Stafholt Health And Rehabilitation Of Cascadia
Inspection history, citations, penalties and survey trends for this long-term care facility in Blaine, Washington.
- Location
- 456 C Street, Blaine, Washington 98230
- CMS Provider Number
- 505395
- Inspections on file
- 40
- Latest survey
- April 2, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Stafholt Health And Rehabilitation Of Cascadia during CMS and state inspections, most recent first.
A resident on warfarin with an INR goal of 2–3 had multiple INR tests showing fluctuating and at times critically high results, with corresponding changes in warfarin dosing and eventual bleeding symptoms requiring hospital admission. Surveyors found the INR flowsheet for this resident was incomplete and missing several test entries. Staff reported that INR testing was done in-house using a Coag-Sense meter and that quality control (QC) checks were expected when a new box of strips was opened, but there was no formal process to document QC. An opened box of test strips still contained unused high and low control strips matching the lot numbers of strips in use, and staff acknowledged this meant QC testing had not been performed, despite these strips being used for the resident’s INR monitoring.
A resident with multiple broken and missing teeth experienced persistent tooth pain affecting chewing and requiring a downgraded soft diet, but the facility did not adequately assess or manage this dental pain. The resident reported constant pain in a lower molar and limited relief from Tylenol, while staff noted ongoing complaints and pain with oral care. The pain assessment had not been updated to include dental pain, the care plan only addressed arthritis pain, and no targeted analgesic regimen for dental pain was documented. Although a dentist had evaluated the resident and a provider ordered PRN topical gum medication for tooth pain, the MAR showed it was used only once, and the Resident Care Manager had not completed a new pain assessment or monitored use of the ordered topical treatment.
A resident with severe visual impairment and a history of bipolar disorder did not receive assistance from facility staff to understand their financial matters, despite ongoing payment issues and confusion about billing. Staff interviews confirmed that neither the business office nor social services provided the necessary support or documentation to help the resident manage or comprehend their facility charges.
A resident was administered psychoactive medications for depression and anxiety without documented informed consent at admission. Staff believed previous consents could be used for the re-admission, resulting in a delay before new consents were obtained, contrary to facility policy.
A resident with a history of strokes and dependent on staff for ADLs was documented as able to perform oral hygiene with supervision using an electric toothbrush, but observations and staff interviews revealed the toothbrush was not used and only toothettes were provided. The care plan was not updated to reflect the resident's current needs or the actual care being given.
A resident with moderate cognitive impairment and chronic medical conditions did not receive consistent assistance with oral hygiene and the application of offloading boots as required by their care plan. Observations and interviews revealed that oral care was not provided for several days and offloading boots were not consistently applied, despite staff being prompted and documentation indicating these tasks should have been completed.
A resident with cognitive impairment and a history of strokes, falls, and a sacral pressure ulcer experienced ongoing pain that was not adequately managed. Despite regular pain assessments and routine pain medications, the resident frequently exhibited pain behaviors during care, therapy, and transfers, with pain ratings often exceeding the documented goal. Staff did not consistently pre-medicate before known painful procedures, and the as-needed pain medication was only available for moderate to severe pain, leaving mild to moderate pain unaddressed.
A resident with a history of sexual trauma experienced abuse when a NAC attempted to manually remove impacted feces without consent, outside their scope of practice. The resident, who was cognitively intact, felt violated and traumatized, highlighting a failure in communication and adherence to care guidelines. Staff interviews revealed a lack of understanding of the NAC's scope of practice and the importance of obtaining consent.
A facility failed to inform a resident's representative about a new Lasix order, despite the resident's kidney function concerns. The resident, with chronic heart disease and kidney failure, received Lasix without the representative's knowledge. Staff interviews confirmed the notification should have occurred.
The facility failed to weigh three residents with congestive heart failure daily as required by their care plans. Interviews with staff revealed inconsistencies in the process for obtaining and documenting weights, with tasks being passed between shifts and documentation not automatically updating in the MAR or TAR. The Director of Nursing was unaware of the issue, and the electronic system did not flag missing weights.
A facility failed to ensure that 3 out of 6 nursing staff responsible for CPR were current in their training. This issue was discovered when a resident with a full code status was found unresponsive and later declared deceased by EMS. Investigation showed that many staff members lacked current CPR certification, posing a risk of inadequate emergency response.
A resident with a history of embolism, thrombosis, and gangrene did not receive consistent wound care, leading to a severe infection with maggots. The facility failed to follow specific wound care orders, resulting in missed treatments and inconsistent dressing applications. The resident's condition deteriorated, leading to bilateral below-knee amputations due to critical limb ischemia with maggots and infected gangrene.
A resident with mild cognitive impairment and no teeth expressed a desire for new dentures, but the facility failed to follow up on a denturist referral. Despite a referral order and social services being tasked with follow-up, no action was documented over several months. The responsible social services staff had left, and the new staff were unaware of the referral, leading to a repeat citation for the facility.
The facility failed to ensure residents could voice grievances without fear of retaliation, as the Resident Council Committee (RCC) was required to vote on one complaint to file as a grievance. Despite multiple complaints about call light response times, missing items, and excessive wait times, no grievances were recorded in the logs. Staff interviews revealed that residents feared retaliation if their names were attached to grievances, and the facility's process required a majority vote to file a grievance, hindering the resolution of issues.
The facility failed to honor the bathing preferences of two residents, leading to a deficiency in resident self-determination and choice. One resident received only two baths over 18 days, while another received only four baths over 64 days, despite their care plans specifying more frequent bathing.
The facility failed to provide a required refund within 30 days after a resident's discharge. The refund of $3,147.42 was issued 75 days after discharge, contrary to regulations. The Interim Administrator confirmed that refunds should be sent within 30 days.
A facility failed to investigate an allegation of abuse and neglect where a resident was told to urinate in their brief because staff did not know how to apply the resident's back brace. The incident was reported but not documented or investigated properly, leading to a breakdown in communication and procedural adherence.
The facility failed to arrange hospice services for a resident with multiple diagnoses, despite a family member's request for a specific hospice agency. The facility did not provide information about their contracted hospice agencies or offer to transfer the resident to a facility that contracted with the requested hospice agency, denying the resident their hospice benefit.
Failure to Perform and Document INR Meter Quality Control for Warfarin Monitoring
Penalty
Summary
The facility failed to ensure pharmaceutical services included appropriate processes for the provision, monitoring, and use of medication related to devices for a resident receiving warfarin therapy. The resident had orders for warfarin, with a therapeutic INR goal range of 2–3, and underwent multiple INR tests during their stay. The INR results fluctuated, including values of 3.2 (high) with orders to hold warfarin, 1.5 (low) with orders to resume, 1.7 (low) with orders to increase the dose, 3.2 (high) with orders to hold, 3.0 with orders to resume, and a critically high value of 5.3, after which the resident exhibited symptoms of bleeding and was sent to the emergency department and admitted. The resident’s INR results were supposed to be tracked on a flowsheet, but the flowsheet for this resident was observed to be incomplete and missing several INR tests performed while the resident was in the facility. Surveyor interviews and observations showed that the facility used a single Coag-Sense meter for INR testing and that test strips were supplied with high and low control strips and control solution, with manufacturer instructions requiring control testing with each new lot. Staff C stated that the facility performed its own INR testing and that meters were control tested each time a new box of strips was opened, but also acknowledged there was no established process for documenting these control tests and suggested staff might sign the box, although no signatures were found. The box of test strips in use still contained unopened high and low control strips matching the lot numbers of the strips used, and Staff C agreed this indicated that control testing for that box had not been done. Staff C further confirmed that these strips had been used during the period when the resident was receiving INR checks. The DON later confirmed there had not been a system to document quality control checks on the INR meter.
Inadequate Pain Management for Ongoing Dental Pain
Penalty
Summary
The facility failed to provide adequate pain management for a long-term resident experiencing ongoing dental pain. The resident, who had many missing and broken teeth and reported a constantly painful left lower molar, stated that they believed they were only receiving Tylenol for tooth pain and that it did not work well. Observation showed the resident holding their left lower jaw while speaking and reporting that more than one tooth was bad, with one tooth hurting all the time. A CNA reported that the resident had to eat soft foods, complained that their tooth hurt all the time and had been hurting for a while, and that tooth brushing caused pain when the tooth was touched. The resident’s diet had been downgraded to softer textures due to tooth pain and inability to chew, and the resident had been experiencing tooth pain for more than one month. Record review showed the resident was seen by a dentist for tooth pain and prescribed antibiotics for a tooth infection, with a follow-up appointment for extractions pending. The most recent pain assessment, completed in January, did not include dental issues or pain, and the care plan addressed arthritis pain but was not revised to include dental pain. Provider orders included routine Tylenol three times daily since the prior year for difficulty walking and PRN Tylenol for head and leg pain, which had been administered multiple times in March, but there was no specific pain regimen documented for dental pain. A provider note on March 24 documented continued tooth pain and resulted in an order for a topical gum medication PRN for tooth pain; however, the MAR showed this topical medication was administered only once after the order. The Resident Care Manager acknowledged that no new pain assessment had been completed for the dental pain and was unaware that the new topical pain medication order had not been utilized.
Failure to Provide Social Services Assistance for Resident Financial Understanding
Penalty
Summary
The facility failed to provide medically related social services to assist a resident with understanding their financial matters, despite the resident having severe visual impairment and a diagnosis of bipolar disorder. The resident was cognitively intact but had severely impaired vision, and relied on an individual (Collateral Contact) to assist with finances. When the facility contacted this individual for financial information, the individual declined further involvement. There was no documentation that the facility had assisted the resident in understanding facility charges or their financial situation, even though the resident had not made a payment in over a year and expressed confusion about billing. Interviews with facility staff revealed that the Business Office Manager had not collaborated with Social Services regarding the resident's financial issues, and the Social Service Manager stated they had not assisted the resident because the resident had not specifically requested help. The resident reported not receiving clear explanations about billing and expressed difficulty managing finances due to visual impairment. The facility's records lacked evidence of any efforts to help the resident understand their financial responsibilities, and staff acknowledged the absence of such documentation.
Failure to Obtain Informed Consent for Psychoactive Medications
Penalty
Summary
The facility failed to ensure that a resident was fully informed and provided consent regarding the use of psychoactive medications upon admission. The facility's policy requires documentation of resident or advocate notification, education, and consent for psychoactive medication use. However, review of the resident's electronic medical record revealed no documentation or signed consents for psychoactive medication use at the time of admission, despite the resident receiving medications such as aripiprazole, duloxetine, and buspirone for major depressive disorder, depression, and anxiety disorder. Interviews with facility staff indicated that the responsibility for obtaining consents lies with the Resident Care Manager nurses, who stated that consents are typically obtained at admission. In this case, staff believed that consents from a previous admission could be used, and new consents were not obtained until several days after the resident's re-admission. The Director of Nursing Services acknowledged that the issue arose because the resident was a re-admit and the consents were incorrectly marked as completed at the time of admission.
Failure to Update and Revise Care Plan for Oral Hygiene
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised for a resident who was dependent on staff for activities of daily living, specifically oral hygiene. The resident, with a history of strokes and limited ability to perform self-care, was documented in the care plan as being able to perform oral hygiene with supervision and cueing, preferring to use an electric toothbrush. However, observations over several days showed that the electric toothbrush remained unused and dry, and interviews with staff revealed that only foam toothettes were being used for oral care. Staff reported that the resident was unable to assist with oral care due to hand tremors and that they were unaware of the specific care plan instructions regarding oral hygiene. Further interviews with nursing management indicated that care plans should be updated as changes in a resident's condition occur, such as decreased ability or changes in orders. However, the care plan for this resident had not been updated to reflect the resident's current inability to participate in oral care or the use of toothettes instead of the electric toothbrush. This lack of timely review and revision of the care plan resulted in staff not providing care as outlined in the resident's documented plan.
Failure to Provide Consistent ADL Support and Prevent Decline
Penalty
Summary
The facility failed to ensure that a resident's abilities in activities of daily living (ADLs) did not diminish without a medical reason. Resident 206, who had a history of chronic foot ulcer, hypertension, and altered mental status with moderate cognitive impairment, was admitted requiring set-up assistance for oral hygiene and assistance with offloading boots while in bed. Despite care plans indicating the resident could perform oral hygiene independently after set-up and required staff to apply offloading boots, observations and interviews revealed lapses in care. Multiple observations showed that Resident 206's toothbrush remained unused and dry over several days, and the resident reported not having brushed their teeth for many days, despite documentation indicating daily oral hygiene assistance was to be provided. Additionally, the resident was observed in bed without offloading boots, which were instead found on the bedside table. The resident stated they relied on staff to apply the boots and had not refused their use. Staff interviews confirmed a lack of awareness regarding the resident's inconsistent use of offloading boots and oral care, despite care plans and task prompts indicating these interventions were required.
Failure to Provide Resident-Centered Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident with a history of strokes, falls, and a hospital-acquired sacral pressure ulcer. The resident was cognitively impaired and had documented pain, with assessments indicating both verbal and non-verbal expressions of pain, including moaning, grimacing, and vocalizations during care activities. The resident's pain goal was documented as a 2 on a 0-10 scale, but pain ratings were frequently higher, and the care plan interventions were limited to administering medications as ordered and monitoring effectiveness. Despite regular pain monitoring and routine administration of Suboxone and Tylenol, the resident experienced multiple episodes where pain was not adequately controlled, as evidenced by family reports of the resident being in agony and staff observations of pain behaviors during wound care, transfers, and therapy. The as-needed (PRN) pain medication order was only available for moderate to severe pain, with no PRN option for mild to moderate pain, and there was a lack of pre-medication before known painful procedures such as wound care and therapy. Staff interviews confirmed that the resident consistently exhibited pain behaviors during care and therapy, and staff acknowledged that pain was not always addressed proactively. The Director of Nursing and Resident Care Manager were unaware that the PRN pain medication was not available for mild to moderate pain and recognized that pre-medicating before anticipated painful events had not been implemented. These findings demonstrate a failure to assess and implement resident-centered pain interventions as required.
Failure to Prevent Abuse and Ensure Resident Safety
Penalty
Summary
The facility failed to prevent psychosocial and physical abuse of a resident with a known history of sexual trauma. The incident occurred when a Nursing Assistant Certified (NAC) attempted to manually remove impacted feces from the resident without their consent and outside the NAC's scope of practice. The resident, who was cognitively intact and had a history of childhood sexual abuse, experienced significant distress and harm during the procedure, which was performed despite the resident's request for the NAC to stop. The resident's care plan and documentation highlighted the need for sensitivity due to their past trauma, particularly with male caregivers. However, during an episode of constipation, the NAC proceeded with the procedure without obtaining proper consent and without a practitioner's order, as required by the facility's guidelines. The NAC claimed to have applied lubricant and broken up the stool without inserting fingers into the resident's rectum, but the resident reported feeling violated and traumatized by the experience. Interviews with other staff members revealed a lack of understanding and adherence to the scope of practice for NACs, as well as a failure to communicate effectively with the resident. The incident was not immediately reported, and the resident felt ashamed and distressed, which delayed the formal reporting of the incident. The facility's response included re-education of staff on obtaining consent and the appropriate scope of practice, but the deficiency highlighted a significant lapse in protecting the resident from abuse and ensuring their comfort and safety.
Failure to Notify Resident's Representative of Medication Change
Penalty
Summary
The facility failed to notify the resident's representative of a change in treatment for a resident who was reviewed for medication changes. The resident, who was admitted with chronic heart disease, congestive heart failure, low blood pressure, and kidney failure, received a new order for Lasix, a medication used to treat fluid retention. This order was documented in a progress note and the medication was administered the following morning. However, the resident's representative was not informed of this new medication order, despite being previously advised by hospital staff that the resident should not receive Lasix due to kidney function concerns. Interviews with facility staff confirmed that the resident's representative should have been notified of the medication change, but this did not occur.
Failure to Monitor Daily Weights for Residents with Congestive Heart Failure
Penalty
Summary
The facility failed to ensure that three residents with congestive heart failure were weighed daily as per their care plans and medical orders. Resident 1, who was admitted with a diagnosis of congestive heart failure, had no documented weights for 16 out of 29 days in August 2024 and three out of 12 days in September 2024. Resident 2, also diagnosed with congestive heart failure, was not weighed for seven days in August 2024 and eight days in September 2024. Resident 3, with a similar diagnosis, was not weighed 13 times in August 2024 and six times in September 2024. These lapses in daily weight monitoring were contrary to the residents' care plans, which included monitoring weight as a critical intervention for managing congestive heart failure. Interviews with facility staff revealed a lack of consistent procedures for ensuring daily weights were obtained and documented. Staff A, an RN, mentioned that daily communication sheets were used to inform NACs of residents needing to be weighed, but if weights were not obtained in the morning, the task was passed to the evening shift. Staff B, an LPN, noted that while NACs documented weights in their section of the medical record, this information did not automatically populate into the MAR or TAR. Staff C, the Director of Nursing Services, acknowledged that the electronic medical system did not flag missing daily weights, and they were unaware of any issues with obtaining these weights. This lack of coordination and system alerts contributed to the failure to consistently monitor the residents' weights as required.
Deficiency in CPR Certification Among Nursing Staff
Penalty
Summary
The facility failed to ensure that 3 out of 6 nursing staff responsible for providing cardiopulmonary resuscitation (CPR) were current in their CPR training. This deficiency was identified during a review of the facility's policy on CPR, which lacked a process to ensure nursing staff maintained their Healthcare Provider CPR certifications. The deficiency was highlighted when Resident 1, who had a full code status and required full treatment to attempt resuscitation, was found unresponsive. Despite CPR being initiated and emergency services being called, Resident 1 was declared deceased by EMS on site after approximately 20 minutes. Further investigation revealed that the nursing staff present at the time, including Staff F, Staff E, and Staff D, did not have current CPR certifications. A comparison of the facility's employee roster with the CPR certification status showed that 18 out of 27 licensed nurses and 24 out of 28 Nursing Assisted Certified (NAC) staff did not have records of current CPR certification. This lack of current certification among the staff posed a potential risk of inadequate response in emergencies, as acknowledged by Staff G, the Director of Nursing Services, who admitted to identifying gaps in the nursing staff's CPR certification.
Failure to Provide Consistent Wound Care Leads to Severe Infection
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident with non-pressure related skin ulcers, leading to a severe parasitic infection known as myiasis. The resident, who had a history of embolism, thrombosis, atherosclerosis, phlebitis, thrombophlebitis, PTSD, and gangrene, was admitted with necrotic toes and required specific wound care orders. These orders included daily dressing changes, application of betadine, and the use of Rooke boots. However, the facility did not consistently follow these orders, as evidenced by missed treatments on specific dates and inconsistent dressing applications. The resident reported that the timing of their dressing changes was often delayed, and the dressings were not applied consistently, sometimes falling off due to being too loose. The resident also noted the presence of flies in their room days before being discharged to the hospital with maggots in their wounds. Interviews with staff revealed a lack of documentation regarding the resident's noncompliance or risky behaviors, and there was no evidence of education provided to the resident about these issues. Staff also mentioned that the resident was independent and often left the facility, which may have contributed to the deterioration of their condition. The situation escalated when the resident was found with maggots on their right foot and increased redness extending up their leg, leading to an emergency department visit where the wounds were found to have greatly deteriorated. The resident eventually underwent bilateral below-knee amputations due to critical limb ischemia with maggots and infected gangrene. The facility's failure to adhere to professional standards of practice in wound care placed the resident at significant risk, resulting in a severe decline in their condition.
Failure to Coordinate Dental Services for Edentulous Resident
Penalty
Summary
The facility failed to coordinate dental services for a resident who was edentulous, leading to a deficiency in providing necessary dental care. The resident, who had mild cognitive impairment and required assistance with personal care, expressed a desire for new dentures after losing their previous set years ago. Despite a denturist referral order being obtained and social services being tasked with follow-up, there was no documentation of any follow-up action from January to July 2024. Interviews revealed that the social services staff responsible for the follow-up had left the facility, and the new staff were unaware of the referral. The facility's process for handling dental referrals was not effectively executed, as evidenced by the lack of follow-up on the resident's request for dentures. The administrator and director of nursing services expected the nurse managers to ensure the referral was acted upon, but this did not occur. The deficiency was noted as a repeat citation, indicating a recurring issue with coordinating dental services for residents. The failure to follow up on the denturist referral left the resident without the necessary dental care, impacting their ability to eat and overall quality of life.
Failure to Address Resident Grievances Without Fear of Retaliation
Penalty
Summary
The facility failed to ensure that residents could voice grievances related to call light response time, missing personal items, and excessive wait times without fear of retaliation. The facility's policy, dated 11/28/2017, stated that individuals had the right to voice grievances without discrimination or reprisal. However, the Resident Council Committee (RCC) was not allowed to file grievances on complaints without fear of retaliation, which placed residents at risk for ongoing unmet care needs and diminished quality of life. The RCC minutes from meetings in April, May, and June 2024 showed various complaints, including unclean bathrooms, missing laundry, short staffing, cold meals, and long wait times for assistance and medication. Despite these complaints, the grievance logs for these months showed no grievances listed for the concerns raised in the RCC meetings. Interviews with staff revealed that the facility required the RCC to vote on one complaint to file as a grievance, and only the complaint with the majority vote would be filed. Staff B, the Activities Assistant, stated that residents were concerned about retaliation if their names were attached to grievances. Staff C, the Chief Executive Officer/Administrator, confirmed that they followed a process where a majority vote was needed to file a grievance from the RCC meeting. This process was a new directive from the Administrator, and residents were offered personal grievance forms if their complaint did not receive the majority vote. The fear of retaliation and the requirement for a majority vote hindered residents from reporting their grievances, leading to unresolved issues.
Failure to Honor Resident Bathing Preferences
Penalty
Summary
The facility failed to honor the bathing preferences of two residents, leading to a deficiency in resident self-determination and choice. Resident 3, who preferred to take a bath three times weekly, did not receive any baths during their first week at the facility and only received two baths over an 18-day period. This was despite the family member's concerns being communicated to the staff. Resident 3 had diagnoses including a compression fracture, anxiety, and weakness. Resident 4, who preferred a weekly bath and a bed bath if they refused a shower, received only three baths in February, one bath in March, and no baths in April up to the date of the report. Staff interviews revealed inconsistencies in the documentation and scheduling of baths, with some staff unaware of their responsibilities regarding resident bathing. Resident 4 had diagnoses including Adult Failure to Thrive, depression, mild cognitive impairment, and weakness. The facility's failure to adhere to the residents' care plans and preferences for bathing frequency was confirmed through interviews and record reviews.
Failure to Provide Timely Refund After Resident Discharge
Penalty
Summary
The facility failed to provide the required refund for one of four sampled residents within the mandated 30 days after discharge. Resident 1 was admitted to the facility and discharged on 11/21/2023. A review of the Complaint Resolution Unit report dated 03/26/2024 revealed that the facility did not provide the resident or their representative a refund for 10 days, claiming they were owed money for supplies. An interview with the Business Office Manager on 04/04/2024 confirmed that the refund of $3,147.42 was issued in January 2024 and mailed out on 02/05/2024, 75 days after the resident's discharge. The Interim Administrator acknowledged that refunds should be sent within 30 days of discharge.
Failure to Investigate Allegation of Abuse and Neglect
Penalty
Summary
The facility failed to thoroughly investigate an allegation of potential abuse and neglect involving a resident who was told by night staff to urinate in their brief because the staff did not know how to apply the resident's back brace. The incident was reported by the resident's family member via email to the Social Services staff, but it was not documented in the facility's incident or grievance logs, nor in the resident's progress notes. Despite the report being discussed in a Stand Up meeting and communicated to various administrative staff, no formal investigation was conducted, and the complaint was not properly documented as a grievance. Interviews with various staff members revealed that while some education was provided to the night shift staff on how to apply the resident's back brace, there was no comprehensive investigation to determine the extent of the issue or whether it affected other residents. Staff members had differing views on whether the incident rose to the level of abuse and neglect, but there was a consensus that it was a significant issue that warranted immediate attention. However, the necessary steps to document and investigate the complaint were not taken. The lack of a thorough investigation and proper documentation prevented the facility from identifying the full extent and nature of the alleged abuse and neglect. This failure to follow the facility's policy on abuse prevention, identification, and reporting placed residents at risk of diminished quality of life. The incident highlights a breakdown in communication and procedural adherence among the facility's staff and administration.
Failure to Arrange Hospice Services
Penalty
Summary
The facility failed to arrange hospice services for Resident 2, who had multiple diagnoses including a fractured hip, Alzheimer's disease, heart arrhythmia, kidney disease, diabetes, hypothyroidism, high blood pressure, and weakness. Despite a request from Resident 2's family member (CC 2) for a specific hospice agency, the facility did not provide information about their contracted hospice agencies or offer to transfer Resident 2 to a facility that contracted with the requested hospice agency. This lack of action denied Resident 2 their hospice benefit. Documentation showed that a hospice referral was ordered on 10/12/2023, but there was no follow-up to ensure the requested hospice agency was contacted or that Resident 2 was informed about alternative hospice options. The facility had two hospice agreements, but the specific hospice agency requested by CC 2 only signed an agreement with the facility on 03/29/2024, long after the initial request. Interviews with staff and CC 2 revealed that the facility staff did not discuss different hospice agencies with the family and appeared to be stalling the process.
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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