Mirabella
Inspection history, citations, penalties and survey trends for this long-term care facility in Seattle, Washington.
- Location
- 116 Fairview Avenue N, Seattle, Washington 98109
- CMS Provider Number
- 505520
- Inspections on file
- 20
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Mirabella during CMS and state inspections, most recent first.
A resident with paraplegia and mild PI risk had a physician order for a weekly foam offloading dressing to the left heel and a care plan and facility policy requiring weekly skin assessments and CNA reporting of skin changes. The dressing on the heel remained in place far beyond the ordered change interval, with an LPN admitting to peeling it back, briefly inspecting, and reapplying the same dressing without changing it or checking the date. A CNA later noticed dried fluid on the resident’s sock and alerted an RN, who found the dressing dated several weeks earlier and, upon removal, discovered an unstageable PI on the left heel that required debridement.
A resident with gastrointestinal conditions did not consistently receive prescribed Mylanta and lidocaine oral solution as ordered, with multiple missed doses documented and no physician notification when medications were unavailable. Nursing staff failed to follow the MAR and facility policy, leading to resident discomfort and incomplete documentation, as confirmed by interviews with nursing and pharmacy staff.
A resident with paraplegia, dependent on staff for transfers and requiring a mechanical lift, was left unsupervised on the edge of their wheelchair while a CNA left the room to seek help. The care plan and Kardex did not specify the required two-person assistance for mechanical lift transfers. During the CNA's absence, the resident fell and sustained a tibial fracture, highlighting a failure in supervision and documentation.
A resident sustained a tibial tuberosity fracture after an unwitnessed fall during a mechanical lift transfer when a CNA left the room to seek assistance. The facility's investigation did not include a summary of findings, root cause analysis, or a determination regarding abuse or neglect, as required by policy and regulation.
The facility allowed two contract CNAs to work without obtaining required nurse aide registry verification to confirm their competency and eligibility, as their files lacked documentation and the DON assumed the contract agency would provide this verification.
A facility failed to implement its abuse and neglect policies, leading to a deficiency in protecting a resident from misappropriation of property. The facility delayed reporting a missing ceramic figurine to the State Agency and allowed the suspected staff member to continue working during the investigation, contrary to policy requirements.
A resident's allegation of property misappropriation was not reported to the State Agency in a timely manner, as required by regulations. The resident suspected a night nurse of taking a ceramic figurine, and the report was delayed by ten days after being initially reported to the Social Services Director. This delay in reporting placed residents at risk for potential misappropriation or exploitation.
A facility failed to promptly investigate a resident's allegation of misappropriation of a ceramic figurine. The resident, who was cognitively intact, reported the missing item, but the Social Services Director delayed the investigation, initially trying to resolve it independently. The Director of Nursing confirmed the investigation should have been immediate and thorough, including resident interviews. This delay placed residents at risk of unidentified misappropriation and lack of protection from abuse.
The facility failed to complete accurate and timely PASRR assessments for four residents, leading to potential inappropriate placements. A resident's PASRR was completed seven days post-admission, while others had unmarked SMI despite diagnoses of depression and anxiety. Staff admitted to oversight, and the administrator expected adherence to regulations.
The facility failed to develop comprehensive care plans for several residents, leading to unmet care needs. A resident using oxygen since May 2024 did not have an oxygen care plan until June 2024. Another resident's care plan lacked documentation for side rail use, despite its necessity for mobility. Additional residents had missing care plans for oxygen use, restorative programs, and anticoagulant therapy, which were only addressed after staff reviews.
The facility failed to provide proper respiratory care for three residents, including improper storage and labeling of oxygen equipment and lack of signage indicating oxygen use. A resident with COPD had a nasal cannula on the floor, another with pneumonia used an unlabeled cannula, and a third resident's oxygen tubing was undated. Staff acknowledged these issues, which were against the facility's policy.
The facility failed to maintain temperature logs for a medication refrigerator, risking compromised medications. The refrigerator contained various medications, including a pneumococcal vaccine and blood sugar medication pens. Temperature logs were inadequately maintained, with significant gaps in April, May, and June. The DON confirmed the oversight and acknowledged the presence of these medications without proper temperature monitoring.
The facility was found to have expired food items in the kitchen and dry storage, and staff failed to follow hand hygiene protocols during food preparation. Expired items included a jar of dressing, a tray of clams, and jars of mustard. A kitchen cook did not wash hands after handling a thermometer and before preparing food, risking cross-contamination.
The facility failed to implement a comprehensive water management program, review its Infection Prevention and Control Policy annually, and ensure proper hand hygiene and isolation precautions. Staff were unaware of the water management plan details, and the IPCP had not been reviewed since 2017. Observations showed staff neglecting hand hygiene and PPE use during room entry, including for a resident on CPAP therapy.
The facility failed to obtain informed consent for psychotropic medications for two residents. One resident was administered an anxiety medication without consent, and another resident was given an antidepressant without documented consent. Staff acknowledged the oversight and confirmed that consent should have been obtained prior to medication administration.
The facility failed to document advance directives for two residents, despite both residents stating they had them. Staff confirmed that these documents should be in the EHR, but they were not found. The absence of documentation was acknowledged by the Social Services Director and the Administrator, who expected adherence to the policy.
A facility failed to issue a Notification of Medicare Non-Coverage (NOMNC) at least two days before the end of Medicare coverage for a resident. The NOMNC was signed a day after coverage ended, and the Social Services Director could not provide evidence of timely communication with the resident's representative. The facility's policy requires adherence to Medicare guidelines, which was not met in this case.
The facility failed to provide written transfer or discharge notices to two residents and their representatives, as well as to the State Long-Term Care Ombudsman, when the residents were hospitalized. Staff interviews revealed that the required notifications were not provided, despite the facility's policy mandating such actions.
The facility failed to provide written bed hold notices to two residents who were hospitalized, as required by their policy. Despite verbal communication, there was no documentation or written notice provided, placing residents at risk for unwanted room changes upon readmission. The facility's Administrator expected adherence to the bed hold policy, which was not followed.
A resident's discharge status was inaccurately assessed, resulting in incorrect documentation in their clinical record. The nursing progress note indicated the resident was cleared to go home, but the MDS was coded for discharge to a hospital. The MDS coordinator acknowledged the error, and the DON expected the MDS to be accurate.
A facility failed to ensure proper G-tube management for a resident with dysphagia, as a nurse did not check the G-tube placement before administering medications, contrary to the facility's policy and physician orders. Interviews confirmed that staff were expected to perform this check, but it was not done, placing the resident at risk.
A facility failed to perform routine maintenance on side rails, placing a resident at risk for injury. The resident, who required assistance for bed mobility, used the side rails to aid in getting up. The Maintenance Manager was unaware of the side rails' presence, and the Administrator confirmed the lack of a maintenance process, despite the facility's policy requiring regular inspections.
Failure to Follow Pressure Ulcer Prevention Orders and Weekly Skin Assessments
Penalty
Summary
The deficiency involves the facility’s failure to consistently apply and change a foam pressure offloading dressing to a resident’s left heel per physician order and to complete weekly skin assessments as required by facility policy and the resident’s care plan. The facility’s Pressure Injury and Prevention policy required Braden Scale assessments on admission, weekly for four weeks, and quarterly thereafter, along with weekly total body skin examinations and documentation, and CNA reporting of skin abnormalities to licensed nurses. The resident’s comprehensive care plan, initiated in December 2020, directed staff to perform weekly and as-needed skin inspections for redness, open areas, scratches, cuts, bruises, and to report changes to the nurse. The resident, who had paraplegia and required assistance with bed mobility, had a Braden score of 15 (mild risk) and no documented left heel pressure ulcer on the annual MDS dated early January 2026 or in nursing progress notes as of early March 2026. Despite these requirements, the March 2026 Treatment Administration Record showed a physician order for a foam dressing to the left heel for protection once weekly on Mondays, but the dressing on the resident’s left heel was found on April 5, 2026 to be dated March 8, 2026. On that date, a CNA observed dried fluid leaking through the resident’s left sock and notified an RN, who discovered the outdated dressing and, upon removal, identified an unstageable pressure ulcer on the left heel. During the facility’s investigation, an LPN reported that on March 30, 2026, they had peeled back the dressing, “peeked only,” and then reapplied the same dressing without changing it and without checking the date, acknowledging that they should have checked and changed the dressing. These actions and omissions in dressing management and weekly skin assessment led to the development and delayed identification of an unstageable pressure ulcer on the resident’s left heel that required debridement by a wound care specialist.
Failure to Administer and Document Prescribed Medications as Ordered
Penalty
Summary
The facility failed to ensure that pharmaceutical services were provided to meet the needs of a resident with gastrointestinal diagnoses, including hiatal hernia and gastroesophageal reflux disease with esophagitis. The resident had intact cognition and was prescribed aluminum-magnesium simethicone (Mylanta) and lidocaine oral solution to be administered at specific times before meals and at bedtime. Review of the Medication Administration Records (MAR) for August and September showed multiple instances where these medications were not administered as ordered, and there was no documentation that the physician was notified when the medications were unavailable or not given. Staff interviews and record reviews revealed that nursing staff did not consistently follow the MAR or the facility's medication administration policy, which required adherence to the Seven Rights of medication administration and prompt notification to the physician and pharmacy when medications were unavailable. One nurse reported not administering the lidocaine solution because it was not found and did not notify the physician, believing the medication was not pertinent. There was also confusion regarding the storage location of medications, leading to missed doses. The pharmacist confirmed that the medications were compounded and that the MAR required separate documentation for each, but this was not consistently done. The resident reported experiencing discomfort and bloating when the medications were missed, which affected their ability to breathe, eat, sit up, and walk. Facility leadership, including the Resident Care Manager and Director of Nursing Services, acknowledged that staff should have notified the physician and administered the medications as ordered. The deficiency was identified through observation, interview, and record review, and was found to be in violation of facility policy and regulatory requirements.
Failure to Provide Adequate Supervision During Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
The facility failed to provide adequate supervision and ensure safe transfer procedures for a resident with paraplegia who was dependent on staff for transfers and required the use of a mechanical lift. The resident's care plan and Kardex indicated the need for staff assistance with transfers and use of a Hoyer lift, but did not specify the required number of staff for mechanical lift transfers. On the day of the incident, a CNA attempted to apply a mechanical lift sling under the resident, who was left sitting on the edge of their power wheelchair. The CNA left the resident unsupervised to seek assistance, during which time the resident slipped from the chair and fell to the floor, sustaining a tibial fracture that required emergency room treatment. Interviews and record reviews revealed that staff were aware that mechanical lift transfers should be performed with two staff members, but this requirement was not documented in the resident's care plan or Kardex. The CNA involved in the incident did not ensure the resident was safely positioned or supervised before leaving the room, and the lack of clear documentation contributed to the unsafe transfer process. The resident reported being left partially off the cushion and unsupervised for approximately ten minutes before falling. Further interviews with staff, including the Resident Care Manager and Director of Nursing, confirmed that the care plan should have specified the need for two-person assistance during mechanical lift transfers. The absence of this information in the care plan and Kardex, combined with the CNA's actions, resulted in an avoidable accident that caused significant harm to the resident.
Failure to Conduct Thorough Investigation After Resident Fall
Penalty
Summary
The facility failed to conduct a thorough investigation following an incident in which a resident experienced an unwitnessed fall during a mechanical lift transfer, resulting in a tibial tuberosity fracture. The incident occurred when a CNA placed a Hoyer sling under the resident and left the room to get assistance, returning to find the resident on the floor. Documentation showed that the CNA involved would not be able to work at the facility due to not following protocol, but the investigation records lacked a summary of findings, root cause analysis, or a determination regarding the likelihood of abuse or neglect contributing to the incident. Interviews with facility leadership, including the Director of Nursing and Director of Health Services, confirmed that the investigation did not include a completed summary or a clear ruling out of abuse or neglect, contrary to both facility policy and regulatory requirements. The facility's own policies require prompt and thorough investigations, including gathering witness statements, root cause analysis, and a summary of findings, none of which were fully documented in this case.
Failure to Verify Nurse Aide Registry Status for Contract CNAs
Penalty
Summary
The facility failed to obtain registry verification to ensure that two contract Certified Nursing Assistants (CNAs), identified as Staff F and Staff G, met competency evaluation requirements before allowing them to work as nurse aides. Review of the April 2025 staffing schedule showed that both staff members worked multiple shifts at the facility. However, their employee files did not contain documentation from the nurse aide registry verifying their eligibility and qualifications. Further review of email communication confirmed that the Director of Health Services did not have registry verification for these staff members. During an interview, the Director stated that they assumed the contract agency would provide registry verification as part of their compliance package, but acknowledged that the facility should have received this verification prior to the staff working. The facility's policy requires verification of board registrations and certifications before new employees are permitted to work with residents, and prohibits employment of individuals with findings of abuse, neglect, exploitation, or mistreatment.
Failure to Implement Abuse and Neglect Policies
Penalty
Summary
The facility failed to implement its abuse and neglect policies and procedures effectively, leading to a deficiency in protecting residents from misappropriation of property. Specifically, the facility did not conduct a prompt and thorough investigation as required by their policy when Resident 1 reported a missing ceramic carriage figurine. The incident was initially reported to the Social Services Director on 02/07/2025, but the facility delayed reporting the incident to the State Agency until 02/18/2025, ten days later. This delay in reporting and investigation placed Resident 1 at risk for unidentified misappropriation and lack of protection from potential abuse. Additionally, the facility allowed the staff member allegedly involved in the incident to continue working during the investigation. Despite Resident 1 providing a description of the staff member suspected of taking the figurine, the facility did not remove the staff member from resident care as required by their policy. The Director of Nursing Services admitted to being unaware of the requirement to suspend the staff member during the investigation, which further contributed to the deficiency in protecting residents from potential abuse and exploitation.
Delayed Reporting of Property Misappropriation Allegation
Penalty
Summary
The facility failed to report an allegation of misappropriation of property in a timely manner to the State Agency, as required by federal and state regulations. The incident involved a resident who reported that their ceramic carriage figurine had gone missing and suspected a night nurse might have taken it. The resident's representative initially reported the allegation to the Social Services Director on February 7, 2025, but the report was not forwarded to the State Agency until February 18, 2025, ten days later. This delay in reporting was acknowledged by the Social Services Director, who admitted to attempting to resolve the matter independently rather than following the proper reporting protocol. The facility's policy mandates that all allegations of abuse, neglect, exploitation, or mistreatment, including misappropriation of property, be reported promptly. The Director of Nursing Services confirmed that the allegation should have been reported immediately after it was brought to the attention of the Social Services Director. The failure to report the incident in a timely manner placed residents at risk for potential unidentified misappropriation or exploitation and a lack of protection from abuse.
Delayed Investigation of Misappropriation Allegation
Penalty
Summary
The facility failed to timely initiate and thoroughly investigate an allegation of misappropriation of property involving a resident's missing ceramic carriage figurine. The resident, who was cognitively intact, reported the missing item on 02/14/2025, although their representative had initially reported the allegation to the Social Services Director, Staff B, on 02/07/2025. Despite the facility's policy requiring immediate investigation upon notification of such incidents, the investigation was delayed, and the incident was only reported to the State Agency on 02/18/2025, ten days after the initial report. Interviews revealed that Staff B acknowledged the delay in addressing the allegation, admitting they initially attempted to resolve the matter independently. The Director of Nursing Services, Staff A, confirmed that the investigation should have been initiated immediately and included resident interviews, which were not conducted. This failure to act promptly and thoroughly placed residents at risk for potential unidentified misappropriation and lack of protection from abuse, as per the facility's policy and regulatory requirements.
Inaccurate and Delayed PASRR Completion for Residents
Penalty
Summary
The facility failed to ensure that four out of five residents had a completed and accurate Preadmission Screening Resident Review (PASRR) upon admission. This assessment is crucial for identifying individuals with serious mental illness (SMI) or intellectual disabilities to prevent inappropriate placement in nursing homes. Resident 20's PASRR was completed seven days after admission, contrary to the requirement for it to be done prior to or at the time of admission. Staff C, the Social Services Director, acknowledged the delay and admitted responsibility for completing the PASRR if it was not done by the hospital. For Residents 12, 10, and 21, the PASRR forms were inaccurately completed, failing to mark the presence of SMI despite their diagnoses of depression and anxiety. Staff C admitted to not catching these errors and stated that the forms should have been marked for SMI and referred for a Level II PASRR. The facility's administrator, Staff A, expressed an expectation for the PASRR forms to be accurate and for staff to adhere to regulations and facility policy.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop person-centered comprehensive care plans for several residents, leading to unmet care needs. Resident 230, who had been using oxygen since late May 2024, did not have an oxygen care plan until late June 2024. This oversight was acknowledged by both the Resident Care Manager and the Director of Nursing, who confirmed that the care plan should have been initiated when the resident began using oxygen. Similarly, Resident 4's care plan lacked documentation for the use of side rails, which the resident used for mobility. Despite observations and staff interviews confirming the use of side rails, the care plan did not reflect this need. Staff members, including a Registered Nurse and the Director of Nursing, noted that an assessment, consent, and physician's order should have been completed and included in the care plan. Other residents, such as Resident 19 and Resident 21, also had deficiencies in their care plans. Resident 19, who required oxygen monitoring, did not have an oxygen care plan until late June 2024, despite using oxygen since early June. Resident 21's restorative nursing program was not included in their care plan, even though it was part of their routine care. Additionally, Resident 20's care plan initially omitted anticoagulant therapy, which was only added after a review. These omissions were recognized by staff, who noted that these elements should have been included in the residents' care plans.
Failure to Maintain Proper Respiratory Care and Equipment
Penalty
Summary
The facility failed to provide necessary respiratory care and services in accordance with professional standards for three residents. Resident 5, who had chronic obstructive pulmonary disease, was observed with an oxygen concentrator in their room, but the nasal cannula was not stored in a bag when not in use and was found on the floor. There was no signage indicating oxygen was in use. Staff members acknowledged the lack of labeling and improper storage of the nasal cannula, which was placed on the resident despite being on the floor. Resident 19, who had pneumonia and congestive heart failure, was using oxygen via an unlabeled nasal cannula. Observations showed the nasal cannula touching the floor and not stored in a bag. Staff confirmed that the nasal cannula should have been labeled, stored properly, and not placed on the floor. The facility's policy required the nasal cannula to be changed every 72 hours and stored in a bag when not in use, which was not followed. Resident 230 had an order for oxygen supply due to shortness of breath. Observations revealed that the oxygen tubing was undated, and there was no signage indicating oxygen use on the resident's room door. Staff interviews confirmed that the tubing should have been dated and signage should have been present. The facility's policy was not adhered to, as there was no order for tubing change when the resident started using oxygen, and the lack of signage was justified by the facility not being a smoking facility.
Failure to Maintain Medication Refrigerator Temperature Logs
Penalty
Summary
The facility failed to maintain proper temperature logs for one of the three medication room refrigerators, specifically the medicine refrigerator, which contained various medications including a pneumococcal vaccine and medications for multiple residents. According to the facility's policy, medications requiring refrigeration should be kept at temperatures between 36°F and 46°F, with temperatures recorded at least once a day. However, the temperature logs for the medicine refrigerator were inadequately maintained, with only five temperatures logged from April 1 to April 24, one temperature logged from May 1 to May 24, and no temperatures logged from June 1 to June 26. During a joint observation and interview, the Director of Nursing, Staff B, confirmed that the temperature logs for June 2024 were not completed for 26 out of 26 days, and acknowledged that temperatures were not consistently checked in April and May 2024. The medicine refrigerator contained eight unopened medication pens for lowering blood sugar, a test for tuberculosis, three unopened boxes of tuberculosis testing solution, an opened pneumonia vaccine, and four unopened boxes of a medication that prevents blood clots. Staff B admitted that these medications were present on June 26 and should have been monitored for temperature compliance.
Expired Food and Poor Hand Hygiene in Kitchen
Penalty
Summary
The facility failed to maintain proper food storage and hand hygiene practices, which placed residents at risk for foodborne illnesses. During an inspection, expired food items were found in the kitchen refrigerator and dry storage room. A jar of thousand island dressing and a tray of clams were observed with expiration dates that had passed, and staff members were unaware or had not yet discarded these items. Additionally, three jars of mustard with expired labels were found in the dry storage room, and the head chef only discarded them after being prompted by the surveyor. Furthermore, the facility's staff did not adhere to hand hygiene protocols during food preparation. An observation revealed that a kitchen cook failed to wash hands after handling a thermometer and before donning gloves to prepare food. The cook also picked up a dirty rag without washing hands, which could lead to cross-contamination. The facility's hand hygiene policy emphasized the importance of handwashing to prevent infections, but it did not specifically address hand hygiene during food preparation. The administrator confirmed that expired food should be discarded and that staff are expected to follow the hand hygiene policy.
Deficiencies in Infection Control and Water Management
Penalty
Summary
The facility failed to implement a comprehensive water management program to monitor and control the growth of legionella and other waterborne pathogens. During an interview, the Facility Services Director admitted that the facility's water management plan lacked a flow diagram to identify potential growth areas for legionella. Additionally, there was no process in place for communicating the water management program to residents, staff, or others. The oversight of the water management system was left to a vendor, and there was no specific program for the skilled nursing unit. The facility also failed to review its Infection Prevention and Control Policy (IPCP) annually. The Resident Care Manager/Infection Preventionist was unaware of the frequency of IPCP reviews. A joint record review revealed that the IPCP was last revised in November 2017 and approved in February 2023, with the next review scheduled for February 2024. The Director of Nursing and the Administrator were both unaware of the review frequency, indicating a lack of oversight and communication regarding the IPCP. Furthermore, the facility did not ensure proper hand hygiene practices during room tray and activity flyer delivery. Observations showed that staff members failed to perform hand hygiene before and after entering rooms, including those with Enhanced Barrier Precautions (EBP). Additionally, the facility did not implement isolation precautions for Aerosolizing Generating Procedures (AGP) for a resident using CPAP therapy. Staff members were observed entering the resident's room without appropriate Personal Protective Equipment (PPE), and the Special Droplet/Contact precautions sign was not properly displayed.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure informed consent for psychotropic medication was completed prior to administration for two residents. Resident 15 had a physician's order for an anxiety medication dated March 9, 2024, and began taking the medication on March 10, 2024. However, during a joint record review and interview on June 28, 2024, it was discovered that Resident 15 did not have a consent form for the medication. Staff D, the Resident Care Manager, acknowledged that the consent was missed, and Staff B, the Director of Nursing, confirmed that consent should have been obtained before the medication was administered. Similarly, Resident 20, who was admitted with multiple diagnoses including major depression, had an order for an antidepressant medication on January 24, 2024. During a joint record review and interview on June 28, 2024, it was found that there was no consent for the antidepressant in Resident 20's electronic health record. Staff D stated that they would typically obtain consent for psychotropic medications but could not locate it in the records. Staff B also confirmed that obtaining consent for the antidepressant was part of their process.
Failure to Document Advance Directives for Residents
Penalty
Summary
The facility failed to ensure that advance directives were obtained and readily available in the medical records for two residents. Resident 4, who was admitted to the facility, stated they had an advance directive, but a review of their Electronic Health Record (EHR) showed no documentation of it. Staff C, the Social Services Director, confirmed that if a resident had an advance directive, it should be scanned into the EHR, but no such documentation was found for Resident 4. Staff A, the Administrator, also expected a copy of the advance directive to be in the medical records if it existed. Similarly, Resident 21 stated they had an advance directive and that their Power of Attorney (POA) carried a copy. However, a review of Resident 21's EHR showed no documentation of their advance directive. Staff C acknowledged the absence of the document in the EHR and mentioned that they typically ask families to provide a copy. Despite being aware that Resident 21 had a POA, there was no paperwork to support it. Staff A reiterated the expectation that staff should follow the policy and have a copy of the advance directive if it existed.
Failure to Timely Issue Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to issue a Notification of Medicare Non-Coverage (NOMNC) at least two calendar days before the end of Medicare coverage for a resident, as required by Medicare guidelines. The resident was admitted under skilled Medicare A benefits, and the NOMNC was signed a day after the coverage ended. The facility's policy mandates that such notices be delivered according to Medicare guidelines, which were not followed in this instance. During interviews, the Social Services Director claimed that the NOMNC was issued on time and that if a resident was unable to sign, the form would be emailed to their representative. However, the record review showed the NOMNC was signed late, and the Social Services Director could not provide evidence of the email communication with the resident's representative. The facility administrator confirmed the expectation that the NOMNC should be issued at least two days before the last covered day.
Failure to Provide Written Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide a written transfer or discharge notice to residents and their representatives, as well as to the Office of the State Long-Term Care Ombudsman, for two residents who were hospitalized. This deficiency was identified during a review of the facility's policy and interviews with staff members. The policy, revised in November 2017, required that a transfer or discharge notice be issued as soon as practicable when an immediate transfer or discharge is necessitated by a resident's urgent medical condition. However, for Resident 230, who was sent to the hospital for further evaluation, there was no documentation in the Electronic Health Record (EHR) indicating that a written notice was provided to the resident, their representative, or the Ombudsman. Interviews with the Social Services Director, Resident Care Manager, and Director of Nursing revealed that they did not provide the required written notices, and the facility did not send a copy of the transfer notice to the Ombudsman. Similarly, for Resident 10, who was discharged to the hospital due to emesis and abdominal pain, there was no documentation in the EHR showing that the resident or their representative was notified in writing of the reason for discharge. Staff interviews confirmed that the required written notifications were not provided to the resident, their representative, or the Ombudsman. The Director of Nursing acknowledged that the facility had not been notifying residents and their representatives in writing of the reason for discharge, nor sending a notice to the Ombudsman, despite the facility's policy requiring it. The Administrator expressed an expectation for staff to follow the discharge/transfer policy.
Failure to Provide Written Bed Hold Notices
Penalty
Summary
The facility failed to provide written bed hold notices to residents who were hospitalized, as required by their policy. This deficiency was identified for two residents, Resident 230 and Resident 10, who were transferred to the hospital. The facility's policy, revised in January 2020, mandates that before a resident is transferred to a hospital or goes on therapeutic leave, the nursing facility must provide written information to the resident and their representative about the bed hold policy. However, in the case of Resident 230, there was no documentation in the Electronic Health Record (EHR) that a bed hold notice was offered when they were sent to the hospital for further evaluation. Resident 230 confirmed in an interview that they were not offered a bed hold notice. Staff C, the Social Services Director, admitted to discussing the bed hold verbally but did not provide a written notice, citing that the facility had no issues with readmitting residents. Similarly, for Resident 10, who was discharged to the hospital due to emesis and abdominal pain, there was no documentation in the EHR that a bed hold notice was provided. Staff C stated that the bed hold notice was communicated verbally but not documented, and no written notice was given to the resident or their representative. The facility's Administrator, Staff A, expressed that it was their expectation for staff to follow the bed hold policy, which was not adhered to in these instances. This failure to provide written bed hold notices placed residents at risk for unwanted room changes upon readmission.
Inaccurate Discharge Assessment for a Resident
Penalty
Summary
The facility failed to accurately assess a resident's discharge status, leading to incorrect information in the resident's clinical record. Specifically, Resident 28 was reviewed for hospitalization, and the nursing progress note indicated that the resident was cleared to go home safely. However, the discharge Minimum Data Set (MDS) was incorrectly coded for discharge to a Short-term General Hospital instead of the community. During an interview and joint record review, the MDS coordinator acknowledged the error and stated that the MDS should have been coded for community discharge. The Director of Nursing also expressed the expectation for the MDS to be accurate. This inaccuracy in the resident's assessment placed the resident at risk for unidentified care needs.
Failure to Check G-Tube Placement Before Medication Administration
Penalty
Summary
The facility failed to ensure appropriate treatment and services related to gastrostomy tube (G-tube) management for Resident 21, who was receiving nutrition through a feeding tube due to dysphagia and gastrostomy status. The facility's policy required checking the G-tube placement by visual inspection of aspirated stomach content prior to medication administration, as outlined in the resident's medication administration record (MAR). However, during an observation, Staff G, a Registered Nurse, did not check the G-tube placement before administering medications to Resident 21, which was against the facility's policy and the physician's order. Interviews with staff members, including Staff G, the Resident Care Manager, and the Director of Nursing, confirmed that the expected procedure was to check for G-tube placement before administering medications. Staff G admitted to not performing this check, and both the Resident Care Manager and the Director of Nursing stated that they expected staff to follow the MAR and physician orders regarding G-tube placement checks. This oversight placed Resident 21 at risk for medical complications and a diminished quality of life.
Failure to Conduct Routine Maintenance on Side Rails
Penalty
Summary
The facility failed to conduct routine maintenance to ensure the safety of side rails for one resident, identified as Resident 4, who was reviewed for accident hazards. The facility's policy, revised in August 2022, required regular inspections of bed frames, mattresses, and side rails to identify potential entrapment areas. However, the Maintenance Manager, Staff S, admitted that side rails were not routinely checked for safety and were only inspected when a resident was discharged or admitted. This lack of routine maintenance was confirmed during a joint observation with Resident 4, where bilateral side rails were found in the raised position, and Staff S stated they were unaware of any side rails in use. Resident 4, who required extensive assistance for bed mobility and transfers, used the side rails to aid in getting up from a lying position. Despite the resident's reliance on the side rails, the facility did not have a process for routine maintenance or documentation to ensure their safety. Interviews with the Administrator, Staff A, further confirmed the absence of a maintenance process for side rails, placing residents at risk for injury or entrapment due to the facility's oversight.
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.
Trusted data from CMS and state health departments
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.
Trusted by long-term care providers and associations.
