal guardian, and later expressed a lack of understanding of the process.
Failure to Notify State Agency of Resident Elopement
Penalty
Summary
The facility failed to notify the state agency regarding an elopement incident involving a resident. The resident, who had diagnoses including high blood pressure, Parkinson's Disease, reduced mobility, and a history of homelessness, was admitted to the facility and required partial to substantial assistance with transfers, dressing, and toileting. According to the comprehensive assessment, the resident was alert and oriented. On the day of the incident, staff discovered the resident's breakfast tray untouched and their belongings missing, indicating the resident had left the facility without notice. Staff were unaware of the resident's location and the resident had not been assessed as an elopement risk. The incident was not documented in the facility's incident reporting log for the relevant months, and the state agency was not notified as required. The DON confirmed that staff did not know the resident's whereabouts and that the state agency was not contacted. Social Services attempted to reach the resident by phone, but the number was not working, and law enforcement was notified the following day. However, the incident was not logged, and Social Services staff were unaware of the requirement to notify the state agency.
Failure to Maintain Safe and Functional Resident Rooms
Penalty
Summary
The facility failed to provide a safe and comfortable environment in three of six resident rooms (Rooms 27, 28, and 29) due to lack of maintenance and repair. Observations revealed multiple issues, including four-foot-long cuts in the wall, gouges with missing paint, unfinished spackled areas, exposed metal plates with sharp edges, peeling paint, and splintered closet doors. Some areas were uncleanable due to peeling flakes, and significant damage such as broken sheet rock was visible behind a bed headboard. These deficiencies were directly observed during facility rounds and interviews with staff. Review of the facility's maintenance logs from April to June 2025 showed that these rooms were not identified for inspection or repair, despite the facility's policy requiring weekly building interior inspections. The Maintenance Director stated that this was the first time they had seen these areas needing repair and was unaware of the issues in these rooms. The Administrator acknowledged that the rooms should have been repaired promptly.
Deficiencies in Resident Safety and Hazard Management
Penalty
Summary
The facility failed to ensure a safe environment for Resident 29, who required a smoking apron for safety due to dexterity issues following a stroke. Despite the resident's need for supervision and protective equipment when smoking, observations revealed that the resident was not provided with a smoking apron during designated smoking times. Staff members, including a clerk/nursing assistant and the activities director, were unaware or did not enforce the requirement for the resident to wear a smoking apron, despite the resident's history of cigarette burns on clothing and the facility's policy. In the East/West storage room, the facility did not secure compressed oxygen cylinders as required. An observation showed that four cylinders were left unsecured, posing a potential hazard. The maintenance director acknowledged the oversight and indicated that the process for checking the storage rooms weekly was not effective, as evidenced by the unsecured cylinders. The administrator confirmed that the oxygen delivery driver had left the cylinders unsecured, which was not the standard procedure. Additionally, the facility failed to safely store toxic cleaning chemicals, as observed in two hallways. Containers of germicidal wipes were left within reach of residents, including in unsupervised areas. The director of nursing services stated that residents liked to use the wipes to clean their wheelchairs, indicating a lack of awareness of the potential hazards posed by the chemicals. This oversight in chemical storage increased the risk of accidents and injuries among residents.
Deficiency in Food Quality and Service Timeliness
Penalty
Summary
The facility failed to consistently provide appetizing and palatable food to four residents, leading to dissatisfaction and potential nutritional inadequacy. Resident 44, who has diabetes and COPD, reported that their meals were often cold and unappetizing, with specific complaints about mushy pasta and leathery eggs. Resident 34, with dysphagia and COPD, expressed dissatisfaction with the taste and appearance of their meals, resorting to using barbeque sauce to mask the flavor and relying on food brought by others. Resident 21, also diabetic, was unhappy with the cold and unappetizing food, and noted that their dietary preferences, such as avoiding beets, were not respected. Resident 57, another diabetic resident, reported that their dietary restrictions were not followed, and despite complaints, no changes were made. These issues were compounded by the kitchen's delay in meal service, resulting in cold food being served to residents. Observations in the kitchen revealed that meal service was delayed due to staff breaks and cleaning, leading to insufficient pellet inserts for plate warmers and cold meals being served. The Dietary Manager acknowledged the issues with food temperatures and the need for better communication between kitchen and nursing staff. The Administrator recognized the need to adhere to meal service times and ensure adequate equipment to maintain food temperatures.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to ensure proper sanitation of food preparation surfaces, appropriate labeling of open foods, and cleanliness of food delivery carts, which placed residents, staff, and visitors at risk for foodborne illnesses and the spread of infectious diseases. During an observation, a dietary aide was found using expired test strips to check the concentration of a sanitizing solution, which repeatedly failed to pass the test. The dietary manager admitted to not having a process in place for the safe use of the sanitation solution and acknowledged that the sanitation log was likely inaccurate. There was no documentation of training or return demonstration for testing the sanitation solution, indicating a lack of proper oversight and training. In addition to the issues with sanitizing solutions, the facility also failed to properly label and store open foods. During a kitchen tour, several items, including a health shake, hard-boiled eggs, chopped ham and cheese, and various vegetables, were found without proper labeling or dating. Some items were also improperly sealed, which could lead to contamination. The dietary manager admitted that the process for storing leftovers and open packages of food was not being followed consistently, and the responsibility for maintaining the foods in the refrigerator was not being upheld by the cooks. Furthermore, the food delivery carts used for meal service were observed to be dirty, with visible debris, rusty wheels, and sticky rubber bumpers. The dietary manager acknowledged that the carts looked dirty and that the staff were supposed to clean the insides of the carts daily, but the outside of the carts was not being cleaned regularly. The administrator confirmed that there was a training issue in the kitchen regarding food safety, highlighting a systemic problem in maintaining hygiene standards in the facility's food service operations.
Failure to Provide Timely Meal Assistance
Penalty
Summary
The facility failed to ensure timely assistance with meals for residents requiring help, compromising their dignity and quality of life. Resident 14, who is legally blind and severely cognitively impaired, was observed waiting for assistance with meals on two separate occasions. On the first occasion, the resident waited 16 minutes after their meal was served before receiving help from a nursing assistant. On the second occasion, the resident waited 17 minutes, during which they expressed frustration and attempted to smell their food. The delay was attributed to staff being occupied with other residents in different areas of the facility. Similarly, Resident 3, who is deaf and severely cognitively impaired, experienced delays in receiving meal assistance. On one occasion, the resident waited 30 minutes before a staff member cued them to start eating. On another occasion, the resident waited 31 minutes for assistance. The delays were due to the nursing assistant's responsibilities in assisting other residents who dined in their rooms, which often caused them to be late in providing help in the dining room. The facility's administrator acknowledged that it was inappropriate for residents to wait for assistance while others were already eating.
Deficiency in PASARR Process for Residents with SMI
Penalty
Summary
The facility failed to properly review and validate the Preadmission Screening and Resident Reviews (PASARR) for two residents, leading to a deficiency in ensuring that individuals with serious mental illness (SMI) or intellectual/developmental disabilities (ID/DD) were not inappropriately placed in the nursing home. Resident 29 was admitted with diagnoses including PTSD and depression, but their PASARR Level I screening was not accurate, and a Level II referral was not completed prior to admission. Staff H, the Social Service Director, acknowledged the oversight in the PASARR process for Resident 29, which required a Level II evaluation due to the SMI indicators. Similarly, Resident 56 was admitted with PTSD and anxiety, but their initial PASARR Level I screening did not indicate any SMI indicators. A subsequent PASARR Level I screening correctly identified the SMI indicators, but a Level II referral was not made. Staff H was responsible for reviewing the PASARR screenings, and both Staff H and the Director of Nursing Services confirmed the errors in the PASARR process for Resident 56. These failures placed the residents at risk of not receiving appropriate care and services for their needs.
Deficiencies in Discharge Planning and Safety
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for Resident 264, who was admitted with diagnoses including fainting, heart failure, and dehydration. Despite being cognitively intact and requiring partial assistance with activities of daily living, Resident 264 expressed a desire to return to the community. However, the care plan lacked documentation of discharge planning, and the resident was discharged home against medical advice (AMA) without a proper plan in place. This oversight in discharge planning was evident as the social services director noted the resident's request to discharge and the subsequent upset when the process was explained, yet no formal discharge plan was documented. Additionally, the facility failed to ensure a safe discharge for Resident 61, who was admitted with cellulitis, osteomyelitis, and paraplegia, and required substantial assistance with activities of daily living. Resident 61 was receiving antibiotics through a PICC line, which was scheduled to end after their discharge. However, the resident left the facility AMA with the PICC line still in place, and there was no documentation that the provider or relevant authorities were notified of this unsafe discharge. The director of nursing services acknowledged the lack of notification and the risk associated with discharging a resident with a PICC line.
Failure to Adhere to Blood Glucose Monitoring Guidelines
Penalty
Summary
The facility failed to ensure proper treatment and care for a resident with type two diabetes mellitus, specifically in the administration of insulin therapy. The resident, who was cognitively intact and able to communicate their needs, was using a FreeStyle Libre 2 sensor for continuous blood glucose monitoring. However, the facility staff did not adhere to the manufacturer's recommendations, which stated that blood glucose readings from the sensor should not be used for treatment decisions within the first 12 hours after changing the sensor without confirmation from a fingerstick glucose monitor. The resident reported that their blood glucose levels were inconsistent, with readings sometimes higher or lower than expected. Despite this, the nursing staff continued to administer sliding scale insulin based on the sensor's readings without confirming these values with a fingerstick glucose device. This practice was contrary to the facility's policy and the manufacturer's guidelines, which could lead to incorrect insulin dosing and potential health risks for the resident. Interviews with facility staff, including a registered nurse and the resident case manager, revealed a lack of awareness regarding the manufacturer's recommendations for the FreeStyle Libre 2 sensor. The facility did not have a policy in place to confirm the sensor's readings after a sensor change, which contributed to the deficiency. The administrator and director of nursing services acknowledged the absence of a process to ensure compliance with the manufacturer's guidelines, highlighting a gap in the facility's procedures for managing diabetes care.
Failure to Identify and Utilize Implanted Bladder Stimulator Device
Penalty
Summary
The facility failed to identify and utilize an implanted bladder stimulator device, known as InterStim, for a resident with urinary incontinence. The resident, who was cognitively intact and required substantial assistance for daily activities, had a history of urinary incontinence after the InterStim device placement. Despite this, the care plan did not document the presence of the device or any consultation with a urologist. The resident reported not having the remote to control the device and had not seen a urologist since admission to the facility. Interviews with facility staff revealed a lack of awareness regarding the resident's implanted device. The nursing assistant responsible for the resident's daily care was unaware of any scheduled toileting plan, and the resident case manager was not informed about the device or any bladder retraining program. The Director of Nursing Services acknowledged that the process for ensuring accurate medical records on admission should have identified the device, but it was missed, and no care plan was in place for it.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for a resident identified as a trauma survivor. The resident, who was admitted with diagnoses including PTSD, traumatic brain injury, and depression, reported having potential triggers related to their military service, such as being easily startled by loud noises or when woken from sleep. Despite the resident's ability to communicate their needs and history of trauma, no staff member had discussed these triggers with them, and the care plan lacked specific interventions to address the resident's PTSD and history of combat exposure. Interviews with various staff members, including the Social Services Director, Registered Nurse, and Resident Case Manager, revealed that the facility was aware of the resident's PTSD and history of military deployments. However, the staff failed to identify and document the resident's known triggers in the care plan, which should have included strategies to prevent re-traumatization. The oversight was acknowledged by the facility's Administrator and Director of Nursing Services, who admitted that the resident should have been accurately assessed for potential triggers, and an individualized care plan should have been implemented.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a 7.41 percent error rate during 27 medication administration opportunities. This deficiency involved two residents, Resident 218 and Resident 1. Resident 218, who had a diagnosis of type two diabetes and required insulin administration, did not receive the correct procedure for insulin delivery. A registered nurse, Staff E, administered 20 units of Basaglar insulin without priming the insulin pen, which is necessary to ensure the correct dosage is delivered. Staff E was unaware of the need to prime the pen, which could lead to incorrect insulin dosage. Resident 1, who had diagnoses including dementia and heart failure, was at risk due to the administration of expired medication. Staff L, an LPN, initially prepared to administer a medication that had expired, assuming it was valid because it had just arrived from the pharmacy. Upon review, Staff L realized the error and replaced the expired medication. The Director of Nursing Services, Staff B, confirmed that the process for medication administration includes checking expiration dates, but was unaware of the priming requirement for insulin pens.
Improper Disposal of Kitchen Refuse
Penalty
Summary
The facility failed to properly dispose of kitchen refuse, which was observed during a survey. On two separate occasions, flies were seen on plates in the kitchen, indicating a potential unsanitary condition. Additionally, black trash bags containing kitchen food waste were left on a cart outside the emergency exit of the kitchen/laundry hallway, with snow peas scattered on the ground, attracting flies, bees, and gnats. Interviews with staff revealed that the trash was supposed to be taken to the dumpster immediately, but it had been left outside for at least 45 minutes. The facility had pest control measures in place, but the process for removing trash from the kitchen was not followed as required.
Failure to Ensure Resident's Understanding of Arbitration Agreement
Penalty
Summary
The facility failed to ensure that a resident had the cognitive capacity to understand the nature and implications of entering into a binding arbitration agreement. This agreement was intended to settle disputes without a jury trial. The deficiency was identified for one resident, who was admitted with diagnoses including congestive heart failure and bipolar disorder. The resident's comprehensive assessment indicated severe cognitive impairment, with a Brief Interview of Mental Status (BIMS) score of 3 out of 15, confirming their inability to comprehend complex legal documents. The arbitration agreement was signed by the resident upon admission, despite their severe cognitive impairment, as evidenced by their inability to sign their name properly. During interviews, the resident expressed a lack of understanding of the arbitration process. The Social Services Director, who presented the agreement, acknowledged that the resident did not have a power of attorney or legal guardian to sign on their behalf and was unsure if the resident comprehended the agreement. This oversight placed the resident at risk of not understanding the legal contract they had signed and their right to a jury trial in the event of a dispute with the facility.
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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