Willapa Harbor Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Raymond, Washington.
- Location
- 1100 Jackson Street, Raymond, Washington 98577
- CMS Provider Number
- 505349
- Inspections on file
- 24
- Latest survey
- August 21, 2025
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Willapa Harbor Care during CMS and state inspections, most recent first.
A resident exhibiting aggressive and threatening behaviors, including verbal threats and physical actions with a butterknife, was not properly investigated according to facility policy. Staff provided witness statements, but no residents were interviewed, no incident report was filed, and there was no documented assessment of the affected resident's safety or well-being.
Surveyors observed that several opened food items in a kitchen refrigerator were not discarded by their labeled use by dates. The Dietary Manager and DON both confirmed that expired food should have been removed, but these items remained past their expiration.
A resident with severe cognitive impairment was administered psychotropic medications without timely or appropriate informed consent from their representative. Consent for one medication was obtained late, and dose changes for another were not communicated to or consented by the representative, contrary to facility policy and staff expectations.
A resident was admitted and assessed as alert and oriented, but the MDS assessment failed to document the presence of broken or loose teeth. Observations and an LPN assessment later confirmed the resident had broken and loose teeth, and the RN Infection Preventionist acknowledged the MDS was inaccurate.
A resident who was assessed as dependent for oral care and requiring substantial assistance with personal hygiene did not have their care plan updated to reflect these needs. The care plan continued to indicate only set-up assistance was required, despite staff and assessment documentation showing a higher level of dependence. Staff interviews confirmed the care plan was not revised in accordance with the resident's current condition.
A resident with moderate cognitive impairment and a documented preference for listening to country music was not provided with opportunities to engage in this preferred activity. Despite assessments and care plans highlighting the importance of music, activity records showed minimal engagement, and the resident confirmed she had not been offered suitable options such as a radio. Staff interviews revealed that refusals to participate in offered activities were not documented, contrary to facility expectations.
Three residents experienced prolonged periods without a bowel movement, and nursing staff did not initiate the prescribed bowel protocol as required by facility policy and physician orders. Documentation in the EMAR did not show that interventions such as Milk of Magnesia, Bisacodyl suppository, or Fleet Enema were administered after the specified timeframes, and staff interviews confirmed the protocol was not followed.
A resident with COPD and pulmonary fibrosis received continuous oxygen therapy without a physician's order, contrary to facility policy. Staff confirmed the resident had been on oxygen since admission, but the required order was not entered until several days later.
A nurse left a medication cup with multiple pills at the bedside of a cognitively intact resident who was not on a self-medication program, contrary to facility policy requiring staff to remain until medications are taken. The resident was found alone with the medications and reported not knowing what all the pills were for. No self-administration evaluation was documented, and the DON confirmed this was not permitted practice.
A CNA delivered a meal tray to a room under enhanced barrier precautions, and after the resident declined the tray, the CNA returned it to the meal cart with other trays due to be served. The Infection Preventionist/RN confirmed that staff were expected to leave refused trays in the room to prevent cross-contamination, but this protocol was not followed.
Nursing hours were not accurately posted or updated daily for nearly all days reviewed. The staffing coordinator, new to the role, did not update staffing numbers for each shift and was unaware of the requirement to reflect real-time changes. The DON confirmed there was no process in place for updating postings with shift changes, resulting in posted staffing information that did not accurately reflect current staffing levels.
The facility failed to ensure a safe dining environment as the floorboard heater in the dining room was excessively hot. During an observation, the heater was found to be radiating heat, causing an observer to quickly withdraw their hand upon contact. The Maintenance Director confirmed the heater's excessive heat, with a thermometer reading of 100 degrees.
A facility failed to obtain an evaluation assessment, consent, and physician order for a resident's use of full-length bolsters on both sides of the bed. The resident, who was moderately cognitively impaired, was observed multiple times with the bolstered air mattress, but their health record lacked the necessary documentation. Staff acknowledged the oversight, which placed the resident at risk.
A facility failed to develop a comprehensive care plan for a resident at risk of skin breakdown. The resident was observed with a darkened skin impairment on the left great toe, but the care plan did not address this issue. Staff confirmed the absence of a specific care plan for the impairment, despite expectations for such plans to be implemented.
A resident with cognitive intactness and an upper extremity impairment did not receive adequate grooming assistance, specifically nail care, as per their care plan. Despite the resident's preference for shorter nails, they were observed with long, unkempt fingernails. Staff indicated that nail care should occur on shower days, but there was no documentation of nail care being offered or refused, highlighting a deficiency in care provision.
A facility failed to provide a resident-centered activity for a moderately cognitively impaired resident who preferred going outside for fresh air. Despite the resident's expressed preference, there was no documentation of the resident being offered or participating in outdoor activities over several months. Staff interviews revealed uncertainty about whether the resident had been outside, and the facility's documentation of refusals was noted as weak.
A facility failed to provide restorative services for a resident with limited mobility due to a stroke. The resident's care plan lacked interventions for maintaining range of motion (ROM), and staff were unaware of any contractures or restorative programs in place. The resident demonstrated limited hand mobility and reported no ROM exercises were performed by staff.
The facility did not ensure RN supervision for at least eight hours daily on three occasions, risking inadequate care for residents. Despite efforts to hire RNs, the facility primarily received LPN applicants. In response to RN shortages, management or staff from other facilities were used to cover shifts, violating WAC 388-97-1080 (3).
Failure to Conduct Thorough Investigation After Resident Behavioral Incident
Penalty
Summary
The facility failed to conduct a thorough investigation following an incident involving a resident who exhibited heightened behaviors, including refusing medication, throwing objects, attempting to pull the fire alarm, making verbal threats, and having physical contact with aides. The resident, who was cognitively intact, also obtained a butterknife from a meal tray, threatened staff and another resident, and struck a window with the utensil. Despite these actions and the facility's policy requiring a comprehensive investigation of all allegations of abuse, neglect, or mistreatment—including resident and staff interviews and documentation in the electronic incident report system—no incident report was filed, and the event was not documented in the Accident and Injury log. The administrator acknowledged that while staff were asked to provide witness statements, no residents were interviewed or asked for statements, and there was no documented evaluation to determine if the other resident involved felt safe. Additionally, monitoring of the potentially affected resident for harm did not occur. The administrator admitted that a full investigation, as outlined in facility policy and regulatory requirements, was not completed.
Expired Food Items Not Discarded as Required
Penalty
Summary
The facility failed to ensure that food items stored in one of the kitchen refrigerators were properly managed according to professional standards. During an observation, multiple opened food items, including butter pasta, meatballs, diced carrots, bulk ham, deli ham, and parmesan cheese, were found in the refrigerator past their labeled use by dates. The Dietary Manager confirmed that these items should have been discarded by their use by dates but had not been removed. The Director of Nursing also stated that her expectation was for expired food items to be discarded from refrigerators and freezers.
Failure to Obtain Informed Consent for Psychotropic Medication Administration
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were informed and provided consent prior to the administration of psychotropic medications for one of five sampled residents. Specifically, a resident with diagnoses including depression and dementia, and who was assessed as severely cognitively impaired, was started on Sertraline without documented consent from the resident's representative until 18 days after the medication was initiated. Additionally, while consent for Bupropion was obtained on the day it was started, it was signed by the resident despite their low cognitive status, and there was no documentation that the representative was notified or provided consent for subsequent dose reductions of Bupropion. Staff interviews confirmed that the expectation was for consent to be obtained from the resident or their power of attorney prior to starting psychotropic medications, and that any dosage changes should be communicated and documented with the resident or representative. However, documentation in the electronic health record did not show that these procedures were followed for the resident in question, particularly given the resident's cognitive impairment and the need for representative involvement in consent decisions.
Inaccurate Dental Assessment Documented in MDS
Penalty
Summary
The facility failed to complete an accurate comprehensive dental and oral assessment for a resident. Upon admission, the resident was documented as alert and oriented. The Medicare 5-day Minimum Data Set (MDS) assessment indicated that the resident did not have broken or loose natural teeth. However, during an observation, the resident was seen with broken and loose teeth, and was able to move his front teeth with his tongue. A subsequent assessment by an LPN confirmed the presence of loose and broken teeth. The Infection Preventionist/Registered Nurse later reviewed the MDS assessment and acknowledged that it was incorrect, as the resident did have broken teeth. The expectation was that an accurate physical assessment would be completed and documented in the MDS assessment.
Failure to Update Care Plan for Dependent Resident's ADL Needs
Penalty
Summary
The facility failed to revise the care plan for a resident who was dependent with activities of daily living (ADL), specifically oral care and personal hygiene. According to the facility's policy, care plans must be reviewed and revised at a minimum upon admission, quarterly, and with any significant change in condition. Record review showed that the resident's most recent comprehensive assessment documented a need for full staff assistance with oral care and substantial/maximal assistance with personal hygiene. However, the resident's care plan, last revised nearly a year prior, only indicated the need for set-up assistance by one staff member for these tasks. Interviews with facility staff, including a CNA, Infection Preventionist/RN, and the DON, confirmed that the resident's care needs had changed and that the care plan should have been updated to reflect the increased level of assistance required. Staff described the difference between set-up assistance and full dependence, and acknowledged that the care plan did not match the resident's current needs as documented in the assessment. This discrepancy placed the resident at risk for unmet needs and inappropriate care planning.
Failure to Provide Resident-Centered Activities Based on Preferences
Penalty
Summary
The facility failed to provide resident-centered activities that incorporated the preferences of a resident who was moderately cognitively impaired and had expressed a strong interest in listening to music, particularly country music. The resident's care plan and assessments documented the importance of music and specific television channel preferences, as well as occasional participation in religious meetings via Zoom. Despite these documented preferences, activity records showed that the resident only received five one-on-one visits over a 27-day period, with no other activities documented. Observations revealed the resident lying in bed with the television on, unresponsive to external stimuli, and not engaged in preferred activities. Interviews with the resident confirmed that she had not been provided opportunities to listen to her preferred music, stating she would listen to music television but preferred a radio, which was not available. The Life Enrichment Director acknowledged the availability of CD players and country music CDs but noted the resident had declined their use a few times, and refusals were not documented. The Administrator confirmed that refusals should be documented, but this was not done. These actions and omissions resulted in the facility not meeting the resident's individualized activity needs as required.
Failure to Initiate Bowel Protocol per Policy and Physician Orders
Penalty
Summary
The facility failed to initiate bowel interventions in accordance with physician orders and facility policy for three residents who experienced extended periods without a bowel movement. The facility's policy required licensed nurses to assess residents and begin a bowel protocol if no or minimal bowel movement was documented for 64 hours. This protocol included administering Milk of Magnesia, followed by Bisacodyl suppository, and then a Fleet Enema if previous interventions were ineffective, as outlined in the residents' physician orders. For one resident, documentation showed a gap of approximately 118 hours between bowel movements, with no evidence in the Electronic Medication Administration Record (EMAR) that the prescribed interventions were administered after the 64-hour threshold. Another resident experienced a 121-hour interval between bowel movements, and again, the EMAR did not reflect any medication intervention as required by the protocol. A third resident had a 130-hour gap between bowel movements, with no documentation of bowel protocol interventions during this period. Interviews with nursing staff and the Director of Nursing confirmed that the bowel protocol was not initiated as expected and that there were issues with documentation. Staff acknowledged that there should have been records of interventions during the periods of no bowel movement, but none were found. The failure to follow the established bowel management protocol resulted in unmet care needs for the affected residents.
Oxygen Therapy Administered Without Physician Order
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease (COPD) and pulmonary fibrosis was administered continuous oxygen therapy without a physician's order in place, as required by the facility's Oxygen Management Policy. The resident was observed receiving oxygen on two separate occasions, and review of the electronic health record confirmed that no physician's order for oxygen existed prior to a specific date. Staff interviews further confirmed that the resident had been using oxygen since admission, but the order was not entered until several days later. The facility's policy, revised in December 2022, mandates that a physician's order must be obtained before administering oxygen. Despite this, staff acknowledged that the resident was admitted with oxygen and continued to receive it without the necessary order. The Director of Nursing Services also confirmed that oxygen administration should follow facility policy, which was not adhered to in this instance.
Medications Left Unattended at Bedside Without Self-Administration Assessment
Penalty
Summary
A deficiency occurred when a nurse failed to remain with a resident during medication administration, contrary to the facility's policy requiring staff to stay with residents until all medications are taken. During an observation, a resident was found alone in bed with a medication cup containing nine pills left on the bedside table. The resident reported that the nurse left the medications at the bedside because she was not ready to take them, and the nurse did not remain to ensure the medications were ingested. The resident was cognitively intact but stated she did not know what all the medications were for, mentioning some were for nausea, dizziness, and high blood pressure. A review of the resident's electronic health record showed no evaluation for self-administration of medication had been completed, and the DON confirmed that the resident was not on a self-medication program. The DON also stated that medications should not be left at the bedside unless a resident is on such a program. The nurse involved reported that she assumed the resident would take the medications and left the room. This failure to follow professional standards and facility policy was identified through observation, interview, and record review.
Improper Handling of Meal Trays Under Enhanced Barrier Precautions
Penalty
Summary
Staff F, a Certified Nurse Assistant, was observed carrying a meal tray from the food cart into a resident's room that was under enhanced barrier precautions, as indicated by an orange-colored sign at the entrance. When the resident declined the meal tray, Staff F picked up the tray from the bedside table and returned it to the meal cart in the hallway, which contained other meal trays yet to be served. During an interview, Staff F confirmed that it was typical practice to return refused trays to the meal cart. However, the Infection Preventionist/Registered Nurse stated that the expectation was for staff to leave the tray in the room to prevent contamination of other trays, highlighting a failure to follow proper infection control procedures during meal distribution.
Failure to Accurately Post and Update Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nursing hours were accurately posted and updated daily for 30 out of 31 days reviewed. Record review showed that the Daily Nursing Staffing Report postings were not provided for review prior to being edited, and the reports that were provided showed changes to key columns such as Hours Scheduled, Staffing Total, and Actual Hours Worked for every day except one. Interviews revealed that the staffing coordinator, who had only recently taken on the role, was not updating the staffing numbers for each shift on the posted reports and was unaware that updates were required throughout the day. The coordinator admitted to only posting scheduled numbers and not reflecting actual changes as they occurred. Further interviews with the DON confirmed that the staffing coordinator did not have a process in place to update the postings with shift changes and was unaware of the requirement to do so. The coordinator also stated that she would review and correct the postings the day after they were taken down, rather than updating them in real time. As a result, the posted staffing information did not accurately reflect current staffing levels and census information throughout the day, as required.
Unsafe Dining Environment Due to Hot Floorboard Heater
Penalty
Summary
The facility failed to provide a safe dining environment by not ensuring that the floorboard heater in the dining room was not excessively hot. During an observation, the heater was found to be radiating heat, and when touched, it was hot enough to cause an observer to quickly withdraw their hand. The Maintenance Director, identified as Staff D, confirmed that the heater had to be manually turned on and acknowledged its excessive heat after touching it and quickly removing his hand. A thermometer reading taken by Staff D showed the heater's temperature at 100 degrees, confirming the heater's excessive heat.
Failure to Obtain Required Documentation for Use of Bed Bolsters
Penalty
Summary
The facility failed to obtain an evaluation assessment, consent, and physician order for the use of full-length bolsters on both sides of the bed for a resident who was moderately cognitively impaired. The resident was observed multiple times lying in bed with an air mattress equipped with bolsters on both the upper and lower full-length sides of the bed. Despite these observations, the resident's electronic health record did not contain any documentation of an evaluation assessment, consent, or physician's order for the use of the bolstered air mattress. Staff members, including the Resident Care Manager and the Director of Nursing Services, acknowledged the necessity of having an assessment, physician's order, and consent for the use of such safety devices. However, they confirmed that these documents were not present for the resident in question. This oversight placed the resident at risk for injury, unmet care needs, and a diminished quality of life, as the necessary procedural steps for the use of physical restraints were not followed.
Failure to Address Skin Impairment in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident, identified as Resident 20, who was at risk for skin breakdown. Resident 20 was admitted to the facility and was documented as cognitively intact with a risk of developing skin breakdown according to the quarterly Minimum Data Set assessment. On a specific date, Resident 20 was observed with a darkened skin impairment on the left great toe, but the comprehensive care plan did not address this new skin impairment. Staff E, an Infection Preventionist and LPN, confirmed that Resident 20's electronic health record lacked a specific care plan for the left great toe skin impairment. Additionally, Staff B, the Director of Nursing Services and RN, acknowledged that it was expected for a care plan to be implemented for new skin impairments, but confirmed that no such care plan was in place for Resident 20's condition.
Failure to Provide Adequate Grooming Assistance
Penalty
Summary
The facility failed to provide adequate grooming assistance for a resident, identified as Resident 12, who was reviewed for activities of daily living (ADLs). Resident 12, who was cognitively intact and had an impairment on the left side of the upper extremity, required extensive assistance with personal hygiene according to their care plan. However, the care plan did not include specific interventions for nail care. On observation, Resident 12 was found to have long, unkempt fingernails, which was against their preference for shorter nails. The electronic medical record showed no documentation of nail care being offered or refused from late June to late July. Staff interviews revealed that nail care was supposed to be provided on shower days, which occurred twice weekly, and any refusals should be documented. However, there was no record of such documentation. The Director of Nursing Services confirmed the observation of Resident 12's long and unkempt nails, indicating a lapse in the expected care routine.
Failure to Provide Resident-Centered Activities
Penalty
Summary
The facility failed to provide resident-centered activities that incorporated the preferences of a resident, identified as Resident 285, who was moderately cognitively impaired. The resident expressed a preference for going outside to get fresh air when the weather was good, as noted in the admission Minimum Data Set assessment. However, the Activity Participation reports for May, June, and July 2024 did not document any instances where the resident was offered, refused, or had gone outside. During interviews, the resident expressed a desire to go outside, and the Life Enrichment Director acknowledged inviting residents outside but was unsure if Resident 285 had participated. The Director of Nursing Services confirmed that resident preferences should be offered, and the Administrator noted that documentation of refusals was weak.
Failure to Provide Restorative Services for Resident with Limited Mobility
Penalty
Summary
The facility failed to provide restorative services for a resident who was reviewed for range of motion (ROM) and mobility. The resident, who was cognitively intact and had impairment on one side of the body due to a stroke, was not included in a restorative therapy program as per the quarterly Minimum Data Set (MDS) assessment. The care plan, dated several months prior, indicated the resident had limited physical mobility related to stroke and weakness but did not include interventions for maintaining ROM or function. The resident required extensive assistance for bed mobility, repositioning, and transfers with a mechanical lift. During interviews, the resident expressed that her hand did not open and demonstrated limited mobility, indicating that staff had not performed ROM exercises on her left hand. Staff members, including the Resident Care Manager and the Director of Nursing Services, acknowledged the absence of a restorative program and were unaware of any residents with contractures. Upon observation, the Director of Nursing Services noted that the resident's left hand appeared contracted, confirming the lack of a restorative program in place.
Failure to Provide RN Supervision for Required Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight hours daily on three specific days within a 30-day review period. This deficiency was identified through interviews and record reviews, which revealed that on 06/30/2024, 07/07/2024, and 07/14/2024, there was no RN coverage for any of the three shifts (day, evening, and night). The absence of RN supervision on these days placed residents at risk of not receiving the necessary care and supervision. During an interview on 07/24/2024, the facility's administrator, Staff A, acknowledged the difficulty in hiring RNs, noting that their hiring efforts primarily attracted Licensed Practical Nurse (LPN) applicants. Staff A mentioned that in cases of RN shortages, they would utilize their management team or staff from another facility to cover the shifts. This situation was in violation of WAC 388-97-1080 (3), which mandates RN supervision for a minimum of eight hours daily.
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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