BELLINGHAM, WA - A recent state inspection of Shuksan Healthcare Center uncovered significant care failures, including the development of a preventable Stage 3 pressure ulcer that required months of wound vacuum treatment, inadequate investigations of multiple resident falls resulting in injuries, and improper administration of cardiac medications that placed residents at risk for serious complications.
Preventable Pressure Wound Delays Recovery and Discharge
One of the most concerning findings involved a resident who developed a Stage 3 pressure ulcer to their tailbone area while at the facility, despite arriving with existing wounds that should have triggered immediate preventive measures. The resident, who had been admitted with Stage 2 pressure ulcers on both buttocks and an unstageable wound on their left foot, was assessed as moderate risk for developing additional pressure injuries.
Despite this known risk and the presence of existing wounds, the facility failed to provide an appropriate pressure-relieving mattress for over a month. The resident stated they were "supposed to have been on a specialty bed from day one, but I did not get one for over a month." During this critical period on what the resident described as feeling like "an army cot," a new Stage 3 pressure ulcer developed on their coccyx.
Stage 3 pressure ulcers represent full-thickness tissue loss where fat is visible in the wound, indicating significant damage that extends through multiple layers of skin. These injuries require extensive treatment and significantly impact recovery time. The development of pressure ulcers in healthcare settings is largely preventable through proper assessment, appropriate support surfaces, and regular repositioning protocols.
The delayed implementation of proper pressure relief had cascading effects on the resident's recovery. The wound required placement of a wound vacuum system, which was changed three times weekly from December 2024 through April 2025. The resident expressed frustration that the wound vacuum and positioning restrictions prevented effective participation in therapy, causing loss of strength and jeopardizing their goal of returning home.
Falls and Injury Investigations Lacked Critical Information
The inspection revealed systematic failures in investigating resident falls and potential neglect allegations, with four residents affected by incomplete or inadequate investigations. These failures prevented identification of root causes and implementation of appropriate corrective actions.
In one case, a resident with Alzheimer's dementia was found on the floor with a "goose egg/hematoma to their left temple" after reportedly falling while "picking up flower pedals in the bathroom." The investigation failed to include statements from the nursing assistant assigned to the resident's care that shift. Documentation showed staff did not know when the resident had last received toileting, repositioning, or fluids. Additionally, required post-fall monitoring was not completed on multiple shifts following the incident.
Another resident with multiple sclerosis and severe vascular dementia experienced repeated falls from their wheelchair. On January 31, 2025, the resident was found sitting on the floor after sliding from their wheelchair at 6:35 PM. The nursing assistant's statement revealed they had last observed the resident "sitting in their chair slightly slumped over at 5:45 PM" - nearly an hour before the fall. The investigation failed to address whether positioning contributed to the incident or evaluate implementation of care-planned interventions.
A particularly serious incident occurred when a resident sustained a 2-inch laceration to their forehead after falling in the bathroom. The investigation revealed the nursing assistant had observed the resident on the toilet at 12:50 AM, and ten minutes later found them on the floor with significant injury. The resident's care plan specifically required supervision while toileting due to cognitive deficits, yet the staff member documented they "did not provide supervision as directed."
Falls in nursing homes can result in serious injuries including fractures, head trauma, and internal bleeding. Proper investigation of each fall is essential to identify contributing factors such as medication effects, environmental hazards, staffing patterns, or gaps in care plan implementation. Without thorough analysis, facilities cannot develop effective prevention strategies, leaving residents vulnerable to repeated incidents.
Cardiac Medications Given Despite Low Blood Pressure and Heart Rate
The facility repeatedly administered blood pressure medications when vital signs indicated they should have been withheld, potentially causing dangerous drops in blood pressure or heart rate. Three residents received medications despite physician orders specifying clear parameters for holding doses.
One resident received Amlodipine and Metoprolol on multiple occasions when their heart rate or blood pressure fell below safe thresholds. On April 16, 2025, medications were administered despite a systolic blood pressure of 108, diastolic of 58, and heart rate of 52 - all below the specified parameters. Similar violations occurred throughout January through April 2025.
Administering cardiac medications when blood pressure or heart rate is already low can cause hypotension (dangerously low blood pressure), leading to dizziness, falls, confusion, and inadequate blood flow to vital organs. Heart rates below 60 beats per minute combined with blood pressure medications can result in bradycardia, potentially causing fatigue, shortness of breath, or cardiac events.
Mental Health Screening Failures Delay Necessary Services
Four residents did not receive required Pre-Admission Screening and Resident Review (PASRR) assessments, which identify mental health needs and ensure appropriate services. These screenings must occur before admission to identify residents requiring specialized mental health services.
One resident with major depressive disorder was experiencing hallucinations and delusions, including believing they were "naked in a wheelchair on 44th street in Seattle" and seeing "swarms of bugs in the room and the walls were moving." Despite these serious psychiatric symptoms requiring evaluation and treatment, the facility failed to update the resident's PASRR to reflect their condition.
Additional Issues Identified
The inspection also revealed an uncertified nursing assistant worked eight shifts without valid credentials, incomplete care planning for residents receiving psychotropic medications, and a medication error involving duplicate orders that resulted in a resident potentially receiving double doses of osteoporosis medication for three weeks. Care plans for residents on antipsychotic and antidepressant medications lacked documentation of symptoms, treatment goals, and non-pharmacological interventions. Post-fall monitoring protocols were frequently incomplete, with multiple missing assessment periods following injuries. The facility's investigation processes consistently failed to identify root causes, implement corrective actions, or ensure staff education following incidents.
These violations demonstrate systemic breakdowns in multiple areas of resident care, from basic pressure ulcer prevention to medication management and fall investigations. The failures particularly impacted vulnerable residents with cognitive impairment who relied on staff to ensure their safety and wellbeing.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Shuksan Healthcare Center from 2025-05-01 including all violations, facility responses, and corrective action plans.
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