The resident had been admitted with a history of stroke that left them with paralysis on their left side and difficulty swallowing. They depended entirely on staff for grooming, eating, dressing, and moving around the facility.
Their care plan required daily range-of-motion exercises and a splinting program to prevent their left hand from stiffening into contractures. Staff were supposed to place a soft splint on the resident's hand each morning and remove it at bedtime, replacing it with a full splint that included finger separators for overnight wear.
Instead, staff missed the treatments on September 4, 5, 7, 8, 14, 15, 16, 17, 18, 21, 22, 26, 28, and 29. No signatures appeared on the treatment records to show the work had been completed on nearly half the days of the month.
During the inspection, a contact familiar with the resident's care told investigators the left hand splint was frequently dirty. The palm of the resident's hand had developed an odor related to the lack of proper care in that area.
When confronted by inspectors on September 30, Staff B, a restorative nursing assistant, said "I do my best to get them done." The RNA explained that programs went undone because supervisors often pulled them away from restorative duties to work on the general nursing floor.
Staff B also told inspectors that when they took days off or went on vacation, nobody covered the restorative programs. The resident simply went without the required therapy.
The Director of Nursing, Staff A, acknowledged during a separate interview that afternoon that management knew the range-of-motion programs weren't being completed consistently. The DON cited insufficient staffing levels and said the facility was working on the problem.
The missed therapy sessions violated Washington state regulations requiring nursing homes to provide restorative nursing services according to each resident's care plan. For stroke patients with paralysis, consistent range-of-motion exercises and proper splinting are essential to prevent permanent joint contractures that can cause pain and further disability.
The facility's comprehensive assessment had documented that this resident had impaired cognition in addition to their physical limitations from the stroke. They relied completely on staff for basic daily activities including grooming, eating, getting dressed, and moving from place to place.
The September Kardex showed the resident needed both the daily range-of-motion exercises for their left arm and hand, plus the carefully timed splinting routine. The morning soft splint was designed to allow some movement during waking hours, while the overnight full splint with finger separators provided maximum positioning to prevent contractures during sleep.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm to some residents. However, the pattern of missed treatments over nearly two weeks raised concerns about the facility's ability to consistently deliver prescribed therapies to vulnerable residents.
The investigation began after a complaint was filed about care at the facility. Inspectors reviewed medical records, interviewed staff members, and spoke with individuals familiar with residents' conditions to document the scope of the problems.
Staff B's admission that restorative programs simply stopped when the assigned worker was absent highlighted systemic staffing issues beyond just being short-handed on busy days. The facility appeared to have no backup plan to ensure continuity of prescribed treatments when the primary staff member was unavailable.
The resident's dirty, odorous hand splint served as physical evidence of the neglected care. Proper splinting requires not only consistent application and removal but also regular cleaning and monitoring of skin condition underneath the device.
Mountain View Post Acute's failure to maintain the resident's therapy schedule despite their documented need for prevention of contractures reflected broader challenges in providing specialized care to stroke patients with complex medical needs.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mountain View Post Acute from 2025-11-20 including all violations, facility responses, and corrective action plans.