Richmond Beach Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Shoreline, Washington.
- Location
- 19235 - 15th Avenue Northwest, Shoreline, Washington 98177
- CMS Provider Number
- 505488
- Inspections on file
- 28
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Richmond Beach Rehab during CMS and state inspections, most recent first.
Surveyors identified multiple infection control lapses, including a laundry aide transporting uncovered clean clothes and reusing a linen cover that had fallen to the floor, an LPN entering a droplet precaution room without required eye protection, and a nurse practitioner and an RN performing wound care without gowns despite Enhanced Barrier Precautions. An LPN also failed to properly disinfect a shared glucometer between residents and did not clean the rubber seal of a Liraglutide pen with alcohol before attaching a new needle, contrary to policy and manufacturer instructions. In addition, a urine-filled urinal was left on a bedside table next to a meal tray, which staff acknowledged should not have occurred.
A resident who had previously received PPSV23 and PCV13 met CDC criteria for an additional pneumococcal vaccine dose and had signed consent to receive PCV20, but review of the EHR showed no documentation that PCV20 was ever administered. The facility’s policy required offering pneumococcal vaccines and following current CDC recommendations, and both the IP and DON acknowledged the expectation that the resident should have received the vaccine, yet the dose was not provided or recorded.
A resident with a pressure ulcer did not receive prescribed wound care due to the unavailability of Dakin's solution. Despite the resident's report and staff awareness, the physician was not notified, and no alternative treatment was ordered. The resident's wound was treated with wet-to-dry dressing instead, contrary to the physician's order.
The facility failed to ensure accurate PASARR screenings for several residents, leading to missed Level II referrals for those with Serious Mental Illness (SMI) or Intellectual Disabilities (ID). This oversight involved incomplete or incorrect PASARR forms for residents with conditions such as anxiety, depression, and delusional disorders, placing them at risk of not receiving appropriate care.
The facility failed to accurately complete daily nurse staffing forms with actual hours worked for each shift over six days. Observations showed that the posted forms lacked the required information for nursing staff, including RNs, CNAs, and LPNs. The DON admitted to not filling out the actual hours due to previous training. The facility's policy required this information to be recorded, and the Administrator confirmed the need for accurate postings.
The facility failed to properly label and store medications, including insulin pens and a bronchodilator inhaler, and did not remove expired supplies. Additionally, the facility did not adhere to CDC guidelines for vaccine storage, as refrigerator temperatures were not checked twice daily despite storing RSV vaccines. Expired intravenous starter needles were also found in the medication room refrigerator.
A long-term care facility was found to have multiple infection control deficiencies, including improper disinfection of insulin pens, inadequate hand hygiene, and improper storage of personal care items and PPE. Additionally, hand hygiene supplies were lacking in medication rooms, and shared transfer lift equipment was not disinfected between uses, increasing the risk of infection.
A facility failed to notify the State LTC Ombudsman in writing about a resident's transfer to the hospital, as required by their policy. The Social Services Assistant responsible for sending the notice did not document the communication or retain a fax receipt. The Administrator confirmed the expectation for written notification and documentation of such communications.
A facility failed to accurately assess a resident's condition by not documenting oxygen use during the MDS assessment look-back period. The resident, admitted with asthma and respiratory failure, had received oxygen, as noted in the TAR, but this was not captured in the MDS. The Case Manager acknowledged the oversight, and the DON confirmed the expectation for accurate assessments per the RAI Manual.
The facility failed to provide baseline care plan summaries to two residents within 48 hours of admission, as required by policy. Reviews of the residents' EHRs showed no documentation of the summaries being provided, and interviews with staff confirmed the oversight. The residents did not receive the necessary written summaries outlining their care plans, which should have included goals, medication, dietary instructions, and services.
The facility failed to properly store oxygen tubing and cannulae for two residents, leading to a deficiency in respiratory care. One resident's tubing was found hanging on a wheelchair with nasal prongs touching the floor, while another's was on the floor beside their bed. Staff confirmed that the supplies should have been stored in a bag when not in use to prevent cross-contamination.
A facility failed to consistently evaluate and document a resident's dialysis care, despite a care plan requiring monitoring for infection at the access site. Staff interviews revealed a lack of awareness and adherence to the care plan, with some unaware of the access site's location and others acknowledging the order was not reinstated upon readmission. The DON confirmed the oversight, and the resident reported no consistent evaluations post-treatment.
Multiple Infection Control Lapses in Linen Handling, PPE Use, Wound Care, Glucometer Disinfection, Medication Technique, and Urinal Placement
Penalty
Summary
The deficiency involves multiple failures in the facility’s infection prevention and control practices by several staff members in different care processes. A laundry aide transported clean clothes on a rolling rack that was not fully covered, contrary to facility expectations and CDC guidance for linen transport. During transport, the linen cover fell to the floor, and the aide picked it up and placed it back on top of the rack containing clean clothes instead of treating it as soiled and sending it to dirty laundry. The laundry manager and the infection preventionist both stated that clean linens and clothes were expected to be fully covered during transport and that any linen that touched the floor was considered soiled and should be placed in dirty laundry. Another deficiency occurred in the use of PPE for a resident on droplet precautions. An LPN entered a droplet precaution room wearing a gown and gloves but only had prescription eyeglasses on and did not use required eye protection such as a face shield or goggles, despite signage outside the room indicating that eye protection was required. The LPN stated they were unsure if prescription eyeglasses counted as PPE. The infection preventionist and the DON both stated that prescription eyeglasses were not considered PPE and that staff were expected to wear appropriate eye protection when caring for residents on droplet precautions. Additional infection control failures were identified during wound care and medication-related procedures. A nurse practitioner and an RN performed wound care on a resident with a sacral pressure injury requiring dressing changes three times a week, wearing only gloves and no gowns, even though they acknowledged that wound care required Enhanced Barrier Precautions and that gowns should have been worn. For another resident with orders for blood glucose checks before meals and at bedtime, an LPN cleaned a shared glucometer with an alcohol wipe instead of disinfecting it with Sani-cloth or bleach-based wipes between uses, contrary to facility policy and infection control standards. The same LPN also prepared and administered a Liraglutide injection using a pen device without wiping the rubber stopper with an alcohol swab before attaching a new needle, despite manufacturer instructions requiring this step and facility expectations for antiseptic technique. A further deficiency involved improper handling of a resident’s personal care item in relation to food service. A resident’s urinal, filled with urine, was observed on the bedside table next to the resident’s meal tray. A CNA confirmed that the urinal should not have been on the table next to the meal tray and that it should have been emptied. The infection preventionist and the DON both stated they did not expect a urine-filled urinal to be placed next to a meal tray and that it should have been emptied and kept away from the bedside table.
Failure to Administer Indicated Pneumococcal Vaccine per CDC Guidelines
Penalty
Summary
The facility failed to ensure that pneumococcal vaccination was up to date for one resident in accordance with its own policy and current CDC recommendations. The facility’s pneumococcal vaccine policy, dated October 2025, required that all residents be offered pneumococcal vaccines and that administration follow current CDC guidelines. CDC’s Adult Immunization Schedule Notes indicated that an adult who had previously received both PCV13 and PPSV23, but had not received PPSV23 at age 65 or older, should receive one dose of PCV20 or PCV21 at least five years after the last pneumococcal vaccine dose. Record review showed the resident had received PPSV23 on 02/14/2001 and PCV13 on 11/12/2018, meeting criteria for an additional pneumococcal vaccine dose. Further review of the resident’s records showed that on 03/10/2024 the resident had signed a Vaccination History and Consent form agreeing to receive Prevnar 20 (PCV20). However, review of the electronic health record did not show any documentation that Prevnar 20 was administered. During an interview and joint record review, the Infection Preventionist confirmed that the facility followed CDC guidelines, acknowledged the signed consent for Prevnar 20, and stated there was no documentation that the vaccine had been given. The DON also stated the expectation that the resident would have received the pneumococcal vaccination per CDC guidelines. This lack of administration and documentation for the agreed-upon and indicated pneumococcal vaccine constituted the deficiency.
Failure to Provide Prescribed Wound Care for Resident
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with a pressure ulcer, consistent with professional standards of practice. The resident, who had an unstageable pressure ulcer related to a deep tissue injury, reported not receiving wound treatment according to their physician's order due to the unavailability of the prescribed wound cleaning solution, Dakin's solution. Despite having an order to apply moistened gauze with Dakin's solution, the solution was not available from 12/23/2024 to 01/03/2025, and there was no documentation that the resident's physician or wound consultant was notified about this issue. Staff interviews revealed that the resident's wound was being treated with wet-to-dry dressing instead, without notifying the physician or obtaining a new wound care order. The Resident Care Manager acknowledged that the pharmacy and the resident's physician should have been notified when the prescribed solution was unavailable, and the Director of Nursing confirmed that an alternative wound treatment order should have been obtained. The lack of communication and failure to follow protocol placed the resident at risk for deterioration of their pressure ulcer and a diminished quality of life.
Failure to Ensure Accurate PASARR Screening
Penalty
Summary
The facility failed to ensure the accuracy and completion of the Preadmission Screening and Resident Review (PASARR) forms for several residents, which is crucial for identifying individuals with Serious Mental Illness (SMI) or Intellectual Disabilities (ID) who may be inappropriately placed in nursing homes. The report highlights that the PASARR forms for five residents were either incomplete or incorrect, leading to a lack of necessary Level II PASARR referrals. This oversight placed the residents at risk of not receiving appropriate care and services tailored to their specific needs. For Resident 41, the PASARR form was marked for a mood disorder but failed to include the resident's anxiety disorder, and no Level II referral was made. Similarly, Resident 67's PASARR form included anxiety disorder but omitted the depressive disorder, and no Level II referral was completed. Resident 36's form marked mood and anxiety disorders but did not include delusional disorder, and a Level II referral was not sent. Resident 46's form included PTSD and anxiety but omitted major depressive disorder, and no Level II evaluation was indicated. Lastly, Resident 20's form did not mark major depressive disorder, and no Level II referral was completed. Interviews with staff revealed a lack of understanding and adherence to the updated PASARR regulations, which require a Level II referral for any SMI indicators. Staff members acknowledged the discrepancies and admitted to missing necessary corrections and referrals. The facility's social services department was responsible for reviewing PASARR documents for accuracy, but the oversight in these cases indicates a failure to comply with the regulatory requirements, as outlined in the Washington Administrative Code (WAC) 388-97-1915.
Failure to Accurately Complete Daily Nurse Staffing Forms
Penalty
Summary
The facility failed to ensure the daily nurse staffing form was accurately completed with actual hours worked for each shift over a period of six days. Observations on multiple days revealed that the posted daily nursing staffing forms did not include the actual hours worked for each shift by the nursing staff, which included Registered Nurses, Certified Nursing Assistants, and Licensed Practical Nurses. This omission was confirmed during an interview with the Director of Nursing Services, who stated that they had not been filling out the actual total hours due to training received from a previous staffing coordinator. The facility's policy required that shift staffing information must be recorded on a form for each shift, including the actual hours worked during that shift for each category and type of nursing staff. The Administrator acknowledged that daily nurse staff postings need to be visible and available with the actual hours filled out.
Deficiencies in Medication Labeling, Storage, and Expired Supplies Management
Penalty
Summary
The facility failed to ensure proper labeling and storage of drugs and biologicals, as well as the removal of expired supplies, in accordance with professional standards. During an observation, a Licensed Practical Nurse (LPN) did not date two newly opened insulin pens before storing them in the medication cart. Additionally, a prescription bronchodilator inhaler was found with an incomplete label that did not come from the pharmacy, lacking the necessary prescription or pharmacy label. The facility also did not adhere to the Centers for Disease Control and Prevention (CDC) guidelines for vaccine storage. The Cascade medication room refrigerator's temperature was only checked once a day, despite the presence of a Respiratory Syncytial Virus (RSV) vaccine, which requires twice-daily temperature checks. Similarly, the [NAME] medication room refrigerator had missing temperature records and was also checked only once daily, despite storing an RSV vaccine. Expired medical supplies were found in the Baker medication room refrigerator, including intravenous starter needles with an expired date. The facility's Director of Nursing Services and other staff acknowledged these deficiencies, stating that the facility followed CDC guidelines and that expired supplies should have been discarded.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices, as evidenced by multiple deficiencies observed during the survey. One significant issue involved the improper disinfection of insulin pens and inadequate hand hygiene practices during medication administration for a resident. A Licensed Practical Nurse (LPN) was observed administering insulin doses without performing hand hygiene after removing gloves and before donning new ones. Additionally, the insulin pens were placed on a sink counter and stored in the medication cart without being cleaned, contrary to the facility's policy and CDC guidelines. Another deficiency was noted in the storage of personal care items and Personal Protective Equipment (PPE). Personal hygiene items were found unbagged and placed directly on the bathroom floor, which is against the facility's policy that requires such items to be bagged and stored properly. Furthermore, isolation carts for Enhanced Barrier Precautions (EBP) were improperly stocked, with non-PPE items like chips, cups, and linens stored alongside PPE. Some carts lacked essential PPE such as gowns, and staff were unaware of the correct PPE to be stored, indicating a lack of adherence to CDC guidelines and facility expectations. The facility also failed to provide adequate hand hygiene supplies in medication rooms and did not ensure the disinfection of shared transfer lift equipment between resident uses. Observations revealed that handwashing stations lacked necessary supplies like paper towels and hand sanitizer. Additionally, a Hoyer lift used for transferring residents was not disinfected between uses, increasing the risk of cross-contamination. Staff interviews confirmed these lapses, with some staff unaware of the need to disinfect equipment after each use, despite the facility's policy and OSHA standards requiring such practices.
Failure to Notify State LTC Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to properly notify the Office of the State Long Term Care (LTC) Ombudsman in writing regarding the transfer of a resident to the hospital. This deficiency was identified during a review of the facility's policy and resident records. The policy, revised in March 2021, mandates that a copy of the transfer or discharge notice be sent to the State LTC Ombudsman at the same time it is provided to the resident and their representative. However, a review of Resident 36's nursing progress notes from September 30, 2024, to November 25, 2024, revealed no documentation indicating that the notice of transfer was sent to the Ombudsman office. Interviews with facility staff further highlighted the deficiency. Staff I, a Social Services Assistant, acknowledged their responsibility for completing and faxing the transfer notice form to the State LTC Ombudsman office. However, they admitted there was no documentation or fax receipt confirming that the notice had been sent. Additionally, Staff A, the Administrator, confirmed the expectation that the Ombudsman office should have been notified in writing about the resident's hospital transfer and that such communications should have been documented.
Failure to Accurately Assess Resident's Oxygen Use
Penalty
Summary
The facility failed to accurately assess a resident's condition by not capturing the use of oxygen during the Minimum Data Set (MDS) assessment look-back period. The resident, who was admitted with asthma and respiratory failure, had received oxygen during the look-back period, as documented in the Treatment Administration Record (TAR). However, this was not reflected in the MDS assessment, which is a critical tool for evaluating the resident's care needs. The oversight was identified during an interview and joint record review with the Case Manager, who acknowledged that the MDS should have included the oxygen use. The Director of Nursing Services confirmed that the expectation was for staff to adhere to the Resident Assessment Instrument (RAI) Manual and complete MDS assessments accurately. This failure to document the resident's oxygen use placed the resident at risk for unidentified and/or unmet care needs, potentially affecting their quality of life.
Failure to Provide Baseline Care Plan Summaries
Penalty
Summary
The facility failed to develop baseline care plans and provide a written summary of these plans to two residents, identified as Residents 40 and 151, within 48 hours of their admission. This deficiency was identified through interviews and record reviews. The facility's policy, revised in March 2022, mandates that a written summary of the baseline care plan, including goals, medication, dietary instructions, and services, be provided to residents or their representatives. However, reviews of the Electronic Health Records (EHR) for both residents showed no documentation that such summaries were provided. Resident 40's EHR lacked any evidence of a written summary being given, while Resident 151, who had intact cognition, confirmed not receiving the summary. Staff interviews revealed that the baseline care plan was supposed to be developed upon admission, with the summary provided by social service personnel. However, both the Resident Care Manager and the Social Services Director acknowledged the absence of documentation indicating that the summaries were given. The Director of Nursing Services also confirmed the expectation that these plans should be developed and provided within the specified timeframe.
Improper Storage of Oxygen Tubing and Cannulae
Penalty
Summary
The facility failed to ensure proper storage of oxygen tubing and cannulae for two residents, leading to a deficiency in respiratory care. Resident 17, who was admitted with diagnoses including congestive heart failure and asthma, had a physician's order for oxygen via nasal cannula as needed for shortness of breath. Observations on two separate occasions revealed that Resident 17's oxygen tubing and cannula were not stored properly when not in use, with the nasal prongs touching the floor. Staff K, an LPN, confirmed that the tubing and cannula should have been stored in a bag when not in use. Similarly, Resident 46, who was admitted with diagnoses including congestive heart failure, asthma, and chronic respiratory failure with hypoxia, had a physician's order for supplemental oxygen. An observation showed that Resident 46's oxygen tubing and cannula were found on the floor beside their bed instead of being stored properly. Staff N, an LPN, acknowledged that the tubing should have been bagged when not in use and stated that it should be discarded. Both the Resident Care Manager and the Director of Nursing Services confirmed the expectation that oxygen therapy supplies should be stored in a bag when not in use to prevent cross-contamination.
Failure to Consistently Evaluate Dialysis Care
Penalty
Summary
The facility failed to consistently evaluate and document the dialysis care for a resident who required such services. The resident, who was cognitively intact and received dialysis three times a week at an offsite center, had a care plan directing staff to monitor and report any signs of infection at the dialysis access site. However, the facility's records showed no consistent evaluation or documentation of the resident's condition after dialysis treatments. Interviews with staff revealed a lack of awareness and adherence to the care plan, with some staff unaware of the location of the dialysis access site and others acknowledging that the order to check the site was not reinstated upon the resident's readmission. The Director of Nursing Services confirmed that the order to check the dialysis access site was not placed back when the resident was readmitted, and there was an expectation for staff to evaluate and document the resident's condition after each dialysis treatment. The resident also reported that the facility never checked the dialysis access site or evaluated them consistently after treatments. This oversight placed the resident at risk for unmet care needs and potential deterioration of their chronic condition.
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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