View Ridge Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Everett, Washington.
- Location
- 5129 Hilltop Road, Everett, Washington 98203
- CMS Provider Number
- 505362
- Inspections on file
- 22
- Latest survey
- November 24, 2025
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at View Ridge Care Center during CMS and state inspections, most recent first.
The facility failed to maintain sanitary conditions in its kitchen, dining rooms, and nourishment refrigerators, risking foodborne illnesses. Observations showed soiled refrigerators, broken light fixtures with insects, and a dishwashing machine not reaching required temperatures. The kitchen had dust and debris, missing flooring, and lint around vents. Staff were unclear on cleaning responsibilities.
The facility failed to ensure proper storage and expiration management of medications and biologicals, as observed in two medication carts and a medication room. An LPN found an unrefrigerated probiotic and expired glucometer solutions on Cart 4, while an RN identified an expired medication on Cart 3. In the medication room, vaccines were improperly dated and expired, with inconsistent temperature log entries confirmed by a Patient Care Coordinator/RN.
A resident placed on hospice services did not receive a timely Significant Change in Status Assessment (SCSA) within the required 14-day timeframe, as required by the RAI 3.0 User's Manual. Interviews revealed a communication breakdown among staff, with the MDS Coordinator not informed of the resident's change in condition due to the absence of the Patient Care Coordinator and a lapse in communication by the Director of Nursing.
The facility failed to accurately complete MDS assessments for two residents, leading to potential risks in care planning. One resident with Schizophrenia and Bipolar disorder frequently refused medications and exhibited behaviors, but these were not reflected in the MDS. Another resident with dental issues affecting their ability to chew had these concerns unaddressed in their care plan and MDS. The LPN/MDS Coordinator admitted to incomplete documentation review.
The facility failed to complete the federally required PASRR forms for two residents with mental health diagnoses before their admission. One resident was admitted with Major Depressive Disorder, and their PASRR incorrectly indicated no mood disorders. Another resident's PASRR was incomplete, missing required information. The clinical team did not ensure the accuracy and completion of these forms.
A resident with multiple health conditions, including vision impairment, did not have their visual needs addressed in their care plan. Despite being cognitively intact, the resident was unaware of meal options due to difficulty reading menus. Staff interviews revealed a lack of awareness about the resident's vision issues, and the MDS Coordinator could not explain why these needs were omitted from the care plan, risking unmet care needs and diminished quality of life.
A facility failed to ensure proper communication and management of anticoagulant therapy for a hospice resident. The resident, with a history of pressure ulcers and long-term anticoagulant use, had elevated INR levels without proper monitoring or documentation. Facility staff were unclear about the resident's medication management, and there was a lack of coordination with the hospice provider, leading to a deficiency in resident-centered care.
A resident under hospice care did not receive their prescribed antidepressant medication on multiple occasions due to unavailability, with no notification to the physician or pharmacy. The resident experienced sleep difficulties, and staff were unaware of the issue until later. The facility failed to follow procedures for medication unavailability, placing the resident at risk.
A facility failed to monitor and reduce unnecessary psychotropic medications for a resident with dementia. The staff did not identify or monitor target behaviors for antipsychotic medication use and did not attempt a Gradual Dose Reduction (GDR) for Risperdal, despite a pharmacy recommendation. The resident, who exhibited physical behaviors but no hallucinations or delusions, was on hospice care. A second antipsychotic was added but not administered, and there was no psychotic behavior monitoring in place. Staff acknowledged the lack of specific behavior monitoring and that dementia is not an approved diagnosis for antipsychotic use.
A facility failed to ensure residents with swallowing difficulties were fed by trained staff. An Activities Manager, without a nursing license or specialized training, assisted a resident with a swallowing problem during breakfast. The resident's care plan required assistance from one staff member and specified a minced and moist texture diet. Despite the facility's claim of not using paid feeding assistants, the Director of Nursing confirmed that non-nursing staff should not provide feeding assistance.
The facility failed to follow infection control procedures, including the use of PPE and proper storage of respiratory equipment. A nurse did not wear a gown during a dressing change for a resident on Enhanced Barrier Precautions, and respiratory equipment was improperly stored. Additionally, a Maintenance Supervisor entered a contact precaution room without proper hand hygiene or gowning, and did not disinfect equipment used in the room.
Sanitation Deficiencies in Kitchen and Dining Areas
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen, dining rooms, and nourishment refrigerators, which placed residents at risk for foodborne illnesses. Observations revealed that the 2nd floor nourishment room refrigerator and freezer had sticky residue, scattered food debris, and a significant buildup of ice. Similarly, the 1st floor nourishment room refrigerator and freezer were soiled with food residue, and the refrigerator had a layer of frozen water. Additionally, the overhead light fixture in the nourishment room was broken and contained many dead insects. Interviews with staff indicated that housekeeping was responsible for cleaning these areas, but the cleaning was not adequately performed. The dishwashing machine consistently failed to maintain the required minimum wash cycle temperature of 120 degrees Fahrenheit, with recorded temperatures ranging from 103 to 119 degrees Fahrenheit on multiple occasions. The kitchen ceiling in the food preparation area had lint blowing from the air conditioner, and the flooring in front of the dishwashing area was missing linoleum. The food preparation shelving and coffee maker were covered in dust and debris, and several overhead light fixtures contained dead insects. The first-floor dining room ceiling had a buildup of lint and dust around the vents. Staff interviews revealed uncertainty about responsibilities for cleaning these areas, and there were plans to replace the kitchen flooring and potentially the dishwashing machine.
Medication Storage and Expiration Deficiencies
Penalty
Summary
The facility failed to ensure that medications and biologicals were properly stored and unexpired, as observed in two medication carts and one medication room. On Medication Cart 4, an opened bottle of acidophilus probiotic was found, which should have been refrigerated according to the label, and expired glucometer control solutions were present. Staff M, an LPN, confirmed that the probiotic was not stored in the refrigerator and acknowledged the expiration of the glucometer solutions. On Medication Cart 3, an expired bottle of calcium polycarbophil was found, and Staff K, an RN, confirmed its expiration and intended to remove it. In the first-floor medication room, the refrigerator contained several vaccines, including a multidose vial of Flucelvax quad vaccine and a vial of tubersol, both of which were open but not dated. The Flucelvax quad vaccine was also expired. Temperature logs for the refrigerator showed numerous missing entries for both July and August, indicating that temperatures were not consistently recorded twice a day as required. Staff J, a Patient Care Coordinator/RN, confirmed the absence of open dates on the vials and the failure to check refrigerator temperatures twice daily.
Failure to Complete Timely Significant Change Assessment for Hospice Resident
Penalty
Summary
The facility failed to identify a significant change in condition and complete a timely Significant Change in Status Assessment (SCSA) within the required 14-day timeframe for a resident who was reviewed for Hospice Services. The Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual requires that an SCSA be completed no later than 14 days from the determination date of a significant change in status, which includes when a terminally ill resident enrolls in a hospice program. In this case, the resident was placed on hospice services, but no significant change assessment was completed, placing the resident at risk for unmet care needs, decreased quality of care, and diminished quality of life. Interviews with facility staff revealed a breakdown in communication and responsibility. Staff O, the Licensed Practical Nurse/MDS Coordinator, stated that they rely on communication from the nurse manager during morning clinical meetings to identify residents with a change in condition. However, Staff J, the Registered Nurse/Patient Care Coordinator, was on vacation during the first two weeks the resident was on hospice services and was unsure who was responsible in their absence. Staff B, the Director of Nursing Services, acknowledged that they were aware of the coverage for Staff J but failed to communicate the resident's change in condition to the MDS coordinator, resulting in the missed assessment.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate completion of Minimum Data Set (MDS) assessments for two residents, leading to potential risks in care planning and quality of care. Resident 14, who was admitted with diagnoses including Schizophrenia and Bipolar disorder, frequently refused medications and exhibited behaviors such as yelling and cursing, as documented in progress notes. However, the MDS assessments inaccurately reported no behaviors or refusals of care. The Licensed Practical Nurse (LPN)/MDS Coordinator admitted to signing off on these sections without reviewing all relevant documentation, relying instead on incomplete nursing assistant records. Resident 6, admitted with conditions such as Congestive Heart Failure and Diabetes Mellitus Type 2, expressed interest in obtaining dentures due to missing teeth and cavities, which affected their ability to chew. Despite these issues being noted in a dietician's progress note, the MDS assessment inaccurately indicated no dental issues, and the care plan failed to address these concerns. The LPN/MDS Coordinator was unable to explain the discrepancy, indicating a lack of thorough assessment during the admission process.
Incomplete PASRR Forms for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure the completion of the Pre-Admission Screening and Resident Review (PASRR) forms for two residents, which is a federally required screening process for individuals with Intellectual Disabilities or serious mental illnesses prior to admission to a Medicaid-certified nursing facility. For Resident 5, who was admitted with a diagnosis of Major Depressive Disorder and was on Sertraline, the Level 1 PASRR indicated no mood disorders on preadmission, which was incorrect. The Director of Nursing acknowledged the error, and it was revealed that a revision was started but not completed. Resident 47 was admitted with a diagnosis of depression, and their admission Minimum Data Set (MDS) assessment showed intact cognition and prescription of an antidepressant. However, the Level 1 PASRR for Resident 47 was incomplete, with a required section left blank. Staff O confirmed that the clinical team, which includes the unit nurse manager, admission coordinator, Director of Nursing Services, and themselves, failed to ensure the PASRR was completed and accurate prior to admission.
Failure to Address Vision Impairment in Resident Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with multiple diagnoses, including congestive heart failure, chronic obstructive pulmonary disease, diabetes mellitus type 2, cataracts, and displacement of intraocular lens. Despite the resident being cognitively intact, the care plan did not address their vision issues, which were documented in the Care Area Assessment (CAA) as requiring large print documents or having information read aloud. This oversight was evident when the resident expressed difficulty in reading the menu due to limited vision and was unaware of meal options available to them. Interviews with staff revealed a lack of awareness regarding the resident's visual impairment. A Licensed Practical Nurse (LPN) admitted to not knowing about the resident's limited vision and stated that accommodations would have been made if they had been informed. The Dietary Staff was observed reading the menu to the resident, allowing them to choose their meals. The MDS Coordinator acknowledged that the care plan should have included the resident's vision impairment, as it was documented in the CAA, but could not explain why it was omitted. This failure to incorporate the resident's visual needs into their care plan placed them at risk for unmet care needs and diminished quality of life.
Deficiency in Communication and Anticoagulant Management for Hospice Resident
Penalty
Summary
The facility failed to ensure resident-centered care and treatment in accordance with professional standards of practice by not maintaining consistent communication and collaboration with hospice care for a resident receiving hospice services. The deficiency involved the management of a high-risk medication, an anticoagulant, which required regular monitoring of blood clotting levels through PT/INR tests. The facility did not have an order to monitor these levels, and there was a lack of documentation and communication between the facility and the hospice provider regarding the management and monitoring of the anticoagulant. Resident 29, who was on hospice services, had a history of pressure ulcers, long-term use of anticoagulants, and osteomyelitis. The resident's care plan was not updated to reflect their goals and choices for end-of-life care, and the anticoagulant medication was not managed properly. Despite having elevated INR levels, there was no clear documentation or communication between the facility and hospice provider about the necessary adjustments or monitoring of the medication. The facility's staff were unclear about the reasons for the resident's continued use of the anticoagulant and the lack of monitoring orders. Interviews with facility staff and hospice providers revealed a breakdown in communication and coordination of care. The hospice nurse had not documented care in the facility's electronic medical record, and there was confusion about who was responsible for managing the resident's anticoagulant therapy. The facility's Director of Nursing Services was unaware of the communication issues and expected that the hospice provider would document care within 24 hours of each visit. The deficiency was not identified until a significant delay had occurred, leaving the resident at risk for adverse effects from the anticoagulant therapy.
Failure to Provide Necessary Pharmaceutical Services
Penalty
Summary
The facility failed to provide necessary pharmaceutical services for Resident 29, who was under hospice care and had diagnoses including major depressive disorder and insomnia. The resident's physician had prescribed Trazadone HCL, an antidepressant, to be administered at bedtime. However, the medication was not available on multiple occasions throughout August 2024, specifically on the 11th, 12th, 14th, 20th, 21st, 25th, and 26th. Documentation indicated that the medication was not given due to unavailability, and there was no evidence that the physician or pharmacy was notified, nor was there any assessment of the resident's condition due to the missed medication. Interviews with the resident and staff revealed a lack of communication and follow-up regarding the unavailability of the medication. The resident expressed difficulty sleeping due to not receiving their medication. Staff members, including the Physician Assistant, Hospice RN, and Patient Care Coordinator, were unaware of the issue until it was brought to their attention later in the month. The Director of Nursing Services confirmed that the medication was not in the automated dispensing system and acknowledged the lack of action to resolve the issue. This deficiency in pharmaceutical services placed the resident at risk for adverse events related to missed medications.
Failure to Monitor and Reduce Unnecessary Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications. Specifically, the staff did not identify or monitor target behaviors for the use of antipsychotic medication and did not attempt a Gradual Dose Reduction (GDR) for the antipsychotic medication Risperdal, despite a recommendation from the pharmacy. The resident, who was readmitted with dementia and was rarely understood due to severely impaired cognition, exhibited physical behaviors such as grabbing and hitting. Despite these behaviors, there was no documentation of hallucinations or delusions, and the resident was placed on hospice care with a focus on comfort. The resident's physician's orders included Risperdal for dementia with behavior issues, and a second antipsychotic, Quetiapine Fumarate, was added for anxiety/agitation. However, the Quetiapine order had not been administered, and there was no psychotic behavior monitoring in place. Interviews with staff revealed a lack of specific behavior monitoring related to psychosis and an acknowledgment that dementia is not an approved diagnosis for antipsychotic medications. The facility's Director of Nursing Services and Social Services staff noted that the resident's behaviors were likely involuntary responses during care, and the goal was to discontinue antipsychotics.
Untrained Staff Providing Feeding Assistance
Penalty
Summary
The facility failed to ensure that residents with physical impairments and/or swallowing difficulties were fed by staff who were properly trained. This deficiency was observed when Staff L, an Activities Manager without a nursing license or specialized training, provided feeding assistance to Resident 22 during breakfast. Resident 22's care plan indicated the need for assistance from one staff member for eating, due to a swallowing problem, and specified a minced and moist texture diet. Despite the facility's assertion that they did not employ paid feeding assistants, Staff L was observed feeding Resident 22, which was confirmed by Staff B, the Director of Nursing Services. Staff B stated that non-nursing staff should not provide feeding assistance, although they could pass trays and hand items to residents. The lack of proper training and supervision for Staff L in providing feeding assistance posed a risk to Resident 22, who required specialized care due to their swallowing difficulties.
Infection Control and Equipment Storage Deficiencies
Penalty
Summary
The facility failed to ensure staff adhered to procedures for preventing the spread of disease, particularly in the context of Transmission Based Precautions (TBP) and the sanitary storage of respiratory equipment. In one instance, a Registered Nurse, identified as Staff P, entered a room with Enhanced Barrier Precautions (EBP) without wearing a gown, despite the presence of a sign indicating the need for such precautions. This oversight occurred during a dressing change for Resident 252, who was on EBP. Staff P later admitted to being unaware of the resident's precautionary status, highlighting a gap in communication or training. Additionally, the facility did not maintain respiratory equipment in sanitary conditions for Resident 252. Observations revealed that the resident's breathing treatment equipment, including a facemask, medication cup, and tubing, was left uncovered on a bedside table. This equipment was stored alongside personal items in a gray basin, contrary to the facility's policy, which required the equipment to be washed, air-dried, and stored in a labeled plastic bag. Staff K, an LPN, confirmed the correct procedure but noted the failure to adhere to it. Another deficiency was observed with Staff I, the Maintenance Supervisor, who entered a room under contact precautions without performing hand hygiene or wearing a gown. Despite applying an N95 respirator and gloves, Staff I failed to follow proper protocol by not disinfecting a metal cart used in the room and by handling items without appropriate hand hygiene. Staff I admitted to not realizing the room required such precautions, indicating a lack of awareness or training regarding infection control measures.
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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