North Central Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Spokane, Washington.
- Location
- N 1812 Wall Street, Spokane, Washington 99205
- CMS Provider Number
- 505441
- Inspections on file
- 27
- Latest survey
- July 28, 2025
- Citations (last 12 mo.)
- 26
Citation history
Health deficiencies cited at North Central Care Center during CMS and state inspections, most recent first.
The DNS and other nurse managers regularly worked as charge nurses when staffing coverage could not be found, even though the facility's average daily census was consistently above 60. Facility records and staff interviews confirmed this practice, which was not in compliance with regulatory requirements for facilities of this size.
The facility failed to ensure proper food labeling and dating, served cold food items above recommended temperatures, and did not maintain required dishwashing temperatures. Staff did not consistently follow hand hygiene and glove-changing protocols during meal service, including touching potentially contaminated surfaces and personal items while handling food.
The facility did not ensure that required interventions to prevent waterborne bacteria, including Legionella, were consistently monitored and documented. Logs for water temperature checks and flushing of high-risk areas were missing for a period, and the Maintenance Director could not confirm completion of these tasks after delegating them to Central Supply staff.
Residents did not receive mail on weekends due to the facility's practice of locking the front doors and not staffing the front desk, resulting in mail carriers treating the facility as closed and returning mail to the postal station. Staff interviews revealed a lack of awareness about the mail delivery process on weekends, and observations confirmed the absence of clear instructions or a mail receptacle for carriers.
A resident did not receive the necessary care and services to maintain or improve ROM, limited ROM, or mobility, and there was no documented medical reason for the decline.
Annual performance evaluations were not completed as required for three nursing assistants, with personnel files lacking documentation and leadership confirming the oversight. One evaluation was only completed after the survey exit.
A resident who was cognitively intact and receiving antidepressant medication was administered Duloxetine multiple times without documented informed consent. Staff interviews and record reviews confirmed that required consent for the psychotropic medication was not obtained prior to administration, contrary to facility policy and state regulations.
A resident who was frequently incontinent and often refused hygiene care was not provided with adequate interventions to address strong urine odors in their room. Despite staff awareness of the persistent odor, including a saturated mattress and urine found under the bed, there was no documentation or care planning to minimize or address the odors resulting from care refusals.
The facility did not complete timely PASRR screenings for two residents with mental health diagnoses after their exempted hospital stays expired. One resident with depression and end stage renal disease did not have the required PASRR section completed and did not receive a new PASRR upon readmission. Another resident with depression and dementia remained in the facility beyond the exemption period, but an updated PASRR was not completed until two months later.
Two residents who required assistance with ADLs did not consistently receive shaving and nail care. One resident with severe cognitive impairment was repeatedly observed with facial stubble, and their care plan lacked grooming instructions. Another resident with left-sided paralysis had long, unclean fingernails on the right hand, with documentation and staff interviews confirming that nail care was not consistently provided.
Two residents with lower extremity edema did not have individualized care plans or monitoring in place for their condition. One resident with lymphedema and a surgical wound refused ordered compression garments, but no alternative interventions or monitoring were documented. Another resident with a history of Lasix use and ongoing edema had no care plan addressing edema, and no evidence of monitoring was found. Staff confirmed that appropriate interventions and monitoring were not implemented.
A resident with respiratory and heart failure received oxygen at higher flow rates than ordered and had oxygen saturations above the recommended range for COPD. Staff did not consistently document or follow cleaning protocols for the resident's CPAP mask, which was observed to be unclean. These failures were confirmed through observation, interviews, and record review.
A large area of torn and missing linoleum in the kitchen dishwashing area left exposed wood that was not a cleanable surface, creating a tripping hazard and infection control issue. The Dietary Manager acknowledged the problem, and the DON was unaware of the condition due to limited access to the area.
DNS Served as Charge Nurse Despite High Census
Penalty
Summary
The facility failed to ensure that the Director of Nursing Services (DNS) did not serve as a charge nurse when the average daily occupancy exceeded 60 residents. Record review showed the facility's average daily census ranged from 75 to 85 residents, and the staffing plan required a full-time DNS to meet resident care needs. Despite this, interviews with the administrator, resident care manager, staffing coordinator, and DNS confirmed that the DNS and other nurse managers rotated on-call duties during weekends and were required to work as charge nurses if staffing coverage could not be found. The DNS acknowledged working the floor as a charge nurse under these circumstances, even though the facility census was consistently above the threshold where this practice is not permitted. The facility's contingency staffing plan allowed for interdepartmental staff support to address staffing shortages, provided licensure and certification requirements were not violated. However, the DNS and other nurse managers regularly filled in as charge nurses during staffing shortages, contrary to regulatory requirements for facilities with an average daily census over 60. This practice was confirmed through multiple staff interviews and review of facility records, which documented the ongoing use of the DNS in a charge nurse role despite the facility's census and established staffing policies.
Food Safety, Hygiene, and Equipment Failures During Meal Service
Penalty
Summary
The facility failed to adhere to food safety and hygiene standards during meal service and food storage. Observations revealed that food items in the resident refrigerator were not consistently labeled or dated, with some frozen drinks lacking both identifiers. Staff interviews confirmed that all items should have been labeled and dated to ensure proper identification and timely disposal. During lunch meal service, cold food items such as pudding, cottage cheese, fruit cup, salad, and watermelon were served at temperatures above the recommended 41 degrees Fahrenheit. Staff acknowledged that cold items were not maintaining appropriate temperatures once removed from refrigeration, and some items were served despite being above the required temperature. Additionally, staff did not follow proper hand hygiene and glove-changing protocols during meal plating. One staff member was observed touching potentially contaminated surfaces, adjusting their glasses, and wiping their mouth while wearing the same gloves used to handle food. The facility also failed to maintain the required final rinse temperature of 180 degrees Fahrenheit in the high-temperature dishwasher, with temperature logs showing repeated failures over several months. Staff interviews confirmed awareness of the importance of these practices but indicated lapses in execution and monitoring.
Failure to Monitor and Document Water Management Interventions
Penalty
Summary
The facility failed to ensure that interventions outlined in its Water Management Plan to prevent the growth of waterborne bacteria, including Legionella, were consistently monitored and completed. The plan required weekly flushing of unused toilets and sinks, cleaning of shower heads with sanitizing agents, weekly flushing of basement floor drains, and quarterly Legionella testing. During a review, it was found that documentation logs for water temperature checks and flushing of high-risk areas were only available up to early May 2025, with no records available from that date to the present. The Maintenance Director was unable to confirm whether the required water flushes and documentation had been completed after delegating the task to Central Supply staff.
Failure to Ensure Timely Resident Mail Delivery Due to Locked Entry and Lack of Weekend Staffing
Penalty
Summary
The facility failed to ensure residents received their mail on days when mail was delivered, specifically on Saturdays. During a resident group meeting, all six residents present reported not receiving mail on Saturdays, with some stating that the absence of front desk staff prevented mail delivery. Staff interviews revealed a longstanding practice of locking the front doors on weekends for security reasons, with no front desk receptionist available to accept mail. Staff members were generally unaware of the specific process for mail delivery on weekends, and some believed mail was not delivered on Saturdays, despite evidence to the contrary. Interviews with postal service representatives confirmed that mail is delivered to the facility on Saturdays unless the business is closed. However, due to the locked doors and lack of staff to accept deliveries, mail carriers treated the facility as closed and returned the mail to the postal station. Observations during the survey period showed that while there was a sign instructing visitors to ring the bell for admittance, there were no specific instructions for mail carriers and no visible mail receptacle. The Director of Nursing confirmed the doors had been locked on weekends for years and was unaware of any concerns or alternative arrangements for mail delivery to residents on those days.
Failure to Provide Appropriate Care for Range of Motion and Mobility
Penalty
Summary
A deficiency was identified regarding the provision of care to maintain or improve a resident's range of motion (ROM), limited ROM, and/or mobility. The facility failed to ensure that appropriate care and services were provided to prevent a decline in these areas, except in cases where a decline was medically unavoidable. The report notes that the necessary interventions to support or enhance the resident's ROM or mobility were not implemented as required.
Failure to Complete Annual Staff Performance Evaluations
Penalty
Summary
The facility failed to complete annual performance evaluations for three nursing assistants, as required by policy. Personnel files for these staff members did not contain documentation of yearly performance reviews, despite their employment or re-hiring dates indicating that such evaluations were due. Interviews with the Administrator, Director of Nursing, and Resident Care Manager confirmed that annual evaluations were expected but not completed for these staff. Documentation for one staff member's evaluation was only produced after the survey had concluded, indicating it was not completed within the required timeframe.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain and document informed consent for the use of a psychotropic medication, Duloxetine, prior to its administration to a resident diagnosed with depression. The resident was cognitively intact and able to verbalize needs. The care plan required staff to educate the resident about the risks and benefits of antidepressant medication and to monitor for adverse reactions. Despite this, review of the resident’s medical record and medication administration records showed that Duloxetine was administered 55 times over a two-month period without documented consent. Interviews with facility staff, including a registered nurse, resident care manager, and director of nursing, confirmed that consent for psychotropic medications was required prior to administration. Staff were unable to locate documentation of consent for Duloxetine prior to its use, and acknowledged that the consent was not obtained until after the medication had already been administered multiple times. This failure was identified during interviews and record reviews, and was in violation of state regulations requiring informed consent for psychotropic medication use.
Failure to Maintain Clean, Odor-Free Environment Due to Inadequate Response to Incontinence and Care Refusals
Penalty
Summary
The facility failed to maintain a clean, sanitary, and homelike environment free of institutional odors for a resident who was frequently incontinent of urine and required substantial staff assistance for toileting and hygiene. The resident was cognitively intact, able to verbalize needs, and often refused care such as brief changes, bathing, and hygiene multiple times per week. The care plan instructed staff to check and change the resident every 90-120 minutes and as needed, and to notify the nurse and reapproach if care was refused. However, there was no documentation showing how strong odors resulting from care refusals were minimized or addressed. Multiple observations over several days noted a strong urine odor emanating from the resident's room into the hallway. Staff interviews confirmed that the room had a persistent urine odor, the mattress had been saturated and replaced, and a puddle of urine was found under the bed. Housekeeping deep cleaned beds on shower days, but it was unclear if cleaning frequency was increased in response to care refusals. The DON acknowledged the odor issue and the recent disposal of the soiled mattress, but no odor-eliminating interventions had been care planned.
Failure to Complete Timely PASRR Screenings After Exempted Hospital Stays
Penalty
Summary
The facility failed to ensure timely completion of Pre-admission Screening and Resident Review (PASRR) processes for residents with mental disorders or intellectual disabilities following exempted hospital stays. For one resident with end stage renal disease and depression, the initial PASRR indicated an exempted hospital discharge, but the required section of the form was not completed. After the resident was readmitted from the hospital, a new PASRR was not completed as required, despite the resident remaining in the facility beyond the 30-day exemption period. The Social Services Director confirmed that a new PASRR should have been completed upon the resident's readmission. Another resident with medically complex conditions, depression, and dementia was admitted from the hospital with a Level I PASRR indicating exemption due to a hospital stay. However, the resident remained in the facility beyond the 30-day exemption period, and an updated Level I PASRR was not completed until two months after the required timeframe. The Social Services Director acknowledged that the updated PASRR was not completed within the required period and could not locate documentation of timely completion.
Failure to Provide Consistent Shaving and Nail Care for Dependent Residents
Penalty
Summary
The facility failed to consistently provide shaving and nail care for two residents who required assistance with activities of daily living (ADLs). For one resident with severe cognitive impairment and unclear speech, multiple observations over several days showed the presence of facial stubble, indicating that shaving was not consistently performed. The resident’s care plan included interventions for bathing, toileting, oral care, and dressing, but lacked specific instructions or interventions for grooming or shaving. Documentation of personal hygiene care did not specify which aspects of care were provided or refused, and staff interviews confirmed that shaving was expected to be completed during morning care or bathing, but the care plan did not reflect this need. Another resident with a history of stroke and left-sided paralysis required partial to moderate assistance with personal hygiene and had a care plan instructing staff to keep fingernails short. Observations revealed long fingernails with black matter under the right hand, and the resident reported that staff did not clean their fingernails during weekly showers. Documentation showed that nail care was provided to the left hand, but there was no record of nail care for the right hand during the review period. Staff interviews confirmed that nail care was expected to be provided as needed, but this was not consistently done for the resident’s right hand.
Failure to Develop and Implement Edema Management Care Plans and Monitoring
Penalty
Summary
The facility failed to develop and implement care plan goals and interventions for two residents with edema, as well as to monitor their condition as required. One resident, who had diagnoses including lymphedema and osteomyelitis, was admitted with significant lower leg edema and a surgical incision on the left heel. The care plan addressed skin impairment and general skin care but did not include specific interventions or monitoring for lymphedema or lower leg edema. Although an order was given for Tubi-grips to manage edema, the resident consistently refused them, and no alternative interventions or monitoring were documented. Observations showed persistent edema and discoloration, and the resident reported a lack of other measures to address swelling. Another resident, admitted with high blood pressure and irregular heartbeat, also exhibited lower extremity edema. This resident had received Lasix, which was later discontinued with instructions for monitoring blood pressure and fluid status, but documentation showed only one progress note during the monitoring period and no evidence of edema monitoring in the medication administration records. The care plan did not address the resident's edema, and repeated observations showed ongoing swelling, redness, and fluid leakage from the legs. Staff interviews confirmed that interventions such as compression stockings, elevation, and monitoring should have been in place, but these were not documented or observed. The Director of Nursing and other staff acknowledged that care plans and monitoring for edema were lacking for both residents. The facility did not have a specific policy for lymphedema and edema management, relying instead on standard practices. The absence of individualized care planning and monitoring for edema in these cases constituted a failure to provide appropriate treatment and care according to orders, resident preferences, and goals.
Failure to Maintain Ordered Oxygen Saturations and Clean Respiratory Equipment
Penalty
Summary
The facility failed to maintain oxygen saturations according to provider orders and did not ensure that respiratory equipment, specifically a CPAP mask, was cleaned and maintained for a resident with respiratory and heart failure. The resident, who was cognitively intact and dependent on supplemental oxygen, was observed wearing oxygen at higher flow rates than ordered, with documentation showing administration of 3-5L of oxygen when the provider's order specified 1-2L per minute. Additionally, the resident's oxygen saturations were recorded above the recommended range for individuals with COPD, and there was no evidence that staff adjusted the oxygen back down or re-checked and documented the saturations as required. The CPAP mask used by the resident was observed to have white spots inside, and the resident reported that the facility had not cleaned the CPAP. There were no orders for cleaning the CPAP mask in the medication or treatment administration records, and staff interviews confirmed that cleaning protocols were not consistently documented or followed. The Director of Nursing acknowledged the absence of cleaning orders and the importance of routine cleaning to prevent infection. These failures were identified through observation, interview, and record review, and placed the resident at risk for illness and decreased quality of life.
Unrepaired Kitchen Floor Creates Safety and Infection Control Deficiency
Penalty
Summary
The facility failed to maintain the kitchen floor in the dishwashing area, resulting in a large section of torn and missing linoleum measuring approximately 4 feet by 4 feet, with exposed wood underneath. This condition was observed during a kitchen inspection and confirmed by the Dietary Manager, who acknowledged the area as both an infection control issue and a safety hazard. The Director of Nursing stated they were unaware of the floor's condition because they did not enter that part of the kitchen. The exposed wood surface was not cleanable, and the torn flooring created a potential tripping hazard for staff.
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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