SEATTLE, WA - A January 2025 federal inspection of Providence Mount St Vincent revealed a pattern of care breakdowns affecting residents across the 61-page report, including missed medications for a medically vulnerable resident, an unreported bleeding foot wound, and hygiene failures that left multiple residents without bathing for nearly three weeks.
The facility, located at 4831 35th Avenue Southwest in Seattle, was cited for deficiencies spanning medication administration, physician order compliance, wound care, personal hygiene, care planning, and activity programming. Inspectors reviewed 35 residents and found violations affecting a significant portion of the sample population.
Missed Medications for Resident With Heart Failure and Unstable Blood Sugar
Among the most medically significant findings, inspectors documented that a resident with unstable blood sugar levels, high blood pressure, and heart failure did not receive two prescribed medications on the morning of January 8, 2025. The resident had physician orders for a blood sugar-lowering medication to be taken twice daily and a supplemental medication every other day.
When the resident asked why their medications were not administered that morning, a nurse told them the pharmacy needed to be called. The resident reported being "very upset about not receiving their medications due to pharmacy issues" and told inspectors they had called family members to express their frustration, stating they might need to move out of the facility because of the problem.
For individuals managing conditions like heart failure and unstable blood sugar, consistency in medication administration is medically critical. Missed doses of blood sugar-lowering medications can lead to hyperglycemia, which over time damages blood vessels and organs. For heart failure patients, missed diuretic doses can result in dangerous fluid retention.
When interviewed, the nurse responsible for medication administration that morning stated they "did not have time to call the doctor or pharmacy" about the missing medications and could not recall which specific drugs were unavailable. The facility's long-term care nursing manager confirmed the nurse should have contacted the physician for further instructions but did not, and should have documented the missed doses in progress notes but failed to do so.
Bleeding Wound Goes Unreported
Inspectors observed a particularly concerning wound care failure involving a resident with impaired mobility, a history of pressure ulcers, and a diabetic foot ulcer on their left foot. Physician orders required staff to monitor the wounds each shift for signs of infection or worsening and to document observations and notify the provider.
On January 7, 2025, while a licensed nurse was applying a dressing to the resident's lower back, inspectors observed that a separate bandage on the resident's left foot was saturated with blood and had partially detached. The nurse stated that a contracted wound care service had provided treatment the day before and that no staff member had informed them about the bleeding.
A review of progress notes found no documentation from any staff member indicating the foot wound was bleeding before the surveyor's observation. The long-term care nursing manager told inspectors she was not made aware of the bleeding wound and stated that care staff should have reported bloody bed sheets and notified the nurse immediately.
Additionally, inspectors observed the same resident sitting in a wheelchair on two occasions with their left foot heel hanging down unsupported, despite physician orders to float the heel and care plan instructions requiring pressure-reducing boots. A certified nursing assistant confirmed the resident wore a boot while in bed but "did not use anything" while sitting in the wheelchair — a gap that increases the risk of pressure ulcer development or worsening of existing wounds.
Catheter Orders Disregarded
Another resident with a neurogenic bladder condition had a physician's order to remove their indwelling catheter for a trial period, with specific instructions to replace it with a size 16 French catheter if the resident could not urinate, or if a bladder scan showed greater than 500 cubic centimeters of urine retention. When staff documented that the resident had 698 cc of urine, they inserted a size 14 French catheter instead of the ordered size 16 — with no physician authorization for the change and no written orders addressing the duration of the new catheter.
Using an incorrect catheter size without medical authorization introduces unnecessary risk. Improperly sized catheters can cause tissue irritation, increase infection risk, and lead to inadequate drainage. Federal regulations require nursing facilities to follow physician orders precisely, and any modifications require a new order from the prescribing provider.
Residents Left Without Bathing for Up to 18 Days
The inspection revealed a systemic failure in providing basic hygiene assistance. Inspectors identified eight residents who did not receive adequate help with daily living activities including bathing, grooming, nail care, denture assistance, and dressing.
One resident who preferred weekly bed baths on Thursdays told inspectors that staff had not offered bathing since December 19, 2024 — a gap of 18 days at the time of the interview. A review of health records confirmed no bathing had been documented, and no refusals were recorded. The facility's Director of Nursing acknowledged the lapse and stated bathing was important "for infection prevention and to prevent skin breakdown."
Another resident's records showed repeated gaps of 13 to 14 days between showers over a three-month period. Despite being scheduled for weekly showers, this resident received only two showers in October 2024 and three in November. When the resident declined a shower, records showed no follow-up attempt was made on a subsequent shift or day, contrary to facility policy.
A third resident with severe cognitive impairment went 14 days without any documented bathing opportunity in late December 2024. Inspectors observed this resident with hair stubble on their chin and hair that appeared stringy and greasy.
Inconsistent bathing for elderly nursing home residents creates real medical risks beyond comfort. Poor hygiene can lead to skin infections, urinary tract infections, and breakdown of already fragile skin — particularly dangerous for residents who are immobile or have compromised immune systems.
Dentures Withheld, Residents Ate Without Them
Inspectors observed one resident eating breakfast without dentures on multiple occasions. The resident's care plan directed staff to ensure the dentures were worn, yet on January 6, 8, and 9, 2025, the resident was observed eating without them. The resident told inspectors: "They keep forgetting to bring them to me, it does not look good when I do not wear them." During one observation, the dentures were sitting in a cup across the room by the sink.
Eating without properly fitted dentures can compromise nutrition, particularly for elderly residents who may already have difficulty maintaining adequate caloric intake. Poorly chewed food also increases choking risk.
Outdated Care Plans Created Confusion
Inspectors found care plans that did not reflect residents' actual medical conditions, creating a disconnect between documented instructions and what staff should have been doing. In one case, a resident's catheter had been removed on December 27, 2024, but the care plan and staff instruction cards still directed employees to provide catheter care as of early January. In another, a resident who had recently received new dentures had no mention of denture care in their plan, despite also having a diagnosis of malnutrition.
A resident with a history of stroke still had instructions for a passive range-of-motion program that the Director of Nursing confirmed was no longer needed. Meanwhile, a newly admitted resident waited days without a care conference despite wanting one. When asked, a social worker said the resident "did not request a care conference, so they did not schedule one" — contradicting the resident's own account.
Isolated Residents Received No Activities
Three residents were found to have inadequate activity programming. One resident with COVID-19 was placed in isolation but received no in-room activities despite a care plan specifying that staff should provide reading materials, music, and opportunities for emotional expression. The resident told inspectors that while isolated, "no one came to their room."
Another resident who expressed strong interest in activities said they would "absolutely go to activities" and "would love that," but had not attended any since admission because they were unable to walk to the activity room unassisted. Staff did not arrange transportation despite knowing the resident was dependent on assistance for transfers.
The full inspection report details additional findings across care planning, professional standards compliance, and daily living assistance. Readers can review the complete federal survey results for Providence Mount St Vincent through the CMS Care Compare database.
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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