Mckay Healthcare & Rehab Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Soap Lake, Washington.
- Location
- 127 Second Avenue Southwest, Soap Lake, Washington 98851
- CMS Provider Number
- 505390
- Inspections on file
- 30
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Mckay Healthcare & Rehab Ctr during CMS and state inspections, most recent first.
A resident with COPD, depression, chronic pain, polysubstance abuse disorder, and a documented moderate elopement risk required supervision with walking but had no elopement care plan in place. After a family visit with no recorded sign-out, an LPN later found the resident absent from the room, accepted the roommate’s statement that the resident went to lunch with family, did not verify this with the family, and did not initiate the missing resident/elopement protocol despite the resident not returning by the end of the shift. The resident’s absence was not formally recognized until the next day when a nurse noted the resident missing at medication time, contacted the family, and learned the resident had been dropped off in the parking lot the prior afternoon, leading to delayed implementation of the elopement protocol and the resident ultimately being found off premises and sent to the hospital for evaluation.
The facility failed to ensure dignity and privacy for three residents, including inadequate restroom privacy for two residents and neglecting vision care needs for another. Staff used a small restroom with insufficient privacy for residents requiring mechanical lifts, despite a larger option being available. Additionally, a resident's deteriorated glasses were not replaced due to a misunderstanding of palliative care policies.
A resident with Parkinson's disease expressed a desire to eat meals in their room due to noise in the dining room, but was told they had to eat in the dining room because of choking issues. The DON confirmed residents have the right to choose their dining location, but it was unclear why this resident's choice was not honored.
The facility failed to send required Level 2 PASARR referrals for two residents with serious mental illness, despite positive Level 1 screenings indicating conditions such as depression and anxiety. This oversight was acknowledged by the Social Services Director, who had not yet reviewed all resident records for compliance.
A facility failed to provide trauma-informed care for a resident with a history of severe abuse. Despite the resident's representative identifying specific trauma triggers, these were not documented in the care plan. The Social Service Assessment noted the resident's history and triggers, but this information was not communicated or incorporated into the care plan, highlighting a breakdown in the facility's process.
A resident with major depressive disorder and anxiety experienced a significant medication error when their prescribed anti-depressant, paroxetine, was discontinued for 18 days despite a PCP's order to continue it indefinitely. The error was not identified by the facility's staff, and the PCP was not notified, discovering the issue during a medication review.
A facility failed to maintain a current hospice agreement and did not implement a process for effective communication with the hospice provider for a resident with Parkinson's disease and heart failure. The hospice agreement was outdated and unsigned, and the resident's care plan lacked hospice-related interventions until days after enrollment. Staff interviews revealed inadequate documentation and communication processes, placing the resident at risk of not receiving necessary end-of-life care.
A facility failed to ensure agency staff proficiency in mechanical lift use, leading to a resident's fall during a transfer. The facility's policy required two staff members for mechanical lift transfers, but agency staff were not verified for proficiency. A newly trained agency NA, unfamiliar with the facility's policy, was left alone with a resident during a transfer, resulting in the resident sliding off the lift. The facility did not verify proficiency skills for agency staff prior to their assignments.
A resident with a progressive neurological condition fell during a transfer using a sit-to-stand lift due to improper use of the lift and lack of adherence to facility protocols. The resident, who required two-person assistance, was left with only one staff member present, and the safety buckle was not secured, leading to a fall and hospital evaluation.
The facility failed to maintain the scheduled bathing frequency for two residents, compromising their dignity and hygiene. One resident with Parkinson's Disease received only two out of nine scheduled showers, while another with dementia received three out of nine. Staff cited staffing shortages as a reason for missed showers, and the DON was unaware of the issue.
The facility failed to monitor blood pressure when administering medications for two residents, leading to a deficiency. One resident with Parkinson's and high BP was prescribed Lisinopril with instructions to hold if SBP was below 90, but no BP monitoring was documented. Another resident with heart disease and high BP was prescribed Spironolactone with similar instructions, yet no BP monitoring was recorded. Staff interviews revealed a lack of prompts for BP checks, and the DON acknowledged system inadequacies.
A resident with a history of sexually inappropriate behavior was not adequately supervised, leading to a non-consensual incident with a severely cognitively impaired resident. Despite the known risk, the facility did not implement one-on-one supervision, resulting in psychosocial harm to the victim.
The facility failed to report an allegation of neglect involving a resident with a neurological disorder to the State Survey Agency. The resident's representative reported suspected neglect and denial of liquids, but the Director of Nursing did not report it, believing it did not meet the criteria. This placed residents at risk for continued neglect.
Failure to Implement Elopement Protocol for At-Risk Resident
Penalty
Summary
The facility failed to implement its elopement protocol for a resident assessed at moderate risk for elopement, resulting in the resident being missing for an extended period before the protocol was initiated. The facility’s policy defined a suspected elopement as when a resident’s whereabouts are not immediately known and required staff to alert personnel using an internal alert code. The resident had diagnoses including COPD, depression, chronic pain, and polysubstance abuse disorder, and a comprehensive assessment showed the resident required supervision or touching assistance with walking and had intact cognition. An elopement risk assessment documented a moderate elopement risk score of five, but the resident’s care plan did not include an elopement care plan. The visitor sign-in sheet showed a family member visited the resident and signed in late in the morning, with no sign-out time for either the family member or the resident. On the day of the incident, an LPN administered the resident’s morning medications early in the day and later returned to give scheduled afternoon medications, at which time the resident was not in the room. The roommate reported the resident had gone to lunch with a family member, but the LPN did not call the family to verify this information, was unaware of any required time frame to contact the resident or family about return time, and did not implement the missing resident/elopement protocol, even though the resident did not return by the end of the LPN’s shift. Progress notes documented the resident as missing the following morning when the dayshift nurse noted the resident was not present for scheduled morning medications and then contacted the family, learning the resident had been dropped off in the facility parking lot the previous afternoon. The missing resident/elopement protocol was implemented at that time, approximately 18 hours after the resident was missing from the facility, and the administrator later confirmed that nothing had been done when the resident was first missing until the next day, when the resident was subsequently found by the water about half a mile from the facility and sent to the hospital for evaluation.
Failure to Ensure Resident Dignity and Privacy
Penalty
Summary
The facility failed to uphold resident rights to dignity and privacy for three residents, leading to distress and embarrassment. Resident 14, diagnosed with Parkinson's disease and dependent on staff for activities of daily living, was observed waiting in a hallway for restroom use. The restroom used was small, with inadequate privacy due to a curtain that left a gap, and staff discussions about the resident's toileting needs were overheard. The resident's representative expressed concerns about the lack of privacy, noting a larger restroom was available but not used. Resident 27, with a history of stroke, kidney disease, and dementia, was also subjected to inadequate privacy during toileting. Staff used a mechanical lift to transfer the resident to a restroom where the door was not shut, and toileting activities were audible from the hallway. Staff interviews revealed a preference for using a smaller restroom for convenience, despite the availability of a larger, more private option. Resident 29, diagnosed with neurocognitive disorder with Lewy bodies and Alzheimer's disease, experienced neglect in addressing their vision needs. The resident's glasses were visibly deteriorated, obstructing vision, yet staff informed the resident's representative that vision appointments were not typically arranged for residents receiving palliative care. This decision was based on a misunderstanding of palliative care, equating it with hospice care, which led to the resident's needs being unmet.
Failure to Honor Resident's Dining Preferences
Penalty
Summary
The facility failed to honor a resident's right to self-determination regarding their dining experience. Resident 14, who was admitted with Parkinson's disease, difficulty speaking, and difficulty swallowing, expressed a preference to eat meals in their room due to the noise in the dining room. Despite being able to communicate their needs, the resident was told they had to eat in the dining room because of their choking issues. During an interview, the Director of Nursing confirmed that residents have the right to choose where they eat and that staff assistance would be provided if a resident chose to eat in their room. However, it was unclear why Resident 14's choice was not respected, indicating a failure to support the resident's right to make significant life choices, as outlined in the facility's policy on resident rights.
Failure to Complete PASARR Level 2 Referrals
Penalty
Summary
The facility failed to properly review and validate the Preadmission Screening and Resident Reviews (PASARR) for two residents, which is a critical assessment to ensure individuals with serious mental illness (SMI) or intellectual/developmental disabilities (ID/DD) are not inappropriately placed in nursing homes. Specifically, the facility did not send the required Level 2 referral for residents who had a positive Level 1 PASARR, indicating the presence of SMI. This oversight was identified for two residents, both of whom had documented mental health conditions such as depression and anxiety. Resident 31 was admitted with diagnoses including depression, restlessness, agitation, and insomnia, and was found to have a SMI of both depression and anxiety according to their PASARR. However, no Level 2 referral was sent for this resident. Similarly, Resident 26, who was admitted with depression, anxiety, and insomnia, also had a positive Level 1 PASARR indicating SMI, but no Level 2 referral was made. The Social Services Director acknowledged awareness of the requirement but had not yet reviewed all resident records to ensure compliance.
Failure to Provide Trauma-Informed Care for Resident
Penalty
Summary
The facility failed to provide trauma-informed care for Resident 29, who had a history of severe physical and mental abuse. Despite the resident's representative informing the facility of specific trauma triggers, such as fast movements and movements towards the face, these were not documented in the resident's care plan. The Social Service Assessment completed on admission noted the resident's history of abuse and identified triggers like loud noises, but this information was not incorporated into the care plan. Interviews with staff revealed a lack of awareness and communication regarding Resident 29's trauma history. Staff J, the Social Services Director, was responsible for updating the care plan with identified triggers and interventions but failed to do so. The Director of Nursing confirmed that the trauma and triggers should have been addressed in the care plan, indicating a breakdown in the facility's process for ensuring trauma-informed care.
Failure to Administer Anti-Depressant Medication as Ordered
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically concerning the administration of an anti-depressant medication. Resident 2, who was diagnosed with major depressive disorder and anxiety, was prescribed paroxetine to be taken daily. The physician's order, dated November 5, 2024, indicated that the medication should be administered for 90 days, with a reassessment by the Primary Care Provider (PCP) before the stop date of February 3, 2025. However, despite the PCP's order on January 28, 2025, to continue the medication indefinitely, the medication was discontinued on February 3, 2025, and not restarted until February 21, 2025, resulting in an 18-day lapse. Interviews revealed that the Director of Nursing, Staff B, acknowledged the oversight, stating that the process for reviewing medication orders was not followed, leading to the error being missed. The PCP was not informed of the discontinuation and only discovered the error during a medication review. This lapse in medication administration placed Resident 2 at risk for less than optimal therapeutic effects and potential negative health outcomes.
Failure to Maintain Current Hospice Agreement and Communication Process
Penalty
Summary
The facility failed to maintain a current hospice written agreement and did not develop or implement a process to ensure effective communication, collaboration, and coordination of care between the facility and the hospice provider for a resident receiving hospice services. The existing hospice agreement, dated 08/01/2019, had not been reviewed or updated as required, and was not signed by an authorized representative of the facility. This lack of a current agreement and process placed the resident at risk of not receiving necessary end-of-life care and services. Resident 14, who was admitted with diagnoses including Parkinson's disease and heart failure, was enrolled in hospice services on 03/12/2025. However, the resident's care plan did not include any focus area, goals, or interventions related to hospice services until 03/18/2025. Interviews with hospice and facility staff revealed that there was no established process for documenting hospice visits or communication, as evidenced by the absence of entries in the Hospice Communication Log for Resident 14. The Director of Nursing acknowledged the responsibility of the Administrator to ensure a current agreement and described the expected process for communication, which was not being followed effectively.
Failure to Verify Agency Staff Proficiency in Mechanical Lift Use
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Summary
The facility failed to ensure that four out of five sampled agency staff members demonstrated proficiency in operating mechanical lift transfers before or at the time of their assignment. This deficiency was identified through observation, interviews, and record reviews. The facility's policy required two staff members to assist with mechanical lift transfers, ensuring the resident was properly positioned and secured according to the manufacturer's guidelines. However, the facility did not verify the proficiency of agency staff in using these lifts, which placed residents at risk for falls and injuries. Resident 1, who was unable to pull themselves up to a standing position, was involved in a fall incident while being transferred using a sit-to-stand lift. The care plan for Resident 1 specified the use of a sit-to-stand lift with two-person assistance. On the day of the incident, Staff C, a newly trained agency nursing assistant, was left alone with Resident 1 in a standing position on the lift. Staff C, who had limited experience with mechanical lifts and was not familiar with the facility's policy, witnessed Resident 1 slide off the footplate and fall. Staff C did not recall seeing the lift sling buckle secured around the resident's torso, which was a safety requirement. Interviews with facility staff revealed that the facility did not receive or verify proficiency skills checklists for agency staff, including Staff C and Staff D, prior to their assignments. The Director of Nursing confirmed that no competencies or orientation were conducted for these staff members. The staffing coordinator acknowledged that the proficiency skills checklist was not reviewed or used as part of the orientation process. The facility administrator stated that agency staff proficiency should be confirmed before or at the time of their shift, but this was not done in practice.
Failure to Implement Safe Transfer Techniques with Mechanical Lift
Penalty
Summary
The facility failed to ensure the implementation of safe transfer techniques during the use of a mechanical lift, resulting in a fall incident involving a resident with a progressive neurological condition. The resident, who was severely cognitively impaired and dependent on staff for transfers, was being moved using a sit-to-stand lift by two agency nursing assistants. During the transfer, one of the assistants left the room, leaving the other to manage the resident alone. The resident subsequently fell from the lift, as the safety buckle was not secured around their torso, leading to a fall and subsequent hospital evaluation. The facility's policy required two staff members to be present during mechanical lift transfers, and the care plan specifically instructed the use of a sit-to-stand lift with two-person assistance. However, these protocols were not followed, as one staff member left the room during the transfer. The investigation confirmed that the lower waist belt was not buckled, contributing to the resident's fall. The incident resulted in the resident sustaining a bruise and a cut inside the mouth, although no serious traumatic injury was reported.
Failure to Maintain Scheduled Bathing Frequency
Penalty
Summary
The facility failed to provide care in a dignified manner by not adhering to the scheduled bathing frequency for two residents, leading to a deficiency in maintaining their dignity. Resident 1, who has Parkinson's Disease, moderate cognitive impairment, and requires assistance for personal hygiene, was scheduled for showers twice a week. However, over a 30-day period, Resident 1 only received assistance with a shower two out of nine scheduled times. This resulted in a noticeable body odor, as reported by a Resident Representative, indicating a lack of proper hygiene care. Similarly, Resident 2, diagnosed with dementia and moderate cognitive impairment, was also scheduled for showers twice a week but only received assistance three out of nine scheduled times in the same period. Interviews with nursing assistants revealed that showers were often marked as 'Not Applicable' due to staffing shortages, and the Director of Nursing was unaware of the issue. This lack of adherence to the bathing schedule compromised the residents' dignity and hygiene.
Failure to Monitor Blood Pressure with Medication Administration
Penalty
Summary
The facility failed to monitor the effectiveness of medications affecting blood pressure for two residents, leading to a deficiency in medication management. Resident 1, who has Parkinson's Disease, dysarthria, and high blood pressure, was prescribed medications including Lisinopril with instructions to hold administration if the systolic blood pressure (SBP) was less than 90. However, the Medication Administration Records (MARs) for June, July, and August 2024 showed no documentation of routine blood pressure monitoring when administering Lisinopril. Similarly, Resident 3, with diagnoses including heart disease and high blood pressure, was prescribed Spironolactone with instructions to hold administration if the SBP was less than 100. The MARs for the same period also lacked documentation of routine blood pressure monitoring for this medication. Interviews with staff revealed that blood pressure readings were only taken if prompted by the order, and the Director of Nursing acknowledged the system's inadequacy in handling medication orders with parameters.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a severely cognitively impaired resident, Resident 2, from non-consensual sexual abuse by another resident, Resident 1, who had a known history of sexually inappropriate behaviors. Resident 1, who was cognitively intact, was observed interacting with Resident 2 in a non-consensual sexually inappropriate manner in the dining room. Despite Resident 1's history of inappropriate behavior, the facility did not provide adequate supervision, which led to Resident 2 experiencing psychosocial harm. Resident 2, who was diagnosed with Alzheimer's disease, anxiety, and insomnia, was severely cognitively impaired and dependent on staff for personal care. The resident was unable to make healthcare decisions or give informed consent. During an incident, Resident 1 maneuvered their wheelchair to block Resident 2, making physical contact in a manner that was inappropriate and non-consensual. Staff observed this behavior but did not intervene in a timely manner to prevent the incident. Resident 1 had a documented history of sexually inappropriate behavior towards female residents, including making inappropriate comments and gestures. Despite this, the facility did not implement one-on-one supervision for Resident 1, which could have prevented the incident. Staff interviews revealed that Resident 1's behavior was known, yet the facility's response was inadequate, failing to protect Resident 2 and potentially placing other residents at risk.
Failure to Report Alleged Neglect
Penalty
Summary
The facility failed to ensure an allegation of neglect was reported to the State Survey Agency as required. This deficiency involved a resident with a neurological disorder who was able to make their needs known. The resident's representative reported to the facility that they felt the resident was being neglected and denied liquids. Despite an investigation initiated by the facility, the allegation was not reported to the State Agency. The Director of Nursing stated that neglect was not suspected, so they did not think it met the criteria for reporting. This failure to report alleged neglect placed the resident and other residents at risk for continued neglect and poor quality of life.
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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