Sharon Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Centralia, Washington.
- Location
- 1509 Harrison Avenue, Centralia, Washington 98531
- CMS Provider Number
- 505429
- Inspections on file
- 33
- Latest survey
- December 1, 2025
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Sharon Care Center during CMS and state inspections, most recent first.
Two residents who required staff assistance for toileting were not checked or changed as scheduled during the night, resulting in one being found with dried BM and another with a saturated brief and bedding. Staff interviews and facility investigations confirmed that the required two-hour check and change protocol was not followed.
Surveyors observed expired and undated food items in both the kitchen and nourishment refrigerators, as well as missing temperature log entries for the nourishment refrigerator on East Hall. Staff interviews confirmed that required procedures for labeling, dating, and monitoring food storage and temperatures were not consistently followed.
A resident with severe cognitive impairment and diagnoses including dementia with agitation and delirium was prescribed Olanzapine, an antipsychotic medication. Facility policy required an AIMS test to be completed upon admission and when starting antipsychotic therapy, but staff interviews and record review confirmed that this assessment was not performed or documented.
A resident's admission MDS assessment was not completed within the required 14-day timeframe. The MDS nurse, responsible for scheduling and completing the assessment, was on vacation and did not finish the assessment on time, leaving it incomplete 16 days after admission. The DON confirmed the expectation for timely completion.
The facility did not complete or submit required PASRR assessments for two residents with mental health diagnoses who remained in the facility beyond the exempted hospital discharge period. Both residents had documentation indicating the need for a Level II evaluation if their stay exceeded 30 days, but no further assessments were conducted or transmitted, as confirmed by the Social Service Director.
A resident with a history of repeated falls did not have their care plan revised to include a new intervention after experiencing a second fall. Although documentation indicated the care plan was updated after the first fall, review showed no new intervention was added following the subsequent incident, and staff interviews confirmed this omission.
The facility did not obtain daily weights as ordered for a resident with heart failure and failed to check for blood return before flushing a PICC line during medication administration for another resident with endocarditis. These actions did not comply with physician orders and were confirmed by staff interviews and record review.
A resident with severe cognitive impairment and chronic pain conditions did not receive required pain assessments every shift, despite care plans and hospice directives mandating regular monitoring. Staff interviews and documentation review confirmed that pain assessments were inconsistently performed, leaving the resident's pain needs unmet.
Sharps containers in two rooms were found filled above the designated line, causing the lids to malfunction and exposing sharps at the opening. Both nursing and environmental services staff stated they would empty the containers if they noticed they were full, but there was no established process or department responsible for monitoring or replacing the containers. This lack of a defined protocol led to the containers being overfilled and observed as a hazard during the survey.
The facility did not include required health recertification and complaint survey results for two years in its publicly accessible survey binder, maintaining only fire and life safety surveys and omitting health-related reports, as confirmed by staff interviews and record review.
The facility failed to assist residents with completing advance directives and maintaining Durable Power of Attorney documentation for four residents. Despite the facility's policy requiring ADs to be reviewed upon admission, the electronic health records for these residents lacked the necessary documentation. Staff acknowledged gaps in documentation and follow-up, which placed residents at risk of not having their healthcare preferences honored.
The facility failed to obtain physician orders for the use of bed rails for two residents, one moderately cognitively impaired and the other alert and oriented. Both residents were observed with quarter length bed rails, but their EHRs lacked the necessary physician orders, as confirmed by staff.
A facility failed to send a Notice Before Transfer to the State Long-Term Care Ombudsman for a resident transferred to a hospital. The resident had diagnoses including congestive heart failure exacerbation. The administrator admitted to not knowing the requirement and sent notices for previous months only after being questioned.
A resident's MDS assessment inaccurately documented their oral/dental status, failing to reflect missing and broken teeth and reported mouth pain. Observations and staff interviews revealed discrepancies between the MDS and the resident's actual condition, highlighting a lack of direct assessment by the MDS Nurse.
A facility failed to develop a comprehensive care plan for a cognitively impaired resident, omitting the placement of the bed against the wall and a mat on the floor. Staff acknowledged the oversight, which was against facility policy, potentially risking the resident's care needs and quality of life.
A facility failed to provide nail care for a resident who was dependent on staff for ADLs. Despite the facility's policy requiring nail care during baths, the resident's nails were not trimmed for about a month. Staff interviews confirmed that nail care was overlooked, and the DON observed that the resident's nails had not been trimmed for about two weeks.
A resident signed an arbitration agreement without a clear understanding due to confusion and lack of proper explanation by facility staff. The staff, including the Admissions Coordinator and Administrator, were unaware of the 30-day rescission period, leading to potential risks for residents signing legal documents without full knowledge.
The facility failed to ensure proper infection prevention practices, including the use of PPE and hand hygiene, for two residents. A CNA did not perform hand hygiene between changing gloves, and two CNAs did not wear isolation gowns when required. Additionally, a CNA used contaminated gloves outside a resident's room. The DON confirmed that staff were expected to follow isolation precaution signs and perform hand hygiene.
Failure to Provide Timely Toileting Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide timely toileting assistance to two residents who required staff support for activities of daily living. One resident, who was moderately cognitively impaired and dependent on staff for toileting, was found in the morning with dried bowel movement on her sheets and body, and her brief was stuck to her, indicating she had not been checked or changed during the night as required by her care plan. Staff interviews confirmed that the resident was on a two-hour check and change schedule, but this protocol was not followed during the night shift. Another resident, also moderately cognitively impaired and requiring maximum assistance with toileting, reported that her brief was not changed during the night. She was found in the morning with a saturated brief, incontinent pad, and blanket, necessitating a complete bed change. Staff confirmed that this resident was to be checked and changed every two hours, and documentation and interviews indicated that the required care was not provided during the night shift. Both incidents were corroborated by staff and resident interviews, as well as facility investigations.
Failure to Label, Date, and Monitor Food Storage and Temperatures
Penalty
Summary
The facility failed to ensure proper labeling and dating of food items in both the kitchen and nourishment refrigerators. During observations, surveyors found expired and undated food items, including a container of Parmesan cheese and a container of jam in the kitchen refrigerator, as well as a fruit cup past its use-by date and six undated fruit cups in the nourishment refrigerator on East Hall. These items were not removed in accordance with the facility's stated policy of discarding food after three days or by the use-by date. Additionally, the facility did not maintain accurate temperature logs for the nourishment refrigerator on East Hall. The temperature log was missing entries for several consecutive days, indicating a lack of consistent monitoring. Staff interviews confirmed that kitchen staff were responsible for labeling, dating, and monitoring food storage and temperatures, but these procedures were not consistently followed, resulting in the deficiencies observed.
Failure to Complete Required AIMS Test for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to complete an Abnormal Involuntary Movement Scale (AIMS) test for a resident who was prescribed an antipsychotic medication, Olanzapine, upon admission. According to the facility's policy, an AIMS test should be performed when a resident is admitted on antipsychotic medications, every six months, and as needed. Record review showed that the resident, who had diagnoses including dementia with agitation and delirium and was severely cognitively impaired, was receiving Olanzapine as ordered by the physician. However, there was no documentation of an AIMS test being completed for this resident. Interviews with facility staff, including the Resident Care Manager/RN and the Director of Nursing/RN, confirmed that an AIMS test should have been completed upon admission and when the antipsychotic medication was started. Both staff members acknowledged that the AIMS test was missed for this resident, and it was not found in the resident's electronic health record. This omission was identified during the review of records and staff interviews.
Late Completion of Admission MDS Assessment
Penalty
Summary
The facility failed to complete the admission Minimum Data Set (MDS) assessment within the required timeframe for one resident. According to the Resident Assessment Instrument (RAI) User's Manual, the admission MDS must be completed no later than the 14th calendar day after admission. Record review showed that the resident's admission MDS was still in progress 16 days after admission. During interviews, the MDS nurse stated that she typically scheduled the MDS assessment for seven days after admission and aimed to complete it one week after the assessment reference date (ARD). She acknowledged that the assessment was not completed on time because she was on vacation, and it should have been finished two days prior. The Director of Nursing confirmed the expectation that the admission MDS be completed by the 14th day of admission.
Failure to Complete Required PASRR Assessments for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that the Pre-admission Screening and Resident Review (PASRR) assessments were properly reviewed, completed, and submitted for two residents with mental health diagnoses. For one resident admitted with anxiety and depression and identified as moderately cognitively impaired, the PASRR indicated a Mood Disorder and noted an exempted hospital discharge, stating that a Level II evaluation was required if the resident remained beyond 30 days. However, no further PASRR was completed or transmitted after the resident stayed past the 30-day period. The Social Service Director acknowledged during interview that the review was missed and should have been completed. Similarly, another resident admitted with major depressive disorder was documented as alert and oriented, and their PASRR Level 1 assessment also indicated an Exempted Hospital Discharge with the requirement for a Level II evaluation if the stay exceeded 30 days. Record review showed no evidence that a new PASRR Level 1 or Level II was completed after the resident remained in the facility beyond the anticipated discharge period. The Social Service Director confirmed responsibility for PASRR referrals and admitted not submitting the required referral for a Level II evaluation, having not realized the resident's stay had exceeded 30 days.
Failure to Revise Care Plan After Multiple Falls
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised to accurately reflect care needs following multiple falls. A resident with a history of repeated falls was admitted with multiple diagnoses and was assessed as cognitively intact. The facility's records showed that the resident experienced falls on two separate occasions in August, and documentation from fall investigations indicated that the care plan was updated to cue and encourage the resident to use the call light and wait for help. However, review of the resident's fall care plan revealed that after the second fall, no new revision or intervention was documented to address the most recent incident. Interviews with facility staff confirmed that the expected process after a fall was to update the care plan with a new intervention. The Resident Care Manager/LPN acknowledged that a new intervention should have been added after the second fall but stated it was missed. The Director of Nursing/RN also confirmed the expectation that the care plan be updated after each fall. This deficiency was identified through interview and record review, as the care plan did not reflect the resident's most current care needs following the second fall.
Failure to Follow Physician Orders for Weights and PICC Line Care
Penalty
Summary
The facility failed to follow physician's orders for daily weights for a resident with multiple diagnoses, including congestive heart failure. The resident was admitted with severe cognitive impairment, and the physician's orders specified daily weights for one week, then weekly weights unless otherwise ordered. Review of the electronic health record showed missing documentation of weights on several specified dates, indicating that the ordered monitoring was not completed as required. During an interview, the Resident Care Manager/Registered Nurse acknowledged that some weights were missed. Additionally, the facility did not adhere to physician's orders regarding medication administration for another resident with endocarditis and a peripherally inserted central catheter (PICC) line. The orders required flushing the PICC line and checking for blood return before each medication administration. During an observed medication pass, a registered nurse flushed the PICC line and started IV antibiotics without checking for blood return as ordered. When questioned, the nurse stated that blood return had been checked the previous day during a blood draw, but not at the time of the medication administration.
Failure to Complete Shift Pain Assessments for Cognitively Impaired Resident
Penalty
Summary
The facility failed to complete pain assessments every shift for a resident with multiple chronic pain-related diagnoses, including vascular dementia, fibromyalgia, and chronic pain syndrome. The resident was severely cognitively impaired and unable to consistently verbalize pain, requiring staff to use both verbal and non-verbal pain assessment tools. Documentation showed that the care plan and hospice plan of care required regular pain monitoring and assessment using appropriate scales. However, record review revealed that pain assessments were not consistently completed every shift as required. Observations and interviews indicated that the resident experienced ongoing pain, including pain related to a right heel deep tissue injury and generalized discomfort. Staff interviews confirmed that pain assessments were supposed to occur every shift, but this was not consistently documented or ordered. The lack of regular pain assessments placed the resident at risk for unmet care needs and diminished quality of life, as noted in the report.
Sharps Containers Overfilled Due to Lack of Monitoring Process
Penalty
Summary
Sharps containers in two resident rooms were observed to be filled above the designated fill line, as indicated by the warning label on the containers. During observations, the overfilled containers caused the lids to malfunction, with sharps instruments catching on the lid and protruding toward the opening, creating a potential hazard. The containers were not dated consistently, and the issue was noted during multiple observations by surveyors. Staff interviews revealed that there was no clear assignment of responsibility for monitoring or emptying sharps containers, with both nursing and environmental services staff stating they would empty the containers if they noticed they were full. However, there was no established process or department designated to regularly check and replace the containers when full. Staff members, including a registered nurse and the Environmental Services Supervisor, acknowledged that the containers should be emptied at the fill line but confirmed that no specific protocol or department was responsible for this task. The Director of Nursing also stated the expectation that staff would change the containers when they reached the full line. The lack of a defined process led to the containers being overfilled, as observed by surveyors, and placed residents, visitors, and staff at risk for injury and exposure.
Failure to Provide Required Survey Results in Public Binder
Penalty
Summary
The facility failed to ensure that its survey result binder included the required health recertification and complaint survey results for two of the three years reviewed, specifically for 2024 and 2025. During an observation, the survey binder was found in a wall-mounted receptacle near the skilled nursing entrance and was labeled as containing the three most current years of survey reports. However, upon review, the binder only contained a Federal Fire and Life Safety recertification survey and its re-inspection from 2024, with no health recertification or health complaint investigation survey results for 2024 or 2025. Interviews with the DON and the Administrator revealed that only one survey binder was maintained, and the Administrator admitted to not including complaint investigation surveys in the binder, typically only placing annual survey results. The Administrator also stated that the survey results were not available last year and could not be found online.
Failure to Document Advance Directives
Penalty
Summary
The facility failed to have procedures in place to assist residents with completing advance directives (AD) and obtaining and maintaining Durable Power of Attorney (DPOA) documentation for four of nine sampled residents. This deficiency was identified through interviews and record reviews. The facility's policy on advance directives, dated August 1, 2018, requires determining whether a resident has an AD upon admission and providing information about the right to refuse treatment and formulate an AD. However, the electronic health records (EHR) for Residents 1, 24, 26, and 30 did not show any AD or documentation that an AD was reviewed since their admission. Resident 1 was severely cognitively impaired, Resident 24 was moderately cognitively impaired, and Residents 26 and 30 were alert and oriented. Despite these varying cognitive statuses, none of their EHRs contained the necessary AD documentation. Staff K, the Social Services Director, acknowledged gaps in documentation and follow-up, while Staff A, the Administrator, confirmed that ADs should be reviewed and addressed at the initial care conference. The lack of proper documentation and follow-up placed residents at risk of not having their healthcare preferences and decisions honored.
Failure to Obtain Physician Orders for Bed Rails
Penalty
Summary
The facility failed to obtain a physician's order for the use of physical restraints for two residents, which is a requirement according to their policy. Resident 3, who was moderately cognitively impaired, was observed multiple times with quarter length bed rails on both sides of their bed. Despite these observations, a review of Resident 3's Electronic Health Record (EHR) revealed no physician's order for the bed rails. Staff members, including the Resident Care Manager and the Director of Nursing Services, acknowledged that a physician's order was necessary for such enablers, but none was found for Resident 3. Similarly, Resident 288, who was alert and oriented, was observed with quarter length bed rails on both sides of her bed on several occasions. A review of her EHR also showed no physician's order for the use of these bed rails. The absence of physician orders for these enablers was confirmed by staff, indicating a failure to adhere to the facility's policy and procedure regarding the use of devices/enablers.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to ensure that a copy of the Notice Before Transfer was sent to a representative of the Office of the State Long-Term Care Ombudsman for a resident reviewed for transfer notice requirements. This deficiency was identified during an interview and record review. The resident, who was admitted to the facility with diagnoses including congestive heart failure exacerbation and physical deconditioning, was transferred to a local hospital. The facility administrator, Staff A, acknowledged that he was unaware of the requirement to send a copy of the Notice of Transfer to the Ombudsman and only sent out the notices for the months of June, July, and August after being questioned about it.
Inaccurate MDS Assessment of Resident's Oral/Dental Status
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected a resident's oral/dental status, specifically for a resident identified as severely cognitively impaired. The MDS assessment documented that the resident did not have tooth fragments or broken natural teeth, had no mouth pain, and was able to be examined. However, a Nutrition Assessment and a Nutrition/Dietary progress note both documented that the resident's natural teeth were in poor shape. Observations on multiple occasions revealed that the resident had missing upper teeth, lower teeth with sharp edges, and dark tan coloration, and the resident reported experiencing mouth pain. Staff interviews revealed that the MDS Nurse, responsible for gathering information for the MDS, did not personally assess the resident's oral/dental status and relied on medical records and staff input. The Director of Nursing Services acknowledged the inaccuracy of the MDS oral/dental status and indicated the need for a correction. The failure to conduct a visual assessment of the resident's oral/dental status led to the inaccurate documentation in the MDS, placing the resident at risk for unidentified and unmet care needs.
Failure to Develop Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was severely cognitively impaired. The resident's care plan did not address the placement of the bed against the wall and the use of a mat on the floor, which were observed multiple times during the survey. The facility's policy required that such devices or enablers be appropriately care planned and added to the resident's Kardex, but this was not done for the resident in question. Staff members, including a Certified Nursing Assistant and the Resident Care Manager, acknowledged that the care plan should have included the bed and mat arrangements. The Director of Nursing Services also confirmed that it was expected for care plans to be in place for residents with their bed against the wall and mats on the floor. This oversight placed the resident at risk for unmet care needs and a diminished quality of life.
Failure to Provide Adequate Nail Care for Dependent Resident
Penalty
Summary
The facility failed to provide adequate nail care for a resident who was dependent on staff for assistance with activities of daily living (ADLs). The facility's policy stated that nail care is part of personal hygiene and should be provided by a certified nursing assistant unless the resident is diabetic, in which case a licensed nurse should perform the task. Resident 5, who was severely cognitively impaired and required substantial assistance with personal hygiene, had not received nail care for about a month, despite expressing a desire for assistance. The resident's last documented bath or shower was on August 31, 2024, and by September 10, 2024, their fingernails were approximately 1/3 inch long. Staff interviews revealed that nail care was supposed to be performed during baths or showers, but this was not done for Resident 5. The Nursing Assistant confirmed that they checked nails during baths, and the Director of Nursing Services stated that nail care should be done by the shower aid unless the resident was diabetic. Upon observation, the Director of Nursing Services noted that Resident 5's nails appeared to have not been trimmed for about two weeks, indicating a lapse in the facility's adherence to its own nail care policy.
Failure to Explain Arbitration Agreement Properly
Penalty
Summary
The facility failed to adequately explain the arbitration agreement to a resident, identified as Resident 25, who was part of a sample reviewed for arbitration agreements. The resident was admitted and readmitted to the facility, with assessments indicating she was alert and oriented. However, nursing notes documented instances of confusion and forgetfulness. Despite this, the arbitration agreement was signed by the resident and the Admissions Coordinator, Staff J, on a specified date. During an interview, Resident 25 could not recall signing the agreement or having it explained to her, citing pain from a broken hip and uncertainty about the document's meaning. Staff J, responsible for determining a resident's capability to sign such agreements, admitted to not informing residents or their representatives about the 30-day period to rescind the agreement. Staff J believed residents could change their minds at any time, a misunderstanding shared by the facility's Administrator, Staff A, who also did not know the correct rescission period. This lack of awareness and communication placed residents at risk of signing legal documents without full understanding or knowledge of their rights.
Infection Control Deficiency in PPE and Hand Hygiene
Penalty
Summary
The facility failed to maintain proper infection prevention practices, specifically in the use of personal protective equipment (PPE) and hand hygiene, for two residents. In one instance, a Certified Nurse Assistant (CNA) was observed providing care to a resident, removing her gloves, and then retrieving new gloves from an isolation cart without performing hand hygiene in between. This CNA acknowledged that she should have washed her hands between changing gloves. In another instance, two CNAs entered a resident's room, which had an enhanced barrier precautions sign, without wearing isolation gowns. One of the CNAs was observed taking trash out of the room and entering a code on a door with contaminated gloves, then returning to the resident's room and sanitizing her hands only after removing the gloves. The CNA was unsure of the resident's isolation status and admitted to using contaminated gloves outside the resident's room. The Director of Nursing Services confirmed that infection control training was provided and that staff were expected to follow isolation precaution signs and perform hand hygiene before leaving a resident's room.
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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