Transitional Care of Seattle

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice for 1 of 3 residents (Resident 1) reviewed for professional standards. The failure to follow, timely implement or implement and/or clarify physician orders and the failure to determine the reason for refusals, notify the provider of the refusals, and address the reasons for refusals placed all residents at risk for negative health outcomes, unmet care needs, and decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure 1 of 3 residents (Resident 1) reviewed for Pressure Injuries (PI, damage to the skin and underlying tissue caused by prolonged pressure, friction or shear) received the necessary care and services, consistent with professional standards of practice to promote healing, and prevent new PI's from developing. Failure to ensure PI's were consistently assessed to include wound characteristics and measurements, to evaluate the resident's compliance with the plan of care, and prevent new PI's from developing. This failure placed resident's at risk for prolonged wound healing, increased discomfort, diminished quality of life, and development of avoidable PI's.

Inspectors wroteBased on interview and record review, the facility failed to ensure a system by which residents received required written notices at the time of transfer/discharge for 4 of 10 residents (Residents 3, 13, 8, & 60) and report to receiving hospital for 2 of 10 residents (Residents 13 & 60) reviewed for hospitalization. Failure to ensure a written notification was provided to the resident and/or representative in a language and manner the resident and/or representative understood, notify the LTCO as required of the reasons for the discharge, and give a report to the receiving hospital on resident's condition placed residents at risk for a discharge that was not in alignment with the resident's stated goals for care/preferences, and a break in communication and continuity of care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 4 (Residents 5, 67, 53, & 32) of 4 residents reviewed for respiratory care were provided care and services consistent with professional standards of practice. The facility's failure to implement stoma suctioning according to physician orders (Resident 5), obtain physician order prior to administering oxygen therapy (Resident 5), deliver oxygen therapy according to physician ordered flow rates (Resident 67 & 53), and maintain oxygen equipment (Residents 67, 53 & 32) placed residents at risk for potential negative outcomes such as over or under oxygenation, respiratory discomfort, infections, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a system to evaluate staff competencies in skills and techniques to ensure staff provided necessary care and responded to each resident's individualized needs for 7 of 7 sampled staff (Staff I [Registered Nurse - RN] Staff U [Certified Nursing Assistant - CNA], Staff V [CNA], Staff K [CNA], Staff L [CNA], Staff X [RN], & Staff Y [CNA]) reviewed for nursing competency. This failure placed residents at risk of receiving care from under-trained and/or under-qualified care staff, unmet care needs, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure meals were prepared to maintain the palatability of the food served for 6 (Residents 16, 2, 60, 33, 53, & 9) of 9 residents reviewed for food. The failure to ensure the food provided looked and tasted palatable placed residents at risk for weight loss, frustration, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a clean environment to help prevent the transmission of communicable diseases for 2 of 2 residents (Resident 2 & 5) and failed to follow enhanced barrier precautions (EBP) for 1 for of 1 residents (Residents 58) and failed to follow standard precautions and wear protective eye covering for 1 of 1 resident (Resident 5) reviewed for Transmission-Based Precautions (TBP - airborne, contact, droplet and enhanced barrier precautions used to prevent the spread of transmissible diseases. The failure to wear PPE (Personal Protective Equipment - gowns, gloves etc.) when caring for resident on TBP and the failure to maintain a clean environment placed residents at risk for facility-acquired/healthcare-associated infections and related complications.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a comfortable, appropriately sized bed for 1 of 1 resident (Resident 64) reviewed for accommodation of needs. This failed practice placed the resident at risk for discomfort and skin issues.

Inspectors wroteBased on observation and interview, the facility failed to ensure a safe, sanitary, and homelike environment was maintained for 1 (Resident 5) of 1 sampled resident. These failures left the resident at risk for a diminished quality of life and a less than homelike environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure thorough investigations were completed timely for 1 of 2 residents (Resident 6) reviewed for abuse and 1 of 1 (Resident 8) reviewed for falls. Failure to ensure investigations were thorough and completed timely placed residents at risk for further injuries, potential abuse/neglect, and other negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to reassess the resident after a significant change in function lasting more than 14 days occurred for 1 (Resident 60) of 19 sample residents. The failure to identify the need for a Significant Change in Status Assessment (SCSA - an assessment tool) after Resident 60 had a decline in their condition 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 Pre-admission Screening and Resident Review (PASRR) assessments were accurately completed prior to or upon admission to the facility or updated with changes with appropriate follow up with the State PASRR office for 3 of 6 (Residents 67, 60, & 68) reviewed for PASRRs. This failure placed residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health care needs.

Inspectors wroteBased on interview and record review, the facility failed to facilitate quarterly care conferences for 2 of 3 residents (Resident 6 & 33) reviewed for care conferences. This failure placed residents at risk for unmet care needs, unnecessary care, frustration, and other negative health outcomes.<Resident 6>According to a 08/15/2025 re-entry Minimum Data Set (MDS-an assessment tool), Resident 6 had clear speech, understands, and was understood by others. In an interview on 09/16/2025 at 1:30 PM, Resident 6 stated no one at the facility talked to them about their care and stated they did not have a care conference recently. Review of Resident 6's records showed the last care conference was on 03/28/2025. A progress note dated 05/08/2025 showed the resident refused a care conference on that day. The progress notes did not show any further care conferences were scheduled. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure physician orders were followed for 4 residents (Residents 64, 67, 2, & 3), failed to ensure physician orders were clarified for 2 residents (Resident 68 & 3), and failed to obtain physician orders prior to providing treatment for 1 resident (Resident 32) of 19 residents reviewed. These failures placed residents at risk for medication errors, delayed treatment, and adverse outcomes.

Inspectors wroteBased on observation, activity, and record review the facility failed to ensure residents were provided a program of meaningful, life enriching activities for 2 (Residents 60 & 3) of 6 residents reviewed for activities. This failure placed residents at risk for boredom, frustration, a diminished quality of life, and social isolation.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide adequate supervision to prevent avoidable accidents for 1 of 3 residents (Residents 9) reviewed for falls. This failure placed residents at risk for additional falls, discomfort, and substantial injuries.

Inspectors wroteBased on observations, interviews, and record review the facility failed to assess the resident for bowel and bladder needs or provide the necessary care and services to ensure bowel and bladder continence was improved or maintained for 1 of 1 residents (Resident 9) reviewed for bowel and bladder needs. This failure left the resident at risk for unmet care needs, avoidable incontinence, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a person-centered comprehensive Care Plan (CP) was implemented for 1 of 6 residents (Resident 1) whose CP was reviewed for assistance with Activities of Daily Living (ADLs). The failure to implement identified CP interventions for safety and adhere to individualized care of residents with identified behaviors affecting provision of ADL care placed residents at risk for potential abuse and/or neglect, inconsistent and/or inadequate care, worsening resident behaviors, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to: Provide medically-related social services to attain and/or maintain the highest practicable physical, mental, and psychosocial well-being of residents; assist residents in obtaining resolution to their grievances regarding refusals of treatment and care; and advocate for residents in the assertion of their rights within the facility for 1 of 6 residents (Resident 1) reviewed for behavioral health. This failure placed residents at risk of unmet social service needs, unsafe care, psychosocial decline, and a diminished quality of life. <Facility Policy> The Comprehensive Resident Care Plan [CP] facility policy, revised July 2015, showed Social Services would review and update each resident CP quarterly, annually, and as mandated in the Resident Assessment Instrument process after MDS completion. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure quarterly personal fund statements were provided to residents with personal fund accounts for 2 of 3 sampled residents (Residents 17 & 27) reviewed for personal fund accounts. This failure placed residents at risk of not having an accurate accounting of their personal funds held in trust by the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure funds were reimbursed to the resident and/or state Office of Financial Recovery (OFR), within 30 days of resident discharge for 7 (Residents 229, 227, 228, 232, 231, 233, & 230) of 9 discharged residents reviewed. This failure caused a delay in reconciling residents' accounts within 30 days as required.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Care Plans (CPs) were updated and/or revised as needed to reflect person-centered care for 4 (Resident 41, 22, 49, & 2) of 21 sample residents whose CPs were reviewed, and failed to ensure residents participated in Care Conferences (CCs) for 4 (Residents 2, 226, 19, & 27) of 21 sample residents whose CPs were reviewed. This failure left residents at risk for unmet care needs, inappropriate care, and other negative health outcomes.

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure ongoing communication and collaboration occurred with the dialysis (procedure to clean and filter waste from the blood) center for 2 (Resident 2 & 49) of 2 sample residents reviewed. These failures placed residents at risk for unidentified medical complications, adverse health outcomes, and unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure pharmacy recommendations were followed up in a timely manner and/or included in the resident's records for 3 (Residents 43, 27, & 49) of 5 residents who were reviewed for unnecessary medications. This failure placed residents at risk for delays in necessary medication changes, lab work, incomplete medical records, and adverse side effects.

Inspectors wroteBased on observation and interview, the facility failed to ensure resident meals were prepared or stored in accordance with professional standards of food safety for 1 of 1 facility kitchens, and 2 of 3 unit refrigerators. The failure to ensure dried foods were stored as required, that all refrigerated food was dated and labeled as required, to ensure Potentially Hazardous Food (PHF), drinks were served at the appropriate temperature, the kitchen was free from potential contaminants, and unit refrigerators were properly maintained left residents at risk for food contamination, food borne illnesses, and spoiled food.

Inspectors wroteBased on observation, interview, and record review the facility failed to consider and act promptly to address concerns raised by residents at the Resident Council (RC). Facility failure to ensure resident concerns were considered, acted upon, or a rationale provided when action could not be taken left residents at risk for unresolved concerns, frustration, and a less-than-homelike environment.

Inspectors wroteBased on interview and record review, the facility failed to complete Quarterly Minimum Data Set (MDS - an assessment tool) assessments within the regulatory timeframe for 2 of 21 (Residents 17 & 38) sampled residents reviewed for resident assessments and timing. The failure to ensure resident assessments were completed timely placed the residents at risk for delayed care planning, unidentified care needs and services, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 4 (Residents 27, 38, 25, & 5) of 21 resident's Minimum Data Set (MDS - an assessment tool) reviewed were completed accurately to reflect the resident's condition. This failure placed residents at risk for unidentified and/or unmet care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Physician's Orders (POs) were followed for 3 (Residents 27, 41, & 38) of 21 sample residents reviewed, POs were clarified for 3 (Residents 226, 27, & 49) of 21 sample residents reviewed, and nurses signed only for tasks completed for 2 (Residents 49 & 19) of 21 sample residents. These failures left residents at risk for unmet care needs, unnecessary treatment, inaccurate records, and other negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a discharge planning process to effectively transition the residents to the community for 2 (Residents 26 & 22) of 2 residents reviewed for discharge planning. This failure placed the residents at risk for a delay in discharge, unnecessary nursing care, avoidable healthcare expenses, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a restorative program was provided for 2 of 4 (Resident 19 & 38) sample residents identified by staff with mobility limitations and reviewed for Range of Motion (ROM). These failures placed residents at risk for declines in ROM, reduction in mobility, increased dependence on staff, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide residents the required medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing for 1of 18 sampled residents (Resident 66). The failure to address the residents' refusals of care and follow up on essential care needs placed Resident 66 at risk for poor hygiene, skin issues, nd decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food served from the facility kitchen met the dietary preferences or required texture for 6 of 21 sample residents (Residents 43, 56, 41, 18, 38, & 25). The failure to ensure residents were served meals that honored their preferences (Residents 38 & 25) and was prepared with the required texture (Residents 43, 56, 41, & 18) left residents at risk for weight loss, frustration, overly-processed food, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure specialized rehabilitative services were provided as determined by the Physician's Order (PO) for 2 of 2 (Residents 22 & 17) residents reviewed for therapy services. This failure prevented residents from attaining, maintaining, or being restored to their highest practicable level of physical, mental, functional, and psycho-social well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify the risk of hot liquids, adequately supervise, and initiate interventions for the safe use of hot liquids for a resident who required staff assistance for 1 of 1 residents (Resident 1), reviewed for accidents. Resident 1 experienced harm when they sustained a burn to their left lower lip.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the menu was followed during meal service for 9 (Residents 1, 2, 3, 4, 5, 6, 7, 8 & 9) of 15 residents reviewed. Failure of the facility to serve what was listed on the menu and tray cards placed residents at risk of dissatisfaction with the food served, lack of dietary intake, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide written notification of the reason for transfer for 1 (Residents 52) of 1 sample residents reviewed for hospitalization, and 1 discharged resident (Resident 37). Facility failure to provide written notification to residents/their representatives, and the state Long Term Care Ombuds office (LTC Ombuds office - an advocacy group for residents in nursing homes) denied residents/their representatives knowledge of their rights regarding transfer, and prevented the LTC Ombuds office from knowing when residents were hospitalized .

Inspectors wroteBased on observation, interview, and record review the facility failed to accurately assess 4 (Residents 29, 69, 78 & 33) of 24 residents whose Minimum Data Sets (MDS - an assessment tool) were reviewed. Failure to ensure accurate assessments regarding vision (Resident 69), vaccinations (Resident 29), Pre-admission Screening and Resident Review (PASRR) (Resident 29 and 33), and guardianship status and ethnicity/race (Resident 78), placed residents at risk for unidentified and/or unmet needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level 2 comprehensive evaluations were obtained, and/or implemented and incorporated into the Care Plan (CP) for 2 of 8 (Residents 52 and 68) residents reviewed for PASRR. This failure placed residents at risk for not receiving necessary mental health care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) assessments accurately reflected residents' mental health conditions for 2 of 8 (Resident 52 & 69) residents reviewed for PASRR. This failure placed residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Care Plans (CPs) were reviewed, revised, and accurately reflected residents' care needs for 3 (Resident 69, 35 & 52) of 21 residents whose CPs were reviewed. This failure placed residents at risk for unmet care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 1 resident (Resident 33) of 2 residents reviewed for smoking was assessed for the safe use of an e-cigarette (an electronic device that delivers nicotine in a vapor when inhaled). Specifically, Resident 33 was observed using an e-cigarette in their room instead of the facility's designated smoking area. Ths failure placed the resident and others at potential risk for injury.