Citations in Washington
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Washington.
Statistics for Washington (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Washington
The facility did not provide required written transfer or discharge notices to four residents or their representatives, and failed to document that a report was given to the receiving hospital for two residents. Staff confirmed that notices were sent to the LTCO but not directly to residents, and that communication with hospitals was not properly documented.
The facility failed to provide respiratory care and oxygen therapy according to physician orders and professional standards for four residents. This included administering oxygen without a provider order, not following prescribed flow rates, using oral suction equipment for stoma care, and not maintaining or replacing soiled oxygen equipment. Staff were unaware of proper procedures for equipment cleaning and did not consistently follow facility policy or update care plans to reflect accurate orders.
The facility did not have a system to assess or document the competencies of nurses and CNAs, resulting in staff providing care without evidence of proper training or skills assessment. For example, a nurse administered cancer therapy and performed stoma suctioning for a resident with complex needs without documented training or knowledge of required techniques. Staff files lacked competency records, and staff development processes did not ensure completion or collection of orientation and skills checklists.
The facility did not ensure that meals were palatable, visually appealing, or served at appropriate temperatures, as reported by several residents and confirmed by surveyor observations. Residents described the food as bland, repetitive, and unappetizing, with some supplementing their diets with outside food or modifying their meals to improve taste. A test tray review found food items to be unappealing in appearance, taste, and temperature, and the Food and Nutrition Service Manager cited budget limitations as a factor.
Staff failed to maintain a clean environment and adhere to infection control protocols, including not addressing a leaking catheter bag, not reporting a damaged mattress cover, and not following PPE and enhanced barrier precautions during high-contact care and suctioning procedures for multiple residents.
A resident with complex medical needs and limited mobility was provided with a bed and mattress that were too small, resulting in persistent discomfort. Staff used a foam spacer to fill the gap between the mattress and the extended bed frame, but the spacer frequently shifted, causing the bed to remain uneven and preventing the resident from sitting or lying comfortably. Despite repeated reports from the resident, staff indicated there was nothing more they could do, even though longer beds were available in the facility.
A resident's room was found to be cluttered and disorganized, with medical and personal care supplies scattered on furniture, in open boxes, and on an extra bed. The resident reported dissatisfaction with the lack of order, and staff acknowledged the clutter and insufficient storage, resulting in a less than homelike environment.
The facility did not conduct timely or thorough investigations into two incidents: one involving a resident's allegation of verbal abuse and missing property by a staff member, and another involving a resident's fall and subsequent hospital transfer. In both cases, required investigative steps and documentation were incomplete or delayed.
A resident experienced a sustained decline in functional abilities, mood, and care acceptance following a hospitalization, but staff did not complete a Significant Change in Status Assessment (SCSA) as required. Interviews and record reviews confirmed that the resident's condition had changed significantly, yet the necessary reassessment was not performed after the 14-day period.
The facility did not ensure timely and accurate completion or updating of PASRR assessments for three residents with mental health diagnoses. One resident's required Level 2 referral was delayed by several months, another resident's follow-up with the State PASRR office was not documented, and a third resident's PASRR was not updated after new mental health diagnoses and medications were added.
Failure to Provide Required Transfer/Discharge Notices and Hospital Reports
Penalty
Summary
The facility failed to provide required written notices to residents and/or their representatives at the time of transfer or discharge for four residents, and did not ensure that a report was given to the receiving hospital for two residents. In several cases, staff completed the Nursing Home Transfer or Discharge Notice and sent it to the Long Term Care Ombudsman (LTCO) office, but did not provide the notice directly to the resident or their representative as required. Staff interviews confirmed that the notices were not given to residents unless they were being discharged to the community, and that notifications to the LTCO were sent in batches rather than at the time of transfer. Additionally, for two residents who were transferred to the hospital, there was no documentation that a report on the resident's condition was provided to the receiving hospital. Facility forms intended to document this communication were left blank, and staff acknowledged that it was their expectation for such reports to be given and documented, but this was not done. These failures were identified through interviews and record reviews, and were not in accordance with facility policy or regulatory requirements.
Failure to Provide Safe and Appropriate Respiratory Care and Oxygen Administration
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for four residents, resulting in care and services that were not consistent with professional standards of practice. For one resident with a stoma, staff did not implement suctioning according to physician orders and used oral suction equipment for stoma suctioning, contrary to expectations and without clarifying the method or route with the provider. Additionally, this resident received oxygen therapy without a physician order, and staff did not update the care plan to reflect accurate physician orders. Two other residents receiving oxygen therapy did not have their oxygen delivered at the physician-ordered flow rates. One resident's oxygen was set below the prescribed rate, and the nasal cannula was visibly soiled with debris, while the oxygen concentrator filter was covered in dust. Staff were unaware of the need to clean the filter and only replaced tubing when requested by the resident. Another resident was observed receiving oxygen at a higher flow rate than ordered, and the humidifier water bottle attached to the oxygen concentrator was empty on multiple occasions, despite orders to replace it as needed. A fourth resident was observed with a visibly soiled nasal cannula that had not been changed for an extended period, and the oxygen concentrator filter was covered in debris. Staff confirmed the tubing was dirty and needed to be changed, and the filter required cleaning. Across these cases, staff did not consistently follow physician orders, facility policy, or professional standards regarding respiratory care, oxygen administration, and equipment maintenance.
Failure to Assess and Document Nursing Staff Competencies
Penalty
Summary
The facility failed to develop and implement a system to evaluate and document staff competencies in essential nursing skills and techniques for all reviewed staff, including RNs and CNAs. There was no nursing competency policy available, and staff files lacked documentation of completed competency assessments. For example, a registered nurse administered a toxic cancer therapy medication and performed stoma suctioning for a resident with complex medical needs without having received specific training or instructions for these procedures. The nurse was unaware of the differences between oral and stoma suctioning techniques and had not received documented training on handling toxic cancer treatments. Multiple CNAs and nurses had no documented evidence of competency assessments or training in key care areas, such as safe resident transfers. Staff development personnel reported that orientation checklists were not collected, skills workshops for new hires were not yet offered, and the last documented skills workshop was held over a year prior, with no individual competency records available. The last completed staff competency checklists dated back to February 2023. Leadership staff confirmed that competency assessments were expected on hire and annually, but could not provide documentation to support that these assessments had occurred.
Failure to Provide Palatable and Properly Prepared Meals
Penalty
Summary
The facility failed to ensure that meals were prepared and served in a manner that maintained palatability, attractiveness, and safe, appetizing temperatures for six of nine residents reviewed. Multiple residents reported dissatisfaction with the food, describing it as unpalatable, repetitive, bland, and visually unappealing. Observations confirmed that residents were supplementing their diets with outside food, and some were seen attempting to modify their meals to improve taste. Specific complaints included mushy vegetables, unidentifiable dishes, lack of condiments, and food that was often turned away. Residents also noted that the menu was repetitive and that alternative options were not satisfactory. A test tray observation further substantiated these concerns, revealing food items that were visually unappealing, served at improper temperatures, and described as unappetizing by surveyors. The roast turkey had an unappealing color and was overly salty, the green beans had an unpleasant aftertaste, the bread dressing was gelatinous and unidentifiable, and the milk and dessert were served at temperatures that made them unpalatable. The Food and Nutrition Service Manager acknowledged the use of a long-standing menu cycle and indicated that budget constraints affected ingredient quality. These findings were based on resident interviews, direct meal observations, and review of facility policies.
Failure to Maintain Infection Control and Adhere to PPE Protocols
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by multiple observed deficiencies. For two residents, the environment was not kept clean to prevent the transmission of communicable diseases. One resident with a urinary catheter was observed with a leaking catheter bag, resulting in a puddle of urine on the floor beneath the bed. Staff interviews confirmed that both nurses and aides were expected to address such issues promptly, but the leak was not managed in a timely manner. Additionally, a resident's mattress cover was found to be missing a large piece, making it impossible to disinfect the mattress. Staff acknowledged that such issues should be reported to maintenance, but the problem was not logged as required. The facility also failed to follow proper use of personal protective equipment (PPE) and enhanced barrier precautions (EBP) for residents on transmission-based precautions. One resident with a history of multidrug-resistant bacteria had EBP signage posted, but a certified nursing assistant provided high-contact care without wearing a gown as required. Another resident requiring stoma care was attended to by a registered nurse who wore a gown, gloves, and mask, but failed to use eye protection during suctioning, despite knowing it was expected per facility policy. These lapses in following standard and enhanced precautions were confirmed through staff interviews and direct observation.
Failure to Provide Appropriately Sized Bed for Resident with Mobility Limitations
Penalty
Summary
The facility failed to provide a comfortable and appropriately sized bed for a resident with multiple complex medical diagnoses, including partial paralysis and a pain syndrome. The resident was assessed as having functional limitations in both arms and legs and was dependent on staff for mobility and repositioning. Observations showed the resident's feet were propped on pillows over the footboard, and their head was higher than the mattress, indicating discomfort. The resident reported persistent discomfort, describing the bed as too small and the mattress as bowed, with both ends raised compared to the middle. The resident stated that a foam spacer was used to fill the gap between the mattress and the extended bed frame, but the spacer often shifted, causing further discomfort and preventing the bed from lying flat. The resident reported these issues to staff multiple times but was told there was nothing more that could be done. Staff interviews confirmed awareness of the bed's limitations, with maintenance having extended the bed frame but not providing a longer mattress. Staff acknowledged the use of a foam spacer to compensate for the mattress's short length, but were unaware that the spacer could slide and elevate the foot of the bed, making it difficult for the resident to sit up or reposition. The Director of Nursing stated that although the mattress had been changed several times, they were not aware that the current configuration prevented the bed from being fully lowered. The facility had longer beds available, but the resident was not provided with one, resulting in ongoing discomfort and inadequate accommodation of the resident's needs.
Failure to Maintain a Safe and Homelike Resident Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and homelike environment for one resident. Observations revealed that the resident's room contained a 3-drawer cabinet under the television with numerous packages of personal care items and medical supplies on top, a bedside table with several boxes of medical dressing supplies, and an open cardboard box with additional supplies underneath. Two baskets with disposable medical supplies were placed between the cabinet and the bedside table, and an extra bed in the room had a green lift harness draped across it with more supplies scattered on the bed. The resident expressed that the room was not as orderly as they would expect at home and preferred the items to be easily available but less disorganized and visible. Staff acknowledged that the room appeared cluttered and disorderly due to a lack of storage for supplies and agreed there was room for improvement.
Failure to Complete Timely and Thorough Investigations of Abuse Allegation and Fall Incident
Penalty
Summary
The facility failed to ensure timely and thorough investigations for two separate incidents involving two residents. For one resident, who was cognitively intact and able to communicate, an allegation was made that a staff member was verbally abusive and took a personal item (a power bank) from the resident. The resident reported the incident to another staff member but stated that no follow-up occurred and expressed ongoing distress and fear of retaliation. Investigation notes showed that while the incident was reported to the state, the facility's internal investigation was incomplete, lacking interviews with other residents, background checks on the staff involved, and updates to the resident's care plan. There was also no evidence that staff received education on reporting verbal abuse. In a separate incident, another resident with a history of heart failure and a progressive neurological disorder experienced a fall while attempting to get out of bed. The resident was found on the floor and later transferred to the hospital due to shortness of breath and inability to rise. Despite the fall, no investigation was initiated for nine days, and staff attributed the delay to an unusually high number of incidents and staff absence. The facility did not provide documentation of a completed investigation for this event.
Failure to Complete Significant Change Assessment After Resident Decline
Penalty
Summary
The facility failed to reassess a resident following a significant and sustained decline in their functional and mood status after a hospitalization. The resident, who previously was able to get out of bed and go outside, reported that after returning from the hospital, they could no longer get out of bed. Observations confirmed the resident remained in bed, and record review showed a marked decline in their ability to perform activities such as upper body dressing and moving in bed, as well as changes in mood and care rejection behaviors. The most recent Minimum Data Set (MDS) assessment after the resident's return indicated total dependence in several areas and new instances of care rejection, compared to the previous MDS assessment before hospitalization, which showed greater independence and no care rejection. Despite these sustained declines in multiple care areas, the facility did not complete a Significant Change in Status Assessment (SCSA) as required. Interviews with the Director of Nursing and the Corporate MDS Consultant confirmed that the changes in the resident's condition met the criteria for a SCSA, but the assessment was not performed after the 14-day period following the change. This omission was identified through interview and record review, and it was noted that the failure to complete the SCSA could result in unmet care needs and diminished quality of life for the resident.
Failure to Complete and Update PASRR Assessments for Residents with Mental Health Needs
Penalty
Summary
The facility failed to ensure that Pre-admission Screening and Resident Review (PASRR) assessments were accurately completed and updated for residents with mental disorders or intellectual disabilities. For three residents reviewed, there were significant lapses in the PASRR process. One resident with diagnoses of depression and anxiety had a Level 1 PASRR screening indicating the need for a Level 2 referral due to serious mental illness (SMI), but the referral was not made until seven months after the initial assessment. Another resident with anxiety and a mood disorder, who was prescribed antipsychotic medication, had a Level 1 PASRR submitted, but there was no documentation of follow-up with the State PASRR office or evidence of obtaining Level 2 services. For a third resident, hospital staff identified SMI indicators on the Level 1 PASRR, but did not specify the type of SMI, and a subsequent Level 2 evaluation determined no SMI based on hospital records. However, the resident was later prescribed antidepressant medication for an anxiety disorder, and the diagnosis was added to their records without an updated Level 1 PASRR being completed. Staff interviews confirmed that PASRRs were not updated in a timely manner when residents' mental health diagnoses changed or when new medications were prescribed. The facility's policy required timely validation and submission of Level 1 and Level 2 PASRRs, especially with significant changes in residents' mental health status, but these procedures were not followed for the residents in question. Documentation and communication with the State PASRR office were also lacking, resulting in incomplete or delayed assessments and referrals.
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