SEATTLE, WA - State health inspectors documented multiple safety and care violations at Providence Mount St Vincent nursing home during a January 2025 inspection, including unsecured needles and hazardous chemicals accessible to residents, inadequate pain management practices, and missing staff competency assessments.
Hazardous Materials Left Accessible to Residents
Inspectors identified serious environmental safety concerns across multiple units at the 4831 35th Avenue Southwest facility. During observations conducted on January 2, 2025, surveyors documented unlocked storage areas containing medical sharps, cleaning chemicals, and personal care items that should have been secured.
On the 2 North unit, eight blood collection kits containing needles were discovered uncontained on an open shelf at waist height in an unlocked clean utility room. The room's door had no locking mechanism, and nursing staff on duty confirmed they did not possess keys to secure the area. A towel warmer device in the same room was easily accessible and not locked.
Similar conditions were observed on the 4 South unit, where the spa room door was propped open, providing unrestricted access to disinfectant cleaners bearing warning labels to avoid contact with eyes and skin and keep away from children. The clean utility room on this unit was also unlocked, containing bottles of shaving cream, body wash, and barrier creams.
On the 5 North unit, inspectors found the spa room and clean utility room unlocked throughout their observation period. Inside were gallon-size bottles of skin disinfectant and antiseptic solution, spray bottles of facility disinfectant cleaning solution stored in open cabinets at knee height, and razors in unlocked drawers. When questioned, a Licensed Practical Nurse working on the unit acknowledged that both rooms were "always left unlocked" and confirmed this posed potential dangers to residents. The unit's Resident Care Manager admitted the spa room lock was broken and that chemicals and razors should be stored behind locked doors.
In the St. Joseph's Residence unit, a laundry room door displaying a "please keep door closed" sign was observed standing open with no staff nearby. Inside, an unlocked cabinet contained disinfectant bottles labeled "Danger, keep out of the reach of children" and laundry detergent. Additional aerosol disinfectant and sanitizer products with similar warning labels sat on the counter in an open basket. When inspectors returned approximately 30 minutes later, the door was closed but remained unlocked with no locking mechanism installed.
The facility's own policy, revised in January 2025, specifically required all chemicals to remain out of residents' reach and stored behind locked doors. The Director of Nursing confirmed that needles and sharps should be secured and inaccessible to residents, while the Administrator stated proper storage of chemicals and razors was essential to resident safety.
Critical Gaps in Pain Management Protocols
The inspection revealed significant deficiencies in pain assessment and medication availability that affected residents experiencing chronic pain conditions. Two residents' cases illustrated systematic problems with the facility's pain management approach.
One resident with chronic pain and muscle spasms had physician orders for narcotic pain medication to be administered every eight hours as needed. Review of medication administration records from November 2024 through January 2025 showed that staff frequently failed to complete required pain assessments before administering the controlled medication. Documentation areas for pain level, location, interventions, and dosage amount were either incomplete or inaccurate across multiple administration instances.
During an interview, this resident reported that staff did not assess their pain before giving medications and frequently administered pain relief medication late. The situation became problematic enough that the resident requested their physician change the medication to a scheduled routine dose rather than as-needed to ensure more consistent timing.
A second resident with chronic pain related to ongoing wound care experienced a different but equally concerning problem when the facility ran out of their prescribed pain medication. On January 5-6, 2025, nursing staff discovered the resident's pain medication was unavailable. Despite calling the pharmacy on both days, the medication was not delivered as promised. Staff attempted to access the facility's emergency medication supply kit but found the needed pain medication was not stocked in the kit.
This resident was given over-the-counter pain medication as a substitute but expressed frustration that the facility had previously run out of their medications and they couldn't understand why this continued to happen. According to facility policy, when a resident experienced a major change in pain regimen, they should be placed on "alert charting" with pain assessments documented every shift. However, progress notes showed no alert charting was initiated during the period when the prescribed pain medication was unavailable.
Medical standards require comprehensive pain assessment before administering controlled substances to ensure appropriate dosing, identify the pain source, and evaluate non-pharmacological alternatives. Incomplete assessments can result in inadequate pain control, inappropriate medication use, or missed opportunities to address the underlying cause of discomfort. For residents with chronic conditions, inconsistent pain management can significantly impact quality of life, sleep patterns, mobility, and participation in daily activities.
The facility's Long Term Care Manager acknowledged that staff should have documented pain levels, locations, correct doses, and offered non-pharmacological interventions consistently but failed to do so. Regarding the medication supply issue, the manager noted that nurses should have followed protocol by pulling medication from emergency supplies, notifying nursing management and the provider, and documenting all steps in progress notes—none of which occurred.
Weight Monitoring Failure Raises Nutritional Concerns
Inspectors identified a case where nursing staff failed to follow basic protocols for monitoring a resident's nutritional status. The resident, who had been diagnosed with anemia and malnutrition, was assessed as being at risk for weight loss due to poor appetite.
Weight records showed the resident weighed 155 pounds on November 10, 2024, 151.2 pounds on December 13, 2024, and 119.8 pounds on January 3, 2025—an apparent loss of more than 30 pounds in three weeks. Despite this dramatic change, health records contained no documentation that staff reweighed the resident to verify the accuracy of the January measurement. There was also no evidence that nurses notified the physician or the facility's Registered Dietician about the significant weight change.
Accurate weight monitoring is a fundamental component of nutritional care in long-term care settings. Significant weight fluctuations can indicate serious underlying medical conditions, medication side effects, swallowing difficulties, depression, or inadequate nutritional intake. A 30-pound loss over three weeks would represent an extreme and medically concerning change requiring immediate clinical intervention.
The facility's own Weight and Nutrition Monitoring Policy from October 2023 stated that changes in residents' nutritional status and weight should be discussed routinely by clinical staff and the Registered Dietician. The nutritional assessment completed by the dietician specifically instructed staff to notify them of any significant change in the resident's weight.
The Director of Long Term Care acknowledged that the weight loss shown in records was improbable and that staff should have reweighed the resident on January 3 to verify the measurement. The director confirmed the facility should have notified the provider but did not do so.
When weight measurements show unexpected or implausible changes, standard nursing practice requires verification through repeat measurement, review of scale calibration, and assessment of factors that might affect weight such as clothing, time of day, or recent fluid intake. Failure to verify and report significant changes delays necessary medical evaluation and intervention.
Staff Competency Assessments Missing
The inspection revealed that the facility failed to maintain required documentation of nursing staff competencies. When the Director of Nursing was asked to provide verification of competency documentation for four randomly selected staff members—including a Certified Nursing Assistant and three Registered Nurses—they could not produce the requested competency performance evaluations.
The facility's own 2024 Facility Assessment, reviewed in October 2024, outlined that training, education, and competencies of nurses and nurse aides were necessary to provide appropriate support and care to residents. The assessment specified that nurses and nursing assistants would complete skills assessments upon hire and competency-based skills assessments annually.
These competency evaluations serve as verification that staff possess the knowledge, skills, abilities, and behaviors necessary to perform their work roles successfully. Required competency areas include abuse and neglect prevention, resident rights, dementia care, infection control, communication, and meeting specific resident needs based on individualized care plans. For nursing assistants, competencies should also cover personal care skills, vital sign monitoring, safety and mobility, emergency protocols, and cultural competency.
The Administrator acknowledged that the facility should complete nursing staff evaluations to assess competencies, skills, and knowledge to provide safe resident care but admitted the facility had not assessed nursing staff competency as required. This represents a fundamental failure in quality assurance and staff development programs.
Additional Issues Identified
Beyond the major violations, inspectors noted the facility's recent transition to a new pharmacy may have contributed to medication supply issues. The Long Term Care Manager indicated this change in pharmacy providers occurred shortly before the medication shortage incident, though this did not excuse the failure to follow established protocols for managing medication unavailability.
The inspection also highlighted inconsistencies between facility policies and actual practices. Multiple written policies addressed the specific issues identified during the survey—proper chemical storage, pain assessment procedures, weight monitoring protocols, and staff competency verification—yet staff failed to implement these policies consistently across units.
The violations documented during this inspection represent preventable safety risks and care deficiencies that could have been avoided through adherence to the facility's own established policies and basic standards of nursing practice.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Providence Mount St Vincent from 2025-01-10 including all violations, facility responses, and corrective action plans.
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