Marianwood Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Issaquah, Washington.
- Location
- 3725 Providence Point Drive Southeast, Issaquah, Washington 98029
- CMS Provider Number
- 505418
- Inspections on file
- 30
- Latest survey
- November 21, 2025
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Marianwood Health And Rehabilitation during CMS and state inspections, most recent first.
A resident in an LTC facility experienced psychological harm due to repeated verbal abuse by their roommate, which was not addressed promptly by staff. Despite the resident's requests for a room change and reports of distress, staff failed to take immediate action to separate the residents or protect the victim from further abuse. The facility's policy on abuse prevention was not followed, leading to the resident's emotional distress and retraumatization.
The facility failed to implement its abuse prevention policies, leading to unaddressed verbal abuse incidents between residents. Despite reports of abuse, staff did not take immediate action or document necessary interventions, resulting in ongoing psychological harm. The facility's inaction and delayed reporting to state agencies highlight significant lapses in their abuse prevention protocols.
A resident experienced a fall, and the facility failed to notify the resident's representative as required by policy. The resident, who was non-verbal and dependent on staff, was found on the floor, and the incident was not communicated to their representative until much later, causing frustration. The DON confirmed the lack of documentation and notification.
The facility failed to maintain safe hot water temperatures, secure hazardous chemicals, and address fall risks for a resident. Hot water temperatures in resident rooms exceeded safe limits, posing a burn risk. Chemicals were left unsecured in two nursing units, increasing the risk of accidental ingestion. A resident with a history of falls lacked proper footwear and had a broken bed, contributing to their fall risk.
The facility failed to provide sufficient nursing staff to meet residents' needs, resulting in delayed assistance with ADLs and call light responses, particularly during shift changes. Residents reported waiting times of up to two hours, and staff acknowledged the need for more nursing assistants and LPNs to address care demands.
The facility failed to maintain sanitary conditions in food storage, preparation, and service. Observations revealed improperly stored food items, staff not adhering to hygiene protocols, and uncovered food being transported through the facility, even during a COVID-19 outbreak. These actions were acknowledged by various staff members, including the Senior Cook, Director of Nursing, and Infection Preventionist.
The facility failed to properly log and resolve grievances for several residents, including missing personal items and environmental concerns. A resident with impaired memory reported missing items that were not documented or resolved, while another resident experienced delays in retrieving laundry. Additionally, a resident with paraplegia had their AC unit removed, causing discomfort, and was not provided with a grievance report. Staff inconsistencies in handling grievances contributed to these deficiencies.
The facility failed to ensure accurate MDS completion dates for three residents, as the RN coordinator backdated the assessments, which is unethical. Staff T, the MDS Coordinator, admitted to the discrepancy and acknowledged the need for further MDS education. Staff A, the Administrator, confirmed that backdating is unacceptable and emphasized the importance of documenting actual completion dates.
The facility failed to maintain accurate and accessible Level 1 PASRR documentation for three residents, leading to unassessed mental health needs. A resident's PASRR did not include a dementia diagnosis, another's PASRR was not accessible to staff, and a third resident's PASRR was outdated and not updated after significant changes in their condition.
The facility failed to update care plans for several residents, leading to discrepancies between documented care needs and actual conditions. A resident's care plan included nebulizer treatments no longer needed, while another's required continuous oxygen therapy that was not provided. An IV antibiotic care plan was outdated, and a resident with a feeding tube had care plans encouraging oral fluids. A fall mat was not documented in a care plan despite its use, and a resident's care plan lacked guidance for care refusal. The Director of Nursing acknowledged these deficiencies.
The facility failed to provide adequate restorative nursing care to residents with limited range of motion (ROM), as required by their care plans. Several residents did not receive the prescribed active ROM exercises and splint training consistently, and there was a lack of documentation to support that these services were offered. Additionally, residents on hospice care were not evaluated for restorative nursing needs, and there were no orders for necessary interventions such as skin checks for those using braces.
The facility failed to properly manage tube feeding for residents, including inadequate documentation of feeding administration, insufficient weight monitoring, and improper labeling of feeding bags. A resident with multiple medical conditions had no recorded tube feeding intake for nearly a month, and their weight was not monitored as ordered. Two other residents had unlabeled or partially labeled feeding bags, which staff confirmed did not meet facility policy requirements.
Two residents in the facility experienced dissatisfaction with meal accommodations due to the facility's failure to honor their food preferences. One resident, who disliked sausage and rice, continued to receive these items despite informing staff. Another resident, with impaired swallowing and severe malnutrition, was unable to request preferred meals due to inconsistent menu distribution. Staff confirmed the lack of menu distribution, impacting the ability to meet residents' nutritional needs.
A facility failed to obtain informed consent for the use of an antidepressant medication for a resident with schizophrenia, impaired memory, and a history of cancer. The resident received the medication without documented consent, despite the facility's policy requiring informed consent for psychotropic medications. The Director of Nursing acknowledged the requirement but did not provide evidence of consent.
A facility failed to notify a Medicaid recipient when their personal fund account balance exceeded the SSI resource limit, as required by policy. The resident's account balance was $696.53 over the limit, risking their Medicaid coverage. Staff interviews revealed a lack of awareness and communication regarding Medicaid SSI resource limitations.
The facility failed to provide timely assistance in formulating Advanced Directives (ADs) for several residents. One resident with intact memory did not have an AD documented until 47 days after admission. Another resident received the AD packet over two weeks after admission. A resident with severe cognitive impairment was given an AD packet almost two months after admission, despite being unable to make decisions. Additionally, a resident with no memory impairment had incomplete AD documentation, and another resident did not have an AD or declination documented until two months after admission.
A resident, dependent on staff for transfers and toileting, experienced an unwitnessed fall, and the facility failed to conduct a thorough investigation as required by policy. The investigation lacked staff interviews, witness statements, and a neurological assessment, with conflicting information about the fall's circumstances. Interviews with staff revealed undocumented conversations instead of formal documentation, and the facility could not provide evidence supporting claims made in the investigation report.
The facility failed to provide written transfer/discharge notices and notify the LTCO for two residents hospitalized. One resident with severe memory impairment was sent to the hospital without a transfer notice, and another resident with a brain injury was discharged with an unsigned and incomplete notice. Staff confirmed the absence of required notifications and documentation.
The facility failed to complete a resident's Quarterly MDS assessment within the regulatory timeframe, as required by the RAI Manual. The resident's assessment was completed three days late, which was confirmed by the MDS Coordinator and acknowledged by the Administrator. This delay in assessment completion posed a risk for delayed care planning and unidentified care needs.
The facility failed to accurately complete MDS assessments for three residents, leading to potential risks of unmet care needs. A resident's Entry Tracking MDS was incorrectly coded, another's Quarterly MDS omitted a psychosis diagnosis despite antipsychotic medication use, and a third resident's activity preferences were inaccurately recorded due to unresponsiveness during the interview.
The facility failed to develop and implement comprehensive care plans for five residents, including those with malnutrition and feeding tube requirements. Despite the facility's policy, care plans lacked specific goals and interventions, as acknowledged by the DON.
The facility failed to follow and clarify physician's orders for two residents, leading to potential medication errors. A resident received a pain gel without proper measurement, and another had conflicting orders for oral medication despite requiring a PEG tube. Staff interviews confirmed the need for accurate dosing and order clarification.
The facility failed to assist two residents with ADLs, leading to poor hygiene and discomfort. One resident with Alzheimer's was not shaved for several days, despite their care plan. Another resident, with visual impairment, lacked adequate clothing and grooming assistance, resulting in long nails and unkempt hair. The DON acknowledged these deficiencies, noting staff should have reported care refusals.
A facility failed to provide individualized activities for a resident with dementia during a COVID outbreak. The resident expressed feelings of isolation and lack of engagement, as their care plan did not include specific activities. Staff interviews revealed that while group activities were halted, individual activities should have continued, but were not documented. The Resident Council also reported a lack of activities, leaving residents with limited recreational options.
A resident with chronic pain due to osteoarthritis did not receive adequate pain management in the facility. Despite having a care plan, the resident's complaints of sharp pain in the left leg were not documented or communicated between shifts. Interviews revealed that staff were unaware of the resident's pain, and the Director of Nursing acknowledged the lack of proper documentation, leading to ineffective pain management.
The facility failed to properly store, label, and dispose of medications, with issues found across multiple units. Medications were improperly labeled, expired, or stored with disinfectants. Unlocked medication carts and unsecured medications at a resident's bedside were also observed, highlighting lapses in safety protocols.
The facility failed to maintain an effective infection prevention and control program, with issues including overfilled sharps containers, uncleanable surfaces, incomplete Water Management Program, improper wound care, and poor catheter management. These deficiencies increased the risk of infection transmission among residents.
A resident's bed in an LTC facility was found to have a significant gap between the mattress and bed frame, posing an entrapment risk. The resident, with multiple medical conditions requiring substantial assistance, had an air mattress that was smaller than the bed frame, creating a gap confirmed by the Facilities Manager. The Director of Rehabilitation acknowledged the oversight, as the Rehabilitation Department failed to identify the risk despite frequent interactions with the resident.
A resident was discharged without the necessary information being provided to the Home Health Agency (HHA), leading to a delay in home health services. Additionally, the facility did not provide or document education on indwelling catheter care to the resident or their collateral contact (CC), resulting in a significant gap in post-discharge care.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident from verbal abuse and mistreatment, as evidenced by the experiences of a resident who suffered psychological harm due to repeated verbal abuse by their roommate. The resident, who had a history of depression and PTSD, was subjected to derogatory remarks and foul language, which escalated when staff did not address the situation promptly. Despite the resident's requests for a room change and reports of feeling distressed, the staff did not take immediate action to separate the residents or protect the victim from further abuse. The facility's policy on abuse prevention and prohibition was not followed, as staff failed to take measures to protect the resident from further psychological harm during the investigation. The resident's requests for a room change were not accommodated in a timely manner, and staff did not document any actions taken to prevent further abuse. The resident's emails to the social services assistant highlighted the severity of the situation, expressing feelings of disrespect, emotional crisis, and retraumatization due to the verbal abuse. Interviews with staff revealed a lack of adherence to the facility's abuse policy, as staff did not separate the residents or report the incidents to management and the state hotline as required. The Director of Nursing acknowledged that the staff did not follow the facility's abuse policy, which allowed the abuse to escalate and resulted in the resident experiencing emotional distress and retraumatization. The resident was eventually moved to a different room, but only after enduring significant psychological harm.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its abuse policies and procedures effectively, particularly in identifying verbal abuse, conducting thorough investigations, protecting residents, preventing further abuse, and timely reporting of abuse and neglect incidents. This was evident in the case of four residents who were involved in resident-to-resident incidents. The facility's policy on abuse prohibition and prevention required staff to identify abuse, conduct thorough investigations, document incidents, and implement immediate interventions to protect affected residents. However, these procedures were not followed, as seen in the incidents involving Residents 1 and 2, where verbal abuse was not addressed promptly, and the necessary notifications and interventions were delayed. Resident 1, who had a history of depression and other medical conditions, reported verbal abuse from their roommate, Resident 2, shortly after moving into the shared room. Despite Resident 1's requests to move rooms and reports of verbal abuse, staff failed to take immediate action or document the necessary interventions. The facility investigation revealed that Resident 1 experienced distress and psychological harm due to the ongoing verbal abuse, which was not reported to the state agency until four days after the initial incident. Similarly, Resident 3 experienced verbal abuse from Resident 4 during a dining room incident, which was not reported or investigated promptly, and there was a lack of documentation regarding monitoring for psychological harm. The facility's inaction and failure to adhere to its policies resulted in residents being exposed to ongoing verbal abuse and psychological harm. Staff did not separate the residents involved in the incidents, failed to notify management and state agencies in a timely manner, and did not document or implement protective measures for the affected residents. These deficiencies highlight significant lapses in the facility's abuse prevention and response protocols, putting all residents at risk for unidentified and ongoing abuse.
Failure to Notify Resident's Representative of Fall
Penalty
Summary
The facility failed to ensure that the responsible parties of residents were notified of changes in condition or incidents such as falls. This deficiency was identified in the case of one resident who was unable to make their own decisions and was non-verbal due to a history of a brain bleed, high blood pressure, and diabetes. The resident was dependent on staff for mobility and had impairments on one side of their body. Despite the facility's policy requiring notification of the resident's representative after a fall, there was no documentation to confirm that this notification occurred. The incident involved the resident being found on the floor by their bed, and it was believed that the fall was caused by the resident attempting to reposition themselves. The resident's representative was not informed of the fall until a care conference over a month later, leading to frustration and concern. The Director of Nursing Services confirmed that the notification was not documented and therefore not done, acknowledging the lapse in communication with the resident's representative.
Deficiencies in Water Temperature, Chemical Security, and Fall Prevention
Penalty
Summary
The facility failed to maintain safe hot water temperatures in resident rooms, posing a risk of burns and scalding. Observations revealed that hot water temperatures in multiple rooms exceeded the safe range of 105 to 115 degrees Fahrenheit, with some measurements reaching as high as 134 degrees Fahrenheit. The facility's Domestic Water Policy required monthly checks of hot water temperatures, but the logs showed inconsistencies and did not include measurements from resident rooms. Staff interviews confirmed that the hot water system required repairs, which had not been completed despite being identified months earlier. Additionally, the facility did not secure hazardous chemicals in two of its nursing units, increasing the risk of accidental ingestion or skin impairment. Observations showed that shower room doors were left unlocked, and chemicals were accessible to residents. Staff interviews confirmed that the doors should have been locked to prevent residents, especially those who are confused or wandering, from accessing these chemicals. The facility also failed to identify and mitigate fall risks for a resident with a history of falls. The resident, who required assistance with mobility and had visual impairments, reported having inadequate footwear and a broken bed, which contributed to their risk of falling. Despite previous falls and documented interventions, the facility did not adequately address the resident's needs, as evidenced by the resident's continued falls and the condition of their living environment.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient qualified nursing staff were available to meet the needs of all residents, particularly in providing assistance with Activities of Daily Living (ADL) and timely response to call lights. Observations and interviews revealed that call lights were left unanswered for extended periods, especially during shift changes. For instance, on one occasion, call lights were observed alarming for over ten minutes while nurses were in a shift change report. Residents reported waiting times ranging from 10 to 15 minutes to as long as two hours for assistance, particularly during shift changes between evening and night shifts. Multiple residents expressed concerns about the delayed response times and the impact on their care. Resident 52 recounted an incident where they had to manage a bladder accident on their own due to delayed staff response, which posed a risk of slipping and injury. Staff interviews indicated that while the facility was within required staffing ratios, there was a consensus that staffing should be based on the complexity of residents' care needs rather than just the number of residents. Staff members acknowledged that the facility could benefit from more nursing assistants and licensed practical nurses to adequately meet the care demands.
Sanitation Deficiencies in Food Handling and Storage
Penalty
Summary
The facility failed to ensure that food storage, preparation, and service were conducted in a sanitary manner, as observed in both the main kitchen and a unit pantry. In the dry storage area, a box of thickening powder was left open and exposed, and a container of granulated garlic was not labeled with a use-by date. Staff Z, the Senior Cook, acknowledged these storage issues. Additionally, Staff DD, a Dietary Assistant, was observed preparing a drink without securing their hair with a hairnet, contrary to facility policy as stated by Staff AA, the Food Service Director. In the 400 Unit Pantry, a refrigerator contained improperly stored items, including a half-eaten quesadilla and an opened, unlabeled bottle of lemonade. The pantry's water and ice dispensing machine had a buildup of yellow-green slime. Staff B, the Director of Nursing, confirmed the need for cleaning and proper food storage. During lunch preparation, Staff R, a Cook, was observed handling food with soiled gloves after adjusting their surgical mask without performing hand hygiene, despite the facility being in a COVID-19 outbreak. Meal tray service was also compromised, with desserts left uncovered while being transported past an isolation room. Staff P, a CNA, admitted that some desserts were left uncovered, potentially due to concerns about frosting. Staff Q, the Infection Preventionist, and Staff N, the District Dietary Manager, both emphasized the importance of covering food to prevent contamination, especially during a COVID-19 outbreak. Observations on a later date showed similar issues with uncovered food being transported through the facility.
Deficiencies in Grievance Handling and Resolution
Penalty
Summary
The facility failed to maintain a system to ensure resident grievances were identified, logged, and resolved in a timely manner, affecting four residents. Resident 28, who had impaired memory and was dependent on staff for self-care, reported missing personal items, including an electric razor, nail clippers, and a $350 watch. Despite the facility's policy requiring grievances to be resolved within ten days, there was no record of these grievances in the facility's log. Staff E, the Social Services Director, acknowledged the missing watch but could not provide documentation or evidence of resolution, highlighting a gap in the grievance process. Resident 31, who had no memory impairment, expressed frustration over missing clothes that had been sent to the laundry. Despite repeatedly asking staff for assistance, the clothes were not returned promptly, and no grievance was logged. Staff E admitted that missing items were not tracked in the grievance log but were instead communicated via emails, which were set to delete after two years. This lack of formal documentation and follow-up contributed to the delay in resolving Resident 31's grievance. Resident 6, who had paraplegia and required an air conditioner for medical reasons, reported that their AC unit was removed, causing discomfort. Despite verbalizing the need for the AC to nursing staff, the issue was not addressed promptly, and Resident 6 was not provided with a grievance report. Staff interviews revealed inconsistencies in the grievance process, with some staff unaware of how to file grievances and others failing to log or investigate reported issues. These deficiencies in the grievance handling process placed residents at risk for unresolved concerns and a decreased quality of life.
Inaccurate MDS Completion Dates by RN Coordinator
Penalty
Summary
The facility failed to ensure that the Registered Nurse (RN) responsible for attesting to the accuracy and completeness of resident assessments was knowledgeable of the Minimum Data Set (MDS) process. This deficiency was identified for three residents whose Quarterly MDS assessments were reviewed for accuracy and timeliness. The RN coordinator inaccurately recorded the completion dates of the MDS assessments for Residents 67, 20, and 45, as the dates in the medical records did not match the actual completion dates found in the assessment history report. This discrepancy indicates that the assessments were backdated, which is considered unethical and a violation of the guidelines outlined in the Resident Assessment Instrument (RAI) Manual. During interviews, Staff T, the MDS Coordinator, acknowledged referring to the RAI manual for assessment coding and guidance and confirmed that the MDS assessments should be completed accurately. Staff T admitted that the completion dates for the residents' assessments were backdated and expressed a need for further MDS education. Additionally, Staff A, the Administrator, stated that backdating MDS completion dates was unacceptable and emphasized the expectation for MDS coordinators to document the actual completion dates in the residents' medical records.
Failure to Maintain Accurate and Accessible PASRR Documentation
Penalty
Summary
The facility failed to ensure accurate and updated Level 1 Preadmission Screening and Resident Reviews (PASRR) for three residents, which is required to assess the need for further evaluation for serious mental illness or intellectual disabilities. Resident 28's PASRR did not include their dementia diagnosis, despite the resident having impaired memory and receiving antipsychotic, antidepressant, and antianxiety medications. Staff E acknowledged the importance of having accurate PASRRs but failed to update Resident 28's PASRR with the dementia diagnosis. Resident 45's PASRR was not accessible to staff, even though the resident had been referred for a Level 2 evaluation due to serious mental illness. Staff E found the updated PASRR in their office, indicating it was not readily available to other staff members. Resident 32's PASRR was outdated and did not reflect significant changes in their condition, such as the decision to enroll and later dis-enroll from hospice services. Staff E admitted to not knowing that a Level 1 screening was required after significant changes, resulting in the failure to update Resident 32's PASRR.
Care Plan Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure that care plans were revised and updated to reflect the current care needs of six residents. For Resident 28, the care plan included nebulizer treatments for shortness of breath, but observations showed no nebulizer machine in the room, and the Director of Nursing confirmed that the resident no longer received these treatments, indicating the care plan needed revision. Similarly, Resident 32's care plan indicated the need for continuous oxygen therapy, yet observations showed the resident breathing without supplemental oxygen, and the Director of Nursing acknowledged the care plan was outdated. Resident 66's care plan included instructions for monitoring an IV site for antibiotic administration, but the medication had been discontinued weeks earlier, and the Director of Nursing stated the care plan should have been updated. Resident 189's care plan contained instructions to encourage fluid intake, despite a physician's order for no oral intake, which was not reflected in the care plan. The Director of Nursing confirmed the need for revision. For Resident 239, the care plan did not include the use of a fall mat, despite observations and a physical therapy assessment indicating its necessity after a fall. The Director of Nursing stated the care plan should have been updated to include this intervention. Lastly, Resident 64's care plan lacked specific instructions for staff on handling care refusal, and observations showed the resident feeling neglected and lonely. The Director of Nursing acknowledged the care plan needed to be complete and accurate to guide staff in providing care.
Failure to Provide Adequate Restorative Nursing Care
Penalty
Summary
The facility failed to ensure that residents with limited range of motion (ROM) were evaluated or provided with the necessary care and services, including a Restorative Nursing Program (RNP). This deficiency was observed in four residents who were assessed to require such interventions. The facility's policy mandates the provision of restorative nursing services to promote residents' ability to function at their highest level. However, the facility did not adhere to this policy, as evidenced by the lack of consistent RNP offerings and documentation. Resident 45, who had functional limitations due to heart and kidney failure and a brain injury, was not provided with the prescribed active ROM exercises and splint training as frequently as assessed and planned. The facility's documentation showed inconsistencies in offering these services, and there was no evidence of skin checks being conducted as ordered. Similarly, Resident 20, with a brain injury and resulting weakness, did not receive the planned RNP interventions consistently, and there was no documentation to support that the program was offered as required. Resident 58, who was on hospice care, had functional limitations but was not receiving any exercises for their condition. The facility failed to notify the hospice care team of the need for an RNP evaluation. Resident 239, also on hospice care, had a functional limitation in ROM and was using a wrist brace, but there was no assessment or evaluation for RNP. The facility did not have any orders for the use of the brace or for conducting skin checks. These failures indicate a lack of adherence to the facility's policies and procedures, placing residents at risk for further decline in mobility and function.
Deficiencies in Tube Feeding Management and Documentation
Penalty
Summary
The facility failed to implement necessary care for residents with feeding tubes, as evidenced by the lack of documentation of tube feeding (TF) administration, inadequate weight monitoring, and improper labeling of TF bags. Resident 45, who had medical conditions including heart and kidney failure, uncontrolled blood sugar levels, and difficulty swallowing, was on a tube feeding regimen. However, from July 1 to July 29, 2024, there was no documentation of the TF intake being monitored or recorded by nurses during each administration, despite the facility's policy requiring such documentation. Additionally, Resident 45 was not weighed weekly as ordered, with significant fluctuations in weight observed, indicating a failure to monitor the resident's nutritional status effectively. Resident 75, who required a feeding tube for at least half of their nutritional intake, was found with an unlabeled TF bag in their room. The bag did not have the resident's name, product information, date/time, or rate of administration, contrary to the facility's policy. Similarly, Resident 26, who also required a feeding tube for nutritional intake, had a TF bag that was only partially labeled, missing critical information about the contents and administration rate. These labeling deficiencies were confirmed by staff members during observations and interviews. The facility's Director of Nursing (DON) acknowledged the deficiencies, stating that TF orders must be complete and accurately documented to evaluate residents' nutritional needs effectively. The DON also confirmed that weight monitoring was essential for residents on TF to assess the appropriateness of nutritional interventions. The lack of proper documentation and labeling placed residents at risk of not meeting their nutritional requirements and developing complications from tube feeding.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
The facility failed to provide meals that accommodated the food preferences of two residents, leading to dissatisfaction and potential nutritional risks. Resident 31, who had no memory impairment and was able to communicate effectively, expressed dissatisfaction with the meals provided, specifically noting a dislike for sausage and rice. Despite informing staff multiple times, these items continued to be served. Observations confirmed that Resident 31 was not consuming the sausage provided, and the resident expressed frustration over the inability to request meal changes due to the late distribution of daily menus. The resident's care plan highlighted the importance of encouraging meal consumption to prevent pressure ulcers, yet their preferences were not being honored. Similarly, Resident 20, who had medical conditions including impaired swallowing and severe malnutrition, was unable to have their food preferences accommodated due to the late distribution of menus. The resident's care plan required staff to assess and incorporate their food preferences to address nutritional risks. However, the facility's process for distributing menus was inconsistent, and the dietary manager responsible for this task had left the facility. Staff interviews confirmed the lack of menu distribution, which hindered the ability to honor residents' food preferences.
Failure to Obtain Informed Consent for Antidepressant Use
Penalty
Summary
The facility failed to obtain informed consent for the use of an antidepressant (AD) medication for one resident, identified as Resident 79, who was reviewed for unnecessary medications. This oversight placed the resident at risk of receiving unwanted psychotropic medications. Resident 79 had impaired memory, an acute onset change in mental status, and fluctuating attention and consciousness, with medical diagnoses including uncontrolled muscle movements, schizophrenia, and a history of cancer. The resident received an AD medication during the assessment period, as per the physician's order dated 07/15/2024, to be administered at night for schizophrenia. A review of the resident's records showed no evidence that informed consent was obtained before administering the AD medication. During an interview, the Director of Nursing acknowledged that informed consent was required prior to the use of an AD medication and stated they would verify and provide evidence of informed consent for Resident 79's medication use. However, no further information was provided by the facility.
Failure to Notify Resident of SSI Resource Limit Exceedance
Penalty
Summary
The facility failed to notify a Medicaid recipient, Resident 10, when their personal fund account balance reached $1,800, which is within $200 of the $2,000 resource limit that could impact their Medicaid coverage. According to the facility's Resident Trust policy, revised in May 2017, the facility was required to notify the resident, their guardian or durable power of attorney, the facility social worker, and the local department of social and health services in writing when a resident's account balance approached this limit. However, the facility did not adhere to this policy, resulting in Resident 10's account balance exceeding the SSI resource limit by $696.53 as of July 23, 2024. Interviews with facility staff revealed a lack of awareness and communication regarding the Medicaid SSI resource limitations. Staff W, an Administrative Assistant, confirmed the excess balance but was unaware of the Medicaid SSI resource limitations and did not discuss trust balances with the social worker. Staff E, the Social Services Director, mentioned that it had been years since they were notified about a resident exceeding their SSI resource limits. The facility administrator, Staff A, acknowledged that Resident 10 should have been notified as per the policy but was not. This oversight placed the resident at risk for personal financial liability for their care.
Failure to Timely Assist Residents with Advanced Directives
Penalty
Summary
The facility failed to provide timely assistance in formulating Advanced Directives (ADs) for five out of six residents reviewed. Resident 68, who had intact memory, was admitted to the facility and did not have an AD documented until 47 days after admission. The document lacked details on when the AD toolkit was provided or if the resident needed assistance. Resident 31, with no memory impairment, received the AD packet over two weeks after admission, as confirmed by the resident. Resident 75, with severe cognitive impairment, was provided an AD packet almost two months after admission, despite being unable to make decisions and having family involvement noted in their records. Resident 189, who had no memory impairment, had an incomplete AD status section in their records and no documentation of a Power of Attorney (POA), despite the resident stating they had one. Resident 6, who was understood and had clear comprehension, did not have an AD or declination documented until two months after admission. The facility's social services department noted that an AD toolkit was provided and a copy requested from the resident and family. Staff interviews revealed expectations that ADs should be readily available in residents' records, highlighting the facility's failure to meet these expectations.
Inadequate Investigation of Resident Fall
Penalty
Summary
The facility failed to conduct a thorough investigation of an unwitnessed fall involving a resident, identified as Resident 239, which left the resident at risk for unidentified abuse and/or neglect. Resident 239, who was totally dependent on two staff members for transfers and toileting, had a history of falls and was receiving end-of-life care due to multiple medical conditions, including cancer and pressure ulcers. Despite the facility's policy requiring a comprehensive investigation, the report lacked staff interviews or witness statements, and there was conflicting information regarding whether the fall was witnessed or unwitnessed. Additionally, the investigation did not include a neurological assessment for the resident, and there was no documentation to support that the resident was offered toileting assistance multiple times before the fall, as claimed in the investigation report. Interviews with facility staff revealed further deficiencies in the investigation process. The Director of Nursing acknowledged that the fall was unwitnessed and admitted to having undocumented conversations with staff instead of formal interviews or statements. The Administrator emphasized the importance of thorough investigations to rule out abuse or neglect but noted that the designated staff failed to complete the investigation as required. The facility's inability to provide documentation supporting the claims made in the investigation report further highlighted the inadequacy of the investigation process.
Failure to Provide Transfer/Discharge Notices and Ombudsman Notification
Penalty
Summary
The facility failed to provide written transfer or discharge notices and complete notification to the Office of the State Long-Term Care Ombudsman (LTCO) for two residents reviewed for hospitalization. Resident 32, who had severe memory impairment and was diagnosed with Alzheimer's disease and Diabetes Mellitus, experienced an acute change in condition and was sent to the hospital emergently. However, there was no evidence that a transfer notice was completed and given to Resident 32 or their representative. Staff S, the Health Information Manager, confirmed the absence of a written transfer notification and stated that it could not be sent to the LTCO office as it did not exist. Resident 20, who had a brain injury, malnutrition, and difficulty urinating, was discharged to the hospital due to pressure and pain in the lower abdomen and blood clots in the urine. The medical records showed an unsigned and incomplete transfer notice, lacking an explanation to support the discharge. Staff S confirmed the notice was not signed by the resident or their representative and acknowledged the absence of documentation to support that the Ombudsman was notified. Staff A, the Administrator, emphasized the importance of providing written transfer/discharge notifications to communicate the resident's current location and ensure notification of rights and regulations associated with their transfer/discharge.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to complete the Quarterly Minimum Data Set (MDS) assessments within the regulatory timeframe for one of the three residents reviewed, specifically Resident 67. According to the October 2023 Resident Assessment Instrument (RAI) Manual, a Quarterly MDS is a non-comprehensive assessment that must be completed no later than 14 days after the established Assessment Reference Date (ARD) and no later than 92 days from the ARD of the most recent prior quarterly or comprehensive assessment. Resident 67's comprehensive Admission assessment was completed on March 18, 2024, but the subsequent Quarterly assessment, scheduled for June 3, 2024, was not completed until June 17, 2024, which was three days past the 92-day regulatory completion timeframe. During interviews, Staff T, the MDS Coordinator, acknowledged the importance of timely MDS assessments for appropriate and safe care planning and confirmed that Resident 67's Quarterly MDS was completed late. Staff A, the Administrator, stated that they expected MDS coordinators to complete assessments accurately and timely as required. This deficiency in timely assessment completion placed residents at risk for delayed care planning, unidentified care needs and services, and a decreased quality of life.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for three residents, leading to potential risks of unidentified and unmet care needs. For Resident 189, the Entry Tracking MDS was incorrectly coded as an admission instead of a reentry after a hospital stay of less than 30 days. This error was acknowledged by the MDS Coordinator, who admitted to the mistake and emphasized the importance of accurate coding for continuity and coordination of care. Resident 28's Quarterly MDS did not reflect a diagnosis of psychosis, despite the resident receiving antipsychotic medication for delusions. The Director of Nursing confirmed the oversight, noting that the diagnosis should have been included in the MDS. Resident 68's Admission MDS inaccurately recorded their activity preferences due to the resident being unresponsive during the interview. Although the resident was able to answer questions about mood, pain, and daily preferences, the activity preferences section was marked as nonresponsive, and a staff assessment was used instead. This assessment failed to capture the resident's specific interests, such as spending time outdoors, which the resident later expressed. The staff member conducting the interview acknowledged the discrepancy and the lack of a follow-up attempt to gather more detailed information.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans (CPs) for five residents, which is a requirement within 21 days after admission according to the facility's policy. Resident 68, who had intact memory and diagnoses including a wound infection, malnutrition, and depression, was observed to be very thin and expressed a desire to regain lost weight. However, their CP for severe calorie protein malnutrition lacked any associated goals or interventions. Similarly, Resident 31, who had multiple medically complex diagnoses including cancer, had no CP addressing their nutritional concerns despite being assessed for such needs. Resident 66, with mild memory impairment and an unhealed pressure ulcer, had a CP for severe protein calorie malnutrition initiated but without any resident-specific goals or interventions. Resident 75, who required a feeding tube for nutritional intake, also had an altered nutrition CP initiated without goals or interventions. Lastly, Resident 189, who similarly required a feeding tube, had an altered nutrition CP initiated without any goals or interventions. The Director of Nursing acknowledged the importance of complete CPs to ensure necessary interventions are in place, yet these deficiencies were observed.
Failure to Follow and Clarify Physician's Orders
Penalty
Summary
The facility failed to ensure that physician's orders were followed and clarified as needed for two residents, leading to potential risks of medication errors and adverse outcomes. For Resident 13, during a medication pass, a staff member was observed preparing a pain medication gel without using a dose measuring card, as required by the physician's order. The medication administration record indicated that the resident was prescribed four grams of the gel to be applied to the right knee twice daily. However, the staff member used a medication cup instead, which did not allow for accurate measurement of the prescribed dose. Interviews with facility staff confirmed that the correct procedure involved using a dosing card to measure the medication accurately. For Resident 189, the facility failed to clarify conflicting physician's orders regarding medication administration. The resident, who had multiple complex medical diagnoses and required a feeding tube for nutrition, had an order indicating no food or fluids by mouth. Despite this, the medication administration record showed an order to administer a blood-thinning medication orally, contradicting the previous order. The Director of Nursing acknowledged that the order needed clarification to ensure the medication was administered correctly through the PEG tube, as per the resident's dietary restrictions.
Failure to Assist Residents with ADLs
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADL) for two residents who were dependent on staff for their daily care. Resident 32, diagnosed with Alzheimer's disease, was observed over several days with an unshaven beard, despite their care plan indicating a preference for being clean-shaven. The Director of Nursing acknowledged that Resident 32's appearance was important to them and expected staff to assist with shaving as part of their ADL care. However, the resident was not shaved until several days after the initial observation, indicating a lapse in the provision of grooming assistance. Resident 64, who required assistance with dressing and grooming due to visual impairment and functional cognition issues, reported having inadequate clothing and footwear, leading to discomfort and poor hygiene. Observations revealed that Resident 64's fingernails and toenails were excessively long, and their hair was unkempt. Despite the care plan stating that staff should meet Resident 64's ADL needs daily, the resident expressed that they rarely received help with dressing and grooming. The Director of Nursing noted that staff should have reported the resident's long nails and refusals for care, but this was not done, further highlighting the deficiency in providing adequate ADL support.
Failure to Provide Individualized Activities During COVID Outbreak
Penalty
Summary
The facility failed to ensure that activity programs met the needs of each resident, specifically for Resident 64, who was reviewed for activities. Resident 64, who had unspecified dementia and behavioral disturbances, expressed a preference for books, newspapers, music, and choosing daily activities. Despite this, the resident's care plan indicated a need for encouragement to participate in daily activities and assistance in choosing enjoyable activities. However, the Kardex did not list any activities for Resident 64, and the resident expressed feelings of isolation and lack of engagement, stating they had nothing to do and were not allowed to go outside. Interviews with staff revealed that group activities were halted due to a COVID outbreak, but individual activities were supposed to continue. Staff U, the Activities Supervisor, mentioned that newsletters were distributed, and activities for cognitive stimulation were provided, but no specific activities were documented for Resident 64. The Director of Nursing acknowledged the lack of an activity assessment for Resident 64 and emphasized the importance of individualized care plans for residents with dementia. The Resident Council also reported a lack of activities during the outbreak, with residents feeling limited to phone calls or watching television.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide adequate pain management for Resident 12, who was experiencing chronic pain due to osteoarthritis. Despite having a care plan that included goals for pain relief and instructions for staff to report unrelieved pain to the Medical Director, the facility did not follow through with these measures. Resident 12 reported experiencing daily pain and specifically mentioned sharp pain in the left lower leg, which was not addressed by the nursing staff. The resident expressed frustration that their complaints were not being communicated between shifts or followed up by the medical team. Interviews with staff revealed a lack of awareness and documentation regarding Resident 12's pain. Staff V, an LPN, was unaware of the resident's calf pain and stated that residents needed to inform nurses daily about their pain issues. The Director of Nursing, Staff B, acknowledged that documentation of pain was not completed as expected, which hindered the identification and treatment of the resident's pain. The absence of proper documentation and communication among the nursing staff led to the deficiency in managing Resident 12's pain effectively.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage, labeling, and disposal of medications across multiple units, leading to potential risks for residents. On Unit A, a medication cart was found with an open vial of blood thinning medication lacking a date or resident label, and an insulin vial that was not refrigerated as required. Staff HH acknowledged the expectation for medications to be labeled and dated, and for insulin to be refrigerated. On Unit B, an eye drop medication was found expired, and various creams and ointments were improperly stored together. Staff M admitted to missing the expiration and confirmed the improper storage. On Unit D, medications were stored next to a disinfectant container, which was confirmed by Staff CC. In the medication rooms of Units A and B, expired supplies and medications for discharged residents were found. Staff II and Staff M acknowledged the presence of expired items and the need to return medications to the pharmacy. Staff B confirmed the expectation for medications to be labeled, dated, refrigerated, and returned within 30 days of a resident's discharge. Additionally, an unlocked medication cart was observed on Unit C, with Staff EE acknowledging the expectation for carts to be locked. Resident 240 was found with unsecured medications at their bedside, including an inhaler and a cup of pills. Staff KK and Staff B confirmed the lack of a self-medication assessment for Resident 240, despite an order for an inhaler to be kept at bedside. Staff B emphasized the importance of securing medications and conducting assessments for resident safety.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, resulting in several deficiencies. Observations revealed that sharps containers in three resident rooms were filled beyond the maximum fill line, posing a risk of accidental needle sticks and disease transmission. Additionally, one resident room had floor mats with torn and peeling corners, making them uncleanable and increasing the risk of infection. The facility also lacked a complete Water Management Program, as the Facilities Manager admitted to not having a diagram of the facility with identified areas of risk for Legionella, and the risk assessment was incomplete. Further deficiencies were noted in wound care and catheter management. A resident with a Stage IV pressure ulcer did not receive care in accordance with infection control standards, as a Certified Nursing Assistant failed to perform hand hygiene after removing personal protective equipment and before retrieving a clean garbage bag. Another resident with a long-term indwelling urinary catheter was observed with their catheter drainage bag lying on the floor, which was acknowledged by a Licensed Practical Nurse as an infection control concern.
Entrapment Risk Due to Improper Bed and Mattress Fit
Penalty
Summary
The facility failed to ensure that resident beds did not have gaps that could pose an entrapment risk, specifically for one resident whose bed was observed for accident hazards. The facility's policy required regular inspections and maintenance of medical devices and equipment, including beds and mattresses, to ensure resident safety. However, during an observation, it was found that the resident's air mattress was smaller than the bed frame, creating a gap of six inches at the head of the bed, which increased to ten inches when a pillow was removed. This gap was confirmed by the Facilities Manager as an entrapment risk. The resident involved had multiple medical diagnoses, including elevated blood sugar levels, heart and kidney failure, and generalized weakness, requiring substantial assistance with daily activities, including bed mobility. Despite the care plan's instructions to minimize gaps between the mattress and bed frame, the gap was not addressed. The Director of Rehabilitation acknowledged the oversight, noting that the Rehabilitation Department, which frequently interacted with the resident, failed to identify the risk. This deficiency placed the resident at risk for injury, entrapment, or death.
Failure to Ensure Safe Discharge and Provide Necessary Care Instructions
Penalty
Summary
The facility failed to ensure a safe discharge for a resident who was reviewed for discharges. The resident, who had a left hip fracture, left lower leg fracture, and an indwelling catheter, was discharged without the necessary information being provided to the Home Health Agency (HHA). The discharge summary did not specify the required home health services, and the referral to the HHA was incomplete, leading to a delay in the initiation of home health services for five days after discharge. Additionally, the facility did not provide or document education on indwelling catheter care to the resident or their collateral contact (CC). The resident and their CC were unaware of how to care for the catheter, which was crucial for the resident's post-discharge care. The facility's social services director assumed that the HHA would contact them if more information was needed, but this did not happen promptly, resulting in a lack of necessary care instructions being communicated. The HHA required specific information about the resident's care needs, including details about the catheter, which were not provided in a timely manner. The facility's failure to ensure that the HHA had all the required information and to educate the resident and their CC on catheter care led to a significant gap in the resident's post-discharge care, placing the resident at risk for unmet care needs and potential complications.
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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