Transitional Care Of Seattle
Inspection history, citations, penalties and survey trends for this long-term care facility in Seattle, Washington.
- Location
- 2611 S Dearborn Street, Seattle, Washington 98144
- CMS Provider Number
- 505534
- Inspections on file
- 30
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 49
Citation history
Health deficiencies cited at Transitional Care Of Seattle during CMS and state inspections, most recent first.
A resident with dementia, vision problems, and existing pressure injuries was dependent on staff for all ADLs and required two-person assistance and mechanical lift transfers. Hospital discharge orders specified wound care frequencies, turning every two hours, getting the resident out of bed three times daily, nutritional supplements (Ensure TID, Juven BID), and transfer to a tilt-in-space wheelchair. The facility did not enter or clarify the out-of-bed orders, delayed starting Ensure and Juven, reversed the wound treatment frequencies on the TAR, and POC documentation showed no transfers out of bed and multiple shifts with no or "activity did not occur" entries for bed mobility. The resident frequently refused meals, weights, some medications, repositioning at times, and certain procedures, but staff documentation often lacked follow-up actions or provider notification, and the behavior care plan did not include specific behaviors or interventions to guide staff in managing these refusals.
A resident with complex medical conditions, cognitive impairment, and total dependence on staff for care was admitted with two suspected deep tissue injury pressure ulcers and identified as at risk for skin breakdown. Facility policy required weekly wound evaluations with measurements and characteristics, and notification of the provider and RD, but the admission wound evaluation lacked measurements and pain assessment, one of the existing PIs was not evaluated as scheduled, and a new unstageable PI on the upper back was not fully assessed until several days after it was found, with RD notification left blank. Observations later showed significant wounds to the buttocks and upper back with reported pain. Documentation also showed repeated refusals of meals, weights, some medications, and care, yet progress notes did not show that the provider was informed or that reasons for refusals were determined, while staff acknowledged required weekly wound documentation was not consistently completed and could not explain the delay in assessing the new PI.
The facility did not provide required written transfer or discharge notices to four residents or their representatives, and failed to document that a report was given to the receiving hospital for two residents. Staff confirmed that notices were sent to the LTCO but not directly to residents, and that communication with hospitals was not properly documented.
The facility failed to provide respiratory care and oxygen therapy according to physician orders and professional standards for four residents. This included administering oxygen without a provider order, not following prescribed flow rates, using oral suction equipment for stoma care, and not maintaining or replacing soiled oxygen equipment. Staff were unaware of proper procedures for equipment cleaning and did not consistently follow facility policy or update care plans to reflect accurate orders.
The facility did not have a system to assess or document the competencies of nurses and CNAs, resulting in staff providing care without evidence of proper training or skills assessment. For example, a nurse administered cancer therapy and performed stoma suctioning for a resident with complex needs without documented training or knowledge of required techniques. Staff files lacked competency records, and staff development processes did not ensure completion or collection of orientation and skills checklists.
The facility did not ensure that meals were palatable, visually appealing, or served at appropriate temperatures, as reported by several residents and confirmed by surveyor observations. Residents described the food as bland, repetitive, and unappetizing, with some supplementing their diets with outside food or modifying their meals to improve taste. A test tray review found food items to be unappealing in appearance, taste, and temperature, and the Food and Nutrition Service Manager cited budget limitations as a factor.
Staff failed to maintain a clean environment and adhere to infection control protocols, including not addressing a leaking catheter bag, not reporting a damaged mattress cover, and not following PPE and enhanced barrier precautions during high-contact care and suctioning procedures for multiple residents.
A resident with complex medical needs and limited mobility was provided with a bed and mattress that were too small, resulting in persistent discomfort. Staff used a foam spacer to fill the gap between the mattress and the extended bed frame, but the spacer frequently shifted, causing the bed to remain uneven and preventing the resident from sitting or lying comfortably. Despite repeated reports from the resident, staff indicated there was nothing more they could do, even though longer beds were available in the facility.
A resident's room was found to be cluttered and disorganized, with medical and personal care supplies scattered on furniture, in open boxes, and on an extra bed. The resident reported dissatisfaction with the lack of order, and staff acknowledged the clutter and insufficient storage, resulting in a less than homelike environment.
The facility did not conduct timely or thorough investigations into two incidents: one involving a resident's allegation of verbal abuse and missing property by a staff member, and another involving a resident's fall and subsequent hospital transfer. In both cases, required investigative steps and documentation were incomplete or delayed.
A resident experienced a sustained decline in functional abilities, mood, and care acceptance following a hospitalization, but staff did not complete a Significant Change in Status Assessment (SCSA) as required. Interviews and record reviews confirmed that the resident's condition had changed significantly, yet the necessary reassessment was not performed after the 14-day period.
The facility did not ensure timely and accurate completion or updating of PASRR assessments for three residents with mental health diagnoses. One resident's required Level 2 referral was delayed by several months, another resident's follow-up with the State PASRR office was not documented, and a third resident's PASRR was not updated after new mental health diagnoses and medications were added.
The facility did not hold quarterly care conferences for two residents, resulting in missed opportunities to address care needs and concerns. One resident had not had a care conference since March, with no further attempts documented after a refusal in May. Another resident missed a scheduled conference since February and reported unaddressed concerns about food, emergency contacts, and mental health, with staff unaware of these issues.
Staff failed to follow, clarify, and obtain physician orders for several residents, including administering pain medications outside prescribed parameters, not clarifying duplicate or conflicting medication orders, and providing wound care without physician authorization. These actions involved residents with complex medical needs, such as those with feeding tubes, pressure ulcers, and dialysis requirements, and were confirmed by interviews with the DON and other staff.
Two residents with cognitive and mobility impairments did not receive individualized, meaningful activities as required, with one resident only receiving mail delivery and one-to-one visits, and another lacking access to preferred music activities. Both expressed dissatisfaction and a desire for more engagement, while staff failed to document refusals or provide adequate in-room activity support.
A resident with complex medical needs and a history of falls was transferred using a slide board by two CNAs who were not trained or cleared to use this method, contrary to the care plan that required a mechanical lift except during therapy sessions. The resident began to slide during the transfer and was assisted to the floor. Staff interviews confirmed that only therapy staff were authorized to use the slide board, and nursing staff had not received the necessary training.
A resident who was continent upon admission was managed solely with incontinence briefs without being assessed for bowel and bladder needs or offered a toileting program. Staff did not conduct formal assessments or implement a toileting plan, and the resident reported discomfort from the briefs and a willingness to try alternative continence care. The facility lacked a policy and process for bowel and bladder assessments, relying only on care plans focused on incontinence management.
A resident with mental health issues and a care plan requiring paired assistance for ADLs did not receive care as outlined. Staff provided care alone, contrary to the care plan, leading to a deficiency. Facility staff confirmed the care plan was not followed, resulting in inadequate care.
A facility failed to provide necessary social services to a resident with mental health issues, who reported rough handling during care. The resident's care plan required care in pairs, but the facility did not document any interventions or behavior management strategies. Staff confirmed the lack of documentation and involvement from the Social Services Department.
The facility failed to provide quarterly personal fund statements to two residents, as required by policy and regulations. Despite having no memory impairments, the residents reported not receiving the statements. The Business Office Manager admitted that statements were not routinely provided unless requested, contrary to facility policy. The administrator expected staff to follow the policy.
The facility failed to reimburse resident funds within 30 days of discharge for several residents, contrary to policy and regulations. Balances ranging from $0.09 to $43.19 remained in the facility's trust account for periods extending from one to 13 months post-discharge. The Business Office Manager was unaware of the time limit for closing accounts, leading to delayed reconciliation.
The facility failed to update care plans for several residents, leading to discrepancies in care, such as incorrect mattress settings and outdated dietary orders. Additionally, care conferences lacked interdisciplinary team involvement and were often scheduled with minimal notice, affecting resident participation and care coordination.
The facility failed to ensure proper communication with the dialysis center for two residents requiring dialysis, leading to missing documentation and sack lunches. Despite policies and physician orders, staff frequently did not provide necessary paperwork or meals, and the dialysis center reported infrequent communication from the facility.
The facility failed to ensure timely follow-up on pharmacy recommendations for three residents, leading to delays in medication changes and lab work. A resident's nerve pain medication adjustment and lab work were not documented or completed on time. Another resident's asthma inhaler was not discontinued promptly, and a narcotic pain medication evaluation was not recorded. Bloodwork for a third resident was delayed over four weeks. Staff acknowledged expectations for timely processing and documentation of pharmacy recommendations.
The facility failed to maintain food safety standards, with undated food items in the kitchen and improper temperature monitoring in unit refrigerators. Observations revealed undated dried foods and open cartons in the kitchen, along with dusty air vents. During meal service, beverages were left unrefrigerated, reaching unsafe temperatures. Unit pantries lacked proper temperature logs and thermometers, violating facility policy.
The facility did not address concerns raised during Resident Council meetings, such as snack distribution to room-bound residents and food quality issues. Despite the facility's policy to handle these through a grievance process, concerns were not logged or followed up, leading to resident frustration.
The facility failed to complete Quarterly MDS assessments within the regulatory timeframe for two residents. One resident's assessment was completed two days late, and another's was also completed two days late, placing them at risk for delayed care planning and decreased quality of life. The MDS Coordinator confirmed the delay.
The facility failed to ensure accurate MDS assessments for four residents, leading to potential risks of unmet care needs. A resident's mental health status was inaccurately documented, another's tobacco use was omitted, and insulin injections were not recorded despite being administered. These inaccuracies were confirmed by staff during interviews.
The facility failed to follow POs for several residents, including incorrect administration of heart failure medication and oxygen therapy, and excessive nutritional supplements. Pain management orders lacked clarity, leading to inconsistent medication administration. Documentation errors were noted, with staff signing off on incomplete tasks and inaccurately recording medication refusals.
The facility failed to implement an effective discharge planning process for two residents, resulting in delays in their transition to the community. Both residents had incomplete and non-specific discharge care plans, and there was no evidence of a self-medication program despite it being a goal. The Director of Nursing and Social Services Director acknowledged the importance of current and realistic discharge plans, but discussions were not documented.
The facility failed to provide a restorative program for two residents with mobility limitations, as identified by staff and reviewed for ROM. One resident received their RNP only four times in a two-week period, instead of the minimum six times as ordered. Another resident, with a spinal cord dysfunction, was not provided the RNP as ordered, receiving it only five times in May and four times in the first two weeks of June. These failures placed both residents at risk for declines in ROM and mobility.
A resident with complex medical needs consistently refused care, including bathing and weight monitoring, which the facility failed to address adequately. The resident was observed in poor hygiene conditions, and there was a lack of involvement from the Social Services department to resolve the refusals. The care plan did not provide clear guidance for staff, contributing to the deficiency.
The facility failed to meet the dietary preferences and texture requirements for several residents, including serving incorrect food textures and not honoring cultural food preferences. One resident, who preferred Asian food, experienced weight loss due to dissatisfaction with the menu, while another resident with a milk intolerance was repeatedly served milk-based nutritional shakes.
The facility failed to provide specialized rehabilitative services for two residents as required by physician orders. One resident did not receive a PT evaluation for neck-related issues despite an order from April, while another resident did not receive PT/OT evaluations for transfer safety concerns following a December order. The Therapy Director was unaware of these orders, resulting in a lack of necessary therapy services.
A resident with severe vision impairment sustained a burn to their lip after consuming overheated soup. The staff failed to document the food temperature as required by the facility's guidelines, leading to the resident's injury.
Failure to Follow Physician Orders and Address Care Refusals per Professional Standards
Penalty
Summary
The deficiency involves the facility’s failure to ensure services met professional standards of practice for a resident with complex medical conditions, including a history of blood clots, dementia, vision problems, and dependence on staff for all ADLs. The admission MDS and ADL care plan documented that the resident had significant cognitive loss, exhibited care-rejecting behaviors, and required two-person assistance for bed mobility and transfers with a mechanical lift. A hospital discharge summary documented two pressure injuries (right heel and right buttocks) and included specific physician orders for wound care, turning every two hours in bed, getting the resident out of bed three times daily, nutritional supplements (Ensure TID and Juven BID), and transfer with a sit-to-stand lift to a tilt-in-space wheelchair. Record review showed that key physician orders were not timely implemented or were entered incorrectly. The physician orders for the resident to be out of bed three times daily were not entered into the physician order system from admission through early February, and there was no documentation that staff clarified these orders despite repeated notation by the provider in progress notes. POC documentation for transfers out of bed showed no entries indicating the resident was ever transferred out of bed, and bed mobility documentation contained multiple shifts with no documentation or entries that no assistance was given or the activity did not occur. The facility delayed implementation of the Juven order until six days after admission and the Ensure order until twenty days after admission, and the MAR showed several days when Juven was not administered because it was on order and unavailable. The TAR showed the wound treatment frequencies for the right heel and right buttocks were reversed from the hospital discharge orders, with the heel ordered daily instead of every three days and the buttocks ordered every three days instead of daily. The facility also failed to adequately assess, document, and address the resident’s refusals of care and to notify the provider. The behavior care plan contained no specific behaviors or interventions despite documentation that the resident refused seventeen meals, one bath, weekly weights on five occasions, and medications at times. Progress notes documented episodes where the resident refused to swallow medications, refused repositioning at times, refused a bladder scan, and refused or spit out an antibiotic and Ensure, but the notes did not consistently indicate what actions staff took in response or whether the provider or resident representative was notified. The DON later stated that the resident did not have the cognitive ability to understand the risks and benefits of refusing turning, and acknowledged that the provider should have been notified of refusals and that refusals and related behaviors should have been reflected in the behavior care plan to direct staff in managing them.
Failure to Assess and Manage Pressure Injuries and Resident Refusals
Penalty
Summary
The facility failed to provide necessary care and services for pressure injuries (PIs) to one resident by not consistently assessing existing wounds, not documenting required wound characteristics and measurements, and not preventing the development of new PIs. The resident was admitted with medically complex conditions including a history of blood clots, dementia, impaired vision, significant cognitive loss, and behaviors of rejecting care. The admission MDS documented that the resident was at risk for PIs and had two unhealed, unstageable PIs suspected as deep tissue injuries (DTIs) on the right buttock and right heel. A Braden Scale assessment rated the resident at moderate risk for PIs due to being bedfast with very limited mobility and sensory perception, though later facility investigation documents described the resident as at extreme risk for impaired skin integrity. The resident was dependent on staff for eating, hygiene, toileting, bed mobility, transfers, bathing, and dressing. The facility’s skin integrity policy required licensed nurses to document skin impairments with measurements of size, color, odor, exudate, and pain on weekly wound evaluations, and to notify the medical provider, resident representative, and registered dietician, especially when wounds failed to improve or deteriorated. However, the admission skin/wound evaluation, created after admission and backdated, identified the two suspected DTIs but did not include measurements, wound assessment details, or pain documentation. There was no skin/wound evaluation completed on the documented admission date for either PI, and only the right heel PI was assessed on a subsequent date. A new unstageable PI on the resident’s right upper back was documented as identified several days after admission, but the skin/wound evaluation for this lesion was not completed until five days after it was found, and the section for registered dietician notification was left blank with no date entered. Observations later showed the upper back wound as an oblong open area and the right buttock wound as a large wound extending from the right buttock to the tailbone, with the resident stating that the buttocks hurt. Facility investigation of the newly acquired PI on the upper back identified the resident as at extreme risk for impaired skin integrity, citing profound immobility, deconditioning from sepsis, malnutrition, and inadequate hydration as root causes. Staff interviews indicated the resident refused to get out of bed and refused most oral intake, and documentation showed multiple refusals of meals, weekly weights, some medications, and one bath. Despite these refusals, progress notes over several weeks contained no indication that staff informed the provider of the resident’s refusals or explored the reasons for them. Staff also acknowledged that there should have been weekly wound documentation with measurements and characteristics, and could not explain the delay in assessing the new PI on the back or the discrepancy between the Braden assessment rating and the description of the resident as at extreme risk.
Failure to Provide Required Transfer/Discharge Notices and Hospital Reports
Penalty
Summary
The facility failed to provide required written notices to residents and/or their representatives at the time of transfer or discharge for four residents, and did not ensure that a report was given to the receiving hospital for two residents. In several cases, staff completed the Nursing Home Transfer or Discharge Notice and sent it to the Long Term Care Ombudsman (LTCO) office, but did not provide the notice directly to the resident or their representative as required. Staff interviews confirmed that the notices were not given to residents unless they were being discharged to the community, and that notifications to the LTCO were sent in batches rather than at the time of transfer. Additionally, for two residents who were transferred to the hospital, there was no documentation that a report on the resident's condition was provided to the receiving hospital. Facility forms intended to document this communication were left blank, and staff acknowledged that it was their expectation for such reports to be given and documented, but this was not done. These failures were identified through interviews and record reviews, and were not in accordance with facility policy or regulatory requirements.
Failure to Provide Safe and Appropriate Respiratory Care and Oxygen Administration
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for four residents, resulting in care and services that were not consistent with professional standards of practice. For one resident with a stoma, staff did not implement suctioning according to physician orders and used oral suction equipment for stoma suctioning, contrary to expectations and without clarifying the method or route with the provider. Additionally, this resident received oxygen therapy without a physician order, and staff did not update the care plan to reflect accurate physician orders. Two other residents receiving oxygen therapy did not have their oxygen delivered at the physician-ordered flow rates. One resident's oxygen was set below the prescribed rate, and the nasal cannula was visibly soiled with debris, while the oxygen concentrator filter was covered in dust. Staff were unaware of the need to clean the filter and only replaced tubing when requested by the resident. Another resident was observed receiving oxygen at a higher flow rate than ordered, and the humidifier water bottle attached to the oxygen concentrator was empty on multiple occasions, despite orders to replace it as needed. A fourth resident was observed with a visibly soiled nasal cannula that had not been changed for an extended period, and the oxygen concentrator filter was covered in debris. Staff confirmed the tubing was dirty and needed to be changed, and the filter required cleaning. Across these cases, staff did not consistently follow physician orders, facility policy, or professional standards regarding respiratory care, oxygen administration, and equipment maintenance.
Failure to Assess and Document Nursing Staff Competencies
Penalty
Summary
The facility failed to develop and implement a system to evaluate and document staff competencies in essential nursing skills and techniques for all reviewed staff, including RNs and CNAs. There was no nursing competency policy available, and staff files lacked documentation of completed competency assessments. For example, a registered nurse administered a toxic cancer therapy medication and performed stoma suctioning for a resident with complex medical needs without having received specific training or instructions for these procedures. The nurse was unaware of the differences between oral and stoma suctioning techniques and had not received documented training on handling toxic cancer treatments. Multiple CNAs and nurses had no documented evidence of competency assessments or training in key care areas, such as safe resident transfers. Staff development personnel reported that orientation checklists were not collected, skills workshops for new hires were not yet offered, and the last documented skills workshop was held over a year prior, with no individual competency records available. The last completed staff competency checklists dated back to February 2023. Leadership staff confirmed that competency assessments were expected on hire and annually, but could not provide documentation to support that these assessments had occurred.
Failure to Provide Palatable and Properly Prepared Meals
Penalty
Summary
The facility failed to ensure that meals were prepared and served in a manner that maintained palatability, attractiveness, and safe, appetizing temperatures for six of nine residents reviewed. Multiple residents reported dissatisfaction with the food, describing it as unpalatable, repetitive, bland, and visually unappealing. Observations confirmed that residents were supplementing their diets with outside food, and some were seen attempting to modify their meals to improve taste. Specific complaints included mushy vegetables, unidentifiable dishes, lack of condiments, and food that was often turned away. Residents also noted that the menu was repetitive and that alternative options were not satisfactory. A test tray observation further substantiated these concerns, revealing food items that were visually unappealing, served at improper temperatures, and described as unappetizing by surveyors. The roast turkey had an unappealing color and was overly salty, the green beans had an unpleasant aftertaste, the bread dressing was gelatinous and unidentifiable, and the milk and dessert were served at temperatures that made them unpalatable. The Food and Nutrition Service Manager acknowledged the use of a long-standing menu cycle and indicated that budget constraints affected ingredient quality. These findings were based on resident interviews, direct meal observations, and review of facility policies.
Failure to Maintain Infection Control and Adhere to PPE Protocols
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by multiple observed deficiencies. For two residents, the environment was not kept clean to prevent the transmission of communicable diseases. One resident with a urinary catheter was observed with a leaking catheter bag, resulting in a puddle of urine on the floor beneath the bed. Staff interviews confirmed that both nurses and aides were expected to address such issues promptly, but the leak was not managed in a timely manner. Additionally, a resident's mattress cover was found to be missing a large piece, making it impossible to disinfect the mattress. Staff acknowledged that such issues should be reported to maintenance, but the problem was not logged as required. The facility also failed to follow proper use of personal protective equipment (PPE) and enhanced barrier precautions (EBP) for residents on transmission-based precautions. One resident with a history of multidrug-resistant bacteria had EBP signage posted, but a certified nursing assistant provided high-contact care without wearing a gown as required. Another resident requiring stoma care was attended to by a registered nurse who wore a gown, gloves, and mask, but failed to use eye protection during suctioning, despite knowing it was expected per facility policy. These lapses in following standard and enhanced precautions were confirmed through staff interviews and direct observation.
Failure to Provide Appropriately Sized Bed for Resident with Mobility Limitations
Penalty
Summary
The facility failed to provide a comfortable and appropriately sized bed for a resident with multiple complex medical diagnoses, including partial paralysis and a pain syndrome. The resident was assessed as having functional limitations in both arms and legs and was dependent on staff for mobility and repositioning. Observations showed the resident's feet were propped on pillows over the footboard, and their head was higher than the mattress, indicating discomfort. The resident reported persistent discomfort, describing the bed as too small and the mattress as bowed, with both ends raised compared to the middle. The resident stated that a foam spacer was used to fill the gap between the mattress and the extended bed frame, but the spacer often shifted, causing further discomfort and preventing the bed from lying flat. The resident reported these issues to staff multiple times but was told there was nothing more that could be done. Staff interviews confirmed awareness of the bed's limitations, with maintenance having extended the bed frame but not providing a longer mattress. Staff acknowledged the use of a foam spacer to compensate for the mattress's short length, but were unaware that the spacer could slide and elevate the foot of the bed, making it difficult for the resident to sit up or reposition. The Director of Nursing stated that although the mattress had been changed several times, they were not aware that the current configuration prevented the bed from being fully lowered. The facility had longer beds available, but the resident was not provided with one, resulting in ongoing discomfort and inadequate accommodation of the resident's needs.
Failure to Maintain a Safe and Homelike Resident Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and homelike environment for one resident. Observations revealed that the resident's room contained a 3-drawer cabinet under the television with numerous packages of personal care items and medical supplies on top, a bedside table with several boxes of medical dressing supplies, and an open cardboard box with additional supplies underneath. Two baskets with disposable medical supplies were placed between the cabinet and the bedside table, and an extra bed in the room had a green lift harness draped across it with more supplies scattered on the bed. The resident expressed that the room was not as orderly as they would expect at home and preferred the items to be easily available but less disorganized and visible. Staff acknowledged that the room appeared cluttered and disorderly due to a lack of storage for supplies and agreed there was room for improvement.
Failure to Complete Timely and Thorough Investigations of Abuse Allegation and Fall Incident
Penalty
Summary
The facility failed to ensure timely and thorough investigations for two separate incidents involving two residents. For one resident, who was cognitively intact and able to communicate, an allegation was made that a staff member was verbally abusive and took a personal item (a power bank) from the resident. The resident reported the incident to another staff member but stated that no follow-up occurred and expressed ongoing distress and fear of retaliation. Investigation notes showed that while the incident was reported to the state, the facility's internal investigation was incomplete, lacking interviews with other residents, background checks on the staff involved, and updates to the resident's care plan. There was also no evidence that staff received education on reporting verbal abuse. In a separate incident, another resident with a history of heart failure and a progressive neurological disorder experienced a fall while attempting to get out of bed. The resident was found on the floor and later transferred to the hospital due to shortness of breath and inability to rise. Despite the fall, no investigation was initiated for nine days, and staff attributed the delay to an unusually high number of incidents and staff absence. The facility did not provide documentation of a completed investigation for this event.
Failure to Complete Significant Change Assessment After Resident Decline
Penalty
Summary
The facility failed to reassess a resident following a significant and sustained decline in their functional and mood status after a hospitalization. The resident, who previously was able to get out of bed and go outside, reported that after returning from the hospital, they could no longer get out of bed. Observations confirmed the resident remained in bed, and record review showed a marked decline in their ability to perform activities such as upper body dressing and moving in bed, as well as changes in mood and care rejection behaviors. The most recent Minimum Data Set (MDS) assessment after the resident's return indicated total dependence in several areas and new instances of care rejection, compared to the previous MDS assessment before hospitalization, which showed greater independence and no care rejection. Despite these sustained declines in multiple care areas, the facility did not complete a Significant Change in Status Assessment (SCSA) as required. Interviews with the Director of Nursing and the Corporate MDS Consultant confirmed that the changes in the resident's condition met the criteria for a SCSA, but the assessment was not performed after the 14-day period following the change. This omission was identified through interview and record review, and it was noted that the failure to complete the SCSA could result in unmet care needs and diminished quality of life for the resident.
Failure to Complete and Update PASRR Assessments for Residents with Mental Health Needs
Penalty
Summary
The facility failed to ensure that Pre-admission Screening and Resident Review (PASRR) assessments were accurately completed and updated for residents with mental disorders or intellectual disabilities. For three residents reviewed, there were significant lapses in the PASRR process. One resident with diagnoses of depression and anxiety had a Level 1 PASRR screening indicating the need for a Level 2 referral due to serious mental illness (SMI), but the referral was not made until seven months after the initial assessment. Another resident with anxiety and a mood disorder, who was prescribed antipsychotic medication, had a Level 1 PASRR submitted, but there was no documentation of follow-up with the State PASRR office or evidence of obtaining Level 2 services. For a third resident, hospital staff identified SMI indicators on the Level 1 PASRR, but did not specify the type of SMI, and a subsequent Level 2 evaluation determined no SMI based on hospital records. However, the resident was later prescribed antidepressant medication for an anxiety disorder, and the diagnosis was added to their records without an updated Level 1 PASRR being completed. Staff interviews confirmed that PASRRs were not updated in a timely manner when residents' mental health diagnoses changed or when new medications were prescribed. The facility's policy required timely validation and submission of Level 1 and Level 2 PASRRs, especially with significant changes in residents' mental health status, but these procedures were not followed for the residents in question. Documentation and communication with the State PASRR office were also lacking, resulting in incomplete or delayed assessments and referrals.
Failure to Conduct Required Quarterly Care Conferences
Penalty
Summary
The facility failed to conduct quarterly care conferences for two residents as required. For one resident, records showed the last care conference occurred in March, and although the resident refused a conference in May, there was no documentation of further attempts or scheduling of subsequent conferences. The resident reported that no one at the facility had discussed their care with them recently. Staff confirmed that no upcoming care conferences were scheduled for this resident, despite acknowledging the importance of these meetings for care planning and communication. For another resident, the last care conference was held in February, and the social services team missed scheduling the required quarterly conference. This resident expressed concerns about food, emergency contact information, and a desire to speak with a mental health specialist, but reported that staff did not discuss these issues with them. Staff were unaware of the resident's mental health concerns and confirmed that no mental health providers were following the resident for anxiety or panic behaviors, despite the care plan indicating such discussions should occur.
Failure to Follow, Clarify, and Obtain Physician Orders for Multiple Residents
Penalty
Summary
The facility failed to ensure that physician orders were followed, clarified, and obtained as required for several residents. For four residents, staff did not adhere to physician orders regarding medication administration, including administering pain medications outside of prescribed parameters and without proper documentation of pain levels. In some cases, medications were given for pain levels not matching the physician's specified range, and in others, medications were administered without recording the resident's pain level at all. Additionally, some residents had multiple as-needed orders for similar medications, such as laxatives, without clear instructions on which to use first or how to sequence them, leading to potential confusion among staff. Two residents had physician orders that required clarification but were not addressed by staff. One resident with a feeding tube and an order for nothing by mouth had oral medications ordered, which conflicted with their care plan. Another resident had duplicate orders for similar medications without clear guidance, and staff acknowledged that such orders should have been clarified to prevent medication errors. In another instance, a resident requiring dialysis had incomplete orders that did not specify the necessary details for treatment, and staff did not clarify these orders, resulting in the resident not receiving dialysis as needed. The facility also failed to obtain physician orders prior to providing certain treatments. For example, a nurse applied and changed dressings on a resident's lower legs and knee without any corresponding physician orders. The nurse indicated that the dressings were used for protection, but there was no documentation or order to support this practice. The Director of Nursing confirmed that staff were expected to obtain orders before applying dressings and to monitor skin areas under dressings to prevent skin breakdown.
Failure to Provide Individualized, Meaningful Activities for Residents
Penalty
Summary
The facility failed to provide a meaningful and individualized program of activities for two residents, as required by its own policy and regulatory standards. For one resident with moderate memory impairment and significant depressive symptoms, documentation showed participation only in one-to-one visits and group activities over a nearly month-long period, with no records of group activity attendance or refusals. The resident expressed dissatisfaction, noting a lack of engagement and social interaction since returning from the hospital, and reported that the only contact from the Activities department was the delivery of mail and packages. Another resident, who had a severe memory problem and was unable to get out of bed, was observed without access to preferred activity supplies, such as a musical keyboard, which was stored out of reach. The resident and their spouse both indicated a strong interest in music and playing the keyboard, but facility staff only offered in-room activity assistance about once a week. The resident reported having little to do and wished for more engagement, while observations confirmed a lack of available stimulation in the room. Interviews with the Activity Director revealed that resident satisfaction checks were conducted verbally and not documented, and that the frequency of in-room activity assistance for residents unable to leave their rooms was insufficient. The lack of consistent documentation and individualized activity provision led to unmet physical, mental, and psychosocial needs for the affected residents.
Failure to Follow Care Plan and Provide Adequate Supervision During Resident Transfer
Penalty
Summary
The facility failed to provide adequate supervision and follow established care plan interventions to prevent avoidable accidents for a resident with a history of falls and complex medical needs. The resident, who required substantial assistance for bed mobility and was dependent on staff for transfers, was observed to have experienced a fall during a transfer from chair to bed. The care plan specified that the resident was to be transferred using a mechanical lift, except when working with therapy, which was trialing slide board transfers. However, nursing staff used a slide board for the transfer without proper training or clearance from therapy, contrary to the care plan instructions. Multiple staff interviews confirmed that the resident was typically transferred with a mechanical lift and that only therapy staff were authorized and trained to use the slide board with the resident. On the day of the incident, two CNAs used a slide board for the transfer after being told by the resident and another CNA that this was now the method used, despite not being trained or cleared for this technique. The resident began to slide during the transfer and was assisted to the floor. The Director of Therapy confirmed that nursing staff had not been trained or cleared to use the slide board for this resident, and the Director of Nursing stated that staff are expected to follow care plan interventions and be adequately trained to reduce the risk of accidents.
Failure to Assess and Address Bowel and Bladder Continence Needs
Penalty
Summary
The facility failed to assess and provide necessary care and services to maintain or improve bowel and bladder continence for a resident who was always incontinent of bowel and bladder. Despite documentation showing the resident was continent of bowel and had regular urinary frequency upon admission, subsequent quarterly reviews indicated no changes in bowel and bladder status, and the resident was consistently managed with incontinence briefs. Staff interviews revealed that the resident was never tried on a toileting program, and there was no evidence of a bowel and bladder assessment or toileting plan in the resident's records. The resident reported discomfort and difficulty sleeping due to the use of incontinence briefs and expressed willingness to try a toileting plan when asked. The facility was unable to provide a policy regarding bowel and bladder assessments when requested, and staff confirmed that no such assessment process was in place. The care plan interventions focused on managing incontinence with adult incontinence products rather than attempting to maintain or restore continence. Staff relied on the care plan to review bowel and bladder status but did not conduct formal assessments or implement toileting programs, even when the resident indicated awareness of the need to use the bathroom and a willingness to participate in a toileting plan.
Failure to Implement Care Plan for Resident with ADL Needs
Penalty
Summary
The facility failed to implement a person-centered comprehensive care plan for a resident who required assistance with activities of daily living (ADLs). The resident, who had clear speech, intact memory, and serious mental illnesses such as anxiety and depression, exhibited behaviors of rejecting care and was on antipsychotic and antidepressant medications. The care plan for this resident included an intervention that required staff to perform care in pairs due to the resident's ineffective coping skills and risk for impaired psychosocial well-being. However, during an incident, it was observed that staff did not adhere to this intervention, as care was provided by a single staff member, contrary to the care plan. An incident report revealed that the resident felt mistreated during incontinent care provided by a single staff member, which led to the resident dismissing the staff. Another staff member also provided care alone, further violating the care plan's requirement for paired care. Interviews with facility staff, including the Risk Manager, Resident Care Manager, and Director of Nursing, confirmed that the care plan was not followed as required. The staff acknowledged the expectation to follow the care plan and provide care in pairs, but this was not adhered to, resulting in a deficiency in the care provided to the resident.
Failure to Provide Medically-Related Social Services
Penalty
Summary
The facility failed to provide medically-related social services to help residents achieve the highest practicable physical, mental, and psychosocial well-being. Specifically, the facility did not assist residents in resolving grievances related to refusals of treatment and care, nor did it advocate for residents' rights. This deficiency was identified in the case of a resident with serious mental illnesses, including anxiety and depression, who exhibited behaviors such as rejection of care. The resident reported being handled roughly by a staff member during incontinent care, which was not in accordance with the care plan that required care to be provided in pairs. Despite the resident's refusal to receive care in pairs, the facility's Social Services Department (SSD) did not document any interventions or behavior management strategies in the resident's medical records. The facility's policies required the SSD to review and update care plans and address residents' behaviors, but there was no evidence of such actions being taken. Interviews with facility staff confirmed the lack of documentation and involvement from the SSD in addressing the resident's refusal of care and behavior issues.
Failure to Provide Quarterly Personal Fund Statements
Penalty
Summary
The facility failed to provide quarterly personal fund statements to residents with personal fund accounts, as required by their own policy and state and federal regulations. This deficiency was identified for two residents, Resident 17 and Resident 27, who both reported not receiving the required statements. Resident 27, who had no memory impairment according to a recent assessment, confirmed in an interview that they did not receive quarterly statements from the facility staff. Similarly, Resident 17, also without memory impairment, reported the same issue during an interview. The Business Office Manager, identified as Staff G, admitted in interviews that the facility did not routinely provide trust fund statements to residents unless specifically requested. Staff G explained that some residents might find the statements overwhelming and mistake them for bills, which is why they were not distributed as a standard practice. However, this practice was contrary to the facility's policy, which mandates the distribution of these statements. The facility administrator, identified as Staff A, stated that the expectation was for staff to follow the policy and provide the statements as required.
Delayed Reimbursement of Resident Funds Post-Discharge
Penalty
Summary
The facility failed to ensure that resident funds were reimbursed to the residents or the state Office of Financial Recovery (OFR) within 30 days of discharge, as required by their policy and state and federal regulations. This deficiency was identified for seven out of nine discharged residents reviewed. The facility's policy mandates that upon discharge or death, the balance of a resident's personal funds should be returned to the resident, responsible party, or as directed by state regulation. However, the facility did not comply with this policy, resulting in delayed reconciliation of residents' accounts. Specific instances included Resident 229, who had a balance of $0.60 remaining in the facility's trust account 13 months after discharge, and Resident 232, who had a balance of $43.19 remaining five months post-discharge. Other residents had smaller balances that also remained unreturned for periods ranging from one to ten months after discharge. During an interview, the Business Office Manager, Staff G, acknowledged the presence of active remaining balances for residents discharged more than 30 days ago and admitted to being unaware of any time limit for transferring and closing a resident's account.
Deficiencies in Care Plan Updates and Care Conference Participation
Penalty
Summary
The facility failed to ensure that care plans (CPs) were updated and revised as needed to reflect person-centered care for several residents. For Resident 41, the CP did not accurately reflect the physician's order for a specialty air mattress setting, which was crucial for wound prevention due to the resident's limited mobility and multiple pressure injuries. Observations showed discrepancies in the mattress settings, and the resident expressed concerns about the mattress's effectiveness. Staff interviews confirmed that the CP should align with the physician's orders and be resident-specific. Resident 22's CP was not updated to reflect a dietary order change from a regular diet to a minced and moist texture diet, which was necessary due to dental problems. Similarly, Resident 49's CP was outdated, not reflecting a change from a minced and moist texture diet to a regular diet. Staff acknowledged the importance of updating CPs to ensure residents receive the care they require based on current assessments and orders. The facility also failed to ensure resident participation in care conferences (CCs). Resident 2, despite having no memory impairment, was invited to a CC on the same day it occurred, with only the Social Services Director present, lacking interdisciplinary team (IDT) involvement. Similar issues were noted for Residents 226, 19, and 27, where CCs were conducted with minimal notice and without comprehensive IDT participation. Staff interviews highlighted the lack of IDT involvement and the inadequate notice given for CCs, which are crucial for coordinated resident care.
Failure in Communication with Dialysis Center
Penalty
Summary
The facility failed to ensure proper communication and collaboration with the dialysis center for two residents, Resident 2 and Resident 49, who required dialysis services. According to the facility's policy, updated in March 2021, the dialysis center was required to provide pre and post dialysis weights, labs, medications given, and any follow-up care needed. If this documentation was not received, the facility was expected to contact the dialysis center to request the information. However, this process was not consistently followed, leading to a lack of necessary medical information for the residents. Resident 49, who had multiple medically complex diagnoses including kidney failure, expressed frustration with the staff for not sending the required paperwork and a sack lunch for dialysis appointments. Observations confirmed that staff frequently failed to provide the necessary documentation and sack lunch, despite physician orders and care plan interventions directing them to do so. The dialysis center staff also reported that Resident 49 rarely arrived with the required paperwork, and the facility only occasionally called to obtain it. Similarly, Resident 2, who was dependent on dialysis, did not consistently receive the necessary transfer forms upon returning from dialysis appointments. The facility's records showed incomplete documentation regarding the receipt of dialysis transfer forms, and the dialysis center staff noted that the facility had only recently started sending paperwork with Resident 2. The Director of Nursing emphasized the importance of receiving the transfer forms to monitor Resident 2's weight and fluid removal during dialysis, which was crucial for their care management.
Delayed Follow-Up on Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure timely follow-up on pharmacy recommendations and proper documentation in residents' records, affecting three residents. For Resident 27, the pharmacist recommended a decrease in nerve pain medication and lab work for thyroid abnormalities due to heart rhythm medication. Although the provider agreed to these recommendations, the decrease in medication was not documented in the resident's records, and the lab work was not completed nine weeks after the recommendation. Staff S acknowledged the expectation for timely lab work completion but found the lab slip incomplete. Resident 49's pharmacist recommended discontinuing an asthma inhaler, which was agreed upon by the provider but not implemented until almost four weeks later. Additionally, a recommendation to evaluate a narcotic pain medication discontinue date was not documented in the resident's records. Staff B, the Director of Nursing, stated that pharmacy recommendations should be processed within a couple of days and be available in resident records. For Resident 43, a recommendation for bloodwork related to diuretic use was delayed by over four weeks, with Staff B unable to determine when the provider acknowledged the recommendation.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards of food safety in its kitchen and unit refrigerators, leading to potential risks for residents. Observations revealed that dried foods in the kitchen's dry storage area were not dated, including an open bag of carrot cake mix, powdered sugar, orzo pasta, and puffed rice cereal. Additionally, the kitchen's freezer contained an open container of hamburger patties without a date. The kitchen's air duct, located over food preparation areas, was found to have streaks of dust and grime, indicating a lack of regular cleaning. Staff interviews confirmed that these items should have been dated and the vents cleaned monthly, but no documentation was maintained to verify these actions. Further observations in the kitchen's drink fridge showed open, undated cartons of thickened milk, apple juice, and lemon water, which were subsequently discarded by staff. During meal preparation, trays of milk and juice were left unrefrigerated for over an hour, resulting in beverages reaching temperatures of 58 and 63 degrees Fahrenheit, respectively. Staff acknowledged the importance of serving food at the correct temperature to prevent spoilage but did not have measures in place to maintain appropriate temperatures during meal service. In the unit pantries, refrigerators were found to lack proper temperature monitoring. The 300 Unit Pantry had a thermometer but no log for documenting temperatures, while the 200 Unit Pantry lacked both a thermometer and a temperature log. These refrigerators contained various food items with use-by dates, but the absence of temperature logs and thermometers contravened facility policy. Staff interviews highlighted the importance of maintaining correct refrigerator temperatures, yet the facility failed to ensure compliance with its own policies.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to address and act upon concerns raised by residents during Resident Council (RC) meetings, as per their policy. The RC meetings are intended to promote resident involvement and provide a platform for voicing concerns, which should be addressed through the facility's grievance process. However, the minutes from several RC meetings, including those on 12/29/2023, 04/17/2024, and 05/29/2024, showed that concerns such as room-bound residents not receiving snacks, issues with food quality, vending machine accessibility, and missing ice cream were not followed up on or logged as grievances. This lack of action left residents feeling frustrated and unheard. Interviews with RC members and staff revealed further issues with the RC process. Residents expressed dissatisfaction with the lack of department head attendance at meetings and the inadequate response to their concerns, such as the distribution of snacks to room-bound residents. Staff interviews indicated a breakdown in communication and processing of grievances, as seen with the missing ice cream concern, which was not logged or formally addressed. This failure to consider and act on resident concerns as per the facility's policy resulted in unresolved issues and resident dissatisfaction.
Failure to Complete Quarterly MDS Assessments Timely
Penalty
Summary
The facility failed to complete Quarterly Minimum Data Set (MDS) assessments within the regulatory timeframe for two residents. Resident 17's Quarterly MDS had an Assessment Reference Date (ARD) of February 14, 2024, but the assessment was completed and locked on March 1, 2024, which was two days past the required timeframe. Similarly, Resident 38's Quarterly MDS had an ARD of March 20, 2024, and was completed and locked on April 5, 2024, also two days late. This delay in completing the assessments placed the residents at risk for delayed care planning, unidentified care needs and services, and a decreased quality of life. The MDS Coordinator confirmed that the assessments were not completed within the 14-day regulatory timeframe as required by the RAI Manual and WAC 388-97-1000 (4)(a).
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for four residents, leading to potential risks of unidentified and unmet care needs. Resident 27's MDS inaccurately reflected their mental health status by not marking them as having a Serious Mental Illness (SMI) despite a prior Level 2 Preadmission Screen and Resident Review (PASRR) evaluation indicating otherwise. Similarly, Resident 25's MDS did not capture their SMI status, even though they had a history of schizophrenia and a recent Level 2 PASRR assessment. These inaccuracies were confirmed by the MDS Coordinator during interviews. Additionally, Resident 38's MDS failed to document their current tobacco use, despite evidence from a smoking safety evaluation and care plan indicating they were a smoker. Resident 5's MDS inaccurately reported no insulin injections during the assessment period, although medication administration records showed insulin was administered daily. The Director of Nursing confirmed the inaccuracies in Resident 5's MDS. These discrepancies highlight the facility's failure to maintain accurate resident assessments, as required by regulations.
Failure to Follow Physician's Orders and Documentation Errors
Penalty
Summary
The facility failed to ensure that Physician's Orders (POs) were followed for several residents, leading to potential negative health outcomes. Resident 27, who had complex medical diagnoses including heart failure, was administered heart failure medication despite their heart rate being below the prescribed threshold on multiple occasions across April, May, and June 2024. Similarly, Resident 41, who required oxygen therapy, was observed to have their oxygen concentrator set above the prescribed levels on multiple occasions. Additionally, Resident 38 received a nutritional supplement in excess of the prescribed amount consistently over several days. The facility also failed to clarify POs for pain management for several residents, which could lead to inappropriate medication administration. Resident 226, who had a spinal cord injury and pain, had POs for pain medications that lacked specific pain level parameters, resulting in inconsistent administration of both over-the-counter and narcotic pain medications. Resident 27 had similar issues with pain medication orders lacking clarity on which medication to administer based on pain levels. Resident 49 had a pain medication patch order that did not specify the location of pain, leading to potential misapplication. Furthermore, the facility failed to ensure accurate documentation of medication administration. Staff signed off on tasks that were not completed, as seen with Resident 49, who was not provided with necessary documentation before leaving for dialysis, yet the task was marked as completed. Additionally, Resident 19's refusal of certain medications was not accurately documented, as staff recorded the medications as administered despite the resident's refusal. These documentation inaccuracies could lead to significant discrepancies in resident care records.
Deficient Discharge Planning Process
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for two residents, leading to delays in their transition to the community. Resident 26, who had no memory impairment, expressed frustration over the prolonged wait to be discharged to an adult family home. The discharge care plan for Resident 26 was incomplete, lacking specific goals, abilities, dates, and milestones. Additionally, there was no evidence that Resident 26 was on a self-medication administration program, despite this being a goal in their care plan. Similarly, Resident 22, also without memory impairment, was unclear about the reasons for the delay in their discharge to their apartment with caregivers. The discharge care plan for Resident 22 was similarly incomplete and not resident-specific. The facility's Director of Nursing acknowledged the importance of having current and realistic discharge care plans, while the Social Services Director noted that discussions about discharge goals were not documented. This lack of documentation and specificity in discharge planning contributed to the deficiency.
Failure to Provide Restorative Program for Residents with Mobility Limitations
Penalty
Summary
The facility failed to provide a restorative program for two residents with mobility limitations, as identified by staff and reviewed for Range of Motion (ROM). Resident 19, who had no memory impairment and was dependent on staff for mobility, only received their Restorative Nursing Program (RNP) four times in a two-week period, instead of the minimum six times as ordered. This was confirmed by the resident and the restorative nurse, who acknowledged that the program was not provided as scheduled. The resident's care plan indicated a need for RNP three days per week, but this was not adhered to, placing the resident at risk for further mobility decline. Similarly, Resident 38, who also had no memory impairment and suffered from a spinal cord dysfunction with functional limitations in ROM, was not provided the RNP as ordered. The resident was supposed to receive the program three to six days per week but only received it five times in May and four times in the first two weeks of June, falling short of the minimum required sessions. The restorative nurse confirmed the discrepancy in the documentation and emphasized the importance of the program in maintaining and regaining mobility. These failures in providing the restorative program as scheduled placed both residents at risk for declines in ROM and mobility.
Failure to Address Resident's Refusals of Care
Penalty
Summary
The facility failed to provide necessary medically related social services to Resident 66, who had complex medical diagnoses including a history of stroke, anxiety disorder, malnutrition, diabetes, and hearing loss. The resident consistently refused care, including interviews to assess memory, podiatry consultations, and regular bathing, which were not adequately addressed by the facility. Observations noted the resident in poor hygiene conditions, with dry flaky feet and thick, scaly toenails, and in an unlit room with cluttered surroundings. The facility's records showed that Resident 66 refused to be weighed multiple times, and there were no documented attempts to reapproach or involve the Social Services department to address these refusals. The resident also refused bathing for extended periods, receiving only two showers over two months. Despite multiple discussions by the Resident Care Manager about shower refusals, there was no referral to the Social Services department, and the care plan lacked comprehensive strategies to address the resident's refusals. Interviews with staff revealed that the Social Services department was not involved in addressing Resident 66's refusals, and there were no records of attempts to engage behavioral health services. The Social Services Director confirmed that they were not involved with the resident's refusals and could not provide documentation of any attempts to address the issue. The care plan did not provide clear guidance for staff on managing the resident's refusals, contributing to the deficiency in care.
Failure to Meet Dietary Preferences and Texture Requirements
Penalty
Summary
The facility failed to ensure that meals served from the kitchen met the dietary preferences and required textures for six residents. Observations during a lunch service revealed that the minced and moist and soft and bite-sized entrees were prepared with the same finely shredded chicken texture, which did not meet the required texture specifications. Additionally, the staff used an incorrect measuring method for portioning controlled-carbohydrate meals, potentially affecting the nutritional intake of residents. Resident 38, who is of Asian descent, expressed dissatisfaction with the predominantly American food served, leading them to skip meals and order food from outside the facility. Despite a documented preference for Filipino food, the facility's records inaccurately reflected no cultural food preferences. This oversight contributed to Resident 38's weight loss and decreased meal intake, as they felt their dietary preferences were not being honored. Resident 25, who had a documented intolerance to milk, was repeatedly served nutritional shakes containing milk, which they did not consume. This oversight was evident despite the resident's food preference records clearly indicating a dislike and intolerance for milk. The failure to adhere to Resident 25's dietary restrictions contributed to their weight loss, as they were unable to consume the nutritional supplements provided.
Failure to Provide Required Rehabilitative Services
Penalty
Summary
The facility failed to provide specialized rehabilitative services as required by the Physician's Order for two residents. Resident 22, who had multiple medically complex diagnoses and no memory impairment, was supposed to receive physical therapy for headaches associated with neck movements and decreased range of motion. Despite a physician's order dated 04/15/2024 for a PT evaluation and treatment, no evaluation was conducted by the time of the survey, nearly two months later. Resident 22 expressed concerns about not receiving the therapy during an interview, and the Therapy Director confirmed that no PT evaluation had been completed in 2024 for this resident. Similarly, Resident 17, who also had multiple medically complex diagnoses including arthritis and knee pain, was not provided with the necessary therapy services. A physician's order from 12/27/2023 called for a PT/OT re-evaluation due to weakness related to transfer safety. However, no evaluations were conducted in the six months following the order. During an interview, Resident 17 mentioned that their doctor had discussed exercises with them, but no therapy services were available. The Therapy Director acknowledged the lack of PT or OT evaluations since the order was obtained and stated that they were unaware of the order.
Failure to Supervise and Document Safe Use of Hot Liquids
Penalty
Summary
The facility failed to identify the risk of hot liquids, adequately supervise, and initiate interventions for the safe use of hot liquids for a resident who required staff assistance. The resident, who had medically complex conditions and severely impaired vision, sustained a burn to their left lower lip after consuming soup that was heated too hot by a staff member. The facility's Microwave Reheating Guidelines required that foods and fluids heated in the microwave be served at safe temperatures and that the temperature be documented in the Microwave Reheating Log. However, the staff member did not document the food temperature as required, leading to the resident's injury. The resident was observed with an injury to their left lower lip, with a layer of skin missing and small, dark crusted areas on the outer edge of the lip. The resident reported that they had asked a staff member to heat up soup from a vending machine, and despite blowing on the soup, they ate it too fast and bit their lip. The Director of Nursing confirmed that the staff member had heated the soup too hot and failed to document the temperature, as expected. The resident's injury was noted to be healing with mild redness, and the resident had bitten and removed the scab, causing it to bleed again.
Latest citations in Washington
Inaccurate PASARR screening affected two residents. One resident with vascular dementia, depression, and adjustment disorder had a PASARR level one that did not reflect mental health diagnoses, and staff stated it was inaccurate. Another resident with PTSD had a PASARR level one that did not include the PTSD diagnosis, with no additional PASARR level one or level two found in the EHR; staff stated the screening was not accurate and should have been repeated.
Undated open meds were found on 2 medication carts, including an open insulin vial and multiple open eye drop bottles with no dates. An LPN and an RN both stated the items should have been dated when opened, and the DON stated open multidose vials or bottles found without a date should be discarded immediately.
A resident with respiratory failure, HTN, and anxiety became SOB and diaphoretic, received a breathing tx, and was sent by EMS to the hospital. The facility could not locate the required SNF/NF to Hospital Transfer form or other transfer records showing what information was communicated to the receiving provider.
Care plans for two residents were not updated to match their current status and care needs. One resident had PTSD and generalized anxiety disorder and was receiving a psychotropic medication, but the care plan listed monitoring for antipsychotic and anticonvulsant meds that were not prescribed and did not include the anxiety diagnosis or related behaviors and interventions. Another resident had new upper and lower dentures, but the oral/dental care plan only noted edentulous status and difficulty chewing, with no mention of dentures or denture-related interventions.
Failure to Provide Individualized Activities: A resident with anxiety, depression, and weakness was cognitively intact but said they could not attend group activities because of leg problems and wanted more in-room activities. The resident mostly stayed in bed watching TV, and staff documentation showed only limited room visits with no consistent activity documentation despite a care plan goal for participation two to three times per week.
Failure to maintain heel offloading for a resident with a reopened DFU. A resident with dementia and dependence for mobility had a left heel wound that had healed and then reopened; the wound care provider recommended heel floating and pressure relieving boots at all times, but observations showed the resident in bed with heels on the mattress and later reclined in a wheelchair with the heel resting on the footrest strap and no boots in place. Staff stated the resident had not refused the boots or heel floating, and the care plan was not updated after the wound reopened.
Failure to Address Hearing and Vision Services for a Resident: A resident with dementia, bilateral hearing loss, and impaired vision was observed without eyeglasses or a hearing device, despite records showing admission with eyeglasses and a personal sound amplifier. The care plan addressed vision only and did not include hearing-related interventions, while staff interviews confirmed the resident’s hearing was strained and that the resident’s device use and vision needs were not fully reflected in the plan of care.
Respiratory care was not provided consistently for two residents receiving O2. One resident with COPD and chronic respiratory failure had an O2 order missing the indication for use and Sats parameters, no MAR documentation of O2 therapy, and inconsistent Sats charting. Another resident with respiratory failure was observed on continuous O2 via NC, but provider orders for O2 therapy and tubing changes were not present after readmission, despite the care plan stating the resident was dependent on O2.
A resident with dementia, hearing loss, and missing lower teeth had an MDS showing obvious or likely cavities or broken natural teeth, and the care plan identified oral/dental health problems with an intervention to coordinate dental care and transportation. Staff stated the resident’s dental needs were captured on the MDS, but no referral was made for dental services or follow-up with the dentist, and the DON said the lack of referral did not meet expectations.
Inaccurate Meal Intake Documentation: A resident with DM, dysphagia, and protein-calorie malnutrition was observed eating less than 25% of a meal, but the POC documented 76-100% intake. The CNA said the resident usually ate only 25-50% of meals and that intake was sometimes documented based on what a coworker reported. The LPN/RCM and DON stated meal intake should be documented accurately.
Inaccurate PASARR Screening for Two Residents
Penalty
Summary
The facility failed to ensure that two residents were screened for additional mental health supports through the PASARR process. Resident 97 was admitted with diagnoses including vascular dementia, depression, and adjustment disorder, and was able to make needs known. Review of the PASARR level one dated 04/10/2026 showed no mental health diagnoses and no need for a PASARR level two, even though the resident’s record included mental health diagnoses. During interview, the Regional Social Services staff and the Administrator stated the PASARR was inaccurate, needed modifications, and did not meet expectations. Resident 6 was admitted with diagnoses including heart failure, respiratory failure, and PTSD, and was able to make needs known. Review of the PASARR level one dated 03/30/2026 showed no serious mental illness indicators marked and no PASARR level two indicated, and the EHR contained no other documented PASARR level one or level two. The Social Services Director stated the hospital-provided PASARR was reviewed for accuracy and, if inaccurate, another level one would be completed, and stated this resident’s PASARR did not include PTSD and should have had another level one completed. The Administrator also stated the PASARR was not accurate and another level one needed to be conducted, but none could be located in the EHR.
Undated Open Medications on Medication Carts
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications for 2 of 3 sampled medication carts reviewed for medication storage and labeling, including carts on the 400 and 500 halls. On the 500 hall medication cart, an open vial of insulin and an open bottle of eye drops were observed with no dates. During interview, an LPN stated that when an insulin vial or bottle of eye drops is opened, it should be dated immediately and said both items should have been dated upon opening; the LPN stated they would dispose of the undated vial and bottle. On the 400 hall medication cart, two open bottles of eye drops were observed with no dates. During interview, an RN stated both bottles should have been dated as soon as they were opened and said they would get new eye drops and dispose of the undated bottles. The DNS/RN stated that if an eye drop was opened it should have been dated immediately and that any open multidose vial or bottle found without a date should be discarded immediately.
Missing Hospital Transfer Documentation
Penalty
Summary
The facility failed to ensure hospital transfer documentation was completed for one resident who was transferred to the hospital after complaining of not being able to breathe and appearing diaphoretic. The resident had diagnoses of respiratory failure, high blood pressure, and anxiety disorder, and was able to make needs known. A breathing treatment was provided, and the provider agreed to send the resident out for further evaluation, after which emergency transportation took the resident to the hospital. Record review found no documentation showing what information was provided or communicated to the receiving facility for the transfer. Staff stated that transfer documentation should have included a SNF/NF to Hospital Transfer form, the resident's face sheet, and the medication and treatment administration records, but they were unable to locate documentation showing these items were completed or sent for the resident's hospital transfer.
Care plans did not reflect current diagnoses, medications, or denture status
Penalty
Summary
The facility failed to ensure that care plans were revised and accurately reflected residents’ current status and care needs for 2 of 21 sampled residents. Resident 6 was admitted with diagnoses including heart failure, respiratory failure, and PTSD, and was able to make needs known. The EHR showed Resident 6 also had generalized anxiety disorder and was receiving a psychotropic medication, but the current care plan dated 05/05/2026 documented monitoring for side effects of antipsychotic and anticonvulsant medications even though Resident 6 was not prescribed those medications. The care plan also identified PTSD but did not include generalized anxiety disorder or behaviors to monitor and interventions related to PTSD or anxiety disorder. Staff F, LPN/CC, stated the care plan did not accurately reflect the resident’s current status or prescribed medications, and Staff B, DNS, stated it did not meet expectations because it did not address the anxiety disorder or target behaviors and interventions. Resident 71 was admitted with diagnoses including PTSD, high blood pressure, and depression and was able to make needs known. Observation on 05/06/2026 showed a denture cup by the sink with the resident’s name on the lid and new upper and lower dentures dated 01/12/26. The resident stated the lower dentures did not fit well and that denture adhesive had been provided, but the dentures still did not fit right and the resident had not told staff yet. The focused oral/dental care plan, initiated on 06/23/2026, identified the resident as edentulous and having difficulty chewing, but did not show that the resident had dentures or include interventions related to denture use or maintenance. Staff E, CNA, stated they had not seen the resident wear dentures and were unaware of the new dentures, Staff C, LPN/CC, stated the care plan should have been updated when the dentures were obtained, and Staff B, DNS, stated the care plan should have reflected the dentures and interventions.
Failure to Provide Individualized Activities
Penalty
Summary
The facility failed to provide individualized activities for Resident 5, who was admitted with diagnoses including anxiety disorder, depression, and weakness. The admission MDS dated 01/14/2026 showed the resident was cognitively intact. During interviews on 05/03/2026 and 05/06/2026, Resident 5 stated they could not attend in-person activities because of their legs, wanted more activities to occupy them, mostly stayed in bed watching TV, and did not remember the last time activities staff visited to offer activities. The resident also stated activities staff would need to offer something they were able to do because they had difficulty doing some activities. The activities care plan dated 12/26/2026 showed a goal for Resident 5 to participate in activities two to three times per week. Progress notes documented one visit on 12/22/2026 to provide a welcome packet and encourage participation in daily activities, but no further activity documentation was found in the progress notes. Staff H stated room visits should include puzzles, arts and crafts, visiting, and chatting, and that documentation was placed in tasks, but the task record showed no documentation of activities for the past 30 days. Staff J stated paper documentation existed for room visits and that Resident 5 was on a list for room visits every Monday and Wednesday, while the room visit documentation showed only four visits on 01/26/2026, 02/06/2026, 03/10/2026, and 04/08/2026.
Failure to Maintain Heel Offloading for Reopened DFU
Penalty
Summary
The facility failed to consistently implement pressure reducing strategies for a resident with a left heel diabetic foot ulcer that had reopened. The resident was admitted with diagnoses including left hip fracture with surgical repair, a blood clot of the left lower leg, and dementia, and was dependent on staff for mobility and unable to make needs known. The baseline care plan and care plan both included heel offloading interventions, and the wound care provider initially recommended heel floating with pillows or wedge and pressure relieving boots. The wound later resolved, but a weekly skin assessment documented that the left heel wound reopened and was very painful to touch. After the wound reopened, the contracted wound care provider documented that the DFU to the left heel had reopened and recommended the resident wear pressure relieving boots at all times. The current care plan reviewed after the wound reopened did not include new interventions related to the reopened wound. Observations showed the resident seated in a reclined wheelchair with the left foot/heel resting on the footrest strap and no pressure relieving boots in place, and later lying in bed with both heels directly on the mattress without being floated and without boots. Staff interviews indicated the resident had not refused the boots or heel floating, and the LPN/CC and DON stated the resident should have been assessed and the plan of care updated when the wound reopened.
Failure to Address Resident Hearing and Vision Needs
Penalty
Summary
The facility failed to address one resident’s hearing and vision needs. Resident 112 was admitted with diagnoses including a leg fracture, dementia, and hearing loss in both ears, and was able to make needs known. The record showed the resident lost their glasses and was given readers, but the resident did not wear them because they were concerned that wearing glasses that were not their prescription would further degrade their vision. Observation did not show glasses in the resident’s room, and the resident stated they did not use a hearing aid. The resident was observed to be hard of hearing, requiring an elevated voice and repeated questions to understand. The admission MDS dated [DATE] documented adequate hearing with hearing aid and adequate vision with corrective lenses, while the significant change MDS dated [DATE] documented moderate difficulty hearing without a hearing aid and impaired vision without corrective lenses. The care plan initiated 02/24/2026 addressed impaired vision with interventions to arrange consultation with eye care practitioners as needed and remind the resident to wear glasses, but it did not include a focus area or interventions for hearing loss or use of hearing aids. A resident clothing list showed the resident admitted with one pair of eyeglasses and one Super Ear headset personal sound amplifier, yet observation and interview showed the resident in bed without eyeglasses or a hearing device, with the amplifier stored in the bedside table drawer. Staff interviews confirmed the resident’s hearing was strained, that the hearing device and glasses were not being used, and that the resident’s hearing device use should have been included in the plan of care and the resident should have been referred for eye care assessment.
Respiratory Care Orders and Documentation Not Maintained
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for two residents receiving oxygen therapy. One resident with COPD and chronic respiratory failure with hypoxia was observed multiple times lying in bed receiving oxygen at 2 L via nasal cannula. The resident’s oxygen order, dated 02/15/2026, allowed 1 to 4 L per minute continuously via nasal cannula, but it did not include an indication for use or oxygen saturation parameters. The April and May 2026 MARs did not show documentation of oxygen therapy being provided, and the TARs showed only an order to change oxygen tubing if damaged or visibly soiled, not an order for oxygen therapy. Oxygen saturations were not documented consistently daily from 04/01/2026 through 05/04/2026. A second resident with respiratory failure, high blood pressure, and anxiety disorder was observed in the room receiving oxygen at 6 L via nasal cannula on multiple occasions. The resident stated they needed oxygen therapy to breathe, and the care plan identified the resident as dependent on oxygen and to receive oxygen per provider orders. However, provider orders reviewed on 05/04/2026 showed no orders for oxygen therapy or for changing oxygen tubing. Staff stated the oxygen and tubing-change orders had been discontinued when the resident went to the hospital and were not added back to the MAR or TAR when the resident readmitted to the facility.
Failure to Refer Resident With Identified Dental Needs
Penalty
Summary
The facility failed to ensure that Resident 112 received needed dental care. Resident 112 was admitted with diagnoses including a leg fracture, dementia, and hearing loss in both ears. Observation on 05/03/2026 showed the resident had missing lower teeth. The admission MDS, dated [DATE], documented obvious or likely cavities or broken natural teeth, and the care plan dated 02/24/2026 identified oral/dental health problems related to likely cavities or broken teeth with an intervention to coordinate dental care and provide transportation. During interviews, Staff G, Regional Social Services, stated Resident 112's dental needs were captured on the 02/24/2026 MDS and the resident was not referred for dental services. Staff M, Social Services Director, stated residents with dental needs should be referred to social services to be scheduled for assessment by a dental care practitioner, and that Resident 112 should have been referred after the MDS assessment. Staff B, DON, stated residents with identified dental needs should be referred for follow-up with a dentist and that Resident 112 should have been referred to the in-house dental provider; Staff B stated the lack of referral did not meet expectations.
Inaccurate Meal Intake Documentation
Penalty
Summary
The facility failed to accurately document the amount of food eaten for Resident 13, who was admitted with diagnoses including diabetes mellitus, dysphagia, and protein-calorie malnutrition. The quarterly MDS dated 02/12/2026 showed the resident was moderately cognitively impaired. During observation on 05/05/2026 at 12:09 PM, a meal tray was delivered to the resident’s room, set up on a bedside table, and the resident was observed eating slowly, eating less than 25% of the meal, then laying back in bed and closing their eyes while the tray remained in the room. Staff later removed the tray, but the POC documentation for lunch on 05/05/2026 recorded that Resident 13 ate 76-100% of the meal. During interview, the CNA stated the resident typically ate 25-50% of meals and never ate all of the food, and that if they did not pick up a tray they would ask a coworker what the resident ate before documenting it. The CNA stated they were told the resident ate 75-100% of lunch, so that is what was entered. The LPN/RCM stated staff should document meal intake accurately in POC, and the RN/DNS stated it was their expectation that all staff document meal intake accurately.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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