Providence Mount St Vincent
Inspection history, citations, penalties and survey trends for this long-term care facility in Seattle, Washington.
- Location
- 4831 35th Avenue Southwest, Seattle, Washington 98126
- CMS Provider Number
- 505182
- Inspections on file
- 33
- Latest survey
- August 8, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Providence Mount St Vincent during CMS and state inspections, most recent first.
During a COVID-19 outbreak, the facility did not place required Aerosol Contact Precautions (ACP) signage on the doors of several rooms housing COVID-19 positive residents. Although staff were expected to use PPE and follow isolation protocols, there was no designated staff member to monitor signage or PPE compliance, resulting in incomplete implementation of infection control measures.
A CNA physically and verbally abused multiple residents, including one who suffered bruising and a skin tear, leading to significant distress and behavioral changes. Other residents reported rough, intimidating care and fear of the CNA. Facility staff failed to promptly report, investigate, or protect residents as required by policy, allowing the CNA to continue providing care after the initial incident.
A resident experienced physical abuse by a CNA, and multiple staff members who were aware of the incident did not report it or initiate an investigation as required by facility policy. The supervisor failed to suspend the CNA or notify the administrator and state agency, and the incident was not documented or investigated in the facility's reporting log. Additional staff reported witnessing rough and abusive behavior by the same CNA toward other residents, but did not fulfill mandated reporting duties.
A resident with severe cognitive impairment and total care needs was found with unexplained bruises and a skin tear, reportedly caused by a CNA during care. Despite staff reporting the incident, there was no documented assessment, injury report, or investigation, and the event was not logged or reported to facility leadership or the state agency, in violation of abuse prevention policies.
A resident with a chronic neurological disease was not readmitted to the facility after hospitalization for a feeding tube replacement, despite being medically cleared. The facility's internal communication indicated the resident would not return, leading to a two-week delay and psychological distress for the resident. The resident's belongings were removed, and the facility did not respond to hospital staff's attempts to arrange the resident's return.
A facility failed to enforce its non-smoking policy, allowing a resident to repeatedly vape cannabis in their room, despite being cognitively intact and aware of the rules. The resident's actions affected their roommate and posed safety risks. Staff interventions were inconsistent, and the resident continued to possess vape supplies, leading to a discharge notice.
A resident with a fractured hip and intact memory experienced psychological harm when a caregiver inappropriately touched them without consent. The resident identified the caregiver, leading to their dismissal. The incident was substantiated by the facility's investigation.
The facility failed to maintain sanitary conditions in food preparation and distribution, with staff observed not following hand hygiene protocols and using unsanitized equipment. In the main kitchen, equipment was not cleaned properly, and staff did not wash hands between tasks. On the 4th Floor North, a nutrition attendant did not sanitize a thermometer probe between uses, and on the 4th Floor South, CNAs did not secure their hair or perform hand hygiene after serving food, including in rooms with Enhanced Barrier Precautions.
The facility failed to maintain resident dignity and privacy, as observed in dining services, privacy provision, and care delivery. Staff did not consistently remove plastic wrap from drinks, administered medications in the dining room, and failed to provide privacy during care. Additionally, a resident was not promptly informed about an appeal denial, affecting their care. These actions compromised resident dignity and rights.
The facility failed to honor resident preferences for bathing frequency and type, affecting several residents who expressed dissatisfaction with their care. Despite clear communication abilities and stated preferences, residents received fewer showers or different types of baths than desired. Facility records and staff interviews confirmed these discrepancies, highlighting a lack of adherence to resident self-determination rights.
The facility failed to conduct required care conferences for two residents, leading to unmet care needs and potential frustration. One resident expressed a desire for a care conference to understand their care plan, while another was not invited to care conferences despite having communication deficits. Additionally, the facility did not update care plans for four residents to reflect changes in their care needs, including discrepancies in denture use, catheter care, and range of motion programs.
The facility failed to provide adequate ADL assistance, resulting in poor hygiene and grooming for several residents. A resident was observed with long fingernails and debris, while another ate without dentures due to staff oversight. Other residents experienced neglect in dressing, shaving, and bathing, with missed or unoffered care opportunities. Staff expectations for documenting refusals and reattempting care were not consistently met.
The facility failed to meet the activity needs of three residents, leading to a deficiency in care. One resident, who desired outdoor activities, was not offered any opportunities to go outside. Another resident, interested in participating in activities, was not facilitated to attend due to mobility issues. A third resident, initially isolated due to COVID-19, was not provided with in-room activities despite their preferences. Staff acknowledged the lack of documentation and effort to engage these residents.
The facility failed to secure hazardous materials across multiple units, including unlocked utility and spa rooms containing needles, chemicals, and razors. Staff confirmed these areas should have been locked to prevent resident access, but issues like broken locks and lack of keys contributed to the deficiency.
The facility failed to ensure nursing staff had the necessary competencies to provide adequate care, as required evaluations were not conducted. Interviews and record reviews revealed that the Director of Nursing could not provide documentation of competency evaluations for several staff members, despite the Facility Assessment outlining the need for such assessments. This resulted in deficiencies related to staff proficiency in critical care areas.
The facility failed to maintain effective infection control practices, as staff did not adhere to Enhanced Barrier Precautions (EBP) and Transmission-Based Precautions (TBP) for several residents. A CNA and an LPN were observed not wearing required gowns while providing care, and an LPN used contaminated tubing for a resident's tube feeding. Another LPN failed to follow proper hand hygiene and gown protocols during wound care. These actions were against the facility's infection control policies.
The facility failed to thoroughly investigate incidents involving three residents, including an allegation of inappropriate contact by a caregiver and a resident-to-resident altercation. Investigations lacked witness interviews and background checks, leading to discrepancies and potential risks to residents' well-being.
A facility failed to notify local Law Enforcement and the Department of Health after substantiating an abuse allegation involving a resident. The incident involved a CNA who allegedly kissed a resident and attempted to climb into their bed. Despite confirming the allegation and dismissing the CNA, the facility did not report the incident as required, placing residents at risk for harm.
The facility failed to provide timely written transfer notifications to two residents discharged to hospitals. For both residents, there was no documentation of the required notifications in their health records. Staff confirmed the absence of documentation and stated that notifications were expected to be provided in a timely manner. This failure placed residents at risk for discharges not aligned with their care goals.
The facility failed to provide two residents with written notification of its bed-hold policy at the time of their transfer to a hospital or within 24 hours, as required by policy. Interviews with staff revealed that the expected process was not followed, resulting in a lack of documentation for both residents.
A resident with complex medical diagnoses, including cancer, was inaccurately documented in the MDS as not being on hospice, despite receiving hospice services and medications. This discrepancy was confirmed by hospice service indicators on the resident's chart and acknowledged by a Care Manager RN, highlighting the importance of accurate documentation for aligning care plans with resident goals.
The facility failed to develop comprehensive care plans for two residents, leading to potential risks for unmet care needs. One resident with frequent diarrhea did not have a care plan addressing this issue, while another resident with lower leg edema also lacked a care plan for this condition. Staff acknowledged the importance of addressing these conditions in care plans to ensure proper management and prevent complications.
The facility failed to follow physician's orders for two residents and did not administer medications to another resident. One resident had a catheter inserted without proper orders, another had a dressing not applied as ordered, and a third missed medications due to unavailability. Staff interviews confirmed these deficiencies.
A resident with pressure ulcers did not receive necessary care as per professional standards. The resident was observed without required pressure-reducing devices, and staff failed to monitor and report changes in the resident's wound condition. Despite physician orders, interventions like floating the left foot and using boots were not consistently implemented, leading to inadequate pressure ulcer care.
A resident at risk for weight loss due to poor appetite experienced a significant unverified weight drop from 151.2 lbs. to 119.8 lbs. in three weeks. The facility failed to reweigh the resident or notify the physician or RD, contrary to their policy, placing the resident at risk for negative health outcomes.
The facility failed to provide adequate pain management for two residents. One resident did not receive thorough pain assessments before PRN narcotic administration, and another experienced a lack of availability of their PRN pain medication due to pharmacy delivery issues. Staff interviews revealed that pain assessments were not consistently documented, and facility protocols were not followed.
The facility failed to secure medications and dispose of expired items, affecting multiple units. A resident with impaired memory was left with an unsecured inhaler, and expired medications were found in several medication rooms and carts. Staff admitted to not following procedures for monitoring and disposing of expired items.
The facility failed to protect resident-identifiable information on the 5 North unit. A progress note was improperly placed in a grievance file folder accessible to anyone, and a resident roster was left exposed on a cart. Staff acknowledged the importance of maintaining confidentiality, but lapses occurred, compromising resident privacy.
A facility failed to coordinate hospice care effectively for a resident with complex medical diagnoses, including cancer. The resident's Care Plan was not updated to reflect hospice responsibilities, and there was no physician's order for hospice services. Staff were unaware of the hospice care being provided, and necessary documentation was missing from the resident's records, leading to a risk of inadequate care.
A facility failed to document and resolve grievances for a resident with a neurological disorder and mood issues, who reported feeling disrespected by a CNA. Despite the resident's complaints and a report to the ombudsman, the grievance log showed no record of these issues. Interviews revealed that grievances were not properly documented or tracked, highlighting a failure in the facility's grievance process.
The facility failed to implement its abuse prevention policies effectively, leading to incomplete investigations of incidents involving three residents. An allegation of inappropriate touching was substantiated but not reported to authorities, and investigations into other incidents lacked witness interviews, contrary to facility policy.
A facility failed to ensure the safe use of air mattresses for residents, leading to multiple falls and potential risks. The deficiency involved a lack of assessment and monitoring of air mattress settings, no informed consent from residents, and insufficient staff training. One resident experienced three falls due to the wrong size mattress and inadequate monitoring, while similar issues were noted for other residents. Interviews confirmed the absence of necessary assessments and documentation.
A resident was injured during a mechanical lift transfer when a CNA operated the lift alone, contrary to facility policy requiring two staff members. The resident suffered a severe leg laceration and was hospitalized for five days. Interviews confirmed the CNA had been trained on the policy but failed to follow it.
Failure to Implement COVID-19 Transmission-Based Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program to prevent the transmission of communicable diseases, specifically COVID-19. During a COVID-19 outbreak, 16 residents on the third floor south tested positive for the virus. According to facility policy, residents with confirmed or suspected COVID-19 infections were to be placed on Aerosol Contact Precautions (ACP), which included placing signage on the resident's door to inform staff and visitors of required Personal Protective Equipment (PPE) and actions to take before entering. However, observations revealed that four rooms housing COVID-19 positive residents did not have the required ACP signage on their doors. Interviews with staff, including the Infection Control Preventionist, LPN, and DON, confirmed that ACP signage was expected to be present and that staff were required to wear PPE when entering the rooms of isolated residents. Despite this, there was no specific staff member assigned to routinely monitor for ACP signage or staff use of PPE, with oversight being shared among all managers and the Infection Control Preventionist. The lack of proper signage and monitoring led to a failure in fully implementing the facility's infection control protocols as outlined in their policy.
Failure to Protect Residents from Abuse and Inadequate Response to Allegations
Penalty
Summary
The facility failed to protect multiple residents from abuse, as evidenced by physical, verbal, and psychological harm caused by a CNA. One resident, who was severely cognitively impaired and dependent on staff for all care, was physically injured when the CNA grabbed their arms, resulting in fingerprint bruises and a nail-inflicted skin tear. This resident subsequently exhibited significant mood changes, including frequent crying, increased distress behaviors, multiple days of refused care and medications, and repeated verbalizations of fear of being physically hurt. Documentation showed that the injuries and behavioral changes were not promptly assessed, reported, or investigated by nursing or management staff, despite being observed and reported by other CNAs. Other residents, most of whom were cognitively intact but physically dependent, reported or were observed to experience rough, hurried, or intimidating care from the same CNA. Several residents described being treated roughly during transfers or personal care, being spoken to in a demeaning or intimidating manner, and feeling fearful or anxious about receiving care from the CNA. Some residents reported changes in their behavior, such as avoiding common areas or losing sleep, to avoid interactions with the CNA. Despite these reports and observations, the CNA continued to provide care to residents for an extended period after the initial incident. The facility's policies required immediate reporting, investigation, and protection of residents from abuse, but these procedures were not followed. The responsible nurse manager did not suspend the CNA, did not initiate an investigation, and did not report the suspected abuse to facility leadership or the state agency as required. Injuries and behavioral changes were not documented or monitored in a timely manner, and residents were not protected from further potential abuse during the period in question.
Failure to Implement Abuse Prevention Policy and Mandated Reporting
Penalty
Summary
The facility failed to implement its abuse prevention policy for a resident who sustained injuries of unknown origin. The policy required that all allegations or suspicions of abuse be promptly investigated, that the alleged victim be protected, and that the alleged perpetrator be suspended during the investigation. However, after an incident in which a CNA physically abused a resident, multiple staff members who were aware of the incident did not report it as required. The supervisor who was informed of the abuse did not initiate an investigation, did not report the incident to the administrator or the state agency hotline, and did not suspend the alleged perpetrator immediately. The CNA continued to work for several days after the incident before being suspended. Record review showed that the facility did not document or investigate the incident in its reporting log, and there was no evidence that the required screenings for abuse or neglect were completed with the CNA's prior employers or references. Staff interviews revealed that several staff members witnessed or were aware of rough and abusive behavior by the CNA toward multiple residents, including physical injuries and verbal mistreatment, but failed to act as mandated reporters. The facility's mandated reporter training attendance records indicated that not all relevant staff had received the required training. The facility had previously been cited for similar failures to protect residents from abuse, prevent further abuse, complete investigations, and report to the state agency. Despite staff being aware of their responsibilities as mandated reporters, they did not report the incidents, relying instead on supervisors who also failed to act according to policy and regulatory requirements.
Failure to Investigate and Report Potential Abuse Incident
Penalty
Summary
The facility failed to identify and investigate a potential abuse incident involving a resident who was severely cognitively impaired, dependent on staff for all care, and diagnosed with dementia. The resident was found with bruises in the shape of fingers on both arms and a significant skin tear on the left arm. Staff interviews revealed that a CNA admitted to grabbing the resident's arms during care, which was reported to a licensed nurse and the resident care manager. Despite this, there was no documentation of a thorough assessment, injury report, or investigation into the cause of the injuries, as required by both state guidelines and the facility's own abuse prevention policy. Review of the resident's records showed no adequate description or measurement of the injuries, and the incident was not logged in the facility's incident and accident log. The administrator confirmed that the required steps, including reporting to the administrator, DON, and state agency, were not taken. The facility's failure to follow its abuse prohibition and prevention policy, as well as state reporting guidelines, resulted in a lack of protection for the resident and potentially others from further abuse or neglect.
Facility Fails to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after a hospitalization, resulting in psychological harm. The resident, who had a chronic, progressive neurological disease and required assistance for all personal care and mobility, was sent to the emergency room (ER) for a possible abdominal infection and feeding tube replacement. Despite being medically cleared for discharge, the facility did not allow the resident to return, leading to a two-week hospitalization delay while another nursing facility was arranged. The facility's internal communication indicated that the resident would not be readmitted, and the admissions assistant informed the hospital of this decision. The resident's belongings were packed and removed from their room, which was not occupied by another resident until 12 days after the resident was sent to the ER. The facility's staff, including the administrator and admissions assistant, were aware of the situation but did not facilitate the resident's return. Interviews with the resident's representative and hospital staff revealed that the resident experienced significant distress, expressing feelings of homelessness and hopelessness. The resident's representative reported that the resident was discouraged and talked about suicide. The hospital discharge coordinator and physician attempted to communicate with the facility, but the facility did not respond to their calls. The facility's failure to readmit the resident after hospitalization led to the resident being transferred to a different nursing facility.
Failure to Enforce Non-Smoking Policy and Prevent Cannabis Vaping
Penalty
Summary
The facility failed to maintain a safe environment free from hazards for two residents, specifically concerning Resident 2's use of cannabis through a vape pen. Despite the facility's non-smoking policy, Resident 2, who was cognitively intact but required maximum assistance for personal care and mobility, repeatedly vaped cannabis in their room. This behavior was documented in multiple nursing progress notes, indicating that Resident 2 used air freshener to mask the smell and was found with vape supplies on several occasions. The facility's staff intervened by removing the vape supplies and reporting the incidents to management, but Resident 2 continued to vape, leading to a 30-day discharge notice. The facility's records showed that Resident 2 had acknowledged the non-smoking policy upon admission and was aware of the consequences of non-compliance. Despite this, Resident 2 continued to vape, affecting their roommate, Resident 3, who was non-responsive during an interview. The facility's care plan for Resident 2 included reminders of the non-smoking policy and discussions about alternatives, but these measures were ineffective in preventing further incidents. Interviews with facility staff revealed that there was a lack of consistent action in addressing the ongoing issue. Although the nurse was expected to remove vape materials and report to the supervisor, there were instances where this did not occur. Additionally, there was no evidence of an assessment being conducted to evaluate the safety of Resident 2's vaping behavior. The facility's management acknowledged that Resident 2 still had vape supplies in their possession, which were eventually surrendered to the facility.
Resident Experienced Psychological Harm Due to Inappropriate Staff Conduct
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse, resulting in psychological harm to a resident who was touched inappropriately without consent by a staff member. The incident involved a resident with intact memory and a history of social isolation, who required assistance with mobility due to a fractured right hip. The resident reported that a male caregiver entered their room, kissed them, and attempted to climb into their bed. The resident was able to identify the caregiver from a photo array, leading to the caregiver's removal from the schedule. The facility's investigation confirmed the resident's account, noting the resident's alert and oriented status, intact memory, and daily journaling as factors supporting the reliability of their report. The investigation concluded that the incident occurred in the early morning, and the caregiver involved was dismissed following the substantiation of the claim. The resident continued to recall the incident unprompted in subsequent interviews, indicating ongoing psychological impact.
Sanitation and Hand Hygiene Deficiencies in Food Service
Penalty
Summary
The facility failed to ensure that food and drinks served to residents were prepared and distributed under sanitary conditions. Observations in the main kitchen revealed several pieces of equipment, such as a meat slicer and food processor bases, were not maintained in a sanitary manner, with visible dust and food residue. During lunch preparation, a cook was observed handling food without proper hand hygiene, changing gloves without washing hands, and touching various surfaces and food items without sanitizing hands in between tasks. In the 4th Floor North Unit, a nutrition attendant was observed checking food temperatures with a thermometer probe that was not properly sanitized between uses. The attendant used a paper towel to wipe the probe instead of using alcohol swabs, as expected by the facility's standards. Additionally, the attendant's hair was not fully covered, which is against the facility's policy for food preparation. On the 4th Floor South Unit, CNAs were observed serving food without securing their hair and failing to perform hand hygiene after delivering trays to residents' rooms, including those under Enhanced Barrier Precautions. One CNA entered a resident's room without donning the required protective equipment and continued to serve food without washing hands. These actions were contrary to the facility's policy and placed residents at risk of exposure to contaminants.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to uphold resident rights and dignity for 10 out of 35 sampled residents, as observed during dining services, privacy provision, and care delivery. During meal services, staff did not consistently remove plastic wrap from residents' drinks, despite residents expressing a preference for uncovered drinks. This was observed with several residents, including one who preferred to drink without a straw, yet staff routinely punctured the plastic wrap with a straw. Additionally, medications were administered in the dining room, which was identified as a dignity concern by staff, as it compromised the privacy and dignity of residents. Privacy issues were also noted, with staff failing to close doors or curtains during care provision. For instance, a resident receiving tube feeding was left exposed to the hallway, and another resident's catheter bag was visible from the hallway without a privacy cover, contrary to the care plan directives. These lapses in privacy were acknowledged by staff as not meeting the expected standards of care. Furthermore, care was not always provided in a dignified manner. A resident was subjected to a sign outside their room regarding food delivery, which they found bothersome and unclear. Another resident experienced a delay in being informed about the denial of their rehabilitation services appeal, which was crucial information affecting their care and mobility. The social worker admitted to not notifying the resident promptly, which was against the expected process. These incidents collectively highlight the facility's failure to maintain and promote resident dignity and rights.
Failure to Accommodate Resident Bathing Preferences
Penalty
Summary
The facility failed to honor and facilitate resident self-determination by not accommodating the bathing preferences of several residents, which is a violation of their rights. Resident 22, who had a history of stroke and was dependent on staff for bathing, expressed a preference for more frequent tub baths. However, the facility's records showed that Resident 22 received only one shower in December and a bed bath instead of a tub bath on multiple occasions, contrary to their stated preference and the instructions on their care plan. Similarly, Resident 142, who had intact memory and clear communication abilities, expressed a desire for more frequent showers. Despite this, the facility's documentation indicated that Resident 142 received fewer showers than scheduled and preferred. The care plan for Resident 142 also showed unanswered questions regarding their bathing preferences, indicating a lack of attention to their personal choices. Resident 170, who also had clear communication abilities, reported dissatisfaction with the frequency of their bathing, stating they only received one bath per week. The facility's records lacked specific instructions for bathing frequency or type for Resident 170, and the unit's shower schedule confirmed that all residents were scheduled for only once-a-week bathing. Additionally, Resident 100, who was dependent on staff for transfers and bathing, was not offered their preferred type of bath, receiving only bed baths instead. These failures to accommodate resident preferences were confirmed through interviews with staff and review of facility documentation.
Failure to Conduct Care Conferences and Update Care Plans
Penalty
Summary
The facility failed to conduct care conferences as required for two residents, leading to unmet care needs and potential frustration. Resident 427, who was admitted without memory impairment, reported not having a care conference scheduled since their admission, despite expressing a desire for one to understand their care plan. Staff M, a social worker, confirmed that care conferences were scheduled as needed or upon request, but since Resident 427 did not request one, it was not scheduled. Similarly, Resident 28, who had medically complex conditions and a communication deficit due to hearing loss, was not invited to care conferences held on two separate occasions. Staff K, a manager, acknowledged that the facility's process for inviting residents to care conferences was not followed for Resident 28. The facility also failed to update care plans to reflect changes in residents' care needs for four residents. Resident 22, who had multiple medically complex diagnoses, was noted to have discrepancies in their care plan regarding denture use, with the Kardex indicating the use of lower dentures instead of the upper dentures specified in the care plan. Staff K acknowledged the inaccuracy and the need for updates. Resident 142, who had malnutrition and recently had all teeth extracted, was using dentures, but their care plan and Kardex did not reflect this change. Staff K confirmed that the care plan and Kardex should be updated to address the resident's denture use. Resident 170, who had multiple medically complex diagnoses including cancer, had an indwelling catheter removed, but their care plan and Kardex still indicated the need for catheter care. Staff K confirmed that the care plan and Kardex should be updated to reflect the resident's current toileting status. Additionally, Resident 7, who had a history of stroke and one-sided limitations to their range of motion, was receiving a bed mobility restorative nursing program but no range of motion programs, despite the care plan indicating the need for a passive range of motion program. Staff B confirmed that the care plan was not up to date.
Deficiencies in ADL Assistance and Hygiene in LTC Facility
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADLs) for several residents, leading to deficiencies in personal hygiene and grooming. Resident 14, who was dependent on staff for personal hygiene due to weakness on the left side of their body, was observed with long fingernails and black debris under them. Despite the care plan indicating the need for extensive assistance, staff did not provide the necessary nail care. Interviews with staff revealed an expectation for staff to check resident preferences and provide assistance, yet this was not documented or followed through. Resident 22, who required setup assistance for eating and was dependent on staff for dressing, was observed eating without dentures on multiple occasions. The resident expressed a desire to wear dentures, but staff failed to provide them, leaving the dentures in a cup across the room. This oversight was contrary to the care plan, which directed staff to ensure the resident wore dentures. Staff interviews confirmed the expectation for daily assistance with dentures, especially before meals. Other residents, such as Resident 170, 93, 112, 120, 126, and 82, experienced similar neglect in ADLs, including dressing, shaving, and bathing. Resident 170 was left in a hospital gown without being offered to get dressed, while Residents 93 and 112 were not assisted with shaving, resulting in long chin hairs. Residents 120, 126, and 82 did not receive regular bathing as per their preferences and schedules, with documentation showing missed or unoffered bathing opportunities. Staff interviews highlighted the expectation for documenting refusals and reattempting care, which was not consistently practiced, leading to these deficiencies.
Failure to Provide Meaningful Activities for Residents
Penalty
Summary
The facility failed to provide meaningful activity programs that met the needs of three residents, leading to a deficiency in their care. Resident 110, who had intact memory and sometimes experienced social isolation, expressed a strong desire to go outside, which was not facilitated by the staff. Despite the resident's care plan indicating the importance of outdoor activities, the activity flow sheets showed no offers to take the resident outside since their admission. The recreation therapist confirmed that no such offers were made, highlighting a gap in meeting the resident's preferences. Resident 170, who required substantial assistance for mobility and expressed a keen interest in participating in activities, was not facilitated to attend any since their admission. Despite the resident's care plan encouraging activity attendance and an interest in bingo, the activity flow sheets documented minimal offers and no refusals, indicating a lack of effort to engage the resident in meaningful activities. The recreational therapist acknowledged the oversight in documentation and the failure to provide adequate activity opportunities. Resident 171, who was initially on isolation due to COVID-19, was not provided with in-room activities despite their preferences for reading, music, and religious services. Observations showed a lack of engagement materials in the resident's room, and staff admitted to not providing activities due to infection control concerns. Even after the resident tested negative for COVID-19, the facility did not adjust their approach to meet the resident's activity needs, as confirmed by the administrator and recreation therapist assistant.
Unsecured Hazardous Materials in Facility
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards across multiple units, including 2 North, 4 South, St Joseph's Residence (SJR), and 5 North. On the 2 North unit, the clean utility room was found unlocked with eight blood collection kits containing needles uncontained on a shelf. Staff confirmed the absence of a locking mechanism on the utility room door, which should have been secured to prevent resident access. Similarly, on the 4 South unit, the clean utility room was unlocked, allowing access to various personal care products, and the spa room was propped open with a bottle of disinfectant cleaner accessible, despite warnings to keep it out of reach of children. On the SJR unit, the laundry room door was left open, and an unlocked cabinet inside contained hazardous chemicals, including disinfectants and laundry detergent, which were accessible to residents. The 5 North unit also had unsecured areas, with the spa room and clean utility room left unlocked, containing a skin disinfectant solution, facility cleaning solutions, and razors. Staff interviews confirmed that these areas should have been locked to prevent resident access to potentially dangerous items, but issues such as broken locks and lack of keys contributed to the deficiency.
Deficiency in Nursing Staff Competency Evaluation
Penalty
Summary
The facility failed to ensure that nursing staff, including Certified Nursing Assistants and Registered Nurses, possessed the necessary competencies and skills to provide adequate care and ensure the safety and well-being of residents. This deficiency was identified through interviews and record reviews, which revealed that the facility did not conduct the required competency evaluations for four staff members. The 2024 Facility Assessment indicated that skills assessments were to be completed upon hire and annually, covering areas such as abuse and neglect, resident rights, dementia care, infection control, and specific resident needs. However, the Director of Nursing was unable to provide documentation verifying the competency evaluations for the staff in question. Interviews with the Director of Nursing and the Administrator confirmed that the facility did not perform the necessary evaluations to assess the competencies, skills, and knowledge of the nursing staff. This lack of assessment resulted in deficiencies related to the competency of nursing staff, as the facility did not adhere to its own policies outlined in the Facility Assessment. The failure to ensure proficiency in critical areas such as personal care skills, vital sign monitoring, and emergency protocols compromised the ability of the staff to provide safe and effective care to residents.
Inadequate Infection Control Practices
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of staff not adhering to Enhanced Barrier Precautions (EBP) and Transmission-Based Precautions (TBP). Resident 14, who had intravenous access and was dependent on staff for personal hygiene, was observed receiving care from a CNA who did not wear the required isolation gown. The CNA acknowledged forgetting to put on the gown, which was a breach of the facility's infection control policy. Resident 85, who was primarily fed through a tube and had severely impaired vision, was also subject to inadequate infection control measures. A Licensed Practical Nurse (LPN) was observed administering tube feeding without wearing a gown, as required by the EBP sign on the resident's door. Additionally, the LPN used tubing that had fallen on the floor, which was against the facility's policy for maintaining cleanliness and preventing contamination. The LPN admitted to being nervous and forgetting to replace the tubing. Resident 15, who had a pressure ulcer requiring skin treatments, was another case where infection control protocols were not followed. An LPN providing wound care did not wear a gown, failed to perform proper hand hygiene, and used ungloved hands to handle used wound supplies. The facility's Director of Nursing and other staff members acknowledged that the expected infection control protocols were not followed, placing residents at risk for healthcare-associated infections.
Inadequate Investigation of Abuse and Resident Interactions
Penalty
Summary
The facility failed to thoroughly investigate reportable incidents involving three residents, leading to deficiencies in handling allegations of abuse and resident-to-resident interactions. Resident 110 reported an incident where a caregiver kissed them and attempted to climb into their bed. The facility's investigation substantiated the allegation but lacked thoroughness, as it did not include interviews with other potential witnesses or victims, nor did it verify if the caregiver had worked on other units. Additionally, the investigation did not include a background check to determine if the caregiver had any disqualifying history. Resident 95 experienced a fall after intervening in a resident-to-resident altercation involving a hot beverage. The facility's investigation categorized the incident as a non-injury fall and did not include witness interviews from other staff or residents. This lack of thorough investigation led to discrepancies in the characterization of the incident, which Resident 95 feared could negatively impact their independence. Resident 124 reported an incident where they backed their wheelchair into another resident, who then cussed at them. The investigation ruled out abuse but did not include witness statements from other staff or residents who may have been present. The investigation was completed by multiple staff members but lacked signatures to confirm its completion. These deficiencies in the investigation process placed residents at risk of verbal and mental abuse, psychosocial harm, and diminished quality of life.
Failure to Report Abuse to Authorities
Penalty
Summary
The facility failed to notify local Law Enforcement (LE) and the Department of Health (DOH) after substantiating an allegation of inappropriate touch/abuse involving a resident, identified as Resident 110. The incident occurred on December 24, 2024, when a Certified Nursing Assistant (CNA), referred to as Staff I, allegedly kissed Resident 110 and attempted to climb into their bed. The facility's investigation confirmed the allegation, and Staff I was immediately dismissed. However, the facility did not report the incident to LE or DOH, as required by Washington State's Department of Social & Health Services guidelines and the facility's own Abuse Prohibition and Prevention policy. Resident 110, who had intact memory and required assistance with mobility due to a fractured right hip, reported the incident during an interview on January 2, 2025. The Director of Nursing, identified as Staff B, acknowledged using the Purple Book for guidance on investigation and reporting but failed to notify the appropriate authorities. Additionally, a follow-up report filed with the Department of Social & Health Services' Complaint Resolution Unit contained errors in Staff I's name, further complicating the reporting process. This oversight placed residents at risk for verbal and mental abuse, psychosocial harm, and diminished quality of life.
Failure to Provide Timely Written Transfer Notifications
Penalty
Summary
The facility failed to ensure that residents or their representatives received the required written notices at the time of transfer or discharge, or as soon as practicable, for two residents reviewed for hospitalizations. Resident 14 was discharged to an acute care hospital, and there was no documentation in their health records indicating that the required written transfer notification was provided within 24 hours. Staff D, the Social Services Director, confirmed the absence of such documentation and stated that their process was to provide written notification the same day or email it the next day. However, they were unable to locate a copy of the notification for Resident 14. Similarly, Resident 120 was discharged to an acute care hospital, and their health records also lacked documentation of the required written transfer notification. Staff D reviewed Resident 120's records and confirmed the absence of documentation showing that the notification was provided as required. Staff A, the Administrator, stated that they expected staff to provide written notifications in a timely manner during hospitalizations. The failure to provide these notifications placed residents at risk for discharges that were not aligned with their stated goals for care and preferences.
Failure to Provide Bed-Hold Notification
Penalty
Summary
The facility failed to provide written notification of its bed-hold policy to two residents, Resident 14 and Resident 120, or their representatives, at the time of their transfer to an acute care hospital or within 24 hours as required. According to the facility's policy, residents and their representatives should receive bed-hold information at admission and before a hospital transfer or therapeutic leave. For emergency transfers, the facility is expected to contact residents or representatives to offer bed-hold information within 24 hours. However, for Resident 14, who was discharged to a hospital on November 14, 2024, there was no documentation indicating that a bed-hold notification was provided. Similarly, for Resident 120, who was transferred to a hospital on August 15, 2024, there was no record of a bed-hold notification being given. Interviews with facility staff revealed a lack of adherence to the policy. Staff N, a Social Services Assistant, stated that the facility's process was to offer bed-hold information on the same day residents were sent to a hospital. Staff A, the Administrator, and Staff D, the Social Service Director, both acknowledged the expectation that bed-hold notifications should be provided in a timely manner, either at the time of transfer or shortly thereafter. Despite these expectations, the absence of documentation for both residents indicates a failure to comply with the facility's policy, potentially leaving residents and their representatives uninformed about their rights and the costs associated with holding a bed during hospitalization.
Inaccurate MDS Documentation for Hospice Resident
Penalty
Summary
The facility failed to ensure an accurate assessment for Resident 170, as evidenced by discrepancies in the Minimum Data Set (MDS) documentation. Resident 170, who had multiple medically complex diagnoses including cancer, was inaccurately documented in the 12/11/2024 Admission MDS as not being on hospice, despite being on hospice services since 12/06/2024. This was confirmed by the presence of hospice service stickers on the resident's chart and the resident receiving an antianxiety medication as part of a hospice comfort kit. Staff SS, a Care Manager and Registered Nurse, acknowledged the inaccuracy in the MDS, emphasizing the importance of capturing hospice care to ensure the resident's care plan aligned with their comfort-focused goals.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, leading to potential risks for unmet care needs and inappropriate care. Resident 428, who was admitted to the facility with a history of frequent bowel incontinence and diarrhea, did not have a care plan addressing these issues. Despite being ruled out for infectious causes, the resident continued to experience diarrhea, which was unmanaged and not documented in the care plan. This oversight was confirmed by the Infection Preventionist, who acknowledged the importance of a care plan to manage the resident's condition and prevent complications such as dehydration and skin breakdown. Similarly, Resident 93, who was at risk for pressure ulcers and required assistance with mobility and personal hygiene, was observed to have edema in both lower legs. However, the resident's care plan did not address this condition, despite it being identified in a progress note. The Director of Nursing and the Manager of Long Term Care both stated that it was expected for staff to develop care plans that address current resident conditions, including monitoring and documenting interventions for edema. The lack of a comprehensive care plan for Resident 93's edema was a clear deficiency in the facility's care planning process.
Failure to Follow Physician Orders and Administer Medications
Penalty
Summary
The facility failed to follow physician's orders for two residents, leading to potential risks for the residents involved. Resident 22, who had a neurogenic bladder and required an indwelling catheter, was observed with a catheter bag hanging from the bed frame. The physician's orders specified the removal of the catheter for a trial and replacement with a size 16 FR catheter if necessary. However, staff inserted a size 14 FR catheter without a physician's order, and there were no directions for the duration of its use. Staff K acknowledged that the physician's orders were not followed. Resident 85, who had severe cognitive impairment and was at risk for pressure ulcers, had a physician's order for a dressing to be applied to a sacral wound every three days. The Treatment Administration Record indicated that the resident refused treatment on one occasion, and staff documented that the dressing was applied as ordered. However, observations showed that the resident had no dressing on the sacral area, and staff interviews confirmed the absence of a wound or dressing. Staff E stated that the physician's orders should have been clarified if there were changes, but this was not done. Resident 28, with medically complex conditions including unstable blood sugars and high blood pressure, did not receive prescribed medications due to unavailability. The resident reported missing medications and expressed distress over the situation. Staff J confirmed the medications were unavailable and did not notify the provider or document the issue. Staff K stated that the nurse should have sought further instructions from the provider and documented the situation, but this was not done.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary care and services for a resident with pressure ulcers, consistent with professional standards of practice. The resident, who had impairments to both sides of their lower body and was dependent on staff for activities of daily living, was observed without the required pressure-reducing devices while in a wheelchair. Despite physician orders to float the resident's left foot and use boots, staff interviews revealed that these interventions were not consistently implemented. Observations showed the resident's left foot hanging down while seated, contrary to the care plan instructions. Additionally, the facility did not adequately monitor and report changes in the resident's wound condition. A dressing on the resident's left foot was observed to be saturated with blood, yet staff failed to report this bleeding to the nurse or document it in the progress notes. The lack of communication and documentation regarding the resident's wound condition, as well as the failure to follow physician orders and care plan interventions, contributed to the deficiency in providing appropriate pressure ulcer care.
Failure to Monitor Resident's Weight Accurately
Penalty
Summary
The facility failed to accurately monitor the weight of a resident, identified as Resident 14, who was at risk for weight loss due to poor appetite. According to the facility's Weight and Nutrition Monitoring Policy, changes in residents' nutritional status and weight should be routinely discussed by clinical staff and the Registered Dietician. Resident 14, who had diagnoses including anemia and malnutrition, was dependent on staff for various needs and required assistance with meals. The resident's weight records showed a significant drop from 151.2 lbs. on December 13, 2024, to 119.8 lbs. on January 3, 2025, indicating a potential weight loss of over 30 lbs. in three weeks. The facility did not reweigh Resident 14 to verify the accuracy of the recorded weight loss, nor did they notify the physician or the Registered Dietician about this significant change. Staff E, the Director of Long Term Care and a Registered Nurse, acknowledged that the facility's process was to weigh residents weekly unless otherwise ordered by a provider, and that the staff should have reweighed Resident 14 due to the improbability of such a drastic weight loss. The failure to follow these procedures placed the resident at risk for negative health outcomes.
Inadequate Pain Management for Residents
Penalty
Summary
The facility failed to provide adequate pain management for two residents, leading to deficiencies in care. Resident 120, who had no cognitive impairment and a diagnosis of chronic pain, was not given a thorough pain assessment before the administration of PRN narcotic pain medication. The Medication Administration Records for November 2024, December 2024, and January 2025 showed incomplete documentation of pain assessments, including pain level, location, and non-pharmacological interventions. Interviews with Resident 120 and staff revealed that pain medications were not administered timely, and pain assessments were not consistently documented, contrary to the facility's expectations. Resident 28, who suffered from chronic pain due to chronic wounds, experienced a lack of availability of their PRN pain medication. The facility ran out of the medication, and the pharmacy did not deliver it as expected. The resident was given over-the-counter medication for breakthrough pain, but the facility's emergency medication supply kit did not contain the necessary pain medication. Staff interviews indicated that the recent switch to another pharmacy might have contributed to the delay, and the facility's protocol for handling such situations was not followed, as the nurses failed to notify management or the provider and did not document the issue in progress notes.
Medication Security and Expiration Oversight
Penalty
Summary
The facility failed to ensure the security and proper disposal of medications and biologicals across multiple units and medication storage areas. On the 300 South unit, a resident with severely impaired memory and a chronic respiratory disease was left unsupervised with an unsecured and unlabeled inhaler. The nurse responsible, who was new to the unit, admitted to not verifying the resident's ability to self-administer the medication. This oversight placed the resident at risk of receiving incorrect or expired medications. Additionally, expired medications and supplies were found in several medication rooms and carts, including the 5 North, 5 South, 4 South, and 3 South medication rooms, as well as the 5 South Medication Cart 1. Items such as urinary catheter kits, wound dressings, injectable medications, and various medical supplies were past their expiration dates. Staff interviews revealed a lack of adherence to the facility's policy on monitoring and disposing of expired items, with staff acknowledging the oversight and the potential harm to residents from using expired products.
Failure to Protect Resident Information on 5 North Unit
Penalty
Summary
The facility failed to maintain the confidentiality of resident-identifiable information on the 5 North unit, as observed during a survey. A paper copy of an interdisciplinary team progress note was found in a grievance file folder accessible to anyone near the elevator on the fifth floor. Staff E, a Resident Care Manager, acknowledged that the progress note should not have been placed there, as it compromised resident confidentiality. Additionally, a resident roster/report sheet was left exposed on top of a cart, visible to anyone passing by. Staff UU, an LPN, admitted to forgetting to cover the sensitive information before leaving the cart unattended. The Director of Nursing, Staff B, confirmed that staff were expected to keep resident information covered and out of sight to protect resident rights.
Deficient Coordination of Hospice Services
Penalty
Summary
The facility failed to ensure effective coordination of care between the facility and hospice staff for a resident receiving hospice services. The resident, who had multiple medically complex diagnoses including cancer, was admitted to hospice services, but the facility did not update the resident's Care Plan to reflect which agency was responsible for hospice care. Observations showed that the resident's chart indicated hospice services, but there was no physician's order for hospice, and the Care Plan lacked detailed interventions and collaboration notes. Additionally, the Kardex used by staff for care instructions did not indicate the resident was on hospice or specify the care to be provided by the facility or hospice. Interviews with facility staff revealed a lack of awareness and understanding of the hospice care being provided to the resident. The Certified Nursing Assistant responsible for the resident's care was unsure of the hospice providers' role, and the Manager of Long Term Care acknowledged the records were lacking in necessary documentation and collaboration. The facility's Administrator also expected hospice services to be coordinated with the facility, including ensuring orders, Care Plans, and progress notes were readily available in the resident's records. These deficiencies in communication and documentation placed the resident at risk of not receiving necessary care and services.
Failure to Document and Resolve Resident Grievances
Penalty
Summary
The facility failed to identify and resolve grievances for Resident 70, who was reviewed for grievances. According to the facility's Resident Grievance Policy, residents have the right to file grievances verbally or in writing and receive a written decision. However, the facility did not document any grievances from Resident 70, despite the resident expressing issues with a staff member, Staff ZZ. Resident 70, who has a progressive neurological disorder, depression, and a mood disorder, reported feeling disrespected by Staff ZZ, who did not respect their boundaries and was not patient during care. The resident had also reported these issues to the ombudsman. Interviews with staff revealed that grievances were not documented or tracked properly. Staff ZZ acknowledged the accusations made by Resident 70 and reported them to their nurse and the Director of Nursing, Staff B. However, the grievance log did not reflect any grievances from Resident 70. The Social Services Director, Staff D, stated that grievances should be documented, especially when residents complain about staff. Despite this, there was no record of grievances from Resident 70, indicating a failure in the facility's grievance process.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to effectively implement its abuse prohibition and prevention policies, resulting in deficiencies related to the handling of incidents involving three residents. For Resident 110, an investigation substantiated an allegation of inappropriate touching by a Certified Nursing Aide, Staff I. However, the investigation did not include necessary actions such as notifying law enforcement or the Department of Health, conducting a background check on Staff I, or interviewing potential witnesses or other residents who might have been affected. This lack of thoroughness in the investigation process was acknowledged by the Director of Nursing and the Administrator. For Resident 95, an incident initially categorized as a non-injury fall was later described by the resident as a slip on liquid thrown by another resident. The investigation did not include interviews with witnesses, which was a deviation from the facility's policy. Similarly, for Resident 124, an incident involving verbal abuse was reported, but the subsequent investigation failed to include witness statements from staff or residents who were present. Both the Director of Nursing and the Administrator recognized that these investigations were incomplete and did not adhere to the facility's established procedures.
Deficiency in Safe Use of Air Mattresses
Penalty
Summary
The facility failed to ensure the safe use of air mattresses for four residents, leading to multiple falls and potential risks for other residents using similar equipment. The deficiency was identified through observations, interviews, and record reviews, which revealed that the facility did not implement a comprehensive system for assessing and monitoring the use of air mattresses. Specifically, there was a lack of assessment regarding the type, size, and settings of the air mattresses, and no informed consent was obtained from residents or their representatives. Additionally, staff training on the use and monitoring of air mattresses was not provided, and care plans were not updated to include necessary interventions. Resident 1, who was admitted with a history of falls and pressure injuries, experienced three falls from the bed while using an air mattress. The facility's records showed that the wrong size air mattress was initially delivered, and there was no documentation of a safety assessment or discussion of risks and benefits with the resident or their representative. The Treatment Administration Record (TAR) lacked specific parameters for air mattress settings, and staff were only directed to monitor the mattress for function and comfort, without assessing or documenting the pump settings. Similar deficiencies were noted for Residents 2, 3, and 4, who also used air mattresses without proper safety assessments or documentation of settings. Interviews with facility staff confirmed that the necessary assessments and monitoring were not conducted, and no documentation was provided to show that staff were trained on the use and monitoring of air mattresses. The facility's failure to implement a system for the safe use of air mattresses placed residents at risk for falls, injury, and other negative outcomes.
Failure to Follow Mechanical Lift Policy Results in Resident Injury
Penalty
Summary
The facility failed to ensure an environment free of avoidable accidents and injuries for a resident who required mechanical lift transfers. The facility policy mandated that two staff members operate the mechanical lift to ensure resident safety. However, a Certified Nursing Assistant (CNA) transferred the resident alone, resulting in a severe laceration on the resident's right leg. The resident, who had limited mobility and fragile skin, was hospitalized for five days due to the injury, which required surgical intervention. The resident's care plan and Kardex clearly indicated the need for two staff members during mechanical lift transfers to prevent injuries. Despite having attended training that reinforced this policy, the CNA proceeded with the transfer alone. During the transfer, the resident's leg was cut by the wheelchair's footrest, causing a deep laceration that exposed connective tissue and resulted in significant bleeding. The CNA then transferred the resident back to bed without assistance, further violating the facility's policy. Interviews with facility staff confirmed that the CNA had previously used the mechanical lift without a second person on multiple occasions. The Director of Clinical Operations and the Director of Nursing both stated that the CNA had been trained and was aware of the policy requiring two staff members for mechanical lift transfers. The incident report and hospital records detailed the extent of the resident's injury and the subsequent medical treatment required, including surgery and a five-day hospital stay.
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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