Life Care Kennewick: Restraint Strangulation Risk - WA
The incident at Life Care Center of Kennewick triggered immediate jeopardy findings on August 23, when inspectors found the restraint had moved from the resident's chest to their windpipe area. Staff Member M, a nursing assistant, told investigators the restraint had slid up under the resident's chin and pointed to the mid-windpipe area on their own neck to demonstrate where it had been positioned.
Resident 1, who has severe intellectual disabilities and encephalitis, was found three separate times with the four-point restraint improperly applied. On August 20, inspectors observed the resident behind a closed curtain in their wheelchair, tilted back with four inches of loose space between their chest and the restraint. Two days later, the resident had slid down in their wheelchair, causing the restraint to move to collar bone level instead of chest level, again with four inches of dangerous slack.
The most serious violation occurred August 23, when the right bottom strap was placed over the resident's arm instead of under it, with five inches of space between the resident's chest and restraint. Staff P, a licensed practical nurse and unit care coordinator, admitted the restraint was not applied correctly and immediately adjusted it after inspectors pointed out the problem.
"No one told me that I was supposed to," Staff P said when asked about conducting ongoing assessments or maintaining a check and release schedule for the restraint.
None of the nursing staff had received training on the proper use or application of four-point restraints. Staff N, a nursing assistant, confirmed they had not received any training on the restraint's application or use. Staff O, another licensed practical nurse, said they had been trained years ago on a different wheelchair but received no training when the current wheelchair and restraint system was ordered in 2021.
The facility's own policy required extensive documentation and safeguards that were never implemented. According to the December 2023 policy, restraint use required an assessment showing least restrictive alternatives had been tried and failed, a physician's order specifying type and medical symptoms, and detailed care plan interventions including where and how to apply the device and frequency of release.
None of these requirements were met for Resident 1. The physician's order from June 26 simply stated "tilt in space wheelchair with harness to aid in positioning" without medical justification, application directions, or release schedules. The resident's care plan from July 25 contained no interventions for restraint use, medical symptoms justifying it, or safety protocols.
No initial assessment or ongoing reassessments had been completed for the four-point restraint, despite facility policy requiring quarterly evaluations.
A second resident faced similar problems. Resident 5, who has cerebral palsy and epilepsy, was observed August 25 with a four-point restraint loosely placed, with the top two straps lying across their upper arms instead of over their shoulders as intended. Like Resident 1, this resident had no proper physician's order, no appropriate care plan, and no required assessments for restraint use.
Administrator Staff A acknowledged the facility had failed to follow proper procedures. "Their process was not at all followed correctly for Resident 1 and 5," they told inspectors. The administrator said expectations included trying least restrictive alternatives first, making four-point restraints the very last resort, and ensuring ongoing evaluations, training, and quarterly assessments.
The facility removed the immediate jeopardy by providing education with return demonstrations to nursing staff before their next shifts and implementing a supervisory plan to ensure Resident 1 would be observed and repositioned as needed. Staff were instructed not to leave the resident in an unsupervised area while wearing the restraint.
But other safety failures emerged during the same inspection. The facility served food at unsafe temperatures, resulting in injury to one resident when reheated food burned them. Investigators found problems with food temperature controls in microwaves that placed other residents at risk.
Safety hazards extended to shower rooms and equipment storage. Two of three shower rooms in the transitional care unit and all eight personal protection equipment carts contained unsecured cleaning agents that could harm residents if ingested or cause skin and eye injuries.
The facility also failed to provide adequate restorative nursing services, limiting programs to just ten residents despite having many more who needed such care. Resident 22, who had muscle weakness and limited mobility, told inspectors they tried to do exercises by themselves because no one helped them. "I would like to try and have exercises and see what that would be like," the resident said.
Resident 31, who had Parkinson's disease and muscle weakness, was supposed to wear a resting hand splint at night to keep their fingers straight. But the splint had been missing for an extended period. "I had a glove for the swelling and a splint that helped keep my fingers straight but did not wear it any longer due to them not being able to find the splint or the glove," the resident told inspectors.
The facility's physical therapist said all residents should be on restorative nursing programs to maintain mobility and was unaware of the ten-resident limit. "As a therapist they felt that was not appropriate," according to the inspection report.
Staff Member M's description of the restraint reaching the resident's windpipe illustrated the severity of the safety breakdown. The nursing assistant had to physically pull the resident up in their wheelchair to reposition the restraint away from their neck, a situation that should never have occurred with proper training and monitoring.
The immediate jeopardy finding meant the facility posed an immediate threat to resident health and safety. While the facility corrected the specific restraint problems within hours of being notified, the broader pattern of missing assessments, inadequate training, and policy violations revealed systemic problems with resident safety oversight.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Life Care Center of Kennewick from 2024-08-26 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
LIFE CARE CENTER OF KENNEWICK in KENNEWICK, WA was cited for violations during a health inspection on August 26, 2024.
Resident 1, who has severe intellectual disabilities and encephalitis, was found three separate times with the four-point restraint improperly applied.
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.