Shoreline Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Seattle, Washington.
- Location
- 2818 Northeast 145th Street, Seattle, Washington 98155
- CMS Provider Number
- 505262
- Inspections on file
- 27
- Latest survey
- December 19, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Shoreline Health And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to provide a homelike dining environment by serving meals on trays in the dining room, a practice that began during the COVID-19 pandemic. Staff confirmed this as the current process, which deviates from the facility's policy of creating a homelike environment.
The facility failed to properly store drugs and biologicals, with expired supplies found in two medication rooms and an unlabeled capsule in a medication cart. Staff acknowledged the issues, which violated the facility's storage policy.
The facility failed to follow food safety standards, with unlabeled cereal in storage and uncovered food items during meal delivery. Staff interviews confirmed expectations for labeling and covering food, but these practices were not consistently followed.
The facility failed to follow Contact Precautions for a resident with MRSA, as an Activities Assistant entered the room without proper PPE. Additionally, a Housekeeping Staff member did not perform hand hygiene after handling soiled laundry and before touching clean linens, and their gown was not properly tied. These actions were contrary to the facility's infection control policies.
A resident was not informed about the bed hold option during a hospital transfer, contrary to facility policy. The resident, who was their own financial responsible party, was not given the opportunity to make an informed decision, leading to a change in room upon their return. The facility contacted the resident's emergency contact instead, resulting in confusion and frustration for the resident.
A facility failed to accurately assess a resident's preferences for daily routines and activities, as required by the RAI manual. The resident, who had dementia and was non-verbal, did not have family interviews conducted to gather preference information. MDS assessments were incomplete, with sections either coded as non-responsive or left dashed. Staff confirmed that family interviews were not conducted, despite expectations, leading to inaccurate MDS documentation.
A facility failed to implement the activity care plan for a resident with dementia, as observations showed no one-on-one in-room activities were provided. The Activities Supervisor could not provide documentation, and the EHR lacked records of activity participation. The Resident Care Manager and Administrator confirmed the absence of documentation, leading to the deficiency.
The facility failed to update care plans for three residents, leading to potential risks. Two residents required medication administration during meals for compliance, but this was not initially reflected in their care plans. Another resident self-administered higher oxygen levels than prescribed, a behavior not documented in their care plan. Staff interviews confirmed the need for earlier revisions.
Two residents experienced medication administration errors in an LTC facility. One resident received oxycodone despite a pain level below the prescribed threshold, while another resident refused an anticoagulant injection for seven days without provider notification. Staff interviews revealed a lack of adherence to physician orders and facility policies.
A resident with dementia did not receive an individualized activity program as outlined in their care plan, which included one-on-one activities like story time and music. Observations showed a lack of these activities, and staff interviews revealed inadequate documentation and implementation. The facility's activity department failed to provide the necessary support, leading to a deficiency in meeting the resident's needs.
A facility failed to implement a bowel management protocol for a resident, leading to multiple five-day periods without documented bowel movements. Despite the care plan's requirement to monitor and document bowel movements, no PRN medications were administered, and there was no documentation of assessments or physician notifications. Interviews with staff revealed inconsistencies in following the protocol, highlighting a deficiency in providing care according to professional standards.
The facility failed to adhere to professional standards for respiratory care for three residents. A resident with COPD was observed receiving incorrect oxygen levels, with staff unaware of the resident's behavior of adjusting the flow. Another resident's nebulizer mask was improperly stored, risking contamination. A third resident's nasal cannula and portable oxygen tank were not stored according to policy, posing safety risks. Staff interviews confirmed these deficiencies in care and equipment management.
A resident's medical records were found to be inaccurate, with a discharge notice incorrectly documented as given to a non-existent daughter and a misdiagnosis of paranoid schizophrenia instead of bipolar disorder. The facility's policies require accurate documentation, but errors were acknowledged by the DON and Social Services staff.
Failure to Provide Homelike Dining Environment
Penalty
Summary
The facility failed to provide a homelike environment for residents during meal times in the Second Floor Dining Room. Observations revealed that residents were served their meals on trays, which were not removed from the tables, contrary to the facility's policy that emphasizes a homelike environment. This practice was observed on multiple occasions, involving several residents who were assisted by staff members to eat directly from their trays. Interviews with staff members, including a Restorative Nurse Assistant and a Resident Care Manager, confirmed that the use of meal trays in the dining room was a standard practice. The staff indicated that this practice began during the COVID-19 pandemic and has continued since then. The Director of Nursing also confirmed that the current process involves serving meals on trays in the dining room, which deviates from the facility's policy of creating a homelike environment.
Medication Storage Deficiencies in Facility
Penalty
Summary
The facility failed to appropriately store drugs and biologicals in two medication storage rooms and one medication cart, which placed residents at risk for receiving compromised and ineffective medications. In the West 1 Medication Storage Room, an expired Aquacel Advantage wound dressing was found, and in the Second Floor Medication Room, several expired SafeDay IV administration sets were discovered. Staff members acknowledged the presence of expired supplies and stated that they should have been disposed of. In the East 1 Medication Cart, an unpackaged and unlabeled red capsule, identified as a prescription antibiotic, was found in the top drawer. Staff confirmed that prescription medications should be packaged and labeled, and the presence of the loose capsule was not expected. The facility's policy requires that all drugs and biologicals be stored in a safe, secure, and orderly manner, which was not adhered to in these instances.
Deficiency in Food Safety Practices
Penalty
Summary
The facility failed to adhere to professional standards of food safety, as evidenced by improper food labeling and handling practices. During an observation, two unopened bags of cereal in the dry storage room were found unlabeled, which was confirmed by the Nutritional Services Manager, Staff C. Staff C mentioned that the cereal would be labeled once placed in bins, but admitted to not labeling them when taken out of the box. Interviews with Staff K, a Dietary Aide, and Staff A, the Administrator, revealed an expectation for food items to be labeled, although this was not consistently practiced. Additionally, the facility did not ensure that food items were covered during meal tray delivery, which was observed on multiple occasions. Staff members, including CNAs and other personnel, were seen delivering trays with uncovered food items such as blueberries, peaches, strawberries, salad, and grapes. Interviews with various staff, including Staff K and Staff T, a Registered Dietician, indicated that food should be covered during transport, especially when walking down hallways. However, this practice was not consistently followed, as confirmed by observations and staff interviews.
Infection Control Deficiencies in PPE Use and Hand Hygiene
Penalty
Summary
The facility failed to adhere to Contact Precautions for a resident diagnosed with MRSA in the right hip, as observed when an Activities Assistant entered the resident's room without donning the required gown and gloves. Despite the presence of signage indicating the need for such precautions, the staff member did not comply, which was acknowledged during an interview. The Infection Preventionist and Director of Nursing both confirmed the expectation for staff to wear appropriate PPE when entering rooms of residents on contact precautions. Additionally, the facility did not ensure proper use of PPE and hand hygiene in the laundry room. A Housekeeping Staff member was observed sorting soiled laundry with a gown that was not properly tied, leading to contamination of their clothing. After removing their PPE, the staff member failed to perform hand hygiene before handling clean linens. Interviews with the Infection Preventionist and Director of Nursing confirmed the expectation for staff to perform hand hygiene after glove removal and to ensure gowns are securely tied during use.
Failure to Provide Bed Hold Notice to Resident
Penalty
Summary
The facility failed to provide a bed hold notice to a resident, identified as Resident 65, during their transfer to a hospital. According to the facility's policy, residents or their representatives should be informed in writing about the bed hold provision upon admission and again before a transfer to a hospital. In the case of an emergency transfer, the notice should be provided within 24 hours. However, there was no documentation in the electronic health record or nursing progress notes indicating that Resident 65 was offered a bed hold notice for their hospital transfer. Resident 65, who was their own financial responsible party, was not informed about the bed hold option. Instead, the facility contacted the resident's emergency contact by phone, as indicated by Staff L, who was responsible for issuing bed hold notices. Staff L initially claimed that the notice was provided in person but later corrected this to indicate it was done over the phone. Despite this, there was no evidence that Resident 65 was directly informed or given the opportunity to make an informed decision regarding the bed hold. The oversight resulted in Resident 65 returning to the facility to find their private room had been changed to a shared room, causing frustration and confusion. The resident expressed a desire to have been informed about the bed hold option to make an informed decision, including understanding any associated costs. The facility's administrator, Staff A, acknowledged that the expectation was for staff to first discuss the bed hold notice with the resident if they were their own responsible party, which did not occur in this instance.
Failure to Accurately Assess Resident Preferences
Penalty
Summary
The facility failed to accurately assess a resident's preferences for daily routines and activities, as required by the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual. The manual specifies that information regarding a resident's preferences should be obtained directly from the resident, or through family or significant other interviews if the resident cannot communicate. In this case, the facility did not conduct or attempt to conduct interviews with the family or significant others for a resident who was non-verbal and unable to communicate their preferences. The resident in question, who had a diagnosis of dementia, was admitted to the facility and had been discharged from hospice care services. The facility's Minimum Data Set (MDS) assessments for this resident showed that interviews for daily and activity preferences were not completed, and the sections were either coded as non-responsive or left dashed, indicating no information was gathered. Staff members involved in completing the MDS assessments confirmed that family interviews were not conducted, despite the expectation that they should have been. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing, revealed that the facility followed the RAI manual for coding accuracy but failed to adhere to the guidelines for conducting interviews with family members. The staff acknowledged that family interviews should have been completed to ensure accurate assessments of the resident's preferences, but these were not done, leading to incomplete and inaccurate MDS documentation.
Failure to Implement Activity Care Plan for Resident with Dementia
Penalty
Summary
The facility failed to implement the activity care plan for Resident 20, who was admitted with a diagnosis of dementia. The care plan, revised on 10/02/2024, included interventions such as offering in-room story time and frequent one-on-one visits. However, observations on multiple dates in December 2024 showed that Resident 20 did not receive these one-on-one in-room activities. Staff O, the Activities Supervisor, was unable to provide documentation of these activities in the resident's electronic health record (EHR) and admitted to discarding daily paper documentation. Further investigation revealed that Resident 20's EHR lacked documentation of one-on-one activity participation in various activities such as nail care, auditory stimulation, and family video calls over the last 30 days. Staff U, the Assistant Director of Nursing, confirmed that Resident 20 had been discharged from hospice services in August 2024, and there was an expectation for activity documentation when activities were provided. Staff D, the Resident Care Manager, acknowledged involvement in the care planning process but admitted that the care plan goal was not met due to the absence of documentation. The Administrator, Staff A, confirmed that there was no activity documentation for Resident 20 in the EHR and that the activity department was responsible for providing individualized activities. Staff A also stated that the MDS and care plans should support each other and that activities offered should be documented. The lack of documentation and implementation of the care plan interventions led to the deficiency, as the facility's policy required staff to implement the resident's individual care plan.
Failure to Revise Care Plans for Medication and Oxygen Administration
Penalty
Summary
The facility failed to revise comprehensive care plans for three residents, leading to potential risks for unmet care needs. For Resident 17, the care plan did not initially include the intervention to administer medications during meals, despite observations and staff interviews indicating that the resident was more compliant with medication intake during meal times. This intervention was only added to the care plan on December 16, 2024, after it was observed that the resident would spit out medications if not given with meals. Similarly, Resident 20's care plan lacked the intervention to administer medications during meals, even though staff noted that the resident, due to advanced dementia, was more likely to accept medications during meal times. This intervention was also added on December 16, 2024, after it was observed that the resident would refuse medications if not given with meals. Staff interviews confirmed that the care plans should have been updated earlier to reflect these needs. For Resident 6, there was a discrepancy between the care plan and the actual oxygen administration. The care plan indicated an oxygen setting of two to three liters continuously, but observations showed the resident self-administering five liters. Staff interviews revealed that the resident would increase the oxygen flow when frustrated, a behavior not documented in the care plan. The Director of Nursing acknowledged that the care plan should have been revised to match the physician's orders and the resident's behavior once it was known.
Medication Administration Errors and Lack of Provider Notification
Penalty
Summary
The facility failed to adhere to a physician's order for two residents, leading to medication administration errors. Resident 26 was prescribed oxycodone to be administered only when their pain level exceeded six out of ten. However, the medication was given on five out of eleven days when the resident's pain level was documented as less than six. This discrepancy was confirmed through interviews with the nursing staff, including a Registered Nurse and the Director of Nursing, who acknowledged that the physician's order was not followed as required. Resident 335, who was admitted with a diagnosis that included a closed fracture, refused their prescribed anticoagulant injection for seven consecutive days. Despite the refusals, there was no documentation indicating that the medical provider was notified of the resident's refusal, as required by facility policy. Interviews with nursing staff revealed a lack of awareness of the proper procedure for handling medication refusals, including the need to educate the resident and notify the provider. The Director of Nursing confirmed that providers should be notified after the first refusal, which did not occur in this case.
Failure to Implement Individualized Activity Program for Resident
Penalty
Summary
The facility failed to provide an individualized activity program for a resident, identified as Resident 20, who was reviewed for activities. Resident 20, who was admitted with a diagnosis of dementia, had been discharged from hospice care services and required a personalized activity plan to support their preferences and needs. The resident's care plan included interventions such as in-room story time and frequent one-on-one visits, with a goal to support end-of-life activities. However, observations over several days showed that the resident did not receive the planned one-on-one activities, and there was no documentation of such activities being provided. Interviews with facility staff revealed a lack of proper documentation and implementation of the resident's activity plan. The Activities Supervisor, Staff O, admitted to not knowing how to generate activity documentation from the electronic health record (EHR) and stated that daily paper documentation was discarded. A joint record review with the Assistant Director of Nursing, Staff U, confirmed the absence of activity documentation for Resident 20, despite the expectation that activities would be documented when provided. Additionally, the MDS Coordinator, Staff P, confirmed that family interviews were not conducted for the resident's significant change in status assessment, which was expected given the resident's inability to respond. The Director of Nursing, Staff B, and the Administrator, Staff A, acknowledged the lack of documentation and the failure to implement the resident's individualized care plan. The Administrator confirmed that the activity department was responsible for providing ongoing individualized activities and that the MDS and care plans should support each other. Despite these expectations, the facility did not document or provide the necessary activities for Resident 20, leading to a deficiency in meeting the resident's needs for activity pursuit and social engagement.
Failure to Implement Bowel Management Protocol
Penalty
Summary
The facility failed to implement a bowel management protocol for Resident 48, which is a deficiency in providing care according to professional standards. The facility's policy required accurate documentation of bowel movements for each resident per shift, and Resident 48's care plan included monitoring medications for constipation side effects and recording bowel movement patterns daily. However, documentation showed that Resident 48 did not have a bowel movement for multiple five-day periods in November and December 2024, and there was no record of any as-needed (PRN) medications being administered during these times. Interviews with staff revealed inconsistencies in following the bowel management protocol. Staff Z, an LPN, acknowledged that no PRN medications were given, and there was no documentation of abdominal assessments or physician notifications. Staff D, the Resident Care Manager, confirmed the lack of documentation and interventions for Resident 48 during the periods without bowel movements. The Director of Nursing, Staff B, stated that the protocol required PRN medication administration and documentation of assessments if a resident went three days without a bowel movement, which was not followed in this case.
Deficiencies in Respiratory Care and Equipment Storage
Penalty
Summary
The facility failed to provide respiratory care in accordance with accepted professional standards for three residents. Resident 6, diagnosed with Chronic Obstructive Pulmonary Disease (COPD), was observed receiving five liters of oxygen via nasal cannula, contrary to the physician's order of two liters per minute. Staff interviews revealed that Resident 6 sometimes increased the oxygen flow themselves, and there was a lack of documentation or care planning to address this behavior. The Director of Nursing was unaware of this behavior until informed by staff, indicating a communication gap regarding the resident's care needs. Resident 16, who was readmitted with pneumonia, had issues with the storage of their nebulizer mask. Observations showed that the nebulizer mask was not properly stored in a bag when not in use, as required by the facility's policy. Instead, it was found on top of a bedside table, covered by a white cloth and a book. Staff interviews confirmed that the nebulizer mask should have been stored in a bag to prevent contamination, but this practice was not followed. Resident 285, diagnosed with hypoxemia, had their nasal cannula improperly stored on a wheelchair cushion, and their portable oxygen tank was unsecured on a chair. Facility policy requires nasal cannulas to be stored in a plastic bag when not in use and portable oxygen tanks to be secured to a wheelchair or stored in the oxygen room. Staff interviews confirmed these storage practices were not adhered to, posing a risk of equipment contamination and safety hazards.
Inaccurate Medical Records and Diagnosis for a Resident
Penalty
Summary
The facility failed to ensure the accuracy of clinical records for a resident, which placed the resident at risk for unmet care needs and medical complications. The facility's policy on charting and documentation requires that medical records be objective, complete, and accurate. However, the Nursing Home Transfer or Discharge Notice form for the resident was inaccurately documented as being provided to the resident's daughter, despite the resident not having any children. The Director of Nursing acknowledged the error, stating that the notice should have been given to the resident or their power of attorney. Additionally, the resident's medical records inaccurately listed a diagnosis of paranoid schizophrenia, which was not supported by the resident's electronic health records or other medical documentation. Instead, the resident had an active diagnosis of bipolar disorder. The Social Services staff confirmed the discrepancy and acknowledged the error in the diagnosis. The Director of Nursing also confirmed that the diagnosis of paranoid schizophrenia was incorrect and should have been recorded as bipolar disorder.
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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