Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
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 Marysville Care Center during CMS and state inspections, most recent first.
A resident was not protected from a significant medication error, as required, due to a failure in the medication administration process.
A resident with a prosthetic heart valve and on long-term Warfarin therapy did not have a comprehensive care plan addressing anticoagulant use, including monitoring for side effects. Staff interviews confirmed the lack of a formal care plan for this medication, despite expectations that such care should be documented.
A resident's legal guardian was not provided timely access to the resident's medical records after multiple requests, due to lack of communication about required forms and fees, and confusion regarding electronic delivery. The guardian was not informed of the process or costs, resulting in delayed access to important clinical information.
A resident with multiple neurological and psychiatric diagnoses was started on Risperidone without documented consent or notification of the legal guardian. The guardian was not informed of the medication's risks and benefits, and the medication was not discontinued until several days after the guardian requested its removal. Staff and DON confirmed that the required consent process was not followed.
The facility did not conduct thorough investigations for two residents following a resident-to-resident altercation and a medication error. The investigations lacked documentation of alert charting for monitoring, staff statements, and root cause analysis, resulting in incomplete reviews of the incidents as required by state guidelines.
A facility failed to thoroughly investigate abuse allegations involving a resident with Alzheimer's, missing key elements like staff statements and root cause analysis. The investigation into a bruise and abuse allegation lacked interviews with the resident's roommate and documentation from direct care staff, social services, or law enforcement, leaving the resident at risk for unidentified abuse or neglect.
The facility failed to maintain complete and accurate medical records for several residents, including incomplete dialysis communication forms for two residents, missing consultation reports for a resident's dental visit, and inadequate documentation of oxygen orders for two residents. Staff interviews confirmed the lack of follow-up actions to obtain missing information and inconsistencies in oxygen administration documentation.
The facility failed to implement its compliance and ethics program, resulting in inaccurate documentation of therapy missed visits for several residents. Missed visit notes were falsely signed by a COTA/DOR on behalf of other staff who were not present, linked to understaffing issues. Residents affected had conditions requiring therapy, and the falsification of documentation was against facility policy.
The facility failed to address grievances for two residents, one with unresolved mattress concerns and another with missing dentures. Despite requests and discussions, issues remained unresolved due to communication breakdowns and funding difficulties, with no grievances logged.
A facility failed to comply with PASRR requirements for a resident with major depressive disorder and unspecified psychosis. Despite signs of serious mental illness and hallucinations, the resident's PASRR did not indicate a need for a level two evaluation. The Social Services Director was unaware of the resident's hallucinations, and the Director of Nursing Services acknowledged issues with inaccurate PASRRs from the hospital.
The facility failed to complete required PASRR evaluations for three residents with mental health conditions. One resident with dementia and anxiety had no Level 2 evaluation despite a positive Level 1 PASRR. Another resident with depression and panic disorder was admitted without a necessary Level 2 evaluation. A third resident with bipolar disorder and anxiety was not referred for Level 2 evaluation despite SMI indicators. Staff misunderstood the requirements, leading to non-compliance with federal guidelines.
A resident with a Stage 2 pressure ulcer, diabetes, and respiratory failure did not have a comprehensive care plan addressing their needs. The care plan lacked interventions for oxygen therapy, wound care, and diabetes management. Staff were unaware of the wound type, and the Kardex did not provide guidance on care. The Resident Care Manager was responsible for updates, but the care plan was not current, risking the resident's quality of life.
The facility failed to update care plans for three residents, leading to deficiencies in care. A resident on comfort care had an outdated care plan not reflecting their current condition. Another resident's care plan inaccurately stated they wore dentures, despite not wearing lower dentures for a year. A third resident's care plan did not reflect their current mobility status, as they could move their affected side without resistance. The facility did not meet the expectation of updating care plans quarterly and with any change of condition.
A resident with severe cognitive impairment and functional limitations was not provided with dentures before meals, as required by their care plan. The resident was observed eating without dentures, leading to difficulty chewing. Staff interviews revealed a lack of communication and oversight, resulting in the dentures not being provided in the morning as needed.
A resident with intact cognitive function reported difficulty hearing and a desire for hearing aids, but the facility failed to assist in accessing hearing services or making referrals. Despite assessments indicating hearing impairment, care plans lacked specific interventions, and staff did not facilitate access to audiology services. This oversight risked the resident's quality of life due to unaddressed hearing issues.
A facility failed to create a comprehensive dementia care plan for a resident with dementia, anxiety, and depression. The care plan lacked personalized goals and interventions, relying solely on psychotropic medications. The resident exhibited frequent agitation and yelling, which were not addressed in the care plan, leading to unmet needs and increased distress.
The facility failed to ensure two residents were free from unnecessary psychotropic medications. One resident was prescribed Divalproex Sodium for seizures without a valid diagnosis, while another was given Quetiapine without proper documentation or evaluation. The facility did not monitor for adverse effects or implement non-pharmacological interventions, and care plans lacked specific behavioral management strategies.
A resident with missing and broken teeth experienced delays in receiving dental care due to inadequate coordination and communication within the facility. Despite multiple requests and referrals, there was a lack of follow-up, leading to a delay in dental services. Staff interviews revealed issues in scheduling and documenting appointments, with the DON noting challenges in finding dentists for residents with limited mobility.
The facility failed to ensure an orderly discharge for two residents, leading to potential unmet care needs. One resident was discharged without follow-up physician care documentation, and another was discharged without proper instructions for ongoing skin care and follow-up appointments.
The facility failed to provide recommended nutritional supplements for two residents, leading to a risk of delayed wound healing. One resident with protein-calorie malnutrition and a Stage 3 pressure injury did not receive the prescribed Prosource and House Shakes. Another resident with an unstageable pressure injury and end-stage renal disease received Prosource only once daily instead of the recommended twice daily. Staff interviews revealed communication breakdowns and discrepancies in the Nutrition Assessment Recommendations.
The facility failed to ensure accurate clinical records for two residents with pressure injuries. One resident's dressing change frequency did not match the Physician Assistant's recommendation, and another resident's wound was packed with a different material than recommended. These discrepancies were acknowledged by the nursing staff but not properly documented.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the medication administration process. Specific details regarding the actions or inactions that led to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Develop Comprehensive Care Plan for Anticoagulant Use
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for one resident who was admitted with multiple diagnoses, including a prosthetic heart valve and long-term use of anticoagulants such as Warfarin. Upon review of the resident's medication orders, it was found that there was no care plan addressing the use of Warfarin, specifically regarding potential adverse side effects or necessary monitoring associated with the medication. Interviews with facility staff revealed that while Certified Nursing Assistants relied on the Kardex to identify residents on blood thinners and monitor for signs of bleeding or bruising, there was no formal care plan in place for this resident's anticoagulant therapy. The Nurse Manager confirmed the absence of a care plan for Warfarin use, and the Director of Nursing stated that such medications should be care planned, but this was not reflected in the resident's documentation at the time of review.
Failure to Timely Provide Medical Records to Legal Representative
Penalty
Summary
The facility failed to provide a resident's medical record to the legal representative in a timely manner, as required by facility policy and federal regulation. The legal guardian of a resident with multiple complex diagnoses, including intracranial hemorrhage, cerebral infarction, hemiplegia, bipolar disorder, depression, and anxiety, requested a copy of the resident's medical record during a care conference and through subsequent emails. Despite these requests, the guardian was not informed at the time of the initial request that a specific form needed to be completed, nor were they notified of any associated fees. The guardian made multiple attempts to obtain the records, both in person and via email, but did not receive the requested information within the required timeframe. Facility staff interviews confirmed that the process for requesting records required a form, but this was not communicated to the guardian at the time of the request. Additionally, staff did not inform the guardian of the potential fees for obtaining the records, and there was confusion regarding the ability to send records electronically. The medical records director acknowledged responsibility for processing such requests but did not provide the necessary information about fees or electronic delivery options. As a result, the legal representative was unable to access the resident's clinical information in a timely manner.
Failure to Obtain Guardian Consent for Psychotropic Medication
Penalty
Summary
The facility failed to review the risks and benefits of a newly prescribed psychotropic medication with the legal representative of a resident who had a legal guardian. The resident, who had a history of intracranial hemorrhage, cerebral infarction, hemiplegia, hemiparesis, bipolar disorder, depression, and anxiety, was started on Risperidone without documented consent or evidence that the guardian was informed of the medication's risks and benefits. The guardian reported not being notified of the new medication order and did not provide consent for its use. During a care conference, the guardian requested discontinuation of the medication, but it was not stopped until eleven days later. Record review confirmed that there was no documentation of the guardian being notified or consenting to the use of Risperidone. Staff interviews revealed that the facility's expectation was to obtain consent from the resident's legal representative prior to administering psychotropic medications, but this process was not followed in this case. The Director of Nursing acknowledged that the required consent form was not signed by the guardian and that the medication was not discontinued promptly after the guardian's request.
Failure to Conduct Thorough Investigations of Incidents and Medication Error
Penalty
Summary
The facility failed to conduct thorough investigations for two residents involved in separate incidents, including a resident-to-resident altercation and a medication error. For the altercation, the investigation did not document that both residents were placed on alert charting for monitoring after the incident, despite facility protocol and staff statements indicating this should have occurred. Additionally, the investigation lacked comprehensive details regarding the circumstances and actions taken immediately following the event. In the case of the medication error, the investigation for one resident did not include staff statements or a root cause analysis to determine how abuse or neglect was ruled out. The resident involved had significant medical conditions, including intracranial hemorrhage, cerebral infarction, hemiplegia, and a legal guardian responsible for their care. The investigation also failed to document the process for discontinuing a medication as requested by the responsible party, and the medication was not discontinued in a timely manner. These omissions resulted in incomplete investigations that did not meet the requirements outlined in state guidelines.
Incomplete Investigation of Abuse Allegations
Penalty
Summary
The facility failed to conduct a thorough investigation into allegations of abuse and neglect concerning a resident with severe cognitive impairment, diagnosed with Alzheimer's Disease. The investigation into an abuse allegation dated 01/29/2025 and a bruise found on 02/02/2025 was incomplete, lacking essential information such as staff statements, a root cause analysis, and interviews with the resident's roommate. The facility's investigation did not adequately determine how abuse or neglect was ruled out, and there was no documentation of staff in-service or statements from direct care staff, social services, or law enforcement. During interviews, facility staff acknowledged the shortcomings in the investigation process. Staff A, the Administrator, admitted to not interviewing the resident's roommate and failing to retain staff statements or in-service documentation. Staff B, the Director of Nursing, noted that the bruise was unwitnessed and not considered significant, which led to a less extensive investigation. The facility's failure to follow the Washington State Reporting Guidelines for Nursing Homes resulted in an incomplete investigation, leaving the resident at risk for unidentified abuse or neglect.
Deficiencies in Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for several residents, leading to deficiencies in documentation. For Resident 50 and Resident 64, both of whom were undergoing dialysis, the facility did not ensure that the pre/post dialysis communication forms were fully completed. The sections that were supposed to be filled out by the dialysis staff were left incomplete, and there was no documentation of attempts to obtain the missing information. This lack of documentation was confirmed by interviews with staff members, who acknowledged the incomplete records and the absence of follow-up actions to retrieve the necessary information. Resident 17's medical records were also found to be incomplete. After a dental appointment, there was no consultation report in the resident's records, despite the resident being started on antibiotics for a dental infection. Staff interviews revealed that there was no established process for following up with outside providers to obtain records from appointments, leading to a gap in the resident's medical documentation. For Residents 10 and 60, the facility failed to document specific oxygen orders accurately. Observations showed inconsistencies in the administration of oxygen, with no specific documentation of the liters per minute being provided. Staff interviews indicated that the oxygen orders were incomplete, lacking parameters for when to administer oxygen. The facility's policy did not require nurses to document the specific flow of oxygen given, resulting in incomplete records for these residents.
Inaccurate Documentation of Therapy Missed Visits
Penalty
Summary
The facility failed to properly implement its compliance and ethics program, leading to the submission of inaccurate and unethical documentation for therapy missed visits for eight out of ten residents reviewed. This deficiency was identified through interviews and record reviews, revealing that missed visit notes were falsely signed by Staff Z, a Certified Occupational Therapy Assistant and Director of Rehab, on behalf of other staff members who were not present or had not worked at the facility during the documented times. This practice was linked to understaffing issues within the therapy department, as noted by a Licensed Physical Therapist Assistant who expressed concern over the falsification of documentation. The residents affected by this deficiency had various medical conditions requiring therapy services, including hemiplegia, Parkinson's disease, multiple sclerosis, and muscle weakness. The missed visit documentation falsely indicated that residents were unavailable for therapy on specific dates, with notes being signed by Staff Z on behalf of other therapists who were either not scheduled to work or had not been employed at the facility for some time. Interviews with the involved staff members, including a Physical Therapist and a Licensed Physical Therapist Assistant, confirmed that they were unaware of the missed visit notes being signed in their names and had not authorized such actions. Staff Z admitted to completing the missed visit notes under the direction of corporate, citing reasons such as resident unavailability and staffing concerns. However, the reasons listed were not resident-specific, and there was no documented communication with the staff members whose names were used. The facility's policy on compliance and ethics explicitly prohibits falsification of documentation, highlighting the severity of the deficiency. The Regional Support to the Director of Rehab acknowledged the inappropriate signing of notes on behalf of other staff and indicated that education for Staff Z would be necessary moving forward.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to maintain a system to ensure resident grievances were identified, logged, and resolved in a timely manner for two residents. For Resident 1, who was admitted with diagnoses including lung cancer, malnutrition, and spinal stenosis, there was a grievance regarding the need for an air mattress to alleviate back pain. Despite multiple discussions and referrals to hospice, the issue remained unresolved, and there was no documentation of the request in the resident's progress notes. Staff members, including the Director of Nursing Services, were unaware of the ongoing concern, indicating a breakdown in communication and grievance handling. For Resident 2, who had been in the facility since 2018, there was an issue with missing lower dentures, which were reported to not fit properly, causing difficulty in chewing food. Despite a request for a dental appointment being made months earlier, the issue remained unresolved due to funding difficulties, and there was no grievance filed for the missing dentures. Staff members, including the Social Services Director, were unaware of the missing dentures, highlighting a failure in the facility's grievance process and communication system.
Failure to Comply with PASRR Requirements for Resident with Mental Health Needs
Penalty
Summary
The facility failed to ensure compliance with the Preadmission Screening and Resident Review (PASRR) requirements for a resident with a history of major depressive disorder and unspecified psychosis. The resident, identified as Resident 17, was admitted with these diagnoses, yet the PASRR dated June 17, 2020, indicated no need for a level two evaluation despite signs of serious mental illness (SMI) and management with psychotropic medication. A subsequent review of the resident's medication administration record for October 2024 showed no psychotropic medications were prescribed, and a provider note dated October 5, 2024, documented the resident experiencing hallucinations. The Social Services Director, Staff G, stated that changes in a resident's condition, such as behaviors, mood, hallucinations, and mental health status, would prompt a review of the PASRR. However, Staff G was unaware of Resident 17's hallucinations, indicating a lapse in communication and monitoring. The Director of Nursing Services, Staff B, acknowledged awareness of PASRR concerns, particularly regarding inaccurate PASRRs received from the hospital, which contributed to the oversight in Resident 17's case.
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 48 was admitted with diagnoses including dementia, anxiety, and depression, and had a positive Level 1 PASRR indicating a severe, chronic disability. However, there was no documentation of an intellectual disability or a Level 2 evaluation prior to admission. Staff interviews revealed that the facility had not yet obtained a Level 2 invalidation statement and had scheduled an appointment with a PASRR evaluator to address the issue. Resident 59, admitted with depression and panic disorder, was on anti-depressant and anti-anxiety medications. The Level 1 PASRR indicated a need for a Level 2 evaluation due to mood disorder and anxiety, but no such evaluation was found in the records. Staff acknowledged the oversight and planned to follow up with the PASRR coordinator. Resident 60, with bipolar disorder, anxiety, depression, and dementia, had a PASRR form indicating a Serious Mental Illness (SMI) but no Level 2 evaluation was conducted. Staff believed the resident's stability negated the need for further evaluation, contrary to guidelines. A state PASRR evaluator confirmed the requirement for a Level 2 evaluation when SMI indicators are present.
Incomplete Care Plan for Resident with Multiple Needs
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident, identified as Resident 60, who was admitted with diagnoses including a Stage 2 pressure ulcer, diabetes, and respiratory failure. The care plan lacked specific interventions for respiratory care, as it did not include monitoring for signs of hypoxia or administering oxygen therapy, despite the resident receiving oxygen via nasal cannula. Additionally, the care plan for skin integrity did not specify the type of wound, nor did it include interventions to prevent the wound from worsening or instructions on who to notify. The diabetes care plan was also incomplete, as it did not include interventions for managing hypoglycemia or hyperglycemia. Observations and interviews revealed that staff were unaware of the specific wound type and relied on a wound care nurse for dressing changes. The Kardex, a care directive for CNAs, did not mention the resident's pressure ulcer or provide guidance on care and monitoring. Interviews with staff indicated that the responsibility for updating the care plan lay with the Resident Care Manager, who reviewed it quarterly. However, the care plan was not updated to reflect the resident's current needs, leading to a lack of consistent interventions and placing the resident at risk for diminished quality of life.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to ensure care plans were reviewed and revised for three residents, leading to a deficiency in care. Resident 13, who was initially admitted to the facility and later readmitted from the hospital, experienced a decline in activities of daily living (ADL) abilities and was on comfort care due to kidney failure. Despite these changes, Resident 13's care plan was not updated to reflect their current condition, including their refusal to get out of bed and the absence of wounds except for a vascular condition. The care plan contained outdated and duplicated information, such as goals for mobility and risk for rehospitalization, which were not revised to match the resident's current needs. Resident 2, a long-term resident, had not been wearing their lower dentures for a year due to poor fit, yet their care plan still indicated they wore full upper and lower dentures. Interviews with staff revealed that the care plan was not updated when the resident stopped wearing the lower dentures or when they were lost. This oversight in updating the care plan did not accurately reflect the resident's current dental status, potentially affecting their oral health and nutrition. Resident 28, admitted with a stroke affecting their left side, had a care plan that did not specify the location of their contracture and included interventions for limited physical mobility. Observations showed the resident participating in activities and able to move their left arm, hand, and fingers without resistance, contradicting the care plan's assessment. The care plan was not updated to reflect the resident's current functional status, as confirmed by evaluations showing no functional limitations due to contracture. The Director of Nursing Services acknowledged the expectation for care plans to be updated quarterly and with any change of condition, which was not met in these cases.
Failure to Provide Dentures Before Meals
Penalty
Summary
The facility failed to provide dentures to a resident prior to meals, which was necessary for their ability to chew food properly. The resident, who had severe cognitive impairment and functional limitations due to hemiplegia and hemiparesis following a stroke, was observed eating breakfast without dentures on multiple occasions. The resident's care plan and Kardex indicated that dentures should be provided in the morning, but this was not done, as evidenced by the Medication Administration Record not being signed off. The resident expressed difficulty chewing food without dentures, and it was noted that their lower dentures had been broken for over a week. Staff interviews revealed that the dentures were kept in the medication room overnight and were supposed to be given to the resident in the morning. However, due to a lack of communication and oversight, the new nursing assistant was not informed of the need to provide dentures before breakfast. The LPNs acknowledged that the dentures were not provided as required, and the resident was left to eat without them, impacting their ability to chew and enjoy their meals.
Failure to Address Resident's Hearing Deficit
Penalty
Summary
The facility failed to accurately assess and provide necessary interventions for a resident's hearing deficit, which was identified during a survey. Resident 12, who had intact cognitive function, reported difficulty hearing and expressed a desire to obtain hearing aids. Despite this, the facility staff did not assist the resident in accessing hearing services or making a referral for audiology evaluation. The resident's communication challenges were evident during interactions, as the surveyor had to increase the volume of speech for the resident to hear adequately. The facility's documentation and care planning processes were inadequate in addressing the resident's hearing needs. The admission assessment noted moderately impaired hearing, yet subsequent assessments and care plans did not reflect appropriate interventions. The Care Area Assessment (CAA) for communication was incomplete, lacking documentation on the cause of hearing loss and necessary interventions, such as assisting with obtaining hearing aids or adjusting communication methods. The care plan also failed to include specific strategies to mitigate the resident's hearing difficulties, such as reducing background noise or speaking distinctly. Interviews with facility staff revealed a lack of awareness and action regarding the resident's hearing needs. Staff members acknowledged the resident's hearing impairment but did not take steps to facilitate access to hearing aids or audiology services. The MDS coordinator admitted to using prepopulated interventions without tailoring them to the resident's specific needs, resulting in a care plan that did not adequately address the resident's communication deficit. This oversight placed the resident at risk of decreased quality of life due to unaddressed hearing issues.
Failure to Develop Comprehensive Dementia Care Plan
Penalty
Summary
The facility failed to develop a comprehensive dementia care plan for Resident 48, who was diagnosed with dementia, anxiety, and depression. The care plan did not address the resident's significant mental and psychosocial needs, nor did it establish personalized and achievable goals or identify interventions to promote a person-centered environment. The only policy in place was related to staff education on dementia, and there was no documentation of a detailed assessment of the resident's dementia or effective interventions for their behaviors. Resident 48 was admitted with moderate cognitive impairment and exhibited behaviors such as agitation and yelling out, which were documented over numerous shifts. Despite these behaviors, the care plan only included the administration of psychotropic medications like Quetiapine and Risperidone, without any non-pharmacological interventions. The resident's behavior of calling out was not addressed in the care plan, and there was no evidence of a psychiatric consult as indicated in the care plan. Observations and interviews revealed that Resident 48 frequently called out because their needs were not being met, such as wanting to get up in a chair or call their daughter. The resident expressed frustration that staff did not respond to their call light, leading them to yell out instead. The lack of a comprehensive care plan and appropriate interventions for Resident 48's behaviors resulted in unmet psychosocial needs and increased distress for both the resident and their roommate.
Failure to Ensure Residents are Free from Unnecessary Psychotropic Medications
Penalty
Summary
The facility failed to ensure that two residents, identified as Resident 60 and Resident 48, were free from unnecessary psychotropic medications. For Resident 60, the facility did not have a valid diagnosis for the use of Divalproex Sodium, which was prescribed for seizures despite no documented history of seizures. The medication was actually being used for mood stabilization related to bipolar disorder, but this was not accurately reflected in the medical records. Additionally, there was no monitoring for adverse side effects or behaviors related to the medication, which is a requirement for psychotropic drugs. Resident 48 was admitted with multiple diagnoses, including encephalopathy and dementia with behavioral disturbances. The facility administered Quetiapine, an antipsychotic medication, without proper documentation of the specific situations or indications for its use. The medication was initially prescribed as needed for agitation but was later increased to a regular nightly dose and then to twice daily without documented justification. The facility also failed to conduct necessary evaluations, such as a PASRR Level 2 evaluation or a psychiatric consult, to assess the resident's behavioral health needs. The facility's care plan for Resident 48 lacked specific interventions for managing behaviors such as calling out and agitation, relying instead on administering psychotropic medications. Interviews with staff revealed a lack of understanding and documentation regarding the resident's behaviors and the rationale for the use of antipsychotic medications. The facility did not adequately assess or address the resident's needs, goals, and comorbid conditions, nor did it implement non-pharmacological interventions as required.
Failure to Coordinate Dental Services for Resident
Penalty
Summary
The facility failed to ensure proper coordination of dental services for a resident, identified as Resident 17, who had missing and broken teeth. This deficiency was identified through interviews and record reviews, which revealed that despite multiple requests and referrals for dental care, there was a lack of follow-up and coordination. Resident 17, who was admitted with conditions including diabetes mellitus type two and arthropathic psoriasis, expressed the need for dental care to address missing teeth and a failing filling. The dental hygienist's consultation reports from December 2023 and June 2024 indicated the resident's need for a dentist referral, yet there was a delay in scheduling and coordinating these services. The progress notes from June 2023 to October 2024 showed several instances where the resident requested dental care, but there were gaps in follow-up and communication. Although a referral was made in June 2023, and the resident was seen by a dentist in August 2024, there were missed opportunities for timely intervention. Interviews with staff revealed a lack of clear communication and documentation regarding the scheduling of dental appointments, with the unit coordinator and resident's representative playing roles in the process. The Director of Nursing Services acknowledged the difficulty in finding dentists for residents with limited mobility, highlighting a systemic issue in coordinating dental care for residents.
Failure to Ensure Orderly Discharge for Residents
Penalty
Summary
The facility failed to ensure an orderly discharge for two residents, leading to potential unmet care needs. Resident 5, who had a cognitive communication deficit, was discharged without any documentation regarding follow-up physician care. The discharge summary form for Resident 5 was left blank in sections that should have included the primary care provider's contact information and whether an appointment had been made or needed to be scheduled. This lack of information could have hindered the resident's ability to receive necessary post-discharge medical care. Similarly, Resident 2, who had a cognitive communication deficit and a pressure ulcer, was discharged without proper documentation or instructions for ongoing care. The discharge summary for Resident 2 did not include information about the treatment of their buttocks skin cellulitis or follow-up physician care. Despite having specific orders for skin care and needing follow-up for various medical conditions, the discharge summary lacked essential details such as physician names, addresses, phone numbers, and appointment information. Staff D, a Registered Nurse/Resident Care Manager, confirmed that no follow-up appointments were made for Resident 2 and that no skin care instructions were provided, further contributing to the deficiency.
Failure to Provide Recommended Nutritional Supplements
Penalty
Summary
The facility failed to provide nutritional supplements as recommended by the registered dietitian for two residents, leading to a risk of delayed wound healing. Resident 1, who was admitted with protein-calorie malnutrition, developed a Stage 3 pressure injury while in the facility. Despite the dietitian's recommendation for daily Prosource protein supplementation and No Added Sugar House Shakes three times a day, these orders were not implemented. Staff interviews revealed a communication breakdown and discrepancies in the Nutrition Assessment Recommendations, resulting in the resident not receiving the necessary supplements for wound healing. Resident 4, who had an unstageable pressure injury and end-stage renal disease requiring dialysis, was also affected by the facility's failure to follow the dietitian's recommendations. The dietitian had recommended Prosource 30 ml twice daily to aid in wound healing and meet increased nutritional needs due to dialysis. However, the resident only received Prosource once daily, as indicated by the Medication Administration Records. Staff interviews could not explain why the dietitian's recommendations were not fully implemented, highlighting a significant lapse in the facility's nutritional care processes.
Inaccurate Clinical Records for Wound Care
Penalty
Summary
The facility failed to ensure clinical records were complete and accurate for two residents reviewed for wound care. Resident 1, who developed a Stage 3 pressure injury on their right buttocks while in the facility, had a wound care recommendation from a Physician Assistant to change the dressing every seven days. However, the facility implemented a routine dressing change every three days instead. The Director of Nursing Services acknowledged the discrepancy but did not provide additional documentation to justify the deviation from the recommendation. Resident 3, who had a Stage 4 pressure injury, had a recommendation from the same Physician Assistant to use calcium alginate to fill the wound with each dressing change. Instead, the facility used Xeroform for each dressing change. The Assistant Director of Nursing Services stated that they had clarified the wound care order to continue using Xeroform but failed to document this clarification. These inaccuracies in clinical records placed residents at risk for unmet needs.
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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 Marysville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mountain View Rehabilitation And Care Center | 0.8 mi | — | 9 | 0 |
| Bethany At Pacific | 5.2 mi | — | 0 | 0 |
| Everett Transitional Care Services | 6.3 mi | — | 7 | 0 |
| View Ridge Care Center | 8.2 mi | — | 16 | 0 |
| Madison Post Acute | 8.8 mi | — | 1 | 0 |
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