Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bethany At Pacific during CMS and state inspections, most recent first.
A resident discharged home with orders for Home Health (HH) services did not have the HH agency or contact information documented on the Discharge Instruction Form, and there was no physician-signed medication list in the medical record. Staff interviews confirmed that required discharge documentation was incomplete and that HH services were not properly coordinated.
The facility did not provide required social services to eight residents, including lack of support for care planning, advance directives, discharge planning, and mental health referrals. Residents and families reported poor communication and incomplete documentation, while the social services department was understaffed and unable to meet residents' needs.
Two residents with minimal or no cognitive impairment were not offered the opportunity to participate in care conferences or discussions about their person-centered care, including discharge planning and goal setting. Staff interviews and record reviews confirmed that required care plan meetings were neither conducted nor documented, and the residents' care plans lacked discharge planning focus areas.
The facility did not ensure that advance directives or DPOA documentation were obtained, completed, or properly recorded for three residents, including those with cognitive impairment. Staff interviews confirmed that required documentation and follow-up were not completed, despite established procedures for admission and care conferences.
A resident and their representative were not given the required written Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) explaining potential financial liability after Medicare coverage ended. Although a phone call was made to notify about the end of skilled services, no written notice or signature was obtained, and the representative was not informed about appeal rights or specific costs.
The facility did not consistently follow its grievance policy, resulting in unresolved complaints from residents about room cleanliness, missing personal items, and delayed showers. Two residents' grievances were not properly documented or resolved, and concerns raised during resident council meetings were not addressed through the formal grievance process. These failures led to repeated reporting of the same issues without resolution.
A resident with severe cognitive impairment and full dependence on staff was repeatedly observed in a recliner with the legs elevated and an over-the-bed table across their lap, unable to adjust or remove these items independently. Staff confirmed that the recliner's leg rest could only be operated by staff, and there was no documentation of assessment, evaluation, or consent for the use of these devices as potential restraints, contrary to facility policy.
The facility did not identify or report multiple allegations of abuse and neglect, including inappropriate physical contact between residents, delayed response to call lights resulting in resident distress, and staff scolding a resident after a prolonged wait for assistance. Staff and leadership interviews confirmed these incidents should have been reported to the state, but required reporting and documentation did not occur.
The facility did not thoroughly investigate multiple allegations and incidents involving delayed call light response, inappropriate staff behavior, and possible resident-to-resident abuse. For three residents with cognitive impairments and significant medical needs, the facility failed to document allegations, conduct required interviews with staff and residents, perform necessary assessments, or provide evidence of support services, resulting in incomplete investigations and insufficient documentation.
A resident with a diagnosis of major depressive disorder was admitted and received daily antidepressant medication, but the PASARR Level I screening did not indicate a mood disorder, resulting in no Level II evaluation. Staff interviews confirmed the PASARR was not accurately reviewed or updated prior to admission, and this was a repeat deficiency.
A resident with a history of mental health disorders was prescribed new antidepressant and antipsychotic medications after readmission, but the facility did not update the PASRR assessment to reflect these changes. Staff interviews indicated unclear processes and responsibilities for initiating a new PASRR when psychotropic medications were started post-admission, especially in the absence of a social worker.
Surveyors found that three residents received oxygen therapy without proper physician orders and with inconsistent adherence to facility policy on tubing changes and documentation. Staff responses to oxygen tubing found on the floor varied, and there was confusion about the frequency of tubing changes and required documentation. In some cases, oxygen was administered outside the parameters of the physician's order, and care plans were not updated to reflect current oxygen use.
A resident with depression and insomnia was evaluated by a mental health provider, who recommended changes to medication and further psychological testing. These recommendations were documented in the medical record but were not reviewed or implemented by nursing staff for over three weeks. Interviews revealed that staff were unaware of the recommendations due to a new documentation process, and the DON confirmed the oversight.
A resident with multiple chronic conditions did not receive restorative therapy services after being moved to a different floor, resulting in a decline in mobility and increased dependence on staff. Staff interviews revealed a lack of documentation and unclear processes for reassessment and reapproach after removal from the restorative program, and the care plan interventions were marked as resolved without supporting documentation.
Two residents with dysphagia did not receive appropriate safety interventions to prevent aspiration. One resident ate meals without required assistance or monitoring for oral pocketing, despite care plan and physician orders. Another resident, ordered NPO with tube feeding, repeatedly consumed outside food without staff awareness, documentation of refusal, or monitoring for aspiration risk. The facility failed to follow its own policy for documenting treatment refusal and updating care plans.
A resident with a history of vascular and cardiac conditions was not assessed or provided with a bowel/bladder retraining program despite being identified as a candidate in multiple assessments. Staff relied on incontinence care and did not implement restorative or toileting interventions, and therapy recommendations for restorative services were not followed. Documentation and staff interviews revealed inconsistencies and a lack of direct resident engagement regarding toileting needs.
A treatment cart containing prescribed medications, wound care supplies, and hypodermic needles was found unlocked and unattended on a unit, accessible to residents and unauthorized staff. Facility policy requires such carts to be locked when not in use, but staff interviews confirmed the cart was left unsecured for an extended period while residents were present in the area.
A resident experienced significant weight loss due to the facility's failure to assess dietary preferences, document nutritional intake accurately, and notify the physician of weight changes. The resident, with multiple health conditions, was not offered meal substitutes when consuming less than 50% of meals and reported dissatisfaction with the food provided. Staff interviews revealed a lack of communication and adherence to policies, contributing to the resident's nutritional risk.
The facility failed to ensure their designated Infection Preventionist (IP), an RN, met the necessary qualifications for the role, leading to a lack of infection surveillance and analysis. The IP was hired without completing the required credentials, and both the Administrator and DON were unaware of the need for specialized training in infection prevention and control.
A long-term care facility failed to comply with infection prevention and control guidelines, particularly in managing a COVID-19 positive resident. Observations revealed inadequate PPE provision and improper donning and doffing procedures by staff. The facility also lacked a comprehensive infection surveillance system and failed to implement a proper Respiratory Protection Program, with many staff not fit-tested for respirators. These deficiencies placed residents and staff at risk of infection.
The facility failed to assist four residents in formulating Advance Directives, compromising their healthcare decision rights. Delays in admission paperwork completion, due to staffing issues, led to the absence of documented Advance Directives for these residents, despite their medical conditions requiring clear healthcare preferences.
The facility failed to ensure a safe and clean environment on the 3rd floor. Maintenance and housekeeping rooms were left unsecured with hazardous items, and a resident's room was found in poor condition with unclean floors and improperly hung pictures. Staff confirmed these issues during interviews.
The facility failed to comply with PASRR requirements for four residents, leading to a lack of necessary Level II evaluations for those with serious mental illnesses. Residents with conditions such as anxiety, depression, bipolar disorder, and psychotic disorders were not properly assessed, and the facility lacked an audit system to ensure PASRR validations. The Social Services Director was unaware of the need for further evaluations, highlighting a systemic issue in the PASRR process.
The facility failed to develop and implement comprehensive care plans for residents, including those with mental health needs, discharge planning, dental care, and safety measures. Residents with PASRR requirements, PTSD, and dental issues lacked appropriate care plans, while a resident with impaired vision had a call light consistently out of reach, highlighting deficiencies in care planning and execution.
The facility failed to update care plans for four residents, leading to potential risks. A resident on hospice care had no specific interventions for oxygen use, while another's care plan did not reflect changes in antidepressant medication. Edema management was not addressed for a third resident, and a fourth resident's preference for female caregivers was not documented. Staff interviews revealed a lack of coordination and awareness.
The facility failed to ensure thorough monthly medication regimen reviews by a consultant pharmacist for three residents, leading to unaddressed medication-related irregularities. This oversight involved missing documentation for March and April reviews and placed residents at risk for adverse consequences due to complex medication regimens.
The facility did not ensure that three NACs received the required 12 hours of in-service education per year. Employee files for these NACs, hired on different dates, lacked evidence of the necessary training. The DON acknowledged the deficiency, noting that education logs were outdated and could not provide further documentation.
A resident was found self-administering medications without proper evaluation or a physician's order. The resident, who had no cognitive impairment, was observed with Pedialyte and NeuroBion B12 Forte at their bedside. An LPN was unaware of the medications, and the resident's care plan did not include a self-medication program. The physician later disagreed with the use of NeuroBion, highlighting a failure in the facility's medication management process.
The facility failed to accurately assess a resident's dental needs and two residents' PASRR requirements. A resident was observed with dental issues not reflected in their MDS, and staff had inconsistent understandings of their oral care needs. Additionally, two residents required Level II PASRR evaluations for potential serious mental illness, but their MDS assessments were not coded correctly.
The facility failed to complete required PASRR evaluations for three residents with serious mental illness or intellectual disabilities. One resident's stay exceeded 40 days without a Level II referral, while two others had no evidence of completed Level II assessments despite indications for such evaluations.
A resident at risk for pressure ulcers was not provided with foam boots as required by their care plan. Despite being identified as needing pressure-reducing devices, the resident was observed without foam boots, and the LPN/RCM was unaware of this requirement. This failure to implement necessary interventions placed the resident at risk for pressure ulcer development.
Two residents with limited ROM did not receive necessary restorative services to maintain their functioning. One resident, with a history of stroke and dementia, had inconsistent ROM services without a specified frequency, and the last evaluation was outdated. Another resident, with peripheral vascular disease and cancer, had a sporadic restorative program despite a care plan for regular sessions. Staff documented refusals inaccurately, and there were concerns about the safety of the walking component for one resident.
A resident with peripheral vascular disease, depression, and cancer experienced a failure in receiving necessary dermatology services due to a lack of coordination and documentation by the facility. Despite a referral for a dermatology consult due to a distressing rash, no appointment was scheduled or documented, and staff were unaware of the referral, placing the resident at risk for unmet care needs.
The facility failed to provide written notice to residents, their representatives, and the Ombudsman for three emergency hospital transfers, preventing informed decision-making and access to advocacy.
The facility failed to provide a written bed hold notice at the time of transfer to the hospital or within 24 hours of transfer for three residents. A review of their medical records showed no documentation that the residents or their representatives had been provided with a written bed hold notification. During an interview, the Administrator was unable to provide any information regarding bed holds for these residents. This failure is in violation of the facility's Bed Hold Policy and WAC 388-97-0120 (4)(a-c).
The facility failed to complete and transmit MDS assessments to CMS within the required timeframes for a resident admitted with altered mental status, dementia, anxiety, and COPD. The resident exhibited severe symptoms, leading to their return to the emergency room. The resident was not activated into the computer system, resulting in incomplete MDS assessments.
The facility failed to maintain a homelike environment for two residents. One resident reported non-functional lights and unclean conditions, while another reported an inoperable light and empty soap dispenser. Staff were unaware of these issues until notified, and maintenance repairs were confirmed later.
The facility failed to resolve grievances for a resident who reported not being listened to when requesting changes, being left on the bedpan for extended periods, and missing activities due to staff unavailability. Despite these concerns being communicated, the facility did not log or address these issues, and there was no documentation of actions taken to resolve the grievances.
The facility failed to provide necessary care and services for two residents. One resident did not have their medication orders updated after a doctor appointment, leading to incorrect medication administration. Another resident had to wait all morning for transfer assistance, causing them to miss activities.
The facility failed to obtain and file clinical laboratory reports for a resident who had a doctor appointment and lab tests done. Staff members, including an LPN and the Assistant Director of Nursing Services, were unable to provide any information about the missing documentation, and the Administrator could not explain why the lab results were not obtained and filed.
The facility failed to obtain and file a radiology report for a resident who had a chest X-ray done during a doctor appointment. Staff members and the administrator were unable to provide information about the missing X-ray results.
The facility failed to maintain accurate and complete clinical records for three residents, leading to unimplemented medication orders, undocumented care conferences, and missing discharge medications.
Failure to Coordinate Home Health Services and Provide Complete Discharge Documentation
Penalty
Summary
The facility failed to coordinate Home Health (HH) services, provide a medication list, and complete discharge instructions for one resident who was discharged home. The resident had a history of subluxation of the left shoulder, falls, difficulty walking, and chronic pain, and required setup for showers and supervision for ambulation. The discharge summary indicated the resident would require HH services for physical and occupational therapy as well as RN services. However, the Discharge Instruction Form did not include the HH agency or contact information, and there was no documentation of a physician-signed medication list in the resident's medical record. Interviews with facility staff confirmed that Social Services was responsible for arranging HH services and that the discharge instruction form should have included the HH agency name, contact information, and a complete medication list. Staff acknowledged that the Discharge Instruction Form for the resident was incomplete and that there was no documentation of the HH agency or contact information. Additionally, staff were unable to provide documentation of a signed medication list or evidence that HH services had been arranged for the resident at the time of discharge.
Failure to Provide Medically-Related Social Services and Care Planning
Penalty
Summary
The facility failed to provide medically-related social services to all eight residents reviewed, resulting in unmet social service needs. Several residents did not receive support with the care planning process, as evidenced by missing or incomplete documentation of care conferences and lack of communication with residents and their families. For example, one resident's family member, who was the power of attorney, reported a lack of updates and care conferences, despite the resident's declining condition. Another resident expressed frustration over not receiving assistance from social services to address a Medicaid-related issue due to physical limitations, and there was no documentation of recent care conferences for this resident. The facility also failed to provide support for advance directive (AD) formulation and discharge planning. Two residents had no documentation or evidence of being assisted with ADs, and their care plans did not address this area. Additionally, two residents were not kept informed about their discharge plans, with one resident and their family left uncertain about the discharge process and another resident expressing concern about financial matters related to discharge. Documentation in the electronic health records was lacking, and there were no recent notes or updates regarding discharge planning for these residents. Furthermore, the facility did not complete referrals or follow up on recommendations for appropriate mental health services for residents with depression or other mental health diagnoses. In one case, a resident had a psychological evaluation with recommendations, but there was no update to the plan of care by social services. Another resident's PASARR assessment was found to be inaccurate and not updated for a necessary level II evaluation. The facility's social services department was understaffed during this period, with key staff positions vacant or on leave, and temporary support from another facility was being used to cover essential social work tasks.
Failure to Involve Residents in Care Plan Development
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were offered the opportunity to participate in care conferences for two of six sampled residents. Both residents had minimal or no cognitive impairment and were capable of participating in their care planning. Interviews revealed that neither resident was informed about care plan meetings, nor were they involved in discussions regarding their person-centered care, including discharge planning and goal setting. Review of their electronic medical records showed no documentation of interdisciplinary care plan meetings or discussions about initial comprehensive admission care plans, resident-specific goals, or discharge planning. Staff interviews confirmed that the process for arranging and documenting initial care plan meetings was not followed for these residents. The facility's policy requires encouraging and assisting residents or their representatives to participate in care planning, including establishing goals and discharge planning, but there was no evidence this occurred for the two residents in question. The care plans for both residents also lacked focus areas addressing discharge planning.
Failure to Obtain and Document Advance Directives for Multiple Residents
Penalty
Summary
The facility failed to ensure that advance directives (ADs), such as living wills or Durable Power of Attorney (DPOA) for health care, were obtained and completed for three residents. For one resident with minimal cognitive impairment, the admission documentation indicated uncertainty about having an AD, and there was no evidence in the electronic health record (EHR) or care plan that assistance was provided to formulate one. Another resident, who was alert and oriented, also had no AD or DPOA documented, and no follow-up or assistance was recorded in the EHR or care plan. For a third resident with moderate cognitive impairment, the admission packet noted a DPOA, but no copy was found in the EHR, and care conference notes did not mention the AD or DPOA. Interviews with staff, including the Medical Records staff, Assistant Director of Nursing Services, and Director of Nursing, confirmed the absence of required AD documentation and lack of follow-up to assist residents in formulating ADs. Staff described the expected process for obtaining and uploading ADs, as well as social services' responsibility to follow up during initial care conferences, but could not explain why documentation was missing. This deficiency was noted as a repeat issue from a previous survey.
Failure to Provide Written Notice of Medicare Non-Coverage and Potential Liability
Penalty
Summary
The facility failed to provide written notification to a resident and their designated representative regarding potential financial liability for services not covered by Medicare following the end of the resident's skilled nursing facility (SNF) Medicare Part A stay. The resident, who had mild cognitive impairment and an advance directive designating a representative, was notified by phone that Medicare coverage for skilled services would end. However, the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN), which details the costs the resident would be responsible for if they remained in the facility, was not issued to either the resident or their representative. The record showed that while a Notice of Medicare Non-Coverage (NOMNC) was communicated by phone, no written ABN was provided, nor was a signature obtained. The resident's representative confirmed they were not informed about appeal rights, specific costs, or asked to sign any forms, despite being available for in-person communication. The facility administrator acknowledged that both the NOMNC and ABN should have been provided in person or sent by mail or email, with a physical signature obtained as soon as possible.
Failure to Address and Resolve Resident Grievances
Penalty
Summary
The facility failed to ensure that resident grievances were properly addressed and resolved, as required by their grievance policy. Review of the policy indicated that the social services director was designated as the Grievance Official, and staff were expected to document grievances and provide written decisions at the conclusion of investigations. However, during resident council meetings in February and March, residents raised concerns about garbage not being emptied, delays in room painting, and requests for assistance with room organization, but there was no documentation of resolution for these issues. The Activity Director stated that grievances from resident council meetings were sometimes handled informally, such as by writing notes to maintenance, rather than following the formal grievance process. For individual residents, the facility did not follow the grievance process as outlined. One resident reported a missing blanket to their nursing aide and a collateral contact, but no grievance form was completed, and the issue was not entered into the grievance log. The administrator confirmed that no grievance had been filed for this incident. The nursing aide involved stated that a grievance form would only be completed if the resident was upset or needed the item replaced immediately, which is not consistent with the facility's policy. Another resident complained during a resident council meeting about not receiving a shower for four weeks. Although a grievance form was completed and indicated that a shower would be provided the next day, electronic health records showed that the resident did not receive a shower until seven days later. The DON confirmed that the resident should not have had to wait that long for a shower. These failures resulted in residents repeatedly reporting the same care issues without resolution.
Failure to Assess and Care Plan for Use of Potential Physical Restraint
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints unless required for medical treatment, as required by policy. A resident with severe cognitive impairment, Parkinson's, Alzheimer's, and full dependence on staff for mobility and transfers was observed multiple times sitting in a recliner with the legs elevated and an over-the-bed table across their lap. The resident was unable to control the recliner or remove the table independently, and staff confirmed that the recliner's leg rest could only be adjusted manually by staff. There were no physician orders for the recliner, and the resident's medical record lacked documentation of an assessment for safety, evaluation, or consent regarding the use of the recliner and table as potential restraints. Interviews with nursing assistants, an LPN/Staff Development Coordinator, and the Director of Nursing confirmed that the resident could not operate the recliner independently and that required assessments, evaluations, and consents for the use of such equipment were not present in the medical record. The facility's policy required therapy assessment, documentation of medical symptoms warranting restraint use, consent, and care plan updates for any device that could restrict movement, none of which were completed for this resident.
Failure to Identify and Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to identify and report allegations of abuse and/or neglect for three of five sampled residents. For one resident with severe cognitive impairment, a family member submitted a grievance after witnessing the resident's roommate engage in inappropriate physical contact, including kissing the resident on the lips. The facility's social worker investigated by interviewing the resident and others, but did not report the incident to the state, as required by policy. Staff interviews confirmed that all were aware of their mandated reporter responsibilities, and both the LPN/Staff Development Coordinator and the Administrator acknowledged that the incident should have been reported as an allegation of abuse. Another resident, who was alert and oriented, reported waiting 30 minutes for their call light to be answered when needing to use the bathroom, causing distress. The facility documented the incident as a grievance and determined that abuse and neglect were ruled out, as the nursing assistant had gone on break without informing the nurse. The incident was not initially reported to the state, and the LPN/SDC who investigated was unsure why it was handled as a grievance. The Administrator later submitted an incident report to the state after being questioned. A third resident, with moderate cognitive impairment and a history of brain injury, complained during a resident council meeting about waiting over 30 minutes for assistance with toileting and being scolded by an aide after self-transferring to the toilet. There was no documentation of this allegation in the resident's health record, nor was it reported to the state. Staff interviews confirmed that such incidents should be reported as potential abuse or neglect, and facility leadership agreed that the complaint should have been escalated and reported.
Failure to Conduct Thorough Investigations of Abuse and Neglect Allegations
Penalty
Summary
The facility failed to conduct thorough investigations into allegations and incidents involving three residents, as required by its own policies and state regulations. For one resident with a history of a left arm fracture and moderate cognitive impairment, an allegation of delayed call light response was reported during a resident council meeting. However, there was no documentation of the allegation in the state reporting log or the resident's health record, and the investigation lacked interviews with night shift staff, physical or psychosocial assessments, and evidence of support services provided to the resident. Another resident, who had a contusion and laceration of the cerebrum and required moderate assistance with transfers, reported waiting over 30 minutes for call light response at night and being scolded by a nursing assistant after self-transferring to the bathroom. The facility did not log this allegation, failed to document the incident in the resident's health record, and did not conduct or document interviews with relevant night shift staff or provide evidence of education or training for night shift staff. The investigation also lacked ongoing assessments, care plan revisions, and interviews with other residents or staff involved in the incident. A third resident with severe cognitive impairment and Alzheimer's was the subject of a grievance alleging inappropriate touching by a roommate. There was no investigation conducted for this allegation, and key staff were unaware of the grievance. The facility did not escalate the grievance to an abuse allegation or initiate a thorough investigation as required. These failures resulted in incomplete investigations and insufficient documentation for incidents and allegations of abuse or neglect.
Failure to Complete Accurate PASARR Screening for Resident with Mental Disorder
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) Level I was accurately completed for a resident with a diagnosis of recurrent and unspecified major depressive disorder. The resident was admitted with this diagnosis and was receiving daily antidepressant medication, as documented in the Minimum Data Set (MDS) and Medication Administration Record. However, the Level I PASARR form did not indicate the presence of a mood disorder under the Serious Mental Illness (SMI) indicators section, and therefore, no Level II evaluation was initiated. Interviews with facility staff confirmed that the PASARR should have been obtained prior to admission and reviewed for accuracy by social services. The Director of Nursing acknowledged that the PASARR for this resident was not accurate and should have been updated and sent for Level II evaluation before admission. This deficiency was also noted as a repeat issue from a previous survey.
Failure to Update PASRR Assessment After Significant Change in Resident Condition
Penalty
Summary
The facility failed to ensure that Preadmission Screening and Resident Review (PASRR) assessments were completed for residents following a significant change in status or when newly evident or possible serious mental disorders were present. Specifically, one resident with a history of depression, psychotic disorder with delusions, and dementia was readmitted and subsequently prescribed both antidepressant and antipsychotic medications. However, the resident's most recent PASRR did not reflect the use of these medications, nor did it indicate a Level II recommendation, and no updated PASRR was found in the electronic health record. Interviews with facility staff revealed that the process for reviewing and updating PASRR assessments was not consistently followed, particularly in the absence of a social worker. Nursing staff described their roles in monitoring psychotropic medication use and obtaining consents, but there was a lack of clarity regarding responsibility for initiating a new PASRR when a resident began new psychotropic medications after admission. This lapse resulted in a potential delay in access to appropriate Level II PASRR services for the resident.
Failure to Ensure Professional Standards in Oxygen Therapy Administration
Penalty
Summary
The facility failed to ensure that professional standards of practice were implemented for residents receiving oxygen therapy. For three residents reviewed, there were multiple instances where oxygen was administered without a current physician's order, and facility staff were inconsistent in following the facility's policy regarding the changing and dating of oxygen tubing. Observations revealed that oxygen tubing was found on the floor on several occasions, and staff responses to this situation varied, with some staff cleaning and reusing the tubing, while others replaced it. There was also confusion among staff regarding the frequency of tubing changes and the proper documentation required. For one resident with COPD, oxygen was observed in use during the day, despite the physician's order specifying nighttime use only. The oxygen tubing was repeatedly found on the floor, and staff provided conflicting accounts of how to handle such situations. Another resident with chronic respiratory failure reported that their oxygen tubing had not been changed since admission, and observations confirmed that the tubing was undated. The oxygen flow meter settings did not match the physician's order, and staff were unclear about the correct procedures for changing and dating the tubing. A third resident was observed using oxygen without a current physician's order, as the previous order had been discontinued and not renewed. The care plan did not address oxygen use, and staff were unaware of the need for an order or the appropriate care plan updates. Interviews with nursing staff and management revealed a lack of clarity regarding facility policy and expectations for oxygen administration and tubing changes, as well as inconsistent documentation practices.
Failure to Implement Mental Health Recommendations for Resident with Depression
Penalty
Summary
A deficiency occurred when the facility failed to provide treatment and care in accordance with professional standards for a resident with depression and insomnia. The resident, who had moderately impaired cognition and moderate depression, was evaluated by a mental health provider who recommended starting an antidepressant, discontinuing the current sleep medication, conducting further psychological testing, and scheduling a follow-up. Despite these recommendations being documented in the resident's medical record, none were implemented into the plan of care for over three weeks following the evaluation. Interviews with facility staff revealed a lack of awareness regarding the mental health provider's recommendations. The LPN/Staff Development Coordinator was unaware that the resident had been seen by a mental health provider and did not know about the recommendations, citing a new process where mental health providers document directly into the medical record. The DON confirmed that the expectation was for nursing staff to review and implement such recommendations, but acknowledged that the recommendations for this resident were missed and not reviewed.
Failure to Provide and Document Restorative Therapy Services for Resident with Declining Mobility
Penalty
Summary
The facility failed to ensure that restorative therapy services were implemented to prevent avoidable reduction of range of motion (ROM) for a resident with a history of peripheral vascular disease, high blood pressure, and atrial fibrillation. The resident reported not receiving any therapy since being moved to a different floor about a year prior, and stated that therapy was discontinued due to insurance coverage issues. Review of the resident's Minimum Data Set (MDS) assessments showed a decline in mobility and increased dependence on staff for transfers and bed mobility, but no significant change MDS was completed to reflect this change in status. The care plan documented resolved interventions for restorative nursing services, but there was no documentation in the progress notes regarding the implementation or resolution of these services. Interviews with staff revealed a lack of clarity regarding the resident's participation in restorative therapy and the process for reassessment and reapproach after removal from the program. The restorative nurse confirmed that the resident had refused the Restorative Nursing Program and was removed from it, with no current system in place to reassess or reapproach residents who had been discontinued from the program. The Director of Nursing Services acknowledged a performance improvement plan related to restorative nursing services, but it was not active and did not address reassessment of residents previously on the program.
Failure to Implement and Document Aspiration Precautions for Residents with Dysphagia
Penalty
Summary
The facility failed to ensure appropriate safety interventions were developed and implemented for two residents with dysphagia who were at risk for aspiration. For one resident with a history of stroke, heart failure, and facial weakness, observations showed that the resident was eating meals without assistance, despite care plan directives and physician orders for aspiration precautions and checks for oral pocketing after meals. Staff interviews revealed confusion and lack of awareness regarding the resident's swallowing issues and the required level of assistance, with some staff stating the resident did not require help and others indicating the care plan called for substantial assistance. Documentation and communication among staff were inconsistent, and the care plan was not consistently followed. For another resident with dysphagia and a feeding tube, the facility did not address the resident's refusal to comply with an NPO (nothing by mouth) order. The resident was observed eating food brought from outside and reported ordering and consuming regular food, despite a care plan and diet order indicating tube feeding only. There was a lack of documentation regarding the resident's refusal of the NPO order, absence of monitoring for aspiration risk, and no evidence that the physician or family/legal representative was notified. Staff were unaware of the resident's oral intake, and the care plan and Kardex were not updated to reflect the resident's non-compliance or the need for monitoring. The facility's policy required documentation of treatment refusal, notification of the physician and legal representative, referral to social services, and care plan updates when refusal or non-compliance occurred. However, these steps were not followed for the resident who refused the NPO order. The lack of appropriate interventions, monitoring, and documentation placed both residents at risk for aspiration and related health complications.
Failure to Provide Bowel/Bladder Retraining and Appropriate Toileting Services
Penalty
Summary
A resident with a history of peripheral vascular disease, hypertension, and atrial fibrillation was admitted to the facility and initially assessed as frequently incontinent of bowel and bladder, requiring extensive assistance for toileting. Over time, the resident's care documentation showed a progression to total dependence for toileting, with no transfers to the toilet occurring. Despite quarterly and admission assessments indicating the resident was a possible or likely candidate for bowel and bladder retraining, there was no documentation of any assessment or implementation of a bowel/bladder retraining program. The resident reported being able to use the toilet for bowel movements during therapy but was told to use briefs after being moved to a different floor, where staff stated there was no accessible bathroom. Staff interviews revealed inconsistencies and errors in the completion of bowel and bladder assessments, with some staff unaware of the resident's current abilities or not having spoken directly to the resident about toileting needs. The care plan directed staff to check and change the resident every two to three hours but did not address restorative or retraining interventions. Therapy discharge notes indicated the resident would benefit from restorative nursing services, but no further therapy or restorative services were provided. The lack of appropriate assessment and services to restore continence contributed to the deficiency identified in the report.
Unlocked Treatment Cart with Medications and Needles Left Unattended
Penalty
Summary
A treatment cart on the 3 South Unit was found unlocked and unattended, containing prescribed topicals, ointments, wound cleaning agents, and hypodermic needles. Observations showed that the drawers of the cart were accessible to anyone passing by, including residents, with no licensed staff present in the area. Items found in the cart included a tube of topical pain gel, three bottles of Dakin's solution, multiple tubes of Medi honey, iodine swabs, five bottles of nystatin powder, several hypodermic needles, and various wound bandages. The facility's policy requires that medications and biologicals be stored properly and only accessible to licensed nursing personnel, with supplies remaining locked when not in use or unattended. Interviews with staff confirmed that the expectation was for treatment carts to always be locked when not in use. The Registered Nurse on duty was stationed elsewhere and did not have the cart in view, and the Assistant Director of Nursing Services/Infection Preventionist reiterated that treatment carts should always be locked. The Director of Nursing Services was unaware that the cart had been left unlocked and unattended for 22 minutes. Residents were observed moving past the unlocked cart during this time.
Failure to Address Nutritional Needs Leads to Significant Weight Loss
Penalty
Summary
The facility failed to adequately assess and document the dietary preferences and nutritional intake of a resident, leading to significant weight loss. Resident 46, who was admitted with conditions including sepsis, urinary tract infection, diabetes, muscle wasting, and atrophy, experienced a severe weight loss of 11.8% over 34 days. The facility did not maintain accurate documentation of the resident's nutritional intake, failed to notify the physician of the significant weight loss, and did not perform consistent and accurate weight measurements. Additionally, the care plan for the resident did not include any food preferences, and the resident reported not receiving culturally appropriate meals. Observations and interviews revealed that Resident 46 was not consistently offered meal substitutes or replacements when consuming less than 50% of their meals. The resident expressed dissatisfaction with the food provided, stating a preference for vanilla shakes over chocolate, which was not communicated to the dietary staff. Despite the resident's significant weight loss, the facility staff failed to notify the physician or take appropriate action to address the resident's nutritional needs. The documentation inaccurately reflected the resident's meal consumption, further complicating the assessment of their nutritional status. Interviews with facility staff highlighted a lack of communication and coordination in addressing the resident's nutritional needs. Staff members were unclear about their responsibilities in notifying the physician of weight loss and offering meal alternatives. The facility's policies on weight monitoring and nutrition were not followed, contributing to the resident's continued weight loss and diminished quality of life. The failure to adhere to these policies and procedures placed the resident at nutritional risk and compromised their overall well-being.
Inadequate Qualifications for Infection Preventionist Role
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP) met the necessary qualifications for experience, education, and training or certification required for the role. This deficiency was identified through interviews and record reviews, which revealed that the IP, a Registered Nurse (RN) named Staff C, was hired on 05/06/2024 but only completed their infection prevention credentials on 06/06/2024. The facility's policy requires the IP to lead surveillance activities, maintain documentation, and report findings, but Staff C was not adequately prepared to fulfill these responsibilities. Further investigation showed that there was no interpretation or analysis of infection data for March and April 2024, and no infection surveillance was conducted in May 2024. During an interview, Staff C admitted to being unaware of the infection surveillance process for the facility's Quality Assurance Improvement Process and acknowledged the need for more training. Additionally, the facility's Administrator and Director of Nursing Services were unaware that the IP role required specialized training in infection prevention and control, confirming that Staff C had been in the role since their hire date.
Infection Control and PPE Failures in LTC Facility
Penalty
Summary
The facility failed to ensure compliance with Infection Prevention and Control Guidelines, particularly in the management of a resident who tested positive for COVID-19. Resident 14, who had a history of heart disease and stroke, was placed on transmission-based precautions after testing positive for COVID-19. However, observations revealed that the necessary personal protective equipment (PPE) was not adequately provided, as there was no eye protection available near the resident's room. Additionally, staff were observed not following proper donning and doffing procedures for PPE, including the reuse of N95 respirators and improper hand hygiene practices. The facility also failed to maintain an effective infection surveillance system. Despite requests, the facility could not provide a comprehensive infection surveillance log for the past 90 days, particularly for May 2024. The logs that were provided lacked analysis, interpretation, and evaluation of infection data, which are essential components of an infection prevention and control program. This lack of documentation and analysis indicates a failure to monitor and manage infections effectively within the facility. Furthermore, the facility did not implement a proper Respiratory Protection Program (RPP) for its staff. A significant number of employees had not been fit-tested for respirators, and some had never been fit-tested at all. Observations showed staff wearing N95 respirators incorrectly, with facial hair interfering with the seal, and discomfort due to improper fit. The Infection Preventionist, who was responsible for overseeing the RPP, had not received training on the process, further contributing to the facility's failure to protect staff and residents from respiratory hazards.
Failure to Formulate Advance Directives for Residents
Penalty
Summary
The facility failed to obtain, provide, and assist with completing Advance Directives for four out of five sampled residents, which compromised their right to have their healthcare preferences and decisions honored. Resident 32, admitted with a tibia fracture and infection, had no Advance Directives formulated upon review of their medical record. Although the facility's process included Advance Directive documentation in the admission agreement, a delay in completing admission paperwork due to a new administrative assistant resulted in the absence of a signed Advance Directive document for Resident 32 until several days after admission. Similarly, Resident 65, admitted with multiple fractures, also lacked formulated Advance Directives in their medical record. Staff could not confirm the existence of such documents until days later. Resident 22, a long-term care resident, reported not being asked about Advance Directives, and their medical record showed no documentation of being informed of their rights. Resident 62, admitted for aftercare treatment post-heart surgery, had no Advance Directives formulated, and the admission paperwork indicating they were offered information was signed 23 days post-admission. The facility's social services and administrative staff were behind on admission agreements, contributing to these deficiencies.
Failure to Maintain a Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on the 3rd floor, as observed during a survey. Maintenance and housekeeping rooms near a resident's room were found unlocked and unsecured, containing potentially hazardous items such as paint, caulk, tools, and chemicals like Aromazyne drain and grease trap maintenance odor eliminator. Staff interviews confirmed that these rooms were supposed to be locked, yet they remained unsecured during multiple observations. Additionally, a resident's room was observed to be in poor condition, with walls showing stains, patches of different colors, and improperly hung pictures. The floor was not cleaned, as evidenced by the presence of small, round debris near the bedside table and oxygen concentrator, which remained over several days. The oxygen tubing was found touching the debris, and a staff member confirmed that the floor was not cleaned despite daily housekeeping visits.
Failure to Ensure PASRR Compliance for Residents
Penalty
Summary
The facility failed to ensure compliance with the Preadmission Screening and Resident Review (PASRR) requirements for four residents, which is a federal mandate to ensure individuals with mental disorders or intellectual disabilities receive appropriate care. Resident 7, who was admitted with diagnoses including anxiety, depression, and bipolar disorder, had a PASRR indicating a serious mental illness and the need for a Level II evaluation. However, there was no documentation in the medical record showing that the PASRR had been validated or that there was any communication with the PASRR validator. Similarly, Resident 42, admitted with multiple psychiatric disorders, had a PASRR indicating a serious mental illness and the need for a Level II evaluation. The medical record lacked documentation of PASRR validation or communication with the validator. Staff D, the Social Services Director, admitted there was no audit system in place to follow up on PASRRs requiring further assessments or validations, and they were unaware of the need for Level II evaluations for Residents 7 and 42. Resident 21, with a history of major depressive disorder and psychotic disorder, had a PASRR that inaccurately indicated no need for a Level II evaluation despite evidence of psychosis and antipsychotic medication use. Resident 26, diagnosed with depression and cancer, also had a PASRR that did not indicate the need for a Level II evaluation, despite documented depressive symptoms. Staff D was unaware of the inaccuracies in the PASRRs for Residents 21 and 26, indicating a systemic issue in the facility's PASRR process.
Deficiencies in Care Planning and Implementation
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for several residents, leading to deficiencies in care. Resident 32 and Resident 6, both with diagnoses including depression and anxiety, had positive Level I PASRR screenings indicating the need for a Level II PASRR care plan. However, their clinical records showed no such care plans were developed. Interviews with staff revealed confusion about responsibility for completing these care plans, with social services identified as the responsible department, yet no action was taken. Resident 65, admitted with fractures, expressed concerns about discharge planning, specifically regarding the need for a hospital bed at home. Despite the resident's imminent discharge, no care plan was in place, and the resident reported no discussions with facility staff about their discharge needs. Staff interviews confirmed that discharge planning should have been initiated upon admission, but it was not completed for this resident. Additional deficiencies were noted for Resident 42, who had PTSD and other mental health diagnoses, yet lacked a care plan addressing their PTSD. Staff were unaware of the resident's PTSD diagnosis due to the absence of a psycho-social assessment. Resident 26, with dental issues, had no care plan for dental care despite assessments indicating potential cavities and broken teeth. Lastly, Resident 422, with impaired vision and communication, had a care plan intervention to keep the call light within reach, but observations showed the call light was consistently out of reach, indicating a failure to implement the care plan effectively.
Failure to Revise Comprehensive Care Plans
Penalty
Summary
The facility failed to revise comprehensive care plans for four residents, leading to potential risks for unmet care needs. Resident 8, who was admitted to hospice services, had an oxygen concentrator in their room, but their care plan lacked specific interventions related to hospice aide use, medication changes, or oxygen concentrator use. Staff interviews revealed a lack of awareness and coordination between hospice and facility staff, with no hospice care plan maintained by the facility. Resident 21's care plan did not reflect changes in their antidepressant medication use, despite pharmacy reviews and representative input indicating medication adjustments due to side effects like lethargy. The care plan still listed outdated medications, and there was no routine interdisciplinary meeting to update care plans for residents on psychotropic medications, as confirmed by the Social Services Director. Resident 26's care plan did not address edema management, despite observations of swelling and interventions like medication use and leg elevation being in place. The care plan only mentioned cellulitis and skin integrity issues. Additionally, Resident 58's care plan failed to document their preference for female caregivers, even after a fall incident and family input indicated this preference. The care plan only addressed scheduled toileting without considering the resident's caregiver preference.
Failure in Conducting Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that the consultant pharmacist conducted thorough monthly medication regimen reviews (MRRs) and identified and reported medication-related irregularities for three of the five sampled residents. This deficiency was identified during a review of pharmacy consultant reports and interviews with facility staff. The facility was unable to provide pharmacy reviews for March and April 2024 initially, and later, when the reports were found, there was no documentation that recommendations had been reviewed and acted upon. This lack of action placed residents at risk for medication-related adverse consequences and unnecessary psychotropic medications. Resident 18, who was admitted with multiple diagnoses including chronic pain syndrome, diabetes, and PTSD, had a complex medication regimen involving multiple medications for cardiac use, blood sugar regulation, pain management, mental health, and bowel movements. There was no documentation of a pharmacist's review of this resident's medication regimen. Similarly, Resident 21, with diagnoses including major depressive disorder and Alzheimer's disease, and Resident 26, with peripheral vascular disease and cancer, also had no documented pharmacist review of their medication regimens since February 2024. These oversights in medication management highlight the facility's failure to adhere to established guidelines for medication regimen reviews.
Deficiency in Required In-Service Education for NACs
Penalty
Summary
The facility failed to ensure that three Certified Nursing Assistants (NACs), identified as Staff G, H, and I, received the required 12 hours of in-service education per year. This deficiency was identified through a review of employee files and interviews. Staff G was hired on 05/19/2019, Staff H on 03/10/2020, and Staff I on 12/03/2022. None of their files showed evidence of the required in-service education for the prior year. During an interview, the Director of Nursing Services, Staff B, acknowledged that the education logs were mostly from 2022 and could not provide further documentation to verify the required training hours for the staff in question.
Failure to Evaluate and Approve Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was properly evaluated and assessed for self-administration of medications, and a physician's order was not obtained for this practice. Resident 46, who was admitted without cognitive impairment, was observed with a bottle of Pedialyte and a box of NeuroBion B12 Forte on their bedside table. The resident reported taking one dose of NeuroBion daily. However, there was no documentation in the resident's care plan indicating they were on a self-medication program. During an interview, an LPN stated they were unaware of the Pedialyte and did not see the NeuroBion container. The LPN also did not know if the resident was on a self-medication program. A nursing progress note later revealed that the resident's physician did not agree with the use of NeuroBion due to potential problems and allowed only a limited quantity of Pedialyte. This oversight placed the resident at risk for adverse medication interactions and complications.
Inaccurate Assessments for Dental and PASRR Needs
Penalty
Summary
The facility failed to complete accurate assessments for several residents, leading to potential unmet care needs. Resident 58, who was admitted with diagnoses including kidney failure and atrial fibrillation, was observed to have visibly missing teeth and dark gray discoloration at the gumline, despite their Minimum Data Set (MDS) assessment indicating no dental issues. Interviews with staff revealed inconsistencies in the understanding of Resident 58's oral care needs, with some staff believing the resident completed oral care independently or with assistance from their spouse. The MDS nurse stated that if a resident would not allow an oral cavity assessment, the MDS should be coded as unable to examine, but this was not done for Resident 58. Additionally, the facility failed to accurately complete the Pre-Admission Screening and Resident Review (PASRR) for two residents. Resident 6 and Resident 32 both had positive Level I PASRR screenings, indicating the need for a Level II evaluation due to potential serious mental illness. However, their MDS assessments did not reflect this requirement, and interviews with the Social Services Assistant confirmed the MDS was not coded correctly for these residents. These inaccuracies in assessments could lead to inadequate care planning and support for the residents' mental health needs.
Failure to Complete PASRR Evaluations for Residents
Penalty
Summary
The facility failed to ensure the completion of the Pre-Admission Screening and Resident Review (PASRR) forms according to federal guidelines for three residents. Resident 2 was admitted from an acute care hospital and was initially exempted from a Level II PASRR referral due to an expected discharge within 30 days. However, the resident's stay exceeded 40 days without a Level II referral being made, despite the resident no longer meeting skilled Medicare criteria. Staff E, a Social Services Assistant, confirmed that no referral was made, and there were no notes indicating such an action. Residents 6 and 32 were both admitted with diagnoses including depression and anxiety, and their Level I PASRRs indicated the need for a Level II assessment. However, there was no evidence in their clinical records that these evaluations were completed. Staff E and Staff D, the Social Services Director, acknowledged the oversight and stated they would follow up with the PASRR coordinator. The lack of completed Level II evaluations for these residents indicates a failure in the facility's process for ensuring appropriate assessments and referrals for residents with serious mental illness or intellectual disabilities.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to provide necessary care planned interventions for a resident at risk for pressure ulcers (PU). The resident, who was admitted with diagnoses including stroke, high blood pressure, spinal stenosis, and a rotator cuff tear, was identified as being at risk for skin breakdown due to incontinence and immobility. The care plan for the resident included the use of a low air loss mattress, pressure reduction cushion, and foam boots to prevent PU development. However, observations and interviews revealed that the resident was not provided with foam boots as required by their care plan. Despite the care plan and Kardex directing the use of foam boots for protection, the resident was observed without them on multiple occasions. The Licensed Practical Nurse/Resident Care Manager (LPN/RCM) was unaware of the resident's need for foam boots and stated there was no order for them. This lack of implementation of pressure-reducing devices, as per the physician's orders, placed the resident at risk for the development and worsening of pressure ulcers.
Inadequate Restorative Care for Residents with Limited ROM
Penalty
Summary
The facility failed to provide necessary services to maintain or improve the range of motion (ROM) for two residents, leading to a deficiency in care. Resident 14, who had a history of stroke and dementia, was supposed to receive active and passive restorative ROM services. However, the care plan did not specify the frequency of these services, and the last restorative evaluation was conducted in 2021. Documentation showed inconsistent provision of ROM services, with numerous refusals and instances marked as not applicable, without clear indication of the expected frequency. Interviews revealed that staff documented refusals even when services were not offered, and there was no current restorative assessment to support the program. Resident 26, diagnosed with peripheral vascular disease, depression, and cancer, also did not receive adequate restorative care. Although their care plan included a restorative program to be conducted five to six times a week, documentation showed sporadic implementation of the program. The resident expressed concerns about losing strength due to inactivity and stated they were not receiving the restorative program. Staff interviews indicated that refusals were documented when the program was not administered, and there were concerns about the resident's ability to safely participate in the walking component of the program. Overall, the facility's failure to ensure consistent and appropriate restorative services for these residents placed them at risk for decreased ROM and diminished quality of life. The lack of updated assessments, clear documentation, and proper implementation of care plans contributed to the deficiency identified by the surveyors.
Failure to Coordinate Dermatology Services for Resident
Penalty
Summary
The facility failed to obtain necessary dermatology services for Resident 26, who was admitted with diagnoses including peripheral vascular disease, depression, and cancer. Despite a dermatology referral being made on 01/18/2024 due to a distressing rash on the resident's legs, there was no follow-up or documentation of a scheduled dermatology appointment in the resident's progress notes. The resident expressed a desire for a second opinion regarding the rash, but was informed by a nurse practitioner that they could not see a skin specialist. Interviews with facility staff revealed a lack of awareness and coordination regarding the dermatology referral. Staff M, a Licensed Practical Nurse/Resident Care Manager, mentioned that an appointment had been scheduled but was canceled at the resident's request, yet there was no documentation to support this claim. Staff W, a Health Unit Coordinator, was unaware of any dermatology referrals and confirmed that no documentation existed in the electronic medical record about such an appointment. This lack of coordination and documentation placed the resident at risk for unmet care needs.
Failure to Provide Written Notice of Emergency Transfers
Penalty
Summary
The facility failed to provide a written notice to the resident, resident's representative(s), and the Office of the State Long-Term Care Ombudsman of an emergency transfer for three residents reviewed for hospitalizations. This failure did not allow residents and/or their representatives to make informed decisions about transfers and prohibited access to an advocate who could inform them of their options and rights. Specifically, Resident 1 was transferred to the hospital without any documentation of a transfer/discharge form or notification to the relevant parties. Similarly, Resident 2 and Resident 3 were also transferred to the hospital without the necessary documentation and notifications. During a joint interview and record review, the facility's administrator confirmed that there were no transfer/discharge notices completed for the three residents when they were transferred to the hospital. The facility's policy on transfer and discharge, revised on 05/01/2024, mandates that a notice of transfer and the facility's bed hold policy be provided to the resident and representative, and copies of notices for emergency transfers be sent to the Ombudsman when practicable. However, this policy was not followed in the cases of Residents 1, 2, and 3.
Failure to Provide Bed Hold Notice
Penalty
Summary
The facility failed to provide a written bed hold notice at the time of transfer to the hospital or within 24 hours of transfer for three residents. Resident 1 was discharged to the hospital on April 20, 2024, Resident 2 on April 15, 2024, and Resident 3 on February 22, 2024. A review of their medical records showed no documentation that the residents or their representatives had been provided with a written bed hold notification. During an interview on May 16, 2024, the Administrator was unable to provide any information regarding bed holds for these residents. This failure is in violation of the facility's Bed Hold Policy dated May 1, 2024, and WAC 388-97-0120 (4)(a-c).
Failure to Complete and Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to complete and transmit resident assessment data to CMS within the required timeframes for one resident whose MDS assessments were reviewed for timeliness. Resident 1 was admitted with diagnoses including altered mental status, dementia, anxiety, and Chronic Obstructive Pulmonary Disease. Upon review, it was found that an Entry or Discharge MDS assessment had not been completed for this resident. Staff D, an LPN/Admission Nurse, reported that the day Resident 1 was transferred was chaotic, and the resident exhibited severe symptoms such as trying to escape and pulling out a catheter. Consequently, the decision was made to send the resident back to the emergency room. Staff A, the Administrator, confirmed that Resident 1 was not activated into the computer system, resulting in the failure to complete the necessary MDS assessments.
Failure to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike environment in resident rooms for two of the three sampled residents. Resident 4 reported that their room was not maintained in a clean condition and had non-functional lights. Resident 7 also reported that the light over the sink in their room was not working and the soap dispenser was empty, despite notifying the staff. During an observation, it was confirmed that the light over the sink was inoperable and the soap dispenser was empty. Staff G, a Nursing Assistant Certified, was unaware of these issues and stated they would notify housekeeping and maintenance. Additionally, the light over the sink in the room next to Resident 7's was also found to be inoperable. The Administrator later confirmed that maintenance had repaired the room lights they had been notified about.
Failure to Resolve Resident Grievances
Penalty
Summary
The facility failed to resolve grievances for Resident 2, who had no cognitive impairment and had been admitted to the facility. The resident's advocate, CC1, emailed the facility staff with concerns that Resident 2 was not being listened to when requesting to be changed, was told by staff they would have to wait, and had not been changed for seven hours on one occasion. Additionally, the resident was missing clothing items. Despite these concerns being communicated, the facility did not log these issues in the grievance logs for February and March 2024, and there was no documentation of any actions taken to resolve these grievances. Resident 2 expressed frustration about missing activities due to having to wait for two staff members to assist with getting out of bed, which often resulted in missing the exercise class. The resident also reported being left on the bedpan for extended periods, sometimes up to an hour, because staff were not available to assist. These issues were discussed in a care conference, but there was no documentation in the resident's clinical record about the conference or the issues discussed. Staff members interviewed were unaware of the resident's toileting concerns and stated that the resident preferred to stay in bed until 11:00 AM. The facility's grievance policy requires prompt efforts to resolve grievances, including acknowledgment and active resolution efforts. However, the facility staff, including the Administrator, Director of Nursing Services, and Social Services, failed to document or address the grievances raised by Resident 2 and CC1. The lack of documentation and follow-up on the resident's concerns about toileting, missing clothing, and missed activities indicates a failure to adhere to the facility's grievance policy and resolve the resident's grievances effectively.
Failure to Provide Necessary Care and Services
Penalty
Summary
The facility failed to provide necessary care and services in accordance with professional standards of practice for two residents. For Resident 1, who had diagnoses including stroke, heart failure, pneumonia, and breathing difficulties, the facility did not obtain and implement physician progress notes and medication orders from a doctor appointment on 02/21/2024. This resulted in the continuation of medications that were ordered to be stopped and incorrect dosages being administered until 02/26/2024. Staff were unaware of the new orders until 04/17/2024, indicating a significant delay in updating the resident's care plan. For Resident 2, who had no cognitive impairment, the facility failed to provide timely transfer assistance, causing the resident to miss morning activities. On 04/10/2024, the resident had to wait until 11:00 AM to be transferred out of bed by two staff members who were not their usual caregivers. The resident expressed frustration about having to wait all morning for assistance, which impacted their ability to participate in daily activities. This delay in care was due to staff being occupied with other duties and not being available to assist the resident in a timely manner.
Failure to File Laboratory Reports
Penalty
Summary
The facility failed to obtain and file clinical laboratory reports for a resident who had a doctor appointment and lab tests done. The resident resided in the facility from an unspecified date until 02/26/2024. A nursing progress note dated 02/21/2024 indicated that the resident had a doctor appointment that day and two lab tests were performed. However, upon review of the resident's clinical record on 04/17/2024, no laboratory results from the 02/21/2024 appointment were found. Staff members, including an LPN/Resident Care Manager and the Assistant Director of Nursing Services, were unable to provide any information about the missing documentation. Additionally, the Administrator could not explain why the lab results were not obtained and filed.
Failure to File Radiology Report
Penalty
Summary
The facility failed to obtain and file a radiology report for a resident who had a chest X-ray done during a doctor appointment. The resident resided in the facility from an unspecified date until 02/26/2024. A nursing progress note dated 02/21/2024 indicated that the resident had a doctor appointment and a chest X-ray was performed. However, a review of the resident's clinical record on 04/17/2024 showed no chest X-ray report was filed. Staff members, including an LPN/Resident Care Manager and the Assistant Director of Nursing Services, were unable to provide information about the missing X-ray results. The facility administrator also could not explain why the chest X-ray results were not obtained and filed in the resident's clinical record.
Failure to Maintain Accurate and Complete Clinical Records
Penalty
Summary
The facility failed to maintain complete, accurate, and accessible clinical records for three residents, leading to unmet care needs and diminished quality of life. For Resident 1, the facility did not have physician progress notes from a doctor appointment, resulting in unimplemented medication orders. Staff C and Staff J confirmed the absence of these notes, which were only obtained after the surveyor's inquiry. This oversight indicates a lapse in maintaining up-to-date medical records for the resident's care and treatment plan. Resident 2's clinical record lacked documentation of a care conference that addressed significant care issues, including missing clothing and toileting assistance delays. Despite multiple staff members acknowledging the conference, no progress notes or documentation were found in the resident's record. For Resident 4, the discharge instructions did not include four topical treatment medications, and staff could not confirm if these medications were sent home with the resident. This inconsistency in medication documentation and discharge procedures further highlights the facility's failure to maintain accurate and complete clinical records.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Everett
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Everett Transitional Care Services | 1.2 mi | — | 7 | 0 |
| View Ridge Care Center | 3 mi | — | 16 | 0 |
| Madison Post Acute | 3.6 mi | — | 1 | 0 |
| Mountain View Rehabilitation And Care Center | 4.5 mi | — | 9 | 0 |
| Marysville Care Center | 5.2 mi | — | 22 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.