Marysville Care Center

Inspectors wroteBased on interview, and record review, the facility failed to conduct a complete and thorough investigation for 1 of 1 sampled resident (Resident 1) reviewed for abuse and neglect. This failure placed residents at risk for unidentified abuse or neglect, potential ongoing abuse/neglect, and a diminished quality of life.

Inspectors wroteBased on interview, and record review the facility failed to protect residents right to be free from neglect for 1 of 3 sampled residents (Resident 1) reviewed for falls. Facility staff failed to follow the plan of care which resulted in Resident 1 falling from their bed. This failure placed residents at risk for potential physical or mental harm, feeling safe, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food items were dated and labeled and expired items were discarded in the 2 of 3 sampled facility nourishment refrigerators (Quilceda and Havenwood) reviewed for safe/sanitary food storage. This failure placed residents at risk of consuming expired food, foodborne illness, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a system was in place in which residents' records were complete, accurate, accessible, and systematically organized for 4 of 8 residents (Residents 3, 7, 54, and 86) reviewed for accurate and complete medical records. The facility failed to ensure the medical records reflected the behavior/psychotropic review documentation for 1 of 5 residents (Resident 3) failed to have accurate documentation for monitoring and consents for anti-anxiety medications for 1 of 5 residents (Resident 7), failed to include bed hold and discharge documentation for 1 of 2 (Resident 86) discharged residents, failed to ensure accessible documentation for hospice documentation for 1 of 1 resident (Resident 54). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to address, respond to and/or resolve concerns and/or suggestions brought forward by the resident council (RC) for 6 of 6 months (March, April, May, June, July and August 2025) of RC minutes reviewed. Additional failed practice included the facility failure to maintain complete and accurate Resident Council meeting minutes that included details of concerns and grievances voiced during Resident Council meetings, and failures to log, report, investigate, and resolve concerns voiced by the Resident Council. These failures resulted in the same unresolved/unaddressed concerns being brought forward for consecutive months without resolution, and resulted in RC members feeling frustrated, unheard and powerless to affect the care they receive and/or their environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure that current legal guardian documents were in the resident's medical record and did not provide written and verbal information related to formulating an advance directive for 1 of 5 (Resident 4) residents reviewed for advance directives. These failures placed the resident at risk of not having correct or updated legal guardian documents to verify the accurate guardian and to allow the legal guardian to formulate an advance directive to express their medical care preferences.

Inspectors wroteBased on interview and record review the facility failed to report an injury of unknown source with significant injury for 1 of 1 resident (Resident 5) reviewed for reporting. The facility's failure to report delayed appropriate oversight and investigation, placing residents at risk for harm and unidentified abuse and/or neglect.

Inspectors wroteBased on interview, and record review, the facility failed to incorporate the recommendations from the Level II Preadmission Screening and Resident Review (PASRR a federally required screening of all individuals who has a serious mental illness (SMI) and or intellectual disability (ID) prior to admission to a Medicaid-certified nursing facility or a significant change of condition) report into the resident's assessment, and care planning for 1 of 1 resident (Resident 2) reviewed for PASRR. Facility failure to incorporate the PASRR recommendations into the residents' assessment and care plan delayed the implementation of recommendations and left the residents at risk for unmet mental health and activity needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure Preadmission Screening and Resident Review (PASRR) assessments were completed timely for all residents following significant change in status for 1 of 5 residents (Resident 20) reviewed for possible serious mental disorders and related conditions. This failure resulted in a potential inability to receive and benefit from Level II PASSR services for Resident 20 and placed other residents at risk for a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to revise care plans to accurately reflect resident conditions and needs for 2 of 4 residents (Resident 5 and 82) reviewed for falls and dental. This failed practice had the potential for unmet resident care needs. Findings Included. Review of the facility policy titled, Comprehensive Care Plans and Conferences, reviewed 08/29/2025 documented the resident's care plan must be reviewed after each assessment and revised based on changing goals, preferences and needs of the resident and in response to current interventions.<FALLS>Resident 5 re-admitted to the facility on [DATE] with diagnoses to include pneumonia, falls, and encephalopathy (brain disease that alters brain function). Review of the facility state reporting log documented Resident 5 had unwitnessed falls on 06/16/2025, 06/17/2025, 07/12/2025 and 08/24/2025. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that services provided met professional standards for 2 of 3 (Resident 6 and 70) residents reviewed for professional standards. Resident 6 did not receive prescribed bowel medications when they experienced constipation and Resident 70 had a change in condition that required monitoring and new medication orders that were not documented timely. These failures placed residents at risk of not being appropriately monitored during a change in condition, effectiveness or side effects of new medications, constipation, pain, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 2 residents (Resident 86), reviewed for hemodialysis (medical procedure that uses a machine to filter and clean the blood when the kidneys are failing), had consistent, completed and accurate assessments on the facility's dialysis communication form (a form containing vital information about the resident which is sent to the dialysis center for coordination of care and services). This failure placed the resident at risk for medical complications and unmet care needs. Review of facility policy Area of Focus: [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a dementia care plan that addressed the significant mental and psychosocial needs of the resident, established personalized and achievable goals, and identified interventions to promote a person-centered environment for 1 of 2 residents (Resident 5) reviewed for dementia care. These failures placed residents at risk for unmet psychosocial needs, increased behaviors and decreased quality of life.

Inspectors wroteBased on observation and interviews, the facility failed to ensure 1 of 4 medication carts and treatment carts (Pilchuck unit) had secured medications. These failures placed residents at risk for unauthorized access to medications and biologicals, and potential drug misuse.

Inspectors wroteBased on interviews, and record review, the facility failed to ensure 1 of 4 sampled residents (Resident 1) reviewed for blood thinning medication (Warfarin) use were free from significant medication errors. Resident 1 experienced harm when they received two doses of a blood thinning medication when the medication was on hold, were hospitalized for a brain hemorrhage (bleeding within the skull), had an INR (International Normalized Ratio - a test to determine how long it takes for blood to clot) of 6.9 (normal range for resident 2.5-3.5) and required Kcentra and Vitamin K (blood clotting medications used for urgent reversal of blood thinner medications) in the emergency room. This failure placed all residents receiving blood thinning medications at risk for significant medication errors, serious complications from bleeding and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 4 residents (Resident 1) reviewed for care planning. The failure to ensure the comprehensive care plan was person-centered to maintain and or attain the resident's highest practicable well-being placed the residents at risk of not receiving services that would meet their needs, adverse health effects and a decreased quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a resident record was provided for review in a timely manner to the legal representative for 1 of 1 sampled resident's (Resident 1) reviewed for requested medical records. This failure placed the legal representative at risk for not having full clinical information about the resident in order to best represent them and make informed decisions.

Inspectors wroteBased on interview and record review the facility failed to review risks and benefits with the resident's legal representative for 1 of 3 residents (Resident 1) reviewed for psychotropic medication use. Failure to review the risk and benefits of a high-risk medication placed the resident at risk for unnecessary medication use and diminished quality of life and this failure placed the legal representative at risk for not having full clinical information about the resident to best represent the resident and make informed decisions.

Inspectors wroteBased on interview and record review the facility failed to conduct a thorough investigation for 2 of 5 sampled Residents (Residents 1 and 2) reviewed for incident investigations. Failure to conduct a thorough investigation to identify the root cause(s) and all contributing factors related to incidents and investigations placed residents at risk for unidentified abuse or neglect, risk for injury, monitoring and unmet care needs.

Inspectors wroteBased on interview and record review the facility failed to conduct a thorough investigation for 1 of 2 sampled Residents (Resident 1) reviewed for abuse/neglect and skin concerns. Failure to conduct a thorough investigation to identify the root cause(s) and all contributing factors related to Resident 1's incidents, placed the resident at risk for unidentified abuse or neglect, risk for injury, and unmet care needs.

Inspectors wrote<RESIDENT 17> Resident 17 admitted to the facility on [DATE] with diagnoses that included weakness, diabetes mellitus type two (condition in which the body had trouble controlling blood sugar), and arthropathic psoriasis (a type of arthritis that affects people with the skin condition psoriasis). Review of Resident 17's progress note dated 08/23/2024 showed the resident had been seen by a dentist and were started on an antibiotic medication for a dental infection. Review of Resident 17's electronic and paper medical record showed no consultation report regarding their visit to the dentist on 08/23/2024. In an interview on 10/10/2024 at 8:47 AM Staff N, Unit Coordinator, stated they send out a blank consultation report with residents when they leave the facility for an appointment, and they rarely get returned. [...]

Inspectors wroteBased on interview and record review the facility failed to properly implement the compliance and ethics program, prevent the submission of data/documentation known to be inaccurate and unethical practice for eight of ten residents (Residents 14, 22,33,36, 42, 58, 60 and 67) reviewed for therapy missed visit documentation. This failure placed residents at risk of not receiving appropriate physician ordered therapy services and potential decline in condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a system to ensure resident grievances were identified, logged, and resolved timely for 2 of 3 residents (Residents 1 and 2) reviewed for grievances. Facility failure to ensure missing personal items were found or replaced and resident representative comfort concerns were addressed placed residents at risk for missing property, discomfort and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR - a federal requirement to help ensure that individuals who had a mental disorder or intellectual disabilities were offered the most appropriate setting for their needs [in the community, a nursing facility, or acute care setting]; and receive the services they need in those settings), was followed for 1 of 6 sampled residents (Resident 17). Failure to accurately complete a level one PASRR for Resident 17 and refer for a level two (an in-depth evaluation to determine whether the resident required specialized rehabilitation services) as indicated placed residents at risk for not receiving care and services in the most integrated setting appropriate to their needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR - a federally required screening of all individuals who has both an Intellectual Disability (ID) or Related Condition (RC) and a serious mental illness (SMI) prior to admission to a Medicaid-certified nursing facility or a significant change of condition) form was completed prior to admission and according to the guidelines specified for 3 of 6 sampled residents (Residents 48, 59 and 60) reviewed. Incomplete or inaccurate PASRR's placed residents at risk for inappropriate placement and/or lack of access to specialized services for residents with identified mental health diagnoses or disability.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive person-centered care plan for 1 of 9 sampled residents (Resident 60) reviewed for care planning. The care plan for respiratory care did not show monitoring for signs of hypoxia (low oxygen (O2) level) and administering O2, the skin care plan did not include the type of wound, wound care, or interventions to prevent the wound from worsening, and the Diabetes (a disease in which blood sugar levels are too high) care plan did not include interventions for hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar). This failure placed residents at risk for unidentified outcomes or goals, inconsistent or lack of interventions, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care plans were reviewed and revised for 3 of 8 (Residents 13, 2 and 28) sampled residents reviewed for care plan revisions. Failure to revise care plans to accurately reflect resident conditions and needs placed residents at risk for unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide dentures prior to meals for 1 of 5 sample residents (Resident 31) reviewed for Activities of Daily Living (ADL). This failure placed the resident at risk for poor nutrition, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately assess and provide care and treatment to improve a resident's communication deficit for 1 of 2 sampled residents (Resident 12) reviewed for hearing. Failure to accurately assess, provide interventions to mitigate hearing loss, and/or offer a referral to improve a hearing deficit placed residents at risk of a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a dementia care plan that addressed the significant mental and psychosocial needs of the resident, established personalized and achievable goals, and identified interventions to promote a person-centered environment for 1 of 3 residents (Resident 48) reviewed for dementia care. These failures placed residents at risk for unmet psychosocial needs, increased behaviors and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 2 of 5 residents (Residents 60 and 48) reviewed for unnecessary medications were free from unnecessary psychotropic drugs (drugs that affect brain activities associated with mental processes and behavior) as required. The facility failed to ensure there were valid and accurate diagnoses for use of psychotropic medications, appropriate indications for treatment with antipsychotic medications, to monitor adverse side effects and monitor and document appropriate behaviors. These failures placed the residents at risk for receiving unnecessary psychotropic medications, for adverse medication-related side effects, and for diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure dental services were coordinated for 1 of 2 residents (Resident 17) reviewed for dental services. Failure to follow up on dental referrals and ensure the coordination of dental services for residents who had missing and broken teeth placed the residents at increased risk for difficulty chewing, associated health complications, and diminished quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to ensure an orderly discharge for 2 of 3 residents (Residents 5 and 2) reviewed for discharges. The failure to provide necessary information on discharge, and to document and/or assist residents with setting up follow-up physician appointments placed them at risk for unmet care needs.

Inspectors wroteBased on interview, and record review, the facility failed to provide nutritional supplements for 2 of 3 residents (Residents 1 and 4) reviewed for nutrition. The failure to provide nutritional supplements that had been recommended by the registered dietitian placed residents at risk for delayed wound healing.

Inspectors wroteBased on interview, and record review, the facility failed to ensure clinical records were complete and accurate for 2 of 3 residents (Resident 1 and 3) reviewed for wound care. The failure to ensure clinical records were complete and accurate placed residents at risk for unmet needs.

Inspectors wroteBased on interview, and record review the facility failed to ensure pharmacy services were provided to meet the residents need for 1 of 4 residents (Resident 1) reviewed. The failure to ensure medications were acquired and administered as ordered on the day of admission to the facility and follow facility process for medications not available placed residents at risk of diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure reported concerns were addressed and investigated timely for 1 of 1 resident (Resident 1), reviewed for grievances. This failure placed the resident at risk for unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure critical laboratory (lab) test results were reported and followed up timely for 1 of 2 resident (2) reviewed for laboratory services. This failure placed residents at risk of medical complications from lack of timely follow up for a chronic medical condition.

Inspectors wroteBased on interview and record review, the facility failed to implement a person-centered discharge planning process/care plan comprehensively and effectively for 4 of 4 residents (Resident 26, 31, 57 and 59), when reviewed for discharge planning. Failure to initiate a discharge plan consistent with the resident's expressed desires, goals, and barriers to discharge, placed the resident at risk for unsafe discharge, and could negatively impact the resident's sense of self-worth and quality of life.

Inspectors wroteBased on record review, interview, and record review, the facility failed to provide care and services in a manner that maintained and promoted dignity for 1 of 16 (Resident 10) sampled residents reviewed for resident rights. The facility failed to ensure Resident 10's medication concern was reviewed with the Director of Nurses Services (Staff B) and follow up information regarding the medication concern was discussed with the resident, which caused embarrassment and low self-esteem for the resident. This failure placed residents at risk for diminished self-worth, self-esteem, and feelings of embarrassment.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents code status was accurately documented in all areas of the medical record for 1 of 3 residents (Resident 17). This failure placed the residents at risk for diminished quality of life, end-of-life care, or health care decisions which potentially did not reflect their wishes.

Inspectors wroteBased on observation, interview, record review, the facility failed to ensure 1 of 5residents (Resident 60) reviewed for unnecessary medications did not receive unnecessary medications. Resident 60 was admitted to the facility with an as needed (prn) order for Zyprexa, an antipsychotic medication, and the order was changed to a scheduled dose without a physician documented rationale.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 4 medication carts (Quilceda Unit, Cart 2) medication was secured and not left unattended. One nurse (Staff C, Registered Nurse) left medications ready for administration unattended on top of the medication cart. This failure placed medications at risk of being tampered with or diverted by a passerby.

Inspectors wroteBased on interview and record review, the facility failed to maintain records in accordance with accepted professional standards and practices for 1 of 3 residents (Resident 31) reviewed for hospitalizations. The facility failed to ensure there was complete and accurate documentation in the clinical record related to Resident 31's hospitalization. Failure to ensure the medical record was complete and accurately documented placed residents at risk for inconsistent care and treatment.