Marianwood Health: Transfer Notice Failures - WA
The 87-year-old with severe Alzheimer's disease left the facility at 1:35 PM on June 14 after nurses discovered the medical emergency at 1:05 PM. Four days later, Resident 32 returned to the nursing home. But inspectors found no evidence that staff ever completed the required written transfer notice or notified the state ombudsman's office.
"The facility should have notified the resident or their representative but could not demonstrate this happened," Health Information Manager Staff S told inspectors on July 31. The manager said because no notice existed, it couldn't be sent to the Long-Term Care Ombudsman office as required by state law.
Federal inspectors cited Marianwood for failing to provide proper transfer notifications for two residents who were hospitalized. The violations put residents at risk for discharges that didn't meet their care goals and prevented the ombudsman from advocating for them.
The facility's own policy required transfer notices to be provided to residents or their representatives "as soon as practical" when someone was hospitalized. Copies were supposed to be sent to the ombudsman's office monthly.
Resident 20 faced similar notification failures during a December hospitalization. The resident, who had suffered a brain injury that left one side of their body weak, was sent to the hospital on December 6 after complaining of abdominal pressure and pain with blood clots in their urine.
"I recall being sent to the hospital from the facility a few times due to an infection and increasing confusion," Resident 20 told inspectors on July 25.
Medical records showed an unsigned, incomplete transfer notice that failed to explain why the hospital discharge was warranted. The document had no signature from the resident or their representative acknowledging they received the required written notification.
Staff S confirmed the transfer notice should have been signed and said no documentation existed showing the ombudsman was notified of Resident 20's hospital transfer.
The inspection revealed systematic breakdowns in a process Administrator Staff A called essential for resident rights. During a July 31 interview, the administrator said written transfer notifications were important to communicate residents' locations and ensure families understood their rights during transfers.
"The provision of a written transfer/discharge notice went hand in hand with the required Ombudsman notification," Staff A told inspectors. The administrator said every staff member involved in nursing and medical records was expected to fulfill their part in the notification process.
Resident 32's case highlighted how the failures affected vulnerable residents with cognitive impairments. A May assessment showed the resident had severe memory problems from Alzheimer's disease and diabetes that made blood sugar regulation difficult. When the medical emergency struck in June, elevated glucose levels triggered the rapid heartbeat and involuntary movements that prompted the emergency hospitalization.
The resident spent four days in the hospital before returning to Marianwood on June 18. Throughout that period, the family had no formal notification explaining the transfer or their rights regarding their loved one's care.
Resident 20's situation demonstrated how incomplete paperwork compounded the notification failures. The resident lived with multiple serious conditions including malnutrition, urinary blockage requiring a catheter, and weakness from the brain injury. When abdominal pain and bloody urine developed, the provider ordered immediate hospital evaluation and treatment.
But the transfer notice sat unsigned and incomplete, offering no explanation for why the hospitalization was necessary. The ombudsman's office never received notification that could have triggered advocacy services for the resident.
The inspection also found Marianwood failed to complete required quarterly assessments on time. Resident 67's assessment was due June 3 but wasn't finished until June 17, three days past the 92-day regulatory deadline.
MDS Coordinator Staff T acknowledged the delay during a July 29 interview, saying timely assessments were crucial because "appropriate and safe care necessary for care planning relied on the timeliness of these assessments."
The quarterly assessments track residents' status between comprehensive evaluations and monitor for gradual changes that could indicate declining health. Late assessments put residents at risk for delayed care planning and unidentified needs that could affect their quality of life.
Administrator Staff A said the facility expected MDS coordinators to complete assessments "accurately and timely as required."
The transfer notification failures represented more than paperwork problems. State regulations require written notices to protect residents' rights and ensure proper oversight of facility decisions. The ombudsman's office serves as an independent advocate for nursing home residents, investigating complaints and monitoring care quality.
When facilities fail to notify the ombudsman of transfers, residents lose access to advocacy services during vulnerable periods when they're moving between care settings. Families remain uninformed about their loved ones' medical situations and their rights to appeal discharge decisions.
Both residents eventually returned to Marianwood after their hospitalizations, but the notification failures meant their transfers occurred without required oversight or family involvement in care decisions.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Marianwood Health and Rehabilitation from 2024-08-01 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
MARIANWOOD HEALTH AND REHABILITATION in ISSAQUAH, WA was cited for violations during a health inspection on August 1, 2024.
The 87-year-old with severe Alzheimer's disease left the facility at 1:35 PM on June 14 after nurses discovered the medical emergency at 1:05 PM.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.