Inspection Reports for Washington Care Center
2821 S Walden St, Seattle, WA 98144, United States, WA, 98144
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
14 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
122% worse than Washington average
Washington average: 6.3 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
41% occupied
Based on a November 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 18, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident fall incident involving failure to provide the assessed level of supervision and assistance.
Complaint Details
The complaint investigation found that Resident 1 fell from a mechanical lift without the required two-person assistance, resulting in serious injuries. The incident was substantiated as staff failed to follow the care plan and Kardex instructions.
Findings
The facility failed to ensure that Resident 1 received the required two-person assistance during mechanical lift transfers, resulting in a fall that caused a traumatic brain injury, upper neck fracture, and facial fractures. Staff did not follow the care plan and Kardex instructions, placing other residents at risk.
Deficiencies (1)
Failure to ensure a nursing home area is free from accident hazards and provide adequate supervision to prevent accidents.
Report Facts
Residents sampled: 4
Residents affected: 1
Dates: Sep 17, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Director of Nursing | Stated expectation that CNAs review the Kardex and that two caregivers are required for mechanical lifts |
| Staff A | Administrator | Stated the incident happened because staff did not follow the Kardex |
| Staff D | Regional Director of Clinical Operations | Stated CNA Staff C was not following the Kardex and the incident could have been prevented |
| Staff E | Assistant Director of Nursing | Stated failure to follow the Kardex led to the resident fall |
| Staff C | Certified Nursing Assistant | Assigned CNA who provided care without a second staff member present; unavailable for comment |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 7, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident who experienced harm after a fall caused by inadequate supervision and failure to follow the care plan.
Complaint Details
The complaint investigation found that Resident 1 was harmed due to staff providing care without the required two caregivers, resulting in a fall and fractures. The investigation showed inadequate staff training and failure to follow the care plan. The complaint was substantiated with actual harm to the resident.
Findings
The facility failed to ensure adequate supervision and assistance for Resident 1, resulting in the resident falling off the bed and sustaining three fractures. The investigation revealed staff did not follow the care plan requiring two caregivers for repositioning, and some staff had not completed required training.
Deficiencies (1)
Failure to ensure a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Report Facts
Residents sampled: 5
Residents affected: 1
Percentage of CNA staff completed training: 75
Fractures sustained: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | CNA | Provided care without a second staff member, resulting in resident fall |
| Staff A | Director of Nursing | Stated expectation that CNA review Kardex prior to care to prevent injuries |
| Staff B | Administrator | Stated incident occurred due to staff not following plan of care |
| Staff D | CNA | Had not completed required training prior to return to work |
| Staff E | Had not completed required training due to login issues | |
| Staff F | Had not completed required training and did not recall receiving education |
Inspection Report
Routine
Census: 19
Capacity: 46
Deficiencies: 2
Date: Nov 12, 2024
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, specifically focusing on the availability and proper use of Personal Protective Equipment (PPE) and the functionality of alcohol-based hand sanitizer dispensers.
Findings
The facility failed to maintain adequate infection control practices by not providing PPE for 12 of 19 residents requiring Enhanced Barrier Precautions and having 25 of 46 hand sanitizer dispensers malfunctioning. Staff interviews revealed inconsistent PPE availability and disregard for isolation signs, increasing the risk of communicable disease transmission and decreased resident quality of life.
Deficiencies (2)
Failure to have Personal Protective Equipment (PPE) available for staff for 12 of 19 residents requiring Enhanced Barrier Precautions.
Failure to ensure alcohol-based hand sanitizer dispensers were properly functioning for 25 of 46 rooms.
Report Facts
Residents requiring Enhanced Barrier Precautions: 12
Total residents observed: 19
Hand sanitizer dispensers malfunctioning: 25
Total rooms observed: 46
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Certified Nursing Assistant | Stated PPE supply was inconsistent and sometimes unavailable |
| Staff D | Certified Nursing Assistant | Reported disregarding isolation signs and lack of Infection Preventionist Nurse |
| Staff E | Certified Nursing Assistant | Stated limited staff ability to address PPE supply and questioned isolation sign posting |
| Staff F | Certified Nursing Assistant | Reported isolation carts had not been stocked with PPE since Infection Preventionist Nurse left |
| Staff B | Director of Nursing | Expected accurate isolation signs and PPE restocking; noted IP nurse position vacant since 10/28/2024 |
| Staff A | Regional Administrator | Stated all staff should know supply locations and ensure hand sanitizer dispensers function properly |
Inspection Report
Routine
Deficiencies: 14
Date: Aug 21, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, infection control, medication management, activities, and facility environment.
Findings
The facility was found deficient in multiple areas including failure to obtain informed consent for medications, maintain a homelike environment, provide timely discharge notifications, complete PASRR evaluations, update care plans, follow physician orders, provide assistance with activities of daily living, ensure safe medication storage, maintain infection control practices, and prevent pressure ulcers.
Deficiencies (14)
Failed to ensure residents were provided informed consent for treatments, including explanation of risks and benefits, for 3 of 5 residents reviewed.
Failed to maintain a homelike environment with clean and undamaged resident rooms and facility entrance.
Failed to provide timely written notification to residents and/or representatives regarding hospital transfers or discharges for 5 of 7 residents reviewed.
Failed to provide written notice of the facility's bed-hold policy at the time of transfer or within 24 hours for 4 of 7 residents reviewed.
Failed to obtain PASRR Level II comprehensive evaluations for 3 of 7 residents reviewed, placing residents at risk for not receiving necessary mental health care.
Failed to ensure PASRR assessments accurately reflected residents' mental health conditions for 3 of 5 residents reviewed.
Failed to develop and update care plans within 7 days of assessment and revise to reflect current resident status for 7 of 27 residents reviewed.
Failed to ensure nurses signed only for tasks completed, clarify physician orders, administer medications within parameters, and label tube feeding supplies for residents reviewed.
Failed to provide assistance with activities of daily living including grooming, shaving, dressing, and getting out of bed for 7 of 10 residents reviewed.
Failed to provide appropriate care and treatment including pain management, bowel monitoring, and edema care for 2 of 5 residents reviewed.
Failed to maintain a safe environment free from accident hazards including unsecured smoking materials, chemicals, and sharps for residents who smoked and in utility rooms.
Failed to ensure medications were stored, labeled, and discarded when expired, and medication refrigerators monitored for appropriate temperatures for medication carts and rooms observed.
Failed to perform hand hygiene during resident care and dining service, use personal protective equipment for residents on transmission based precautions, initiate enhanced barrier precautions, and properly dispose of contaminated gloves.
Failed to provide appropriate care for residents with bowel and bladder incontinence including assessments and assistance to maintain function for 2 of 4 residents reviewed.
Report Facts
Residents reviewed for hospitalization: 7
Residents reviewed for PASRR evaluations: 7
Residents reviewed for care plans: 27
Residents reviewed for ADL assistance: 10
Residents reviewed for medication management: 27
Residents reviewed for infection control: 5
Residents reviewed for bowel and bladder care: 4
Expired needles found: 197
Expired nicotine gum pieces: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Regional Director of Clinical Operations | Interviewed regarding informed consent, bed hold policy, medication orders, and wound care |
| Staff E | Social Services Director | Interviewed regarding discharge notifications, bed hold policy, and PASRR evaluations |
| Staff X | Maintenance Director | Interviewed regarding facility maintenance and environment |
| Staff F | Unit Manager - Licensed Practical Nurse | Interviewed regarding edema care and wound care |
| Staff L | Certified Nursing Assistant | Observed and interviewed regarding hand hygiene and ADL assistance |
| Staff R | Infection Control | Interviewed regarding infection control practices and PPE use |
| Staff B | Assistant Director of Nursing | Interviewed regarding medication storage and expired medications |
| Staff S | Unit Manager | Interviewed regarding care plan accuracy and ADL assistance |
| Staff AA | Activity Director | Interviewed regarding activities program and resident participation |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 30, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding a sexual abuse allegation involving two residents at the facility.
Complaint Details
The complaint investigation involved an incident on 05/22/2024 where Resident 2 was found with pants down on top of Resident 1, who was exposed from the waist down. Resident 1 was transferred to the hospital for evaluation and tested for sexually transmitted infections. Resident 1 and Resident 2 gave conflicting accounts regarding consent. Resident 2 had a documented history of sexual behaviors and was placed on one-on-one supervision. Staff interviews revealed lack of prior awareness and monitoring of Resident 2's sexual behaviors.
Findings
The facility failed to protect a resident's right to be free from sexual abuse when Resident 2 was found in a sexual incident with Resident 1, resulting in psychological harm and transfer of Resident 1 to the hospital for evaluation. The investigation revealed conflicting statements about consent, with Resident 1 diagnosed with a UTI and no physical signs of sexual assault. Resident 2 had a history of sexual behaviors and was placed under one-on-one supervision.
Deficiencies (1)
Failed to protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Report Facts
Residents involved: 2
Residents reviewed for sexual assault: 3
Date of incident: May 22, 2024
Date of report: May 30, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Assistant Director of Nursing, Licensed Practical Nurse (LPN) | Documented the incident and coordinated hospital evaluation |
| Staff D | Licensed Practical Nurse (LPN) | Documented observations and interviews related to the incident |
| Staff F | Licensed Practical Nurse (LPN) | Interviewed regarding the incident, not present during event |
| Staff A | Administrator | Interviewed about prior knowledge and monitoring of Resident 2 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 1, 2023
Visit Reason
The inspection was conducted due to concerns about the facility's failure to provide ordered dietary supplements to a resident, which could affect wound healing and overall care.
Complaint Details
The investigation found that Resident 1 did not receive the ordered dietary supplement for wound healing, despite nurses documenting administration. The supplement was not available in the facility, and staff were unaware or did not notify central supply. The issue was substantiated with evidence from interviews and medication administration records.
Findings
The facility failed to provide the ordered dietary supplement, Impact Advanced Recovery Oral Liquid, to Resident 1 as prescribed, despite documentation indicating it was given. Multiple staff interviews and record reviews confirmed the supplement was not available and nurses signed off on administration when it was not provided.
Deficiencies (1)
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing by not administering the ordered dietary supplement to Resident 1.
Report Facts
Days supplement ordered: 62
Number of nurses documenting supplement given in August 2023: 7
Number of nurses documenting supplement given in September 2023: 6
Number of nurses documenting supplement given in October 2023: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Director of Nursing | Stated unawareness that the supplement was not given and nurses signed falsely |
| Staff D | Registered Dietician | Conducted nutritional evaluation and was notified when supplement was unavailable |
| Staff J | Resident Care Manager | Stated central supply was notified about supplement unavailability |
| Staff E | Central Supply Manager | Confirmed no documentation of supplement availability and provided email about different supplement |
| Staff C | Assistant Director of Nursing | Commented on ordering process and lack of notification to Registered Dietician |
| Staff A | Administrator | Stated no recall of supplement availability |
| Staff G | Registered Nurse | Believed they gave supplement but provided a different supplement instead |
| Staff H | Licensed Practical Nurse | Acknowledged signing for supplement not given and usual notification process |
| Staff F | Licensed Practical Nurse | Uncertain about giving supplement and described usual notification steps if unavailable |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jul 11, 2023
Visit Reason
The inspection was conducted as a routine annual survey of the Washington Care Center nursing home 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: 17
Date: Jun 14, 2023
Visit Reason
The inspection was a routine regulatory survey of Washington Care Center to assess compliance with state and federal regulations related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to honor resident choice, inadequate conveyance of resident trust funds, unsafe and unclean environment, inaccurate resident assessments, incomplete and outdated care plans, failure to provide necessary assistance with activities of daily living, inadequate activity programs, medication management issues including labeling and storage, infection control lapses, and failure to provide timely dental and vaccination services.
Deficiencies (17)
Failure to honor resident choice regarding daily routines and health care including bathing preferences, community access, and access to water pitchers.
Failure to ensure conveyance of resident trust funds within 30 days of discharge for 2 discharged residents.
Failure to maintain a safe, clean, comfortable, and homelike environment including secure handrails, clean resident rooms, and pest prevention.
Failure to notify residents of bed hold policies upon hospitalization for 2 residents.
Failure to ensure accurate Minimum Data Set (MDS) assessments for 9 residents, including cognitive, behavioral, and medical condition inaccuracies.
Failure to develop and implement comprehensive, person-centered care plans for 4 residents, including missing goals and interventions for medical devices, respiratory status, and medications.
Failure to implement and revise care plans and conduct care planning conferences as required for 10 residents, including lack of interdisciplinary input and outdated plans.
Failure to ensure proper medication administration including rotation of injection sites, monitoring for adverse effects, following physician orders, clarifying duplicate orders, signing only for completed tasks, and providing treatment without orders.
Failure to provide assistance with activities of daily living (ADLs) consistently for 7 residents, including bathing, oral care, nail care, dressing, and getting out of bed.
Failure to provide meaningful activities to meet resident needs for 5 residents, including lack of activity materials and opportunities.
Failure to ensure newly identified skin issues were assessed and treated, failure to reposition residents as care planned, and failure to implement pressure reducing mattress orders.
Failure to ensure drugs and biologicals were labeled according to professional principles, expired medications were disposed timely, and medications were secured.
Failure to ensure hand hygiene was consistently performed, failure to use required personal protective equipment (PPE) appropriately, and failure to maintain clean shared resident equipment.
Failure to establish an antibiotic stewardship program to monitor antibiotic use and ensure timely review of culture and sensitivity reports for 2 residents.
Failure to provide or obtain prompt dental services for 1 resident, resulting in unmet dental needs.
Failure to ensure residents were offered and provided influenza and pneumococcal vaccinations as recommended.
Failure to regularly inspect bed frames and mattresses for safety and ensure compatibility to prevent entrapment hazards for 2 residents.
Report Facts
Residents reviewed for MDS accuracy: 29
Residents reviewed for care plans: 32
Residents reviewed for ADL assistance: 12
Residents reviewed for activities: 8
Residents reviewed for medication management: 32
Residents reviewed for infection control: 4
Residents reviewed for antibiotic stewardship: 3
Residents reviewed for dental care: 9
Residents reviewed for vaccinations: 5
Residents reviewed for accident hazards: 9
Medication pens expired: 1
Medication pens without pharmacy label: 12
Residents receiving PRN antianxiety medication: 27
Residents receiving PRN antianxiety medication: 8
Residents receiving PRN antianxiety medication: 5
Residents reviewed for mechanically altered diets: 21
Carrot servings prepared: 22
Hot dogs prepared: 32
Carrot servings prepared: 5
Carrot servings prepared: 2.5
Carrot servings prepared: 2.5
Carrot servings prepared: 2.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff JJ | Registered Nurse | Confirmed Resident 68 had long jagged untrimmed nails and medications unsecured at bedside |
| Staff UU | Licensed Practical Nurse - Unit Manager | Provided multiple statements regarding care plan deficiencies, medication order clarifications, and expectations for staff |
| Staff M | Social Services Director | Provided statements regarding bed hold policies, PASRR assessments, and medication regimen reviews |
| Staff B | Director of Nursing | Provided statements regarding care plan expectations, medication order clarifications, and medication regimen reviews |
| Staff E | Licensed Practical Nurse Assessment Coordinator | Provided statements regarding MDS inaccuracies and medication monitoring |
| Staff F | Registered Nurse - Unit Manager | Provided statements regarding care plan expectations, medication monitoring, and infection control |
| Staff D | Assistant Director of Nursing | Provided statements regarding care plan deficiencies, medication monitoring, and environmental cleanliness |
| Staff W | Activities Director | Provided statements regarding activity program deficiencies |
| Staff Q | Certified Nursing Assistant | Provided statements regarding activity program deficiencies and infection control lapses |
| Staff KK | Registered Nurse | Observed medication cart deficiencies and unclean equipment |
| Staff DDD | Dietary Director | Provided statements regarding food preparation and dietary program deficiencies |
| Staff N | Registered Nurse | Observed infection control lapses and wound care deficiencies |
| Staff O | Certified Nursing Assistant | Observed infection control lapses and wound care deficiencies |
| Staff X | Infection Control Nurse - Licensed Practical Nurse | Provided statements regarding infection control and antibiotic stewardship |
| Staff G | Maintenance Director | Provided statements regarding bed safety and environmental cleanliness |
| Staff P | Certified Nursing Assistant | Observed unsecured mattress and entrapment risk |
| Staff KK | Registered Nurse | Observed unclean ice machine and missing temperature logs |
| Staff EE | Licensed Practical Nurse - Assessment Coordinator | Confirmed significant weight loss for Resident 98 |
| Staff QQ | Certified Nursing Assistant | Observed failure to offer alternate meals and communication issues |
| Staff RR | Certified Nursing Assistant | Observed failure to offer alternate meals |
| Staff PP | Licensed Practical Nurse | Observed failure to offer alternate meals |
| Staff SS | Certified Nursing Assistant | Observed failure to offer alternate meals |
| Staff V | Certified Nursing Assistant | Observed failure to offer alternate meals |
| Staff TT | Medical Records | Confirmed no Medication Regimen Reviews for certain months |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 3, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide adequate supervision to prevent a resident at risk for elopement from leaving the facility unsupervised and sustaining injuries. Additionally, the facility was investigated for failure to maintain hot water heaters in safe operating condition, affecting residents' ability to shower with hot water.
Complaint Details
The complaint investigation revealed that Resident 1, who had traumatic brain injury and was at risk for elopement, left the facility at 9:01 AM and was not identified as missing until 5:00 PM. The resident was found by police at about 6:30 PM with injuries from a fall. Staff interviews indicated failure to respond properly to alarms and lack of awareness of the resident's absence. Additionally, the facility failed to maintain hot water heaters, affecting residents' hygiene and comfort.
Findings
The facility failed to provide adequate supervision for Resident 1, who eloped from the facility and sustained multiple injuries requiring hospital evaluation. The staff failed to respond appropriately to alarms indicating the resident's exit. The facility also failed to maintain hot water heaters properly, causing at least three residents to be unable to shower with hot water for several weeks, with inadequate staff training and documentation on the issue.
Deficiencies (2)
Failure to provide supervision for a resident at risk for elopement who left the facility unsupervised and sustained injuries.
Failure to maintain hot water heaters in safe operating condition, resulting in residents being unable to shower with hot water.
Report Facts
Residents affected: 1
Residents affected: 3
Time resident missing: 8
Date of survey completion: May 3, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Director of Nursing | Stated Resident 1 had a TBI and was wearing a WanderGuard bracelet; described video evidence of elopement |
| Staff C | Central Supply Director | Described video footage showing Resident 1 leaving the facility and staff response |
| Staff D | Licensed Practical Nurse | Turned off alarm without checking outside; unaware of resident elopement |
| Staff A | Administrator | Could not provide documentation on when staff realized Resident 1 was missing; confirmed timeline of elopement and discovery |
| Staff E | Licensed Practical Nurse | Reported not seeing Resident 1 during shift and being notified of missing resident |
| Staff G | Maintenance Director | Reported issues with hot water heater, lack of proper service, and inadequate staff training |
| Staff H | Registered Nurse | Reported maintenance staff comments on hot water issues and resident shower accommodations |
| Staff F | Certified Nursing Assistant | Reported residents being brought to unit with hot water for showers |
| Staff I | Regional Administrator | Reported hot water heater working intermittently and needing repairs |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 4, 2023
Visit Reason
The inspection was conducted due to concerns about the facility's failure to provide appropriate pressure ulcer care and prevent new ulcers from developing in residents, specifically focusing on two residents who developed multiple pressure ulcers during their stay.
Complaint Details
The investigation was complaint-related, focusing on substantiated issues regarding pressure ulcer care deficiencies that caused actual harm to residents, including hospitalization and worsening of wounds.
Findings
The facility failed to ensure timely and adequate pressure ulcer care for two residents, resulting in actual harm including deterioration of wounds, hospitalization, and multiple untreated pressure ulcers. The facility missed weekly skin assessments, failed to update care plans, and did not implement timely preventative measures, leading to worsening of pressure ulcers and diminished quality of life.
Deficiencies (1)
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing, including missed weekly skin assessments, failure to document wound progress, and failure to update care plans.
Report Facts
Pressure ulcers identified on Resident 1 at hospital admission: 6
Missed weekly skin assessments for Resident 1: 2
Missed weekly skin assessments for Resident 2: 2
Stage three sacral wound measurement for Resident 2: 0.5
Stage four pressure ulcer measurement on Resident 1's right heel: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff I | Licensed Practical Nurse | Unable to locate skin assessment or pain assessment documentation for Resident 1; acknowledged failure to complete skin check before hospital transfer |
| Staff C | Resident Care Manager | Provided information on Resident 1's wound care and weekly assessments; unable to locate skin or pain assessments for Resident 1 on 03/29/2023 |
| Staff K | Wound Care Provider | Assessed Resident 1's right heel wound on 03/28/2023; stated facility staff did not notify of other wounds |
| Staff J | Certified Nursing Assistant | Cared for Resident 1 on 03/28/2023; did not look at resident's skin |
| Staff B | Director of Nursing | Acknowledged missed weekly skin assessments and importance of early identification and prevention of pressure ulcers |
| Staff G | Licensed Practical Nurse | Resident 2's regular nurse; acknowledged missed weekly skin assessments for Resident 2 |
| Staff D | Resident Care Manager | Acknowledged missed weekly skin assessments for Resident 2 and described wound care provider's role |
Inspection Report
Routine
Census: 26
Deficiencies: 16
Date: Mar 8, 2022
Visit Reason
The inspection was conducted to assess compliance with medication self-administration, advanced directives, resident rights, abuse prevention, care planning, nursing staffing, medication administration, dental services, dietary services, and other regulatory requirements.
Findings
The facility had multiple deficiencies including failure to assess and care plan for self-administration of medications for 3 residents, failure to ensure residents' rights to formulate advance directives for 15 residents, failure to provide Skilled Nursing Facility Advanced Beneficiary Notices for one resident, failure to maintain a homelike environment in 5 resident rooms, failure to protect a resident from abuse and to implement abuse and neglect policies, failure to develop baseline and comprehensive care plans timely and accurately, failure to provide bathing assistance as scheduled for 2 residents, failure to provide appropriate catheter care for 3 residents, failure to implement dietary orders for one resident, failure to provide restorative nursing services as ordered for one resident, failure to administer medications as ordered for one resident, failure to provide timely dental services for one resident, failure to ensure sufficient nursing staff to meet resident needs, failure to ensure timely response to call lights, and failure to properly store and label food in the dietary department.
Deficiencies (16)
Failure to assess and care plan for self-administration of medications for 3 residents (Residents 16, 85, and 37).
Failure to ensure residents' rights to formulate advance directives for 15 residents.
Failure to provide Skilled Nursing Facility Advanced Beneficiary Notices (SNF ABN) for one resident (Resident 72).
Failure to maintain a homelike environment for 5 resident rooms.
Failure to protect a resident from abuse and to implement abuse and neglect policies, including failure to suspend staff and investigate allegations.
Failure to develop baseline care plans within 48 hours of admission for 3 residents (Residents 125, 430, and 123).
Failure to develop and revise comprehensive care plans with measurable objectives for 2 residents (Residents 13 and 19).
Failure to establish discharge plans including goals and interventions for one resident (Resident 127).
Failure to provide bathing assistance as scheduled for two residents (Residents 25 and 108).
Failure to provide appropriate catheter care for three residents (Residents 376, 7, and 90), including securing catheters with leg straps and proper tubing placement.
Failure to implement dietary orders for one resident (Resident 84), resulting in the resident receiving a regular diet instead of a no added salt diet.
Failure to provide restorative nursing services as ordered for one resident (Resident 108).
Failure to administer medications as ordered by the physician for one resident (Resident 37).
Failure to provide timely dental services and denture replacement for one resident (Resident 108).
Failure to ensure sufficient nursing staff to meet resident needs and timely response to call lights, as reported by multiple residents.
Failure to properly label food, remove expired food, and properly cover prepared/leftover foods in the dietary department.
Report Facts
Residents reviewed for medication self-administration: 26
Residents reviewed for advanced directives: 26
Residents reviewed for SNF ABN: 3
Resident rooms reviewed for homelike environment: 26
Residents reviewed for abuse prevention: 1
Residents reviewed for baseline care plans: 3
Residents reviewed for comprehensive care plans: 3
Residents reviewed for discharge planning: 27
Residents reviewed for bathing assistance: 26
Residents reviewed for catheter care: 9
Residents reviewed for dietary compliance: 26
Residents reviewed for restorative nursing: 1
Residents reviewed for medication administration: 26
Residents reviewed for dental services: 26
Residents interviewed for staffing adequacy: 25
Residents relying on dietary department: 129
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff FFF | Licensed Practical Nurse | Named in medication self-administration findings and medication administration. |
| Staff GG | Licensed Practical Nurse/Unit Manager | Named in medication self-administration, bathing assistance, care planning, and dietary findings. |
| Staff B | Director of Nursing | Named in abuse investigation and medication administration findings. |
| Staff ZZ | Licensed Practical Nurse | Named in abuse allegation and investigation findings. |
| Staff H | Social Services Director | Named in advance directives and psychotropic medication review. |
| Staff VV | Admissions Coordinator | Named in advance directives findings. |
| Staff WW | First Floor Unit Manager | Named in advance directives, care planning, and discharge planning findings. |
| Staff C | Interim Director of Nursing | Named in advance directives, care planning, and dietary findings. |
| Staff DDD | Maintenance Assistant | Named in homelike environment findings. |
| Staff L | Maintenance | Named in homelike environment findings. |
| Staff S | Physician | Named in advance directives and dietary findings. |
| Staff EE | Staffing Coordinator | Named in abuse training findings. |
| Staff II | Staff Development | Named in abuse training findings. |
| Staff G | Dietary Director | Named in dietary findings. |
| Staff KK | Certified Nursing Assistant Lead Restorative Aide | Named in restorative nursing findings. |
| Staff PP | Certified Nursing Assistant Lead Restorative Aide | Named in restorative nursing findings. |
| Staff JJ | Licensed Practical Nurse | Named in medication administration findings. |
| Staff CC | Staff | Named in dietary findings. |
| Staff R | Secretary | Named in dental services findings. |
| Staff D | Medical Director | Named in catheter care findings. |
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