Washington Soldiers Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Orting, Washington.
- Location
- 1301 Orting-kapowsin Hwy E, Orting, Washington 98360
- CMS Provider Number
- 505516
- Inspections on file
- 20
- Latest survey
- August 29, 2025
- Citations (last 12 mo.)
- 36
Citation history
Health deficiencies cited at Washington Soldiers Home during CMS and state inspections, most recent first.
A resident with a history of heart disease reported chest pain and difficulty breathing to staff on multiple occasions, but did not receive timely intervention and was sent to the hospital several hours later. The resident's subsequent allegation of neglect was not reported to the State Agency within the required timeframe, as facility procedures dictate, resulting in a delay of three days before the report was made.
The facility failed to serve food at appetizing temperatures, with residents reporting overcooked and flavorless meals. During a lunch service, a food service worker added gravy to dried-out meatloaf, which was not on the menu, and served tilapia at an inadequate temperature. The dietary manager confirmed these practices did not meet expectations.
The facility failed to provide physician-ordered therapeutic diets and portion sizes to 22 residents, risking medical complications and nutritional deficits. Observations revealed that residents on specific diets received incorrect items, such as garlic bread instead of wheat rolls, and incorrect portion sizes, such as insufficient protein servings. Staff acknowledged the discrepancies but could not explain the failure to adhere to dietary orders.
A facility failed to document and review a resident's healthcare advance directive (AD), leaving the resident without confirmed healthcare decision-making authority. The resident believed their sister was their DPOA for healthcare, but the EHR only showed a DPOA for financial matters. Staff interviews confirmed the absence of required documentation and review of the AD.
A resident reported concerns about personal items being stolen and was distressed over the lack of a lock on their closet. Despite filing a grievance, the facility did not report the alleged theft to law enforcement or the State Survey Agency. Interviews with staff confirmed that the required notifications were not made, placing the resident at risk for further abuse.
A resident reported concerns about stolen personal items and the lack of a lock on their closet, causing emotional distress. The facility addressed the lock issue but failed to investigate the theft allegations. Interviews with staff confirmed that an investigation should have been conducted, but it was not, leading to a deficiency finding.
A resident was admitted with diagnoses of depression and PTSD, but the PASRR assessment completed prior to admission failed to document these serious mental illness indicators. Facility staff acknowledged that the assessment was inaccurate and should have been updated upon admission.
A resident with a left leg amputation received a shrinker to prepare for a prosthetic leg, but the facility failed to document its arrival, obtain provider orders, or update the care plan. The resident applied the shrinker independently without formal guidance from nursing staff, leading to a deficiency in professional standards of care.
A resident with severe malnutrition, a sacral ulcer, and diabetes experienced a decline in ADLs due to the facility's failure to provide a wheelchair. The resident, dependent on staff for transfers, was confined to bed without mobility plans in their care plan or EHR. The DON stated that a loaner wheelchair should have been provided.
The facility failed to monitor and document bowel movements for a resident at risk of constipation, and did not implement the bowel program as needed. Additionally, two residents were not properly positioned or provided with necessary supportive devices, despite having care plans that required specific interventions. Staff interviews confirmed that expectations for monitoring, documentation, and use of devices were not met.
A facility failed to accurately assess a resident's smoking safety, leading to potential fire and injury risks. The resident, with multiple health issues and a history of stroke, was observed with a right-hand splint and an untrimmed beard, yet was allowed to smoke independently. Staff interviews confirmed the assessment was inaccurate, as the resident lacked the dexterity to hold a cigarette safely and had a large untrimmed beard.
A resident with chronic pain syndrome and a recent toe amputation reported inadequate pain management, with medication not administered on time and insufficient to control pain. Facility staff interviews confirmed a lack of documentation and monitoring of the resident's pain levels, contrary to the care plan and facility protocol.
A facility failed to limit PRN psychotropic medication to 14 days for a resident with chronic respiratory failure and anxiety. The resident had an order for lorazepam without a stop date, and the medication was administered multiple times over several months. The pharmacist and DON acknowledged the oversight, as the PRN lorazepam should have been discontinued or justified within 14 days.
Failure to Timely Report Allegation of Neglect
Penalty
Summary
The facility failed to identify and timely report an allegation of neglect for one resident. The resident, who had a history of atherosclerotic heart disease and prior heart attacks, reported experiencing chest pain and difficulty breathing during the early morning hours. Despite informing staff of these symptoms multiple times, the staff did not take immediate action, and the resident was not sent to the hospital until several hours later. The resident later reported this incident to facility staff, expressing that their concerns were not addressed promptly and that they felt their life was at risk while waiting for assistance. A grievance form documented the resident's complaint, and the staff member who received the complaint reported it to their supervisor. However, the facility did not report the allegation of neglect to the State Agency until three days after the resident voiced the allegation. The facility's operating procedure required immediate reporting of suspected abuse or neglect to a licensed nurse and the State Agency hotline, but this protocol was not followed. The Director of Nursing Services confirmed that the delay in reporting was not acceptable and did not meet facility expectations.
Failure to Provide Appetizing and Safe Food Temperatures
Penalty
Summary
The facility failed to provide food at an appetizing temperature, as observed during a review of Kitchen Services. Residents expressed dissatisfaction with the quality of the food, noting that the meat was overcooked and lacked flavor. Specifically, one resident mentioned that the meat was overcooked, while another stated that the food did not taste good. A third resident commented on the lack of flavor and dryness of the chicken and other meats. These observations were made during interviews conducted on July 15, 2024. On July 17, 2024, during the lunch tray service, it was observed that a food service worker was adding gravy to meatloaf slices that appeared dried out, even though gravy was not listed on the menu for regular diets. The temperatures of the food items on a test tray were taken, revealing that the orzo and asparagus were at 135 degrees Fahrenheit, the meatloaf at 136 degrees Fahrenheit, and the tilapia at 125 degrees Fahrenheit. The food service worker acknowledged that the tilapia was not at an appropriate temperature. The dietary manager confirmed that only altered texture diets should have received gravy and that dried-out menu items should not have been served. The tilapia's temperature did not meet the facility's expectations, indicating a failure to maintain proper food quality and safety standards.
Failure to Provide Physician-Ordered Therapeutic Diets and Portion Sizes
Penalty
Summary
The facility failed to ensure that 22 out of 90 sampled residents received physician-ordered therapeutic diets or portion sizes, which placed them at risk for medical complications, nutritional deficits, and a decreased quality of life. During an observation of the lunch tray preparation service, it was noted that residents on Easy to Chew, Soft and Bite Sized, and Puree diets were served garlic bread instead of the wheat roll specified in the lunch extension menu. Staff L, a Food Service Worker Lead, confirmed that only garlic bread and garlic bread sticks were prepared, and there were no wheat rolls available. Staff L was unsure why the wheat rolls were not prepared, indicating a failure to follow the prescribed dietary requirements. Additionally, there were discrepancies in portion sizes provided to residents. For instance, Resident 60's tray card indicated a Large Portion, but they received only one and a half portions of meatloaf, with regular diet portion sizes for other items. Similarly, Resident 48's tray card indicated Double Protein, but they were initially served only one slice of meatloaf, consistent with the regular diet. Staff N, the Food Service Supervisor, had to intervene to correct the portion size for Resident 48. Staff M, the Dietary Manager, acknowledged that tray cards indicating Large Portion should have received one and a half portions of protein and starch, and that the expectation was for extension menus and tray cards to be followed. However, Staff M could not explain why the wheat rolls were not prepared, highlighting a lapse in adherence to dietary orders.
Failure to Document and Review Healthcare Advance Directive
Penalty
Summary
The facility failed to obtain or offer assistance in formulating or periodically checking if a resident had a healthcare advance directive (AD). This deficiency was identified for one of the sampled residents, who was able to make their needs known upon admission. The resident believed their sister was their durable power of attorney (DPOA) for healthcare, but there was no documentation to confirm this in their electronic healthcare record (EHR). The resident's care plan only indicated a DPOA for financial matters, not healthcare. Interviews with facility staff revealed that the necessary documentation and review of the resident's AD for healthcare were not conducted as required. The psychiatric social worker confirmed the absence of documentation offering AD information or reviewing it in the EHR. The facility administrator acknowledged that AD information should be offered, obtained, and reviewed upon admission and quarterly, and that the lack of documentation did not meet the facility's expectations.
Failure to Report Alleged Theft of Resident's Property
Penalty
Summary
The facility failed to report an incident of potential abuse involving the misappropriation of personal property for one resident. Resident 37, who was able to communicate their needs, expressed concerns about personal items being stolen and was distressed over the lack of a lock on their closet. Despite the resident's grievance filed on June 10, 2024, which highlighted their emotional distress and the need for a lock, the facility did not address the allegation of stolen items or report the incident to law enforcement and the State Survey Agency as required. The facility's incident reporting log from February 2024 through July 12, 2024, showed no record of the alleged theft. Interviews with the Director of Nursing Services and the Administrator revealed that the police and State Agency should have been notified, but this did not occur. The failure to report the allegation of misappropriation of personal property placed the resident at risk for further abuse and diminished their quality of life.
Failure to Investigate Alleged Misappropriation of Resident's Property
Penalty
Summary
The facility failed to identify and investigate possible misappropriation of personal property for a resident who was able to communicate their needs. The resident, who had previously experienced theft of personal items, expressed concerns about stolen belongings and the lack of a lock on their closet, which caused them emotional distress. Despite the resident's grievance form indicating these concerns, the facility only addressed the installation of locks on the closet and did not investigate the allegations of stolen items. The facility's incident report log showed no recorded investigation into the resident's allegations of theft. Interviews with the Director of Nursing Services and the Administrator revealed that an incident report investigation should have been initiated but was not, which did not meet the facility's expectations. The failure to investigate the resident's allegations of misappropriation of personal property was identified as a deficiency.
Inaccurate PASRR Assessment for Resident
Penalty
Summary
The facility failed to ensure that the Pre-Admission Screening and Resident Review (PASRR) assessment was accurately completed for a resident upon or prior to admission. This deficiency was identified for one of seven residents reviewed for PASRRs and/or unnecessary medications. The resident in question was admitted with diagnoses including depression, adult failure to thrive, and post-traumatic stress disorder (PTSD). However, the PASRR assessment completed by the hospital prior to admission did not document any serious mental illness indicators, and it incorrectly indicated that no Level II evaluation was needed. Interviews with facility staff revealed that the PASRR assessment was not accurate and should have been reviewed and updated upon the resident's admission to include the diagnoses of depression and PTSD. Both the Psychiatric Social Worker and the Director of Nursing Services acknowledged that the PASRR did not meet expectations and should have been corrected to reflect the resident's mental health conditions.
Failure to Document and Plan for Shrinker Use in Resident with Amputation
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice for a resident with an amputation of the left lower leg. The resident, who was admitted with a diagnosis of an amputation, was waiting for a shrinker to arrive in the mail to help prepare for a prosthetic leg. Upon receiving the shrinker, the resident was responsible for applying it themselves without any documented assessment, provider orders, or care plan in place. The resident was advised by a Certified Nursing Assistant/Restorative Aide to wear the shrinker for about an hour daily and to monitor for skin reactions, but there was no formal guidance or documentation from the nursing staff or physician. Interviews with staff revealed a lack of awareness and documentation regarding the resident's use of the shrinker. The Licensed Practical Nurse confirmed the absence of a provider order or care plan for the shrinker, and the Director of Nursing Services was unaware of the shrinker's arrival and use. The facility did not document the arrival of the shrinker, notify the provider, obtain necessary orders, or update the care plan, which led to a deficiency in meeting professional standards of care for the resident.
Failure to Provide Wheelchair Leads to ADL Decline
Penalty
Summary
The facility failed to provide necessary care and services for a resident, identified as Resident 57, leading to a decline in their ability to perform activities of daily living (ADLs). Resident 57 was admitted with severe malnutrition, a large sacral skin ulcer, and diabetes, and was dependent on staff for transfers in and out of bed. Despite being able to communicate their needs, Resident 57 was observed lying in bed continuously over several days without a wheelchair, which was necessary for their mobility. The resident expressed frustration about being confined to bed since March, unable to go outside or attend medical appointments. The electronic health record and care plan for Resident 57 lacked any mention of a wheelchair or mobility plan. The Director of Nursing Services acknowledged that the facility's expectation was to provide a loaner wheelchair until the resident's personal wheelchair was available.
Deficiencies in Bowel Monitoring and Positioning
Penalty
Summary
The facility failed to consistently monitor and document bowel movements and implement the bowel program for Resident 28, who was at risk for constipation due to impaired mobility, medications, and diet. Despite having a care plan that required monitoring and documentation of bowel movements, there was no record of bowel movements for several days, nor was there documentation of administering constipation medications or any refusals. Interviews with staff revealed that the expectation was to administer medications if the resident did not have a bowel movement for more than 72 hours and to document any refusals, which was not done. Additionally, the facility did not properly position Resident 12, who was dependent on staff for bed mobility due to Parkinson's disease. Observations showed that the resident was not repositioned every two hours as required, and palm protectors were not used consistently, despite the resident having sores on their fingertips and being unable to use the call light. Staff interviews confirmed that the resident should have been repositioned every two hours and should have had palm protectors on at all times. For Resident 52, the facility failed to use prescribed positioning devices, such as an air cast and palm splint, for a resident with a stroke and a leg fracture. Observations showed that the resident's left hand was not supported with a splint, and the left leg was not properly positioned in an air cast. Documentation did not reflect the use of these devices, contrary to the care plan and treatment administration record. Staff interviews indicated that the expectation was for clear documentation and the use of devices as ordered, which was not met.
Inaccurate Smoking Safety Assessment for Resident
Penalty
Summary
The facility failed to provide necessary supervision and safety monitoring for a resident, identified as Resident 28, who was reviewed for accidents. The deficiency was related to an inaccurate smoking safety assessment, which placed the resident and the facility at risk for possible fire and serious injury. The facility's policy on smoking and tobacco use required smoking assessments for residents who smoked upon admission, quarterly, and when warranted by circumstances. However, the assessment for Resident 28, conducted on 06/11/2024, inaccurately indicated that the resident had the hand dexterity to safely hold a cigarette and that their facial hair was trimmed to avoid lit cigarette or ashes falling on it, despite observations to the contrary. Resident 28 was admitted with multiple diagnoses, including heart, lung, and kidney disease, and had a history of stroke with hemiplegia. During an observation, the resident was seen with a right-hand splint and a large, untrimmed beard, and stated they smoked independently after obtaining cigarettes and a lighter from the nurse's station. Interviews with facility staff revealed that the smoking safety assessment was not accurate, as the resident lacked the dexterity to hold a cigarette safely and had a large untrimmed beard, which posed a safety risk. The Director of Nursing Services confirmed that the assessment should have been accurate and that the resident's beard should be trimmed for safe smoking.
Failure to Monitor and Manage Resident's Pain
Penalty
Summary
The facility failed to adequately monitor and manage pain for a resident, identified as Resident 67, who was admitted with a diagnosis of left toe amputation, chronic pain syndrome, and post-traumatic stress disorder. The resident had a provider order for narcotic pain medication to be administered three times a day. However, during an interview, the resident reported that the medication was not administered on time and was insufficient to control their pain, which was described as out of control. A review of the electronic health record revealed a lack of documentation regarding the resident's pain levels, which is necessary to assess the effectiveness of the pain medication. Interviews with facility staff, including the Resident Care Manager and the Director of Nursing Services, confirmed that the facility's protocol required pain levels to be documented every shift and the physician to be notified if the medication was ineffective. Despite this, the resident's care plan, which instructed staff to monitor and document pain management, was not followed. The resident reported experiencing pain at a level of 9 out of 10, and was observed shaking due to the intensity of the pain, indicating a significant lapse in the facility's pain management practices.
Failure to Limit PRN Psychotropic Medication to 14 Days
Penalty
Summary
The facility failed to ensure that as-needed (PRN) psychotropic medications were limited to 14 days for one resident, identified as Resident 59, when reviewed for unnecessary medications. Resident 59, who was admitted with multiple diagnoses including chronic respiratory failure and anxiety, had an order for lorazepam, an antianxiety medication, to be administered every four hours as needed, starting on February 21, 2024, without a stop date. The monthly pharmacy recommendations did not include a suggestion to discontinue the lorazepam PRN after 14 days. The medication administration record indicated that Resident 59 received lorazepam three times in July 2024, seven times in June 2024, and nine times in May 2024. During interviews, both the pharmacist and the Director of Nursing Services acknowledged that the PRN lorazepam should have been discontinued or justified within 14 days, which was not done, leading to the deficiency.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
