Deficiencies (last 3 years)
Deficiencies (over 3 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
5% better than Washington average
Washington average: 6.3 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 5
Jul 2, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication use, care planning, pressure ulcer prevention, infection control, and overall resident care in the nursing facility.
Findings
The facility was found deficient in multiple areas including the use of unnecessary psychotropic medications without valid diagnoses, incomplete and outdated care plans for residents, failure to implement pressure ulcer prevention interventions, lack of monitoring for high-risk medications such as anticoagulants and diuretics, and failure to follow infection prevention protocols related to Enhanced Barrier Precautions for residents with chronic wounds.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure 1 of 5 residents reviewed were free from unnecessary psychotropic medication due to lack of valid diagnosis. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop comprehensive care plans reflecting current medical status and nursing services for residents reviewed for edema management, discharge planning, and dementia care. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide care planned interventions for pressure ulcer prevention, including floating heels as ordered. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure residents were free from unnecessary drugs due to lack of monitoring and care planning for high-risk medications including anticoagulants and diuretics. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to follow established infection control guidelines related to Enhanced Barrier Precautions for a resident with a chronic wound. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for unnecessary psychotropic medication: 5
Residents reviewed for edema management: 1
Residents reviewed for discharge planning: 2
Residents reviewed for dementia care: 2
Residents reviewed for pressure ulcers: 3
Residents reviewed for unnecessary drugs: 3
Medication orders reviewed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Nursing Assistant Certified (NAC) | Interviewed regarding Resident 45's behavior and medication use |
| Staff E | Licensed Practical Nurse (LPN) | Monitored Resident 45's behavior and documented in Behavior Administration Record |
| Staff F | Registered Nurse/Resident Case Manager | Discussed psychotropic medication consent and diagnosis review for Resident 45; also discussed care planning and medication monitoring |
| Staff B | Director of Nursing | Discussed medication review process, care plan expectations, and monitoring of anticoagulants |
| Collateral Contact 1 (CC1) | Pharmacist | Participated in monthly psychotropic medication review and commented on diagnosis appropriateness for Resident 45 |
| Staff G | Licensed Practical Nurse (LPN), Resident Case Manager | Discussed discharge planning for Resident 5 and pressure ulcer prevention for Resident 15 |
| Staff J | Social Services | Discussed discharge planning for Resident 5 |
| Staff K | Nursing Assistant Certified (NAC) | Provided information on dementia care for Resident 15 |
| Staff H | Observed and adjusted pillows to float Resident 15's heels | |
| Staff I | Registered Nurse (RN) | Observed and adjusted pillows to float Resident 15's heels |
| Staff C | Infection Preventionist | Discussed Enhanced Barrier Precautions for Resident 19 |
Inspection Report
Annual Inspection
Deficiencies: 0
Oct 18, 2024
Visit Reason
The document is an annual inspection report for MT Baker Care Center conducted as part of regulatory oversight to assess compliance with health and safety standards.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Annual Inspection
Deficiencies: 6
Apr 12, 2024
Visit Reason
The inspection was conducted as part of the annual survey of MT Baker Care Center to assess compliance with regulatory requirements related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to identify significant changes in resident status, incomplete care plans, inadequate assistance with activities of daily living, insufficient nutritional monitoring and intervention, lack of trauma-informed and culturally competent care, and failure to follow infection prevention and control standards during wound care.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to identify and complete a Significant Change in Status assessment for a resident electing Hospice services. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement complete care plans addressing residents' needs including urinary catheter care, skin conditions, and unnecessary medications. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide assistance with activities of daily living including personal hygiene and bathing for dependent residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to comprehensively assess, monitor, and implement dietary interventions to prevent weight loss for a resident, resulting in significant unaddressed weight loss and dehydration. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide trauma-informed and culturally competent care for residents with PTSD and trauma histories, including lack of appropriate care plans and exposure to triggering stimuli. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure infection control standards during wound care, including lack of hand hygiene between glove changes and contamination of wound supplies. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Weight loss percentage: 12.3
Weight loss in pounds: 25
Weight loss percentage: 9.3
Weight loss in pounds: 18.8
Number of residents affected by ADL deficiencies: 5
Number of residents affected by infection control deficiency: 1
Number of residents affected by trauma-informed care deficiency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Registered Nurse, MDS Coordinator | Named in deficiency related to incorrect coding of Significant Change in Status assessment. |
| Staff B | RN/Director of Nursing Services | Named in deficiencies related to care plan concerns, ADL assistance, and nutritional monitoring. |
| Staff J | RN/Case Manager | Named in deficiencies related to skin care and infection control during wound care. |
| Staff G | Registered Nurse/Case Manager | Named in deficiencies related to urinary catheter care, ADL assistance, and nutritional monitoring. |
| Staff O | Registered Dietician | Named in deficiency related to nutritional assessment and monitoring. |
| Staff P | Advanced Registered Nurse Practitioner | Named in deficiency related to nutritional assessment and monitoring. |
| Staff Q | Licensed Practical Nurse | Named in deficiency related to trauma-informed care and inappropriate TV programming. |
| Staff R | Social Services | Named in deficiency related to trauma-informed care assessment. |
| Staff K | Registered Nurse/Staff Development Coordinator | Named in deficiency related to observation of wound care practices. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Apr 3, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding significant medication errors at the facility, specifically involving administration of medication to a resident with known allergies.
Findings
The facility failed to prevent significant medication errors for one of three sampled residents by administering two doses of an antibiotic to which the resident was allergic. The error placed the resident at increased risk of allergic reaction and other residents at risk of medication errors. Pharmacy flagged the allergy but the medication was still administered before discontinuation.
Complaint Details
The visit was complaint-related due to medication errors. The pharmacy flagged the allergy to sulfa antibiotics, but the medication was administered before the ARNP discontinued it. Resident 1 experienced a light rash and oral discomfort. Staff interviews confirmed nurses were expected to check allergies but no specific policy was documented.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure residents were free from significant medication errors by administering two doses of an antibiotic listed on Resident 1's allergy list. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 3
Doses administered: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN)/Director of Nursing Services | Interviewed regarding medication administration practices and allergy checks |
| Staff B | Registered Nurse (RN) | Interviewed regarding routine allergy checks before medication administration |
| Staff C | Registered Nurse (RN)/Resident Care Manager | Interviewed regarding Resident 1's allergy and medication administration |
Inspection Report
Complaint Investigation
Deficiencies: 1
Mar 4, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure residents received treatment and care according to professional standards, specifically related to oxygen therapy for Resident 1.
Findings
The facility failed to ensure Resident 1's oxygen was replaced after care, resulting in hypoxia and placing other residents at risk. The investigation confirmed unintentional neglect by staff, lack of respiratory care standards for nursing assistants, and plans to improve education and standards of care related to oxygen use.
Complaint Details
The complaint investigation found that on 02/09/2024, Staff A, Nursing Assistant-Registered, failed to replace Resident 1's oxygen after care, resulting in hypoxia. The facility concluded unintentional neglect occurred. Resident 1 and multiple staff interviews confirmed the incident and its seriousness.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide appropriate treatment and care according to orders, resident’s preferences and goals, specifically failure to replace Resident 1's oxygen after care. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Oxygen saturation readings: 77
Oxygen saturation readings: 83
Oxygen flow rate: 3
Oxygen flow rate: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Nursing Assistant-Registered (NAR) | Failed to replace Resident 1's oxygen after care on 02/09/2024. |
| Staff B | Registered Nurse (RN) | Observed Resident 1 without oxygen on 02/09/2024 and replaced oxygen. |
| Staff C | Licensed Practical Nurse (LPN) | Provided care for Resident 1 and aware of hypoxic episode. |
| Staff D | Director of Nursing Services | Acknowledged failure and planned to increase education and add oxygen standards of care. |
Inspection Report
Annual Inspection
Deficiencies: 0
May 1, 2023
Visit Reason
The inspection was conducted as a routine annual survey of the MT Baker Care Center to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection, indicating the facility met all required standards at the time of the survey.
Inspection Report
Routine
Deficiencies: 5
Jan 7, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, medication administration, dental services, dietary staff qualifications, and food safety in the facility.
Findings
The facility was found deficient in accurately assessing residents' dental/oral status, ensuring correct insulin administration procedures, providing timely dental services, employing qualified dietary staff, and maintaining proper food storage temperatures and cleanliness in the kitchen.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to accurately assess one of five residents' dental/oral status, placing residents at risk for unmet care needs. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure correct procedure was followed prior to administering insulin via prefilled syringe for one of two residents observed, risking incorrect insulin dosage. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure timely dental services were provided for one resident, placing them at risk for pain and diminished quality of life. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to employ qualified dietary manager with appropriate competencies and skill sets, potentially affecting all residents consuming food from the kitchen. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure cold food was stored at proper temperature, covered during storage, held at proper temperature for meal service, and stove hood cleaned according to professional standards, potentially affecting all residents consuming food. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 5
Residents affected: 2
Residents affected: 1
Residents affected: 57
Refrigerator temperature: 50
Refrigerator temperature: 50.5
Food temperatures: 45
Food temperatures: 43
Food temperatures: 49
Food temperatures: 55
Food temperatures: 54
Food temperatures: 53
Food temperatures: 47
Food temperatures: 48
Food temperatures: 49
Food temperatures: 64
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff J | Registered Nurse (RN)/ Nurse Manager | Confirmed quarterly nursing assessment marked no dental problems and was unaware of dental issues for Resident 9 |
| Staff K | RN/MDS Coordinator | Confirmed no documentation or observation of dental issues for Resident 9 |
| Staff H | Licensed Practical Nurse (LPN) | Observed administering insulin without priming needle unit |
| Staff B | Director of Nursing Services (DNS) | Confirmed insulin administration procedure and unawareness of dental service needs for Resident 9 |
| Staff C | Dietary Manager (DM) | Not certified dietary manager, started during COVID, not currently enrolled in certification program |
| Staff E | Assistant Dietary Manager | Confirmed refrigerator temperature issues and food storage problems |
| Staff F | Cook | Observed stove hood dirty and food temperatures during meal service |
| Staff A | Administrator | Aware of dietary manager certification requirement and refrigerator temperature issues |
| Staff D | Registered Dietitian (RD) | Conducts kitchen sanitation audits and confirmed food temperature standards |
Report
File
R_SUMMIT_PLACE_ASSISTED_LIVING_62251_65107-ew.pdf
Report
File
R_Summit_Place_Assisted_Living_FIRE_08-23-2023-ec.pdf
Report
File
R_Summit_Place_Assisted_Living_FIRE_09-02-2025_-_SW.pdf
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