Mukilteo Memory Care

The facility failed to ensure a resident received ordered mobile X-ray imaging in a timely manner after a fall, resulting in a 5-day delay in diagnosing a pelvic fracture.

Facility failed to notify the resident's representative, physician, and Wellness Director when a resident experienced a significant change in condition following a fall and pain.

Facility failed to implement emergency procedures when a resident experienced a fall, subsequent pain, and difficulty ambulating, delaying medical evaluation for three days, resulting in five fractured ribs.

Facility failed to complete/maintain preadmission assessments for 2 of 7 sampled residents.

Negotiated Service Agreements (SP) failed to include relevant interventions for medications, home health services, CPAP use, and therapy for 4 of 7 residents.

The Director of Wellness stated the nursing station had no staffing during lunch hours, and staff failed to lock cabinets containing resident confidential records before leaving for lunch.

Personal care supplies (hand sanitizer, body lotion, wound cleanser, skin cream) were left unsecured and accessible to residents in the Memory Care Unit.

Failed to complete ongoing assessments for use of side rails for 2 of 2 sampled residents.

Facility failed to document multiple refusals of continuous oxygen treatment for 1 resident.

Facility failed to ensure 2 of 5 staff members initiated TB screening within 3 days of employment.

Resident medical records were kept in unlocked cabinets in an open nurse's station area, failing to protect privacy.

Facility failed to obtain medications in a timely manner for 3 of 3 sampled Memory Care Unit residents, resulting in missed doses.

Facility failed to ensure 2 of 5 staff members initiated TB screening within three days of employment.

Failed to label food items, maintain food temperatures, provide sanitizing equipment/test strips, and follow proper hygiene/gloving procedures.

The facility employed a staff member (Staff D) who provided care and medication services for 113 days with an expired nursing assistant certification.

The facility failed to monitor a resident with a history of physical assault, resulting in multiple incidents where that resident assaulted or disturbed other residents.

Facility failed to notify the DSHS complaint hotline regarding the staff member who intentionally discarded resident medications.

Staff D intentionally threw away medications for 14 residents instead of administering them as prescribed; medication records were fraudulently documented as given.

Facility failed to ensure accurate medication administration records; staff shared electronic login credentials, resulting in falsified documentation of medication administration for 13 residents.

Facility unable to provide documentation that the annual fire wall inspection has been completed.

Signage not provided on the exhaust hood or system cabinet indicating the type and arrangement of cooking appliances.

Facility unable to provide documentation for the monthly 30 second activation test for emergency lights.

Facility cannot provide a documented emergency plan in accord with WAC 212-12-040.

Facility failed to follow a Respiratory Protection Program (RPP) by ensuring staff were fit-tested for N95 respirators annually. 25 of 33 staff had not been fit-tested.