10 CMS Surveys
Inspection Report — Mar 18, 2025
Routine
Date: Mar 18, 2025
Visit Reason
The inspection was a routine survey of Life Care Center of Federal Way to assess compliance with state and federal regulations related to resident care, safety, infection control, medication management, and facility environment.
Findings
The facility was found to have multiple deficiencies including failure to provide dignified care, obtain resident consents, maintain safe environment, implement comprehensive care plans, ensure proper medication management, maintain infection control, and provide required staff training. Some residents did not receive timely care conferences or appropriate hospice coordination. Water temperatures exceeded safe limits and medication storage was not always compliant. The facility failed to educate residents and staff on COVID-19 vaccination and document consents. Several care and safety protocols were not fully implemented, placing residents at risk.
Deficiencies (22)
WAC 388-97-0180(1-4) - The facility failed to honor Resident 16's right to dignified care by not providing adequate notice or preparation for a care conference, resulting in the resident being unprepared and uncomfortable.
WAC 388-97-0180(1-4) - The facility failed to provide adequate care respecting dignity for Resident 31, including waking them at inappropriate times, not honoring medication preferences, and disrespectful communication.
WAC 388-97-0260, -0200(2), -0300(3)(a) - The facility failed to obtain informed consent for COVID-19 vaccinations, psychotropic medications, and use of a tilt-in-space wheelchair for multiple residents.
WAC 388-97-0280(3)(c)(i-ii), -0300(1)(b)(3)(a-c) - The facility failed to ensure Advanced Directives were in place or that residents were informed about their right to formulate an Advanced Directive for three residents.
WAC 388-97-0880 - The facility failed to maintain a safe, clean, and homelike environment by not repairing wall gouges, damaged furniture, and maintaining comfortable hot water temperatures in resident rooms.
WAC 388-97-0140(1)(a-c)(i-iii) - The facility failed to provide timely written transfer/discharge notifications to residents, their representatives, and the Long-Term Care Ombudsman for two residents.
WAC 388-97-0120(4) - The facility failed to provide written notice of the bed hold policy at time of transfer or within 24 hours for three residents.
WAC 388-97-1915(2)(4) - The facility failed to ensure PASRR Level II evaluations were completed or incorporated into care plans for residents with serious mental illness or intellectual disabilities.
WAC 388-97-1020(1)(2)(a)(b) - The facility failed to develop and implement comprehensive care plans addressing all resident needs, including bathing, wheelchair use, oxygen therapy, bed rails, and diabetes management for multiple residents.
WAC 388-97-1020(2)(c)(d), (4)(c)(i-ii) - The facility failed to facilitate quarterly care conferences and revise care plans as required for multiple residents.
WAC 388-97-1060(3)(e) - The facility failed to assess and notify the provider of refusals of care, agitation, and refusals to eat for Resident 80.
WAC 388-97-1620(2)(b)(ii) - The facility failed to ensure physician orders were clarified and pain medication parameters were established for multiple residents.
WAC 388-97-1060(1) - The facility failed to monitor and document edema for residents with heart failure and edema, increasing risk for complications.
WAC 388-97-1060(3)(g), -3320 - The facility failed to maintain safe water temperatures, assess wheelchair safety, and properly store sharps and chemicals, placing residents at risk for burns, accidents, and exposure.
WAC 388-97-1300(2) - The facility failed to ensure medications were not left unsecured in resident rooms, risking resident safety.
WAC 388-97-1060(3)(j)(vi) - The facility failed to provide oxygen therapy according to physician orders and failed to monitor oxygen equipment properly for Resident 43.
WAC 388-97-1060(3)(g), -0260 - The facility failed to obtain consent and complete safety assessments prior to installing bed rails or placing beds against walls for residents.
WAC 388-97-1720(1)(c), -0360(1-3) - The facility failed to maintain confidentiality of resident medical information by leaving resident lists unsecured on medication carts.
WAC 388-97-1160 (1) - The facility failed to ensure the Dietary Manager had required certification and fulltime Registered Dietician support.
WAC 388-97-1340(2) - The facility failed to provide education and obtain consent for influenza and pneumococcal vaccinations for multiple residents.
WAC 388-97-0200(2), -0300(3)(a) - The facility failed to educate staff and residents on COVID-19 vaccination benefits and side effects and failed to document education and consents.
WAC 388-97-1680(1)(2)(a)(b)(ii)(c) - The facility failed to provide required annual and specialized training to nursing staff, including dementia care, abuse prevention, and hospice care.
Report Facts
Residents affected: 4
Residents affected: 5
Residents affected: 3
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 2
Residents affected: 3
Residents affected: 3
Residents affected: 1
Staff affected: 4
Inspection Report — Mar 18, 2025
Complaint Investigation
Date: Mar 18, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to properly implement Physician's Orders for Life Saving Treatments (POLSTs) for certain residents.
Complaint Details
The complaint investigation focused on the failure to follow POLST instructions for Cardiopulmonary Resuscitation (CPR) for Resident 32 and the absence of POLST forms for Residents 16 and 60. The facility acknowledged the miscommunication and lack of POLST availability. The complaint was substantiated as deficiencies were cited.
Findings
The facility failed to ensure POLSTs were implemented or readily available for 2 of 22 sampled residents and one supplemental resident, resulting in a risk of unwanted CPR and other negative health outcomes. The root cause was identified as misorganization of the POLST book by room rather than resident name.
Deficiencies (1)
WAC 388-97-1060 (1) - The facility failed to implement a system to ensure Physician's Orders for Life Saving Treatments (POLSTs) were followed for 2 of 22 sampled residents and one supplemental resident, risking unwanted CPR and trauma.
Report Facts
Sample residents: 22
Residents affected: 3
Inspection Report — Dec 31, 2024
Complaint Investigation
Date: Dec 31, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding failure to provide written notice and explanation for facility-initiated room changes and failure to provide appropriate treatment and care related to the use of air mattresses, including monitoring and staff training.
Complaint Details
The investigation focused on allegations that the facility failed to provide written notice and explanation for room changes to residents 11, 12, 13, and 14, and failed to properly assess and monitor the use of air mattresses for residents 1 through 7. Interviews and record reviews confirmed these failures, including missing Room Change Notification forms and lack of staff training on air mattress use. The complaint was substantiated with findings of deficient practices leading to resident harm.
Findings
The facility failed to provide written explanations and advance notice for room changes to several residents, violating resident rights. Additionally, the facility failed to properly assess, monitor, and train staff on the use of air mattresses, resulting in a resident fall with injury due to inadequate care. These deficiencies placed residents at risk of harm and diminished quality of life.
Deficiencies (3)
F 0559 - The facility failed to provide written explanation, advance notice, or opportunity for residents to meet new roommates for 4 of 7 residents who were moved to different rooms, placing residents at risk of frustration and diminished quality of life.
F 0684 - The facility failed to develop and implement a system to assess, monitor, and educate residents and staff on the use of air mattresses, including obtaining informed consent, monitoring pump settings, and training staff, placing residents at risk of falls and injury.
F 0689 - The facility failed to ensure staff followed the resident's care plan requiring two caregivers during incontinence care, resulting in a resident falling off an air mattress bed and sustaining an inoperable leg fracture.
Report Facts
Residents affected by room change deficiency: 4
Residents reviewed for air mattress use: 7
Shifts with only one caregiver for Resident 1 bed mobility: 25
Inspection Report — Nov 7, 2024
Complaint Investigation
Date: Nov 7, 2024
Visit Reason
The inspection was conducted to investigate allegations of inadequate investigation of incident reports related to injuries of unknown origin for two residents, Resident 4 and Resident 7.
Complaint Details
The complaint investigation focused on two residents with bruises of unknown origin. Resident 4's facial bruise was discovered late and not properly investigated. Resident 7's bruise investigation lacked vital information and did not identify safety interventions. The facility was unable to substantiate abuse or neglect but failed to conduct adequate investigations.
Findings
The facility failed to ensure incident reports were thoroughly investigated for two residents with injuries of unknown origin. Investigations lacked completeness and timeliness, leaving residents at risk for unidentified abuse or neglect. Some bruises were reported late and investigations did not include necessary safety interventions.
Deficiencies (1)
WAC 399-97-0640(6)(a)(b) - The facility failed to conduct thorough investigations of incident reports for injuries of unknown origin for Residents 4 and 7. Investigations were incomplete, untimely, and lacked documentation to rule out abuse or neglect.
Report Facts
Bruise size: 6
Bruise size: 1.5
Bruise size: 0.5
Investigation timeframe: 5
Incident report documentation period: 10
Delay in reporting: 4
Inspection Report — Sep 26, 2024
Complaint Investigation
Date: Sep 26, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding inadequate pressure ulcer care and prevention at the facility.
Complaint Details
The complaint investigation focused on two residents with pressure ulcers. Resident 1's pressure ulcer worsened to Stage 4 with osteomyelitis due to lack of proper care and treatment. Resident 2 did not receive ordered wound care treatments including an air mattress and ointment. The facility's care plans lacked necessary instructions for turning and off-loading. The complaint was substantiated based on these findings.
Findings
The facility failed to provide appropriate treatment and preventive care for pressure ulcers for two residents, resulting in actual harm including a Stage 4 pressure ulcer with osteomyelitis. The care plans lacked necessary turning/repositioning and off-loading instructions, and treatments ordered by wound care providers were not consistently implemented.
Deficiencies (1)
F 0686 - The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing, resulting in actual harm to residents. Resident 1 developed a Stage 4 pressure ulcer with osteomyelitis due to inadequate treatment and lack of preventive interventions. Resident 2 did not receive ordered treatments including use of an air mattress and aggressive off-loading.
Report Facts
Residents affected: 2
Pressure ulcer measurements: 5.5
Pressure ulcer measurements: 4
Pressure ulcer measurements: 1.5
Pressure ulcer measurements: 4
Pressure ulcer measurements: 3
Pressure ulcer measurements: 2.5
Pressure ulcer measurements: 3
Pressure ulcer measurements: 0.6
Pressure ulcer measurements: 3.5
Pressure ulcer measurements: 4
Pressure ulcer measurements: 4
Pressure ulcer measurements: 2
Inspection Report — Sep 3, 2024
Complaint Investigation
Date: Sep 3, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to provide appropriate treatment and care for Resident 1, specifically related to timely monitoring, assessment, and implementation of physician orders for a suspected urinary tract infection (UTI).
Complaint Details
The complaint investigation focused on Resident 1's care related to a suspected UTI. The allegation was substantiated as the facility failed to collect urine samples timely, notify the practitioner and resident representative, and provide appropriate treatment, leading to Resident 1's hospitalization in the ICU for severe sepsis.
Findings
The facility failed to consistently monitor and assess Resident 1 for a suspected UTI and did not implement physician orders timely, resulting in Resident 1's hospitalization in the ICU for severe sepsis from a bladder and kidney infection. Staff made only one unsuccessful attempt to collect a urine sample, failed to notify the practitioner or resident representative timely, and documentation was incomplete.
Deficiencies (1)
WAC 388-97-1060(1) - The facility failed to monitor Resident 1 for a suspected UTI, collect urine samples as ordered, notify the resident representative and practitioner when samples were not collected, and document these actions, resulting in delayed treatment and hospitalization for severe sepsis.
Report Facts
Temperature: 103.1
Blood Pressure: 85
Blood Pressure: 63
Heart Rate: 113
Respirations: 26
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Director of Nursing | Stated staff should monitor residents for urinary signs and symptoms and follow procedures when urine samples are not collected |
| Staff A | Administrator | Reviewed Resident 1's medical record and noted missing documentation and order drop-out in electronic medical record |
Inspection Report — Apr 3, 2024
Complaint Investigation
Date: Apr 3, 2024
Visit Reason
The inspection was conducted to investigate multiple allegations of abuse and failure to report or respond appropriately to abuse incidents involving residents at the facility.
Complaint Details
The complaint investigation involved multiple abuse allegations: Resident 1 physically abused Resident 2; Resident 4 allegedly abused Resident 3; and failures in reporting and investigating these incidents. Some allegations were substantiated, including the physical abuse of Resident 2 by Resident 1, while others lacked sufficient investigation or were denied by involved parties.
Findings
The facility failed to protect a resident from physical abuse by another resident and did not adequately supervise or mitigate known triggers. The facility also failed to timely report and thoroughly investigate several abuse allegations, placing residents at risk of continued abuse and diminished quality of life.
Deficiencies (3)
F 0600 - The facility failed to protect Resident 2 from physical abuse by Resident 1 and failed to supervise Resident 1 who had a history of aggressive behaviors. Resident 2 experienced psychological harm as a result.
F 0609 - The facility failed to timely report an allegation of abuse by Resident 4 towards Resident 3 to the State Survey Agency as required.
F 0610 - The facility failed to thoroughly investigate allegations of abuse involving Residents 3 and 4 and Residents 1 and 2, and failed to implement preventative measures, placing residents at risk of continued abuse.
Report Facts
Residents affected: 6
Residents affected: 4
Inspection Report — May 10, 2023
Complaint Investigation
Date: May 10, 2023
Visit Reason
The inspection was conducted due to a Norovirus outbreak at the facility, focusing on infection prevention and control practices to prevent transmission of communicable disease among residents and staff.
Complaint Details
The investigation was complaint-driven due to a Norovirus outbreak. The complaint focused on infection control failures during the outbreak. The findings substantiated the complaint with documented lapses in infection control practices and incomplete staff training and compliance.
Findings
The facility failed to effectively implement infection control measures including monitoring and tracking illnesses, enforcing Transmission Based Precautions, and ensuring staff compliance with hand hygiene and PPE use. Several residents and some staff were symptomatic, and lapses in precaution signage and PPE use were observed. The outbreak was declared over by the time of exit, with resumed activities and dining.
Deficiencies (1)
F 0880 - The facility failed to provide and implement an infection prevention and control program to prevent transmission of Norovirus among residents and staff. Failures included inadequate monitoring of illnesses, incomplete use of Transmission Based Precautions, and insufficient staff compliance with hand hygiene and PPE.
Report Facts
Residents symptomatic: 10
Residents observed in dining room: 16
Residents on enteric precautions: 15
Staff absences due to illness: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Director of Nursing | Provided statements regarding infection control monitoring and outbreak management |
| Staff F | Staff Development Coordinator, Licensed Practical Nurse | Conducted hand hygiene education and training during the outbreak |
| Staff G | Licensed Practical Nurse | Observed not redirecting resident and reported on staff reporting of symptoms |
| Staff H | Certified Nursing Assistant | Observed not following posted contact precautions during resident care |
| Staff D | Registered Nurse, Resident Care Manager | Provided surveillance documentation and statements about resident precautions |
Inspection Report — Sep 15, 2022
Routine
Date: Sep 15, 2022
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements including resident care, infection control, medication management, and safety.
Findings
The facility was found deficient in multiple areas including accurate resident assessments, care plan maintenance, medication administration, infection control, and staff training. Several residents had inaccurate or incomplete assessments, care plans were not consistently updated, medication orders were not always followed, and infection prevention protocols were not fully implemented. The facility also failed to maintain accurate staff COVID-19 testing and vaccination records. Despite these deficiencies, the report does not indicate immediate jeopardy or license revocation.
Deficiencies (16)
F 0641 - The facility failed to ensure Minimum Data Set (MDS) assessments were complete and accurate for multiple residents, resulting in inaccurate information for CMS quality ratings and risk for unmet needs.
F 0645 - The facility failed to ensure Pre-admission Screening and Resident Review (PASRR) assessments were completed accurately and timely for 6 of 7 residents reviewed, placing residents at risk for inappropriate placement and unmet mental health needs.
F 0657 - The facility failed to maintain, revise, and update care plans for 7 of 18 residents reviewed, leaving residents at risk for unmet needs and diminished quality of life.
F 0658 - The facility failed to provide nursing services within professional standards for 4 of 18 residents, including failure to clarify physician orders and administer medications as ordered, placing residents at risk for unmet care needs.
F 0684 - The facility failed to provide appropriate treatment and care according to orders for pain monitoring, skin rash assessment, bladder care, and pacemaker care for several residents, placing them at risk for unmanaged pain and complications.
F 0686 - The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for one resident, including inconsistent wound assessment and delayed treatment, placing the resident at risk for deterioration and discomfort.
F 0688 - The facility failed to provide restorative nursing services as assessed for 3 residents, placing them at risk for decline in range of motion, reduced mobility, and decreased quality of life.
F 0692 - The facility failed to ensure adequate nutrition for 2 residents by failing to consistently obtain weights, notify physicians of changes, and implement dietary recommendations, placing residents at risk for delayed intervention and weight loss.
F 0698 - The facility failed to ensure dialysis care policies were implemented for one resident, including failure to monitor and document post-dialysis condition, weigh resident consistently, and complete required communication forms, placing the resident at risk for complications.
F 0740 - The facility failed to provide necessary behavioral health care and services for one resident with significant behaviors, including failure to provide staff training on behavior management, placing the resident at risk for unmet needs and decreased quality of life.
F 0745 - The facility failed to provide medically-related social services to two residents, including failure to identify reasons for refusals of care and follow up, placing residents at risk for poor hygiene, skin issues, infection, and decreased quality of life.
F 0756 - The facility failed to ensure licensed pharmacist monthly medication regimen reviews (MRRs) were documented in resident records and recommendations were timely implemented for 4 residents, placing residents at risk for delays in medication changes and adverse effects.
F 0880 - The facility failed to establish and maintain an infection prevention and control program including proper aerosol generating procedure precautions, transmission based precautions, PPE use, and hand hygiene, placing residents, staff, and visitors at risk for infection transmission including COVID-19.
F 0881 - The facility failed to implement an antibiotic stewardship program including monthly surveillance, timely follow-up on antibiotic use, and effective infection control committee meetings, placing residents at risk for unnecessary antibiotic use and multi-drug resistant organisms.
F 0886 - The facility failed to ensure staff COVID-19 testing was performed as required for 4 staff members, placing residents, visitors, and staff at risk for COVID-19 transmission.
F 0888 - The facility failed to maintain an accurate system to track staff COVID-19 vaccination status, resulting in inaccurate reporting and placing residents at risk for exposure and illness.
Report Facts
Residents with inaccurate MDS assessments: 9
Residents with incomplete care plans: 7
Residents with medication administration errors: 4
Residents with PASRR assessment failures: 6
Residents with restorative nursing service failures: 3
Residents with pressure ulcers reviewed: 4
Residents with infection control deficiencies: 4
Staff not tested for COVID-19 as required: 4
Staff vaccination list discrepancies: 15
CMS Survey — Jan 10, 2024
Jan 10, 2024
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