Snohomish Health And Rehabilitation Of Cascadia
Inspection history, citations, penalties and survey trends for this long-term care facility in Snohomish, Washington.
- Location
- 800 10th Street, Snohomish, Washington 98290
- CMS Provider Number
- 505338
- Inspections on file
- 32
- Latest survey
- April 14, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Snohomish Health And Rehabilitation Of Cascadia during CMS and state inspections, most recent first.
Surveyors found that the facility did not develop or update person-centered care plans for four residents after falls that resulted in fractures, facial injuries, and new mobility restrictions. Despite provider orders for slings, splints, non‑weight‑bearing status, and increased assistance with ADLs, the comprehensive care plans and Kardexes continued to show residents as independent or omitted the new injuries and devices. RNs and LPNs acknowledged that fractures, braces, slings, weight‑bearing status, and changes in mobility and ADL ability were not accurately or timely reflected in the care plans, contrary to facility policy requiring timely, measurable, interdisciplinary care planning based on changes in condition.
The facility failed to obtain accurate MD orders and provide appropriate monitoring for fall-related injuries and devices for several residents. One resident with cognitive impairment and a prior fracture had a left arm fracture treated with a sling and non–weight-bearing instructions, but orders and TAR entries were written for the right arm instead, and monitoring for the actual injured arm was not documented. Another cognitively impaired resident’s fall-related humeral fracture was omitted from the investigation summary, and the reporting log contained incorrect fall details. A third resident with dementia sustained a broken nose and a sutured forehead laceration, yet the laceration was not recorded on the reporting log and had no associated orders or TAR monitoring. A fourth resident with stroke-related deficits suffered a left hand fracture, forehead laceration with sutures, and facial bruising; the reporting log omitted the laceration, orders initially referenced the wrong wrist for brace use and non–weight-bearing status, and there was no TAR documentation for monitoring the left-hand brace, forehead laceration, or facial bruising.
A resident with moderate cognitive impairment, impaired vision, and use of a front-wheeled walker left AMA after signing out and not returning, later reporting by phone that they were staying in a motel and did not wish to come back. Despite facility policy and staff descriptions that AMA departures should include resident education, safety checks, discharge instructions, provider and family notification, APS reporting, and EHR documentation, there were no discharge instructions or discharge summary in the EHR and no documented notifications to the emergency contact, provider, or APS for this resident.
A resident with complex medical needs did not receive a prescribed IV normal saline treatment, and the event was not documented or investigated as a medication error. Staff interviews confirmed that no incident report or investigation was initiated, contrary to facility policy and state guidelines.
A resident with a complex medical history did not receive ordered IV normal saline for diarrhea and elevated creatinine because the physician's order remained unconfirmed and unadministered in the electronic medical record. Nursing staff did not document attempts to start the IV or notify the provider, and the incident was not recorded in facility error logs.
A resident with hemiplegia, hemiparesis, and moderate cognitive impairment experienced a fall that was not investigated by facility staff. Required incident reporting and documentation were not completed, and the event was not logged, as confirmed by interviews with RNs, an LPN, and the DON.
The facility did not ensure that required PASARR screenings and Level II evaluations were accurately completed prior to admission for several residents with mental health diagnoses. Inaccurate documentation, missing evaluations, and a lack of understanding of the PASARR process led to residents being admitted without proper mental health assessments or determination letters.
The facility did not ensure that residents and their representatives were given the opportunity to participate in care conferences, as required. For three residents, there was no documentation of required care plan meetings, and staff interviews confirmed that care conferences were not being held as scheduled. This resulted in residents not being involved in discussions about their person-centered care.
A resident who expressed interest in formulating an Advance Directive was not provided with information or assistance by social services, and there was no documentation of follow-up or support, despite the resident's clear request and cognitive ability.
Surveyors found that care plans were not properly reviewed or updated for three residents, including one on long-term antiviral therapy, one at risk for pressure ulcers who was not using prescribed heel protection, and one with a lower limb amputation whose prosthesis use was not documented in the care plan. Staff interviews and observations confirmed that interventions were either missing, not implemented, or not updated to reflect current care practices.
A resident with severe cognitive impairment and on hospice care was found with their bed placed against the wall and a scoop mattress on the floor, without any physician's order, signed consent, or care plan documentation authorizing this setup as a restraint. Staff confirmed the bed had always been positioned this way and described it as a restraint, but the required assessment, order, and documentation were not completed.
A resident with Type 2 Diabetes Mellitus received Insulin Glargine on multiple occasions when their blood sugar was below the physician-ordered threshold, and in several instances, insulin was administered without any blood sugar being recorded. Documentation and staff interviews confirmed that the process for checking blood sugar prior to insulin administration was not consistently followed, and the care team was not informed of these deviations.
A resident with moderate cognitive impairment and a history of falls was found to have a broken lower denture with a missing tooth, resulting in discomfort when eating. Despite staff awareness of the broken denture, there was no documentation of a dental appointment being scheduled, and several staff members were unaware of the issue or had not initiated a referral for dental services.
Staff did not use required PPE, specifically gowns, during high-contact care activities for two residents on enhanced barrier precautions for wounds. In both cases, staff either misunderstood or disregarded EBP signage and care plan instructions, resulting in transfers and personal care being performed without proper gown use as required by CDC guidelines.
The facility failed to assess and manage the risk of pressure ulcers for four residents, leading to the development and worsening of PUs. Residents were not provided with timely interventions such as air mattresses and pressure-relieving devices, and documentation was inconsistent. These failures resulted in significant harm, including the deterioration of a Stage 2 PU to a Stage 4 PU with osteomyelitis in one resident.
The facility failed to consistently implement care plan interventions related to bed height and mattress type to prevent accidents and falls for a resident. The resident fell out of bed, sustained a left hip fracture, and required hospitalization. Staff were unaware of the specific fall interventions, and the care plan was not updated after the incident.
A resident with severe cognitive impairment fell and sustained a fracture. The facility's investigation was incomplete, lacking staff statements and a root cause analysis. Staff interviews confirmed that proper protocols were not followed, and this is a repeat citation.
The facility failed to ensure timely review and revision of the care plan for a resident with vascular dementia and a left femur fracture. Observations revealed inconsistencies in implementing fall prevention interventions, such as the absence of a perimeter mattress and fall mat. Staff interviews indicated reliance on outdated Kardex information, leading to inconsistent care practices and placing the resident at risk for unmet care needs.
Failure to Update Person-Centered Care Plans After Falls and Fractures
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable goals and interventions for multiple residents following falls and injuries. Facility policy required timely, person-centered comprehensive care plans that reflect individual conditions, risks, needs, behaviors, cultural values, preferences, and include measurable goals, appropriate interventions, and realistic timeframes, with updates as needed for changes in condition. Despite this, the care plans and Kardexes for four residents did not reflect new fractures, use of slings or splints, non‑weight‑bearing orders, changes in mobility, or increased assistance needs after documented falls and hospital evaluations. For one resident with moderate cognitive impairment and a history of falls and a left femur fracture, records showed a fall resulting in a non‑displaced humeral neck fracture and subsequent hospital visit, after which the resident returned with a sling and instructions not to move the left arm and to remain non‑weight‑bearing on that arm. Orthopedic documentation confirmed sling use and non‑weight‑bearing status. However, the comprehensive care plan did not include the left arm fracture, sling use, non‑weight‑bearing status, or increased ADL assistance needs, and the Kardex continued to list the resident as independent with transfers, bed mobility, and ambulation with a walker. Staff interviews confirmed that the care plan and Kardex had not been updated to reflect these changes and that the resident was no longer using a walker or getting out of bed. Another resident with severe cognitive impairment and diagnoses including falls, muscle weakness, and unsteadiness on feet had an X‑ray showing a possible non‑displaced humeral neck fracture and a provider order for a sling to the left arm, but the care plan did not address the fracture, sling use, or non‑weight‑bearing status, and a mobility‑related care plan focus was incomplete. The Kardex still showed the resident as independent with mobility and did not mention the sling or non‑weight‑bearing status. A third resident with dementia and severe cognitive impairment sustained a broken nose, facial abrasion, and a forehead laceration with sutures after a fall, but none of these injuries were added to the care plan. A fourth resident with severe cognitive impairment, stroke, and right‑sided weakness had a fall resulting in a fracture to the left fifth finger, a splint to the left hand, and a forehead laceration with sutures; the care plan did not include the left finger fracture, facial laceration, or bruising, and instead documented non‑weight‑bearing and a brace to the right wrist, which staff acknowledged was the wrong hand and initiated later than the injury. Staff interviews consistently confirmed that fractures, braces, slings, weight‑bearing status, and changes in mobility and ADL ability were not accurately or timely reflected in the care plans.
Failure to Obtain Accurate Orders and Monitor Fall-Related Injuries and Devices
Penalty
Summary
The deficiency involves the facility’s failure to obtain accurate physician orders and provide monitoring for fall-related injuries and interventions for multiple residents. For one resident with a history of falls and a left femur fracture, the resident sustained a non-displaced humeral neck fracture to the left arm after rolling out of bed. Hospital and orthopedic documentation indicated the left arm required a sling and non-weight-bearing status, but the physician orders and Treatment Administration Record (TAR) were written for the right upper extremity instead. There were no physician orders or TAR documentation for monitoring the sling or non-weight-bearing status to the left arm, despite observations showing the resident wearing a sling on the left arm and staff acknowledging that orders and monitoring should have been in place for the correct extremity. Another resident with severe cognitive impairment and a history of falls had a possible non-displaced humeral neck fracture to the left arm identified on an X-ray following a fall. The facility’s investigation summary for this fall did not document that the resident sustained a fracture, and the reporting log contained incorrect date and time information for the fall with fracture. A third resident with dementia and severe cognitive impairment experienced a fall resulting in a broken nose and a forehead laceration requiring sutures, as documented in a hospital After Visit Summary. However, the facility’s reporting log did not document the laceration injury, and there were no physician orders or TAR documentation for monitoring the forehead laceration, which staff later acknowledged was missing. A fourth resident with stroke, hemiplegia, hemiparesis, muscle weakness, and a history of falls sustained a fracture to the fifth metacarpal of the left hand and a forehead laceration with sutures, along with facial bruising, as documented in hospital records. The resident was placed in an ulnar gutter brace and ordered to remain non-weight-bearing through the left hand with specific range-of-motion allowances. The facility’s reporting log did not document the forehead laceration, and physician orders did not include monitoring of the left wrist brace until several weeks later, instead initially referencing non-weight-bearing status and brace use for the right wrist. The TAR lacked documentation of monitoring for the left wrist brace, the forehead laceration, and facial bruising, despite observations of the resident wearing the left-hand brace and staff interviews confirming the absence of appropriate monitoring orders and documentation. The report states that these failures placed residents at risk for further injury, unmet care needs, and diminished quality of life.
Failure to Ensure Safe AMA Discharge and Required Notifications
Penalty
Summary
Surveyors found that the facility failed to ensure a safe discharge plan for one resident who left the facility against medical advice (AMA). The resident had moderate cognitive impairment, impaired vision, and used a front-wheeled walker. A recent hospital discharge summary documented that psychiatry had determined the resident did not have decisional capacity and that the resident’s son was the surrogate decision maker. The facility’s transfer/discharge policy required evidence of discussion with the resident to make an AMA departure a safe discharge. On the date in question, the resident signed out of the facility in the Patient Sign In & Out Log but did not sign back in, and later told a nurse by phone that they were staying in a motel and did not want to return, except possibly to retrieve belongings. Record review showed no discharge instructions or discharge summary in the resident’s EHR, and no documentation that the resident’s emergency contact, provider, or Adult Protective Services (APS) had been notified. Multiple staff, including RNs, Social Services, and the Administrator, described that their usual process when a resident leaves AMA or stays out overnight includes educating the resident on risks, ensuring safety, notifying the Administrator, Social Services, APS, the provider, and the resident’s emergency contact, and documenting these actions in progress notes. Social Services staff also stated they would attempt to arrange home health services, instruct the resident to contact their primary care provider, and provide resources, with all steps documented in the EHR. However, staff were unable to provide any documentation that these steps were taken for this resident, and there was no evidence in the progress notes of APS notification or other required communications related to the AMA discharge.
Failure to Investigate Medication Error Incident
Penalty
Summary
The facility failed to thoroughly investigate a medication error incident involving one resident who was admitted with a fistula of the vagina to the small intestine and an ileostomy. The resident experienced diarrhea and elevated creatinine, for which a physician ordered a one-time intravenous administration of 1 liter of normal saline. Review of the Medication Administration Record (MAR) showed no documentation that the IV normal saline was administered, and the facility's incident reporting logs did not reflect a medication error for this resident. Interviews with facility staff, including LPNs and the Director of Nursing, confirmed that no incident report or investigation was initiated regarding the potential medication error. Staff acknowledged that, according to facility policy and state guidelines, an investigation should have been conducted to determine the circumstances and cause of the incident. The lack of investigation left unanswered questions about the occurrence and whether it was related to neglect or unmet care needs.
Failure to Administer Ordered IV Hydration Due to Unconfirmed Physician Order
Penalty
Summary
A deficiency occurred when a resident with a history of a fistula between the vagina and small intestine, and an ileostomy, was not administered intravenous (IV) normal saline (NS) as ordered by the physician. The physician had ordered 1 liter of NS to be given intravenously for three days due to the resident experiencing diarrhea and elevated creatinine levels. Review of the Medication Administration Record (MAR) showed the order was entered but remained in a pending status and was never confirmed or administered. There was no documentation that the IV NS was given to the resident. Interviews with nursing staff and the Director of Nursing (DNS) revealed that nurses are responsible for checking and confirming pending orders in the electronic medical record system. Staff acknowledged that the order for IV NS was not processed, confirmed, or administered, and that the order was eventually discontinued. The DNS stated that if nurses are unable to start an IV, they are expected to notify the provider and document the attempts, but no documentation of provider notification was found. The incident was not recorded in the facility's incident or medication error logs.
Failure to Investigate Resident Fall
Penalty
Summary
The facility failed to conduct an investigation following a fall experienced by a resident with a history of hemiplegia and hemiparesis after a cerebral infarction, who also had moderate cognitive impairment. The incident occurred when the resident dropped herself to the floor while staff were opening the door for medics, after which she was transported to the hospital. Review of facility records, including the State Incident Reporting log and progress notes, revealed that there was no investigation documented for this fall, nor was the incident logged as required. Interviews with nursing staff confirmed that standard protocol following a fall includes assessment, notification, obtaining staff statements, and completing an incident report in the computer system. However, the Director of Nursing acknowledged that no incident report was completed and the event was not entered into the reporting log. The lack of investigation meant that the root cause and contributing factors of the fall were not identified, and there was no documentation to rule out abuse, as required by state guidelines.
Failure to Complete Accurate PASARR Evaluations Prior to Admission
Penalty
Summary
The facility failed to ensure that four out of six reviewed residents had an accurate Pre-Admission Screening and Resident Review (PASARR) completed on or before admission. For several residents with documented mental health diagnoses such as bipolar disorder, anxiety disorder, and depression, the PASARR forms were either incorrectly completed, missing required Level II evaluations, or lacked determination letters prior to admission. In some cases, sections of the PASARR were marked incorrectly, such as indicating intellectual disability when there was no supporting diagnosis in the resident's medical history. For one resident with bipolar disorder and anxiety, the PASARR indicated the need for a Level II evaluation due to serious mental illness, but no determination letter or evaluation summary was found in the record. Another resident with severe cognitive impairment and on hospice had a PASARR form with incorrect indications of intellectual disability, despite no such diagnosis in their history. Staff interviews revealed a lack of understanding regarding proper PASARR completion and the process for obtaining and documenting Level II evaluations. Additionally, the facility admitted residents without having received the required Level II PASARR determination letters, as confirmed by both the social worker and the administrator. The process described by staff involved admitting residents and then waiting for the evaluation summary or determination letter, rather than ensuring these were completed prior to admission. This resulted in residents being admitted without the necessary mental health evaluations and documentation as required by federal regulations.
Failure to Involve Residents in Care Planning Conferences
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were given the opportunity to participate in care conferences, which are meetings where a resident's care is discussed and coordinated by the interdisciplinary team. For three residents reviewed, there was no documentation that required care conferences had been completed. One resident with moderate cognitive impairment had no record of a quarterly care conference. Another resident, who was cognitively intact, reported not being informed about or involved in any care plan meetings, and there was no documentation of such meetings in their record for over a year. A third resident, with no cognitive impairment, had a care conference scheduled, but there was no documentation that it occurred, and staff confirmed the absence of records for the meeting. Interviews with staff revealed that care conferences are expected to be conducted on admission, quarterly, annually, and as needed, but staff acknowledged that these meetings were not occurring as required for many residents. The lack of documentation and missed care conferences meant that residents were not involved in discussions about their person-centered care, and staff were unable to provide evidence that residents or their representatives were offered the opportunity to participate in care planning as mandated.
Failure to Assist Resident with Advance Directive Formulation
Penalty
Summary
The facility failed to obtain or offer assistance to a resident in formulating an Advance Directive (AD), despite documentation indicating the resident wished to pursue one. Upon admission, the resident was assessed as having no cognitive impairment, and the medical record included an Advance Directive Review stating the resident wanted to formulate an AD. However, there was no further documentation showing that the resident had been provided with information or assistance regarding their right to formulate an AD. Interviews with facility staff revealed that social services are responsible for assisting residents with ADs, including providing Power of Attorney documents and information for a mobile notary. The Social Services Assistant admitted to not following up with the resident, citing the resident's independence and lack of desire for others to be involved in their care or finances. The Administrator confirmed that the process should have started immediately upon the resident's request, but acknowledged that no documentation existed to show the resident was assisted in formulating an AD.
Failure to Review and Revise Care Plans for Multiple Residents
Penalty
Summary
The facility failed to review and revise care plans for three residents as required, resulting in deficiencies in care planning. For one resident with a history of shingles and on long-term antiviral medication, the care plan only referenced the medication under skin impairment without specifying goals or interventions related to the medication use. Staff interviews confirmed that the care plan lacked necessary details and had not been updated to reflect the resident's ongoing therapy and monitoring needs. Another resident, who was dependent on bed mobility and at risk for pressure ulcers, had a care plan intervention for heel protection that was not being implemented. Observations over several days showed the resident was not using pressure-relieving boots as documented, and staff reported that the resident did not tolerate the boots and alternative interventions, such as using pillows, were being used but not reflected in the care plan. The care plan had not been updated to remove the ineffective intervention or to include the actual care being provided. A third resident with a right below-knee amputation had a prosthesis and physician orders for its use, but the care plan did not document the presence of the prosthesis or instructions for its application and removal. Staff interviews revealed that the resident only wore the prosthesis during therapy sessions, and care staff relied on the care plan and Kardex for guidance, which did not include this information. The lack of care plan updates led to inconsistencies in care and documentation for the resident's prosthesis management.
Failure to Document and Authorize Bed Placement as Restraint
Penalty
Summary
A resident with Alzheimer's Disease and on hospice care, who had severely impaired cognition, was observed in bed with a blanket over their head. The bed was positioned in the lowest setting and placed against the wall, with a scoop mattress on the floor on one side. There was no physician's order, signed consent, or care plan documentation authorizing the bed to be placed against the wall for this resident. Multiple staff interviews confirmed that the bed had always been positioned against the wall for this resident, and staff described this practice as a form of restraint used in the facility. Staff also outlined the required process for implementing restraints, which includes assessment, obtaining a physician's order, securing consent, and updating the care plan. However, for this resident, none of these steps were documented or completed regarding the bed's placement against the wall.
Significant Medication Error: Insulin Administered Outside Blood Sugar Parameters
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors related to the administration of insulin. The resident, who had a diagnosis of Type 2 Diabetes Mellitus and intact cognition, had physician orders specifying that Insulin Glargine should be held if blood sugar (BS) was below a certain threshold. Despite these orders, documentation showed that the resident received 25 units of Insulin Glargine on multiple occasions when their BS was below the ordered parameter, and in several instances, there was no BS recorded at all prior to administration. Review of the Medication Administration Record (MAR) revealed that insulin was administered on numerous dates when the resident's BS was less than the ordered threshold, with specific BS values documented as low as 65. Additionally, there were several days where insulin was given without any BS being recorded on the MAR or in progress notes. Staff interviews confirmed that the process was to check BS before administering insulin and to hold the dose if BS was low, but the records indicated this was not consistently followed. Further interviews with nursing staff and management revealed inconsistencies in documentation and a lack of clarity regarding the medication administration process. One nurse stated they may have mistakenly documented administration due to unfamiliarity with the electronic charting system, but injection sites and BS values outside parameters were still recorded. The resident's care team, including the advanced registered nurse practitioner, was not informed that insulin had been administered outside the ordered parameters.
Failure to Coordinate Timely Denture Services
Penalty
Summary
The facility failed to ensure that a resident received timely assistance in coordinating appropriate denture services. The resident, who had a history of pneumonia and vascular dementia and was assessed as having moderate cognitive impairment, was documented as having upper and lower dentures. Despite documentation indicating no issues with broken or loose dentures and no reported mouth pain or difficulty chewing, interviews and observations revealed that the resident's lower denture was broken and missing a tooth following a fall. The resident reported discomfort when eating, and both a collateral contact and a nursing assistant confirmed the dentures were old and missing a tooth. A review of the resident's medical record showed no documentation of a scheduled dental appointment. Multiple staff members, including LPNs and a care manager, were either unaware of the broken denture or had not initiated a dental referral. The process for scheduling dental appointments was described, but there was no evidence that it had been followed for this resident until after the issue was identified during the survey. The deficiency was identified through interviews, record review, and direct observation.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care Activities
Penalty
Summary
Facility staff failed to use personal protective equipment (PPE) in accordance with CDC guidelines for residents on enhanced barrier precautions (EBP). For one resident with an open wound and stage 4 pressure ulcer, a nursing assistant did not wear a gown while transferring the resident from bed to wheelchair, despite EBP signage and care plan instructions indicating that gowns were required for high-contact activities such as transferring. The staff member acknowledged awareness of the signage but did not follow the required protocol. In another instance, two staff members assisted a resident with venous ulcers in transferring, repositioning, and dressing after a shower without wearing gowns, only donning gloves. Both staff members misunderstood the EBP signage, believing gowns were only necessary for nurses performing wound care, not for high-contact activities like transferring. The resident's care plan and physician orders specified EBP with gown and glove use for such activities, but these instructions were not followed.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to comprehensively assess the increased risk for skin breakdown, follow written policy and procedures, and develop and implement timely interventions necessary to prevent the development of avoidable pressure ulcers (PUs) for four residents. Resident 1 admitted with a Stage 2 PU, which deteriorated into an unstageable PU with osteomyelitis, requiring debridement and hospital treatment. The facility did not implement recommended interventions such as an air mattress in a timely manner, leading to the worsening of the resident's condition. Documentation and communication lapses were evident, as the care plan was not updated with new interventions, and the air mattress was not provided until 43 days after it was recommended by the wound care specialist. The resident's condition deteriorated significantly, resulting in a Stage 4 PU and osteomyelitis, necessitating hospital transfer and treatment. The facility's failure to follow through with timely interventions and proper documentation contributed to the resident's harm and deterioration. Resident 2 admitted without PUs, developed a DTPI on the right heel, which was not properly documented or measured initially. Observations revealed that the resident was not provided with pressure-relieving devices as required by their care plan. Further assessments identified additional wounds, indicating a lack of consistent and thorough skin inspections. The facility's failure to implement and monitor appropriate interventions led to the development and worsening of pressure ulcers in this resident. Resident 3, who was cognitively intact, developed a DTPI on the right heel, which was not documented accurately in subsequent skin inspections. The resident's family discovered the wound, and the facility staff failed to provide appropriate pressure-relieving devices. The care plan was not updated promptly, and the resident experienced pain during dressing changes. The facility's lack of timely and accurate documentation, along with the failure to provide necessary interventions, resulted in the resident's harm. Resident 4, admitted without PUs, developed a Stage 3 PU on the right heel. Observations showed that the resident was not consistently provided with pressure-relieving devices, and the care plan was not followed. The facility staff failed to place protective boots on the resident, despite the care plan's requirements. The facility's failure to adhere to care plan interventions and provide consistent pressure relief led to the development and worsening of pressure ulcers in this resident.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to consistently implement care plan interventions related to bed height and mattress type to prevent accidents and falls for a resident reviewed for falls and accident hazards. The resident experienced harm when they fell out of bed and sustained a left hip fracture, pain, and required hospitalization. The care plan for the resident included keeping the bed in a safe position for transfers and using a perimeter mattress, but these interventions were not consistently followed or updated after the fall incident. The facility's incident reporting log documented that the resident sustained an unwitnessed fall in their room, resulting in a fracture. The investigation revealed that the bed was in a high position at the time of the fall, and the resident was found lying on the floor. Staff interviews and observations confirmed that a standard mattress was in place instead of the required perimeter mattress, and the bed was not consistently kept in the low position as per the care plan. Additionally, the Kardex did not reflect the correct fall interventions, and staff were unsure of the specific interventions required for the resident. Further interviews with staff indicated a lack of awareness and adherence to the resident's fall intervention plan. The maintenance department did not maintain a log for perimeter mattresses, and there was no clear communication regarding the need for such mattresses. The facility's failure to implement and monitor the prescribed interventions placed the resident at risk for falls and injuries, as evidenced by the repeated observations of non-compliance with the care plan requirements.
Failure to Conduct Thorough Fall Investigation
Penalty
Summary
The facility failed to conduct a thorough investigation for a resident who experienced a fall. The resident, who had severe cognitive impairment and required extensive assistance with mobility and personal care, sustained a fall in their room, resulting in a left femur fracture. The investigation into the fall was incomplete, lacking statements from all staff involved, contributing factors, and a root cause analysis. This failure to thoroughly investigate the incident left the facility unable to rule out abuse or neglect. Interviews with facility staff revealed that the expected protocol for unwitnessed falls was not followed. The Director of Nursing and the Regional Nurse Consultant both confirmed that the investigation should have included witness statements and a comprehensive assessment of the environment and circumstances leading to the fall. Additionally, the nurse on duty did not call 911 immediately when the resident complained of pain and was unable to move their leg, which was against the expected procedure. This is a repeat citation from previous surveys.
Failure to Update and Implement Care Plan for Fall Prevention
Penalty
Summary
The facility failed to ensure timely review and revision of the care plan for Resident 7, who was admitted with diagnoses including vascular dementia with behavioral disturbances and major depressive disorder, and later re-admitted with a left femur fracture. The care plan, dated 06/20/2022, included interventions for impaired mobility and fall risk, such as keeping the bed in a safe position and using a perimeter mattress. However, observations revealed inconsistencies in the implementation of these interventions, with the resident's bed often lacking the prescribed perimeter mattress and the fall mat not consistently in place. Staff interviews indicated a lack of awareness and reliance on outdated or incorrect information in the Kardex, leading to inconsistent care practices for Resident 7's fall prevention needs. Multiple observations between 04/10/2024 and 05/01/2024 showed that the resident's bed was frequently not in the low position, and the fall mat was not always present. Staff members, including CNAs and RNs, demonstrated uncertainty about the correct fall interventions and admitted to relying on common sense or outdated Kardex information. The RN/Regional Nurse Consultant confirmed that the care plan included a perimeter mattress as of 11/18/2023, but it was not present on the resident's bed during the survey period. This inconsistency in care plan implementation and staff awareness placed Resident 7 at risk for unmet care needs and potential harm. This issue was noted as a repeat citation from a previous survey dated 03/24/2024.
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.
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