Snohomish Health And Rehabilitation Of Cascadia
Inspection history, citations, penalties and survey trends for this long-term care facility in Snohomish, Washington.
- Location
- 800 10th Street, Snohomish, Washington 98290
- CMS Provider Number
- 505338
- Inspections on file
- 30
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Snohomish Health And Rehabilitation Of Cascadia during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment, impaired vision, and use of a front-wheeled walker left AMA after signing out and not returning, later reporting by phone that they were staying in a motel and did not wish to come back. Despite facility policy and staff descriptions that AMA departures should include resident education, safety checks, discharge instructions, provider and family notification, APS reporting, and EHR documentation, there were no discharge instructions or discharge summary in the EHR and no documented notifications to the emergency contact, provider, or APS for this resident.
A resident with complex medical needs did not receive a prescribed IV normal saline treatment, and the event was not documented or investigated as a medication error. Staff interviews confirmed that no incident report or investigation was initiated, contrary to facility policy and state guidelines.
A resident with a complex medical history did not receive ordered IV normal saline for diarrhea and elevated creatinine because the physician's order remained unconfirmed and unadministered in the electronic medical record. Nursing staff did not document attempts to start the IV or notify the provider, and the incident was not recorded in facility error logs.
A resident with hemiplegia, hemiparesis, and moderate cognitive impairment experienced a fall that was not investigated by facility staff. Required incident reporting and documentation were not completed, and the event was not logged, as confirmed by interviews with RNs, an LPN, and the DON.
The facility did not ensure that required PASARR screenings and Level II evaluations were accurately completed prior to admission for several residents with mental health diagnoses. Inaccurate documentation, missing evaluations, and a lack of understanding of the PASARR process led to residents being admitted without proper mental health assessments or determination letters.
The facility did not ensure that residents and their representatives were given the opportunity to participate in care conferences, as required. For three residents, there was no documentation of required care plan meetings, and staff interviews confirmed that care conferences were not being held as scheduled. This resulted in residents not being involved in discussions about their person-centered care.
A resident who expressed interest in formulating an Advance Directive was not provided with information or assistance by social services, and there was no documentation of follow-up or support, despite the resident's clear request and cognitive ability.
Surveyors found that care plans were not properly reviewed or updated for three residents, including one on long-term antiviral therapy, one at risk for pressure ulcers who was not using prescribed heel protection, and one with a lower limb amputation whose prosthesis use was not documented in the care plan. Staff interviews and observations confirmed that interventions were either missing, not implemented, or not updated to reflect current care practices.
A resident with severe cognitive impairment and on hospice care was found with their bed placed against the wall and a scoop mattress on the floor, without any physician's order, signed consent, or care plan documentation authorizing this setup as a restraint. Staff confirmed the bed had always been positioned this way and described it as a restraint, but the required assessment, order, and documentation were not completed.
A resident with Type 2 Diabetes Mellitus received Insulin Glargine on multiple occasions when their blood sugar was below the physician-ordered threshold, and in several instances, insulin was administered without any blood sugar being recorded. Documentation and staff interviews confirmed that the process for checking blood sugar prior to insulin administration was not consistently followed, and the care team was not informed of these deviations.
A resident with moderate cognitive impairment and a history of falls was found to have a broken lower denture with a missing tooth, resulting in discomfort when eating. Despite staff awareness of the broken denture, there was no documentation of a dental appointment being scheduled, and several staff members were unaware of the issue or had not initiated a referral for dental services.
Staff did not use required PPE, specifically gowns, during high-contact care activities for two residents on enhanced barrier precautions for wounds. In both cases, staff either misunderstood or disregarded EBP signage and care plan instructions, resulting in transfers and personal care being performed without proper gown use as required by CDC guidelines.
The facility failed to assess and manage the risk of pressure ulcers for four residents, leading to the development and worsening of PUs. Residents were not provided with timely interventions such as air mattresses and pressure-relieving devices, and documentation was inconsistent. These failures resulted in significant harm, including the deterioration of a Stage 2 PU to a Stage 4 PU with osteomyelitis in one resident.
The facility failed to consistently implement care plan interventions related to bed height and mattress type to prevent accidents and falls for a resident. The resident fell out of bed, sustained a left hip fracture, and required hospitalization. Staff were unaware of the specific fall interventions, and the care plan was not updated after the incident.
A resident with severe cognitive impairment fell and sustained a fracture. The facility's investigation was incomplete, lacking staff statements and a root cause analysis. Staff interviews confirmed that proper protocols were not followed, and this is a repeat citation.
The facility failed to ensure timely review and revision of the care plan for a resident with vascular dementia and a left femur fracture. Observations revealed inconsistencies in implementing fall prevention interventions, such as the absence of a perimeter mattress and fall mat. Staff interviews indicated reliance on outdated Kardex information, leading to inconsistent care practices and placing the resident at risk for unmet care needs.
Failure to Ensure Safe AMA Discharge and Required Notifications
Penalty
Summary
Surveyors found that the facility failed to ensure a safe discharge plan for one resident who left the facility against medical advice (AMA). The resident had moderate cognitive impairment, impaired vision, and used a front-wheeled walker. A recent hospital discharge summary documented that psychiatry had determined the resident did not have decisional capacity and that the resident’s son was the surrogate decision maker. The facility’s transfer/discharge policy required evidence of discussion with the resident to make an AMA departure a safe discharge. On the date in question, the resident signed out of the facility in the Patient Sign In & Out Log but did not sign back in, and later told a nurse by phone that they were staying in a motel and did not want to return, except possibly to retrieve belongings. Record review showed no discharge instructions or discharge summary in the resident’s EHR, and no documentation that the resident’s emergency contact, provider, or Adult Protective Services (APS) had been notified. Multiple staff, including RNs, Social Services, and the Administrator, described that their usual process when a resident leaves AMA or stays out overnight includes educating the resident on risks, ensuring safety, notifying the Administrator, Social Services, APS, the provider, and the resident’s emergency contact, and documenting these actions in progress notes. Social Services staff also stated they would attempt to arrange home health services, instruct the resident to contact their primary care provider, and provide resources, with all steps documented in the EHR. However, staff were unable to provide any documentation that these steps were taken for this resident, and there was no evidence in the progress notes of APS notification or other required communications related to the AMA discharge.
Failure to Investigate Medication Error Incident
Penalty
Summary
The facility failed to thoroughly investigate a medication error incident involving one resident who was admitted with a fistula of the vagina to the small intestine and an ileostomy. The resident experienced diarrhea and elevated creatinine, for which a physician ordered a one-time intravenous administration of 1 liter of normal saline. Review of the Medication Administration Record (MAR) showed no documentation that the IV normal saline was administered, and the facility's incident reporting logs did not reflect a medication error for this resident. Interviews with facility staff, including LPNs and the Director of Nursing, confirmed that no incident report or investigation was initiated regarding the potential medication error. Staff acknowledged that, according to facility policy and state guidelines, an investigation should have been conducted to determine the circumstances and cause of the incident. The lack of investigation left unanswered questions about the occurrence and whether it was related to neglect or unmet care needs.
Failure to Administer Ordered IV Hydration Due to Unconfirmed Physician Order
Penalty
Summary
A deficiency occurred when a resident with a history of a fistula between the vagina and small intestine, and an ileostomy, was not administered intravenous (IV) normal saline (NS) as ordered by the physician. The physician had ordered 1 liter of NS to be given intravenously for three days due to the resident experiencing diarrhea and elevated creatinine levels. Review of the Medication Administration Record (MAR) showed the order was entered but remained in a pending status and was never confirmed or administered. There was no documentation that the IV NS was given to the resident. Interviews with nursing staff and the Director of Nursing (DNS) revealed that nurses are responsible for checking and confirming pending orders in the electronic medical record system. Staff acknowledged that the order for IV NS was not processed, confirmed, or administered, and that the order was eventually discontinued. The DNS stated that if nurses are unable to start an IV, they are expected to notify the provider and document the attempts, but no documentation of provider notification was found. The incident was not recorded in the facility's incident or medication error logs.
Failure to Investigate Resident Fall
Penalty
Summary
The facility failed to conduct an investigation following a fall experienced by a resident with a history of hemiplegia and hemiparesis after a cerebral infarction, who also had moderate cognitive impairment. The incident occurred when the resident dropped herself to the floor while staff were opening the door for medics, after which she was transported to the hospital. Review of facility records, including the State Incident Reporting log and progress notes, revealed that there was no investigation documented for this fall, nor was the incident logged as required. Interviews with nursing staff confirmed that standard protocol following a fall includes assessment, notification, obtaining staff statements, and completing an incident report in the computer system. However, the Director of Nursing acknowledged that no incident report was completed and the event was not entered into the reporting log. The lack of investigation meant that the root cause and contributing factors of the fall were not identified, and there was no documentation to rule out abuse, as required by state guidelines.
Failure to Complete Accurate PASARR Evaluations Prior to Admission
Penalty
Summary
The facility failed to ensure that four out of six reviewed residents had an accurate Pre-Admission Screening and Resident Review (PASARR) completed on or before admission. For several residents with documented mental health diagnoses such as bipolar disorder, anxiety disorder, and depression, the PASARR forms were either incorrectly completed, missing required Level II evaluations, or lacked determination letters prior to admission. In some cases, sections of the PASARR were marked incorrectly, such as indicating intellectual disability when there was no supporting diagnosis in the resident's medical history. For one resident with bipolar disorder and anxiety, the PASARR indicated the need for a Level II evaluation due to serious mental illness, but no determination letter or evaluation summary was found in the record. Another resident with severe cognitive impairment and on hospice had a PASARR form with incorrect indications of intellectual disability, despite no such diagnosis in their history. Staff interviews revealed a lack of understanding regarding proper PASARR completion and the process for obtaining and documenting Level II evaluations. Additionally, the facility admitted residents without having received the required Level II PASARR determination letters, as confirmed by both the social worker and the administrator. The process described by staff involved admitting residents and then waiting for the evaluation summary or determination letter, rather than ensuring these were completed prior to admission. This resulted in residents being admitted without the necessary mental health evaluations and documentation as required by federal regulations.
Failure to Involve Residents in Care Planning Conferences
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were given the opportunity to participate in care conferences, which are meetings where a resident's care is discussed and coordinated by the interdisciplinary team. For three residents reviewed, there was no documentation that required care conferences had been completed. One resident with moderate cognitive impairment had no record of a quarterly care conference. Another resident, who was cognitively intact, reported not being informed about or involved in any care plan meetings, and there was no documentation of such meetings in their record for over a year. A third resident, with no cognitive impairment, had a care conference scheduled, but there was no documentation that it occurred, and staff confirmed the absence of records for the meeting. Interviews with staff revealed that care conferences are expected to be conducted on admission, quarterly, annually, and as needed, but staff acknowledged that these meetings were not occurring as required for many residents. The lack of documentation and missed care conferences meant that residents were not involved in discussions about their person-centered care, and staff were unable to provide evidence that residents or their representatives were offered the opportunity to participate in care planning as mandated.
Failure to Assist Resident with Advance Directive Formulation
Penalty
Summary
The facility failed to obtain or offer assistance to a resident in formulating an Advance Directive (AD), despite documentation indicating the resident wished to pursue one. Upon admission, the resident was assessed as having no cognitive impairment, and the medical record included an Advance Directive Review stating the resident wanted to formulate an AD. However, there was no further documentation showing that the resident had been provided with information or assistance regarding their right to formulate an AD. Interviews with facility staff revealed that social services are responsible for assisting residents with ADs, including providing Power of Attorney documents and information for a mobile notary. The Social Services Assistant admitted to not following up with the resident, citing the resident's independence and lack of desire for others to be involved in their care or finances. The Administrator confirmed that the process should have started immediately upon the resident's request, but acknowledged that no documentation existed to show the resident was assisted in formulating an AD.
Failure to Review and Revise Care Plans for Multiple Residents
Penalty
Summary
The facility failed to review and revise care plans for three residents as required, resulting in deficiencies in care planning. For one resident with a history of shingles and on long-term antiviral medication, the care plan only referenced the medication under skin impairment without specifying goals or interventions related to the medication use. Staff interviews confirmed that the care plan lacked necessary details and had not been updated to reflect the resident's ongoing therapy and monitoring needs. Another resident, who was dependent on bed mobility and at risk for pressure ulcers, had a care plan intervention for heel protection that was not being implemented. Observations over several days showed the resident was not using pressure-relieving boots as documented, and staff reported that the resident did not tolerate the boots and alternative interventions, such as using pillows, were being used but not reflected in the care plan. The care plan had not been updated to remove the ineffective intervention or to include the actual care being provided. A third resident with a right below-knee amputation had a prosthesis and physician orders for its use, but the care plan did not document the presence of the prosthesis or instructions for its application and removal. Staff interviews revealed that the resident only wore the prosthesis during therapy sessions, and care staff relied on the care plan and Kardex for guidance, which did not include this information. The lack of care plan updates led to inconsistencies in care and documentation for the resident's prosthesis management.
Failure to Document and Authorize Bed Placement as Restraint
Penalty
Summary
A resident with Alzheimer's Disease and on hospice care, who had severely impaired cognition, was observed in bed with a blanket over their head. The bed was positioned in the lowest setting and placed against the wall, with a scoop mattress on the floor on one side. There was no physician's order, signed consent, or care plan documentation authorizing the bed to be placed against the wall for this resident. Multiple staff interviews confirmed that the bed had always been positioned against the wall for this resident, and staff described this practice as a form of restraint used in the facility. Staff also outlined the required process for implementing restraints, which includes assessment, obtaining a physician's order, securing consent, and updating the care plan. However, for this resident, none of these steps were documented or completed regarding the bed's placement against the wall.
Significant Medication Error: Insulin Administered Outside Blood Sugar Parameters
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors related to the administration of insulin. The resident, who had a diagnosis of Type 2 Diabetes Mellitus and intact cognition, had physician orders specifying that Insulin Glargine should be held if blood sugar (BS) was below a certain threshold. Despite these orders, documentation showed that the resident received 25 units of Insulin Glargine on multiple occasions when their BS was below the ordered parameter, and in several instances, there was no BS recorded at all prior to administration. Review of the Medication Administration Record (MAR) revealed that insulin was administered on numerous dates when the resident's BS was less than the ordered threshold, with specific BS values documented as low as 65. Additionally, there were several days where insulin was given without any BS being recorded on the MAR or in progress notes. Staff interviews confirmed that the process was to check BS before administering insulin and to hold the dose if BS was low, but the records indicated this was not consistently followed. Further interviews with nursing staff and management revealed inconsistencies in documentation and a lack of clarity regarding the medication administration process. One nurse stated they may have mistakenly documented administration due to unfamiliarity with the electronic charting system, but injection sites and BS values outside parameters were still recorded. The resident's care team, including the advanced registered nurse practitioner, was not informed that insulin had been administered outside the ordered parameters.
Failure to Coordinate Timely Denture Services
Penalty
Summary
The facility failed to ensure that a resident received timely assistance in coordinating appropriate denture services. The resident, who had a history of pneumonia and vascular dementia and was assessed as having moderate cognitive impairment, was documented as having upper and lower dentures. Despite documentation indicating no issues with broken or loose dentures and no reported mouth pain or difficulty chewing, interviews and observations revealed that the resident's lower denture was broken and missing a tooth following a fall. The resident reported discomfort when eating, and both a collateral contact and a nursing assistant confirmed the dentures were old and missing a tooth. A review of the resident's medical record showed no documentation of a scheduled dental appointment. Multiple staff members, including LPNs and a care manager, were either unaware of the broken denture or had not initiated a dental referral. The process for scheduling dental appointments was described, but there was no evidence that it had been followed for this resident until after the issue was identified during the survey. The deficiency was identified through interviews, record review, and direct observation.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care Activities
Penalty
Summary
Facility staff failed to use personal protective equipment (PPE) in accordance with CDC guidelines for residents on enhanced barrier precautions (EBP). For one resident with an open wound and stage 4 pressure ulcer, a nursing assistant did not wear a gown while transferring the resident from bed to wheelchair, despite EBP signage and care plan instructions indicating that gowns were required for high-contact activities such as transferring. The staff member acknowledged awareness of the signage but did not follow the required protocol. In another instance, two staff members assisted a resident with venous ulcers in transferring, repositioning, and dressing after a shower without wearing gowns, only donning gloves. Both staff members misunderstood the EBP signage, believing gowns were only necessary for nurses performing wound care, not for high-contact activities like transferring. The resident's care plan and physician orders specified EBP with gown and glove use for such activities, but these instructions were not followed.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to comprehensively assess the increased risk for skin breakdown, follow written policy and procedures, and develop and implement timely interventions necessary to prevent the development of avoidable pressure ulcers (PUs) for four residents. Resident 1 admitted with a Stage 2 PU, which deteriorated into an unstageable PU with osteomyelitis, requiring debridement and hospital treatment. The facility did not implement recommended interventions such as an air mattress in a timely manner, leading to the worsening of the resident's condition. Documentation and communication lapses were evident, as the care plan was not updated with new interventions, and the air mattress was not provided until 43 days after it was recommended by the wound care specialist. The resident's condition deteriorated significantly, resulting in a Stage 4 PU and osteomyelitis, necessitating hospital transfer and treatment. The facility's failure to follow through with timely interventions and proper documentation contributed to the resident's harm and deterioration. Resident 2 admitted without PUs, developed a DTPI on the right heel, which was not properly documented or measured initially. Observations revealed that the resident was not provided with pressure-relieving devices as required by their care plan. Further assessments identified additional wounds, indicating a lack of consistent and thorough skin inspections. The facility's failure to implement and monitor appropriate interventions led to the development and worsening of pressure ulcers in this resident. Resident 3, who was cognitively intact, developed a DTPI on the right heel, which was not documented accurately in subsequent skin inspections. The resident's family discovered the wound, and the facility staff failed to provide appropriate pressure-relieving devices. The care plan was not updated promptly, and the resident experienced pain during dressing changes. The facility's lack of timely and accurate documentation, along with the failure to provide necessary interventions, resulted in the resident's harm. Resident 4, admitted without PUs, developed a Stage 3 PU on the right heel. Observations showed that the resident was not consistently provided with pressure-relieving devices, and the care plan was not followed. The facility staff failed to place protective boots on the resident, despite the care plan's requirements. The facility's failure to adhere to care plan interventions and provide consistent pressure relief led to the development and worsening of pressure ulcers in this resident.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to consistently implement care plan interventions related to bed height and mattress type to prevent accidents and falls for a resident reviewed for falls and accident hazards. The resident experienced harm when they fell out of bed and sustained a left hip fracture, pain, and required hospitalization. The care plan for the resident included keeping the bed in a safe position for transfers and using a perimeter mattress, but these interventions were not consistently followed or updated after the fall incident. The facility's incident reporting log documented that the resident sustained an unwitnessed fall in their room, resulting in a fracture. The investigation revealed that the bed was in a high position at the time of the fall, and the resident was found lying on the floor. Staff interviews and observations confirmed that a standard mattress was in place instead of the required perimeter mattress, and the bed was not consistently kept in the low position as per the care plan. Additionally, the Kardex did not reflect the correct fall interventions, and staff were unsure of the specific interventions required for the resident. Further interviews with staff indicated a lack of awareness and adherence to the resident's fall intervention plan. The maintenance department did not maintain a log for perimeter mattresses, and there was no clear communication regarding the need for such mattresses. The facility's failure to implement and monitor the prescribed interventions placed the resident at risk for falls and injuries, as evidenced by the repeated observations of non-compliance with the care plan requirements.
Failure to Conduct Thorough Fall Investigation
Penalty
Summary
The facility failed to conduct a thorough investigation for a resident who experienced a fall. The resident, who had severe cognitive impairment and required extensive assistance with mobility and personal care, sustained a fall in their room, resulting in a left femur fracture. The investigation into the fall was incomplete, lacking statements from all staff involved, contributing factors, and a root cause analysis. This failure to thoroughly investigate the incident left the facility unable to rule out abuse or neglect. Interviews with facility staff revealed that the expected protocol for unwitnessed falls was not followed. The Director of Nursing and the Regional Nurse Consultant both confirmed that the investigation should have included witness statements and a comprehensive assessment of the environment and circumstances leading to the fall. Additionally, the nurse on duty did not call 911 immediately when the resident complained of pain and was unable to move their leg, which was against the expected procedure. This is a repeat citation from previous surveys.
Failure to Update and Implement Care Plan for Fall Prevention
Penalty
Summary
The facility failed to ensure timely review and revision of the care plan for Resident 7, who was admitted with diagnoses including vascular dementia with behavioral disturbances and major depressive disorder, and later re-admitted with a left femur fracture. The care plan, dated 06/20/2022, included interventions for impaired mobility and fall risk, such as keeping the bed in a safe position and using a perimeter mattress. However, observations revealed inconsistencies in the implementation of these interventions, with the resident's bed often lacking the prescribed perimeter mattress and the fall mat not consistently in place. Staff interviews indicated a lack of awareness and reliance on outdated or incorrect information in the Kardex, leading to inconsistent care practices for Resident 7's fall prevention needs. Multiple observations between 04/10/2024 and 05/01/2024 showed that the resident's bed was frequently not in the low position, and the fall mat was not always present. Staff members, including CNAs and RNs, demonstrated uncertainty about the correct fall interventions and admitted to relying on common sense or outdated Kardex information. The RN/Regional Nurse Consultant confirmed that the care plan included a perimeter mattress as of 11/18/2023, but it was not present on the resident's bed during the survey period. This inconsistency in care plan implementation and staff awareness placed Resident 7 at risk for unmet care needs and potential harm. This issue was noted as a repeat citation from a previous survey dated 03/24/2024.
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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