ISSAQUAH, WA - Federal inspectors found immediate jeopardy conditions at Marianwood Health and Rehabilitation, a nursing facility where critical safety and care violations placed residents at serious risk.
Immediate Jeopardy Citation Raises Critical Safety Concerns
During an August 1, 2024 inspection, state surveyors identified conditions at the 3725 Providence Point Drive Southeast facility that posed immediate threats to resident health and safety, resulting in an F689 citation - the most serious level of violation under federal nursing home regulations.
The immediate jeopardy finding indicates inspectors determined the facility's practices created situations where serious injury, harm, impairment or death could occur at any time. While the specific details of the immediate jeopardy citation were not detailed in the available portions of the inspection report, such findings typically involve critical failures in resident care, safety protocols, or emergency procedures.
Federal regulations require nursing homes to maintain standards that ensure resident safety at all times. Immediate jeopardy citations trigger mandatory corrective action plans and can result in significant penalties, including potential termination from Medicare and Medicaid programs if violations are not promptly addressed.
Widespread Medication Safety Failures
Inspectors documented extensive medication management violations affecting multiple units throughout the facility. On Unit A, nurses left unlabeled blood-thinning injection medication and improperly stored insulin that required refrigeration. The insulin label specifically indicated refrigerated storage requirements, yet staff stored it at room temperature on the medication cart.
Unit B violations included expired glaucoma eye drops that had been open for over 60 days past their 42-day expiration period, and improper storage of multiple topical medications including antifungal creams, pain gels, and vaginal creams mixed together in a single container. This practice creates significant contamination risks and can lead to incorrect medication administration.
The medication room contained supplies expired for over six months, including syringes that expired in December 2023 and culture swabs that expired in May 2024. Discharged resident medications remained in storage for months, with some dating back to April 2024 - well beyond the required 30-day return period to the pharmacy.
Perhaps most concerning, inspectors observed an unlocked medication cart left unattended in a hallway with a resident sitting nearby. This violation creates immediate risks for medication theft, tampering, or accidental ingestion by confused residents.
In one instance, a nurse left nine pills and two inhalers at a resident's bedside without proper assessment for self-medication capability. The resident had an order to keep one inhaler at bedside but lacked the required safety assessment and care plan documentation to justify unsecured medication access.
Critical Failures in Feeding Tube Management
The facility failed to properly monitor and document tube feeding for residents dependent on nutritional support. Resident 45, who received tube feeding via a surgical opening in their stomach, experienced significant gaps in intake monitoring and weight documentation that could have compromised their nutritional status.
Despite physician orders requiring specific tube feeding volumes and schedules, nursing staff failed to document the amount of formula administered during the month of July 2024. The Director of Nursing acknowledged that accurate documentation was essential for evaluating tolerance and ensuring nutritional needs were met.
Weight monitoring proved equally problematic. Despite orders for weekly weight checks, Resident 45's weight fluctuated dramatically without proper oversight - losing 7 pounds in two weeks, then gaining nearly 11 pounds in six days. These significant weight swings indicate potential fluid retention, nutritional imbalances, or other medical complications requiring immediate attention.
Staff also failed to properly label tube feeding bags with essential safety information including resident names, formula types, dates, times, and administration rates. Unlabeled feeding bags create risks for medication errors, contamination, and administration of incorrect formulas or volumes.
Inadequate Pain Management and Communication
Resident 12 reported daily chronic pain that nursing staff failed to properly assess, document, or treat according to facility protocols. The resident described constant sharp pain in their left calf that made standing difficult, rating their discomfort at 8.5 out of 10 on the pain scale.
Despite multiple reports to nurses and physicians, the resident stated: "Nobody is doing anything to help me with my pain. I told the nurses about the constant pain, and I told my doctor and the staff have not followed up with me."
Nursing staff admitted they were unaware of the resident's pain complaints and had not documented the issues in progress notes or communicated them during shift changes. The facility's own pain management policy required alert charting and every-shift assessment for residents with major pain status changes, but staff failed to implement these protocols.
The Director of Nursing confirmed that proper documentation was critical for alerting the care team and obtaining physician orders for pain management, but acknowledged these essential steps had not occurred.
Severe Staffing Shortages Impact Resident Care
Multiple residents reported dangerous delays in response to call lights, with wait times extending up to two hours during shift changes. Resident 11 described the worst delays occurring between evening and night shifts, attributing problems to understaffing.
During inspection observations, surveyors documented call lights remaining unanswered for over 10 minutes while nursing staff conducted shift reports. In one incident, the Director of Rehabilitation instructed shower aides to answer call lights because only one caregiver was available on the floor.
Resident 52 described a particularly dangerous situation where they activated their call light in the bathroom after a bladder accident but received no response. Growing ill and concerned about slipping on the wet floor, the resident was forced to place towels down and return to bed without assistance.
The facility's January 2024 Resident Council meeting notes documented ongoing concerns about poor call light response times, with administrators acknowledging coordination problems and short-term plans to increase nursing supervision.
Licensed nurses confirmed staffing challenges, with one registered nurse stating the facility "may be short staffed and could use more nursing assistants and licensed practical nurses." Staff emphasized that staffing should be based on resident care complexity rather than simply maintaining minimum ratios.
Food Safety Violations During COVID-19 Outbreak
Inspectors found multiple food safety violations that placed residents at risk for foodborne illness, particularly concerning given the facility was experiencing a COVID-19 outbreak during the inspection period.
Kitchen staff failed to follow basic hygiene protocols, with one cook repeatedly lowering their surgical mask below their chin while handling food, then touching the mask with gloved hands and continuing food preparation without changing gloves or washing hands.
Food storage violations included improperly stored thickening powder left open and exposed, unlabeled granulated garlic without use-by dates, and a unit pantry refrigerator containing a two-month-old quesadilla covered only with a paper towel.
Most concerning for infection control, staff routinely served meals with desserts and other items left uncovered while passing by isolation rooms during the COVID-19 outbreak. When questioned, nursing assistants acknowledged the contamination risk but stated this was standard practice.
An ice and water dispensing machine showed visible yellow-green slime buildup in the dispensing chute, creating additional contamination risks for residents accessing drinking water.
Infection Control Failures
The facility's infection prevention program showed multiple critical gaps that increased risks for healthcare-associated infections. Sharps containers in three resident rooms were overfilled beyond maximum capacity lines, creating needle stick risks for staff and residents.
During wound care procedures, nursing assistants failed to follow hand hygiene protocols after removing personal protective equipment and before handling clean supplies. This fundamental infection control breach can lead to cross-contamination and healthcare-associated infections.
Equipment maintenance issues included uncleanable floor mats with torn corners exposing foam material, and improper positioning of urinary catheter drainage bags on the floor rather than properly secured positions.
The facility's Water Management Program lacked required risk assessments and facility diagrams needed to prevent Legionella growth, despite policy requirements for comprehensive documentation and monitoring.
Equipment Safety Hazards
Bed safety inspections revealed a significant entrapment hazard for Resident 45, whose air mattress was improperly fitted to the bed frame, creating gaps of up to 10 inches. Such gaps pose serious entrapment risks, particularly for residents with limited mobility who cannot reposition themselves independently.
The facility's own care plan specifically required staff to minimize gaps between mattresses and bed frames, but maintenance and rehabilitation staff failed to identify or address this dangerous condition. Federal guidance identifies seven zones of potential bed entrapment that can result in serious injury or death.
Marianwood Health and Rehabilitation must address these systemic failures across multiple departments to ensure resident safety and regulatory compliance. The combination of immediate jeopardy conditions, medication errors, inadequate staffing, and infection control failures represents a pattern of care deficiencies requiring comprehensive corrective action.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Providence Marianwood from 2024-08-01 including all violations, facility responses, and corrective action plans.
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