COLVILLE, WA - Federal inspectors found significant deficiencies in social services and resident advocacy protections at Prestige Care & Rehabilitation - Pinewood Terrace during a May 2025 inspection, including the improper discharge of a resident and failure to notify the state ombudsman of 37 hospital transfers.
Questionable Discharge Raises Documentation Concerns
The most serious violation involved the discharge of a resident with Parkinson's disease and a leg amputation, whose removal from the facility appears to have been based on insufficient documentation. The resident, who had lived at the facility since their admission, was given a 30-day discharge notice in April 2025, citing safety concerns for other residents.
According to inspection records, the resident had multiple complex medical conditions including Parkinson's disease, seizures, anxiety, depression, and chronic pain. They required substantial assistance with daily activities and mobility due to their above-knee amputation. The resident was cognitively intact and had been waiting to be fitted for a prosthetic device while seeking community housing with caregivers.
The facility's discharge notice stated that "the safety of other individuals in this facility is endangered due to the status of the resident." However, inspection findings revealed significant inconsistencies in this justification. The facility's incident reporting log from September 2024 through May 2025 contained no entries showing the resident was involved in altercations or displayed dangerous behavior.
Most notably, the facility's own behavior monitoring records contradicted the discharge reasoning. From March through May 2025, staff were ordered to document all concerning behaviors, but the Treatment Administration Record showed the resident exhibited no problematic behaviors from March 9 through May 7, 2025 - the period leading up to their discharge.
Medical Impact of Inadequate Social Services
When social services fail to properly evaluate and document discharge decisions, residents face serious risks that extend beyond administrative inconvenience. For individuals with complex medical conditions like Parkinson's disease, inappropriate discharge timing can lead to medication management problems, loss of specialized care coordination, and increased risk of falls or other complications.
The discharged resident's medical profile presented particular concerns. Parkinson's disease requires consistent medical monitoring and medication timing, while recovery from leg amputation typically involves specialized wound care and prosthetic fitting coordination. Premature discharge to an unsuitable environment could result in wound complications, delayed prosthetic fitting, medication errors, or falls due to inadequate mobility support.
Additionally, residents with cognitive disabilities or complex medical needs depend on social services to ensure their discharge location can safely meet their care requirements. When this evaluation process fails, residents may be placed in environments lacking necessary medical support, family caregiver training, or accessibility modifications.
Missing Ombudsman Notifications Compromise Resident Rights
The inspection revealed a systematic failure to notify the State Long-Term Care Ombudsman of hospital transfers, with 37 transfers occurring between January and May 2025 without proper notification. This represents a complete breakdown in a critical resident protection mechanism.
The ombudsman serves as an independent advocate for nursing home residents, investigating complaints and ensuring facilities comply with resident rights regulations. When transfers to hospitals go unreported, the ombudsman cannot monitor whether residents are being appropriately treated during medical emergencies or verify that hospital discharges back to the nursing home are handled properly.
Hospital transfers often represent vulnerable moments for nursing home residents. Without ombudsman oversight, there's increased risk that residents' rights could be violated during medical crises, that family members might not be properly notified, or that residents could be inappropriately discharged from hospitals to unsuitable care settings.
The facility's social services coordinator acknowledged being unaware of the notification requirement, stating "As far as I know we don't need to notify the Ombudsman [for hospital transfers]. We haven't been trained on that." This knowledge gap suggests systemic training deficiencies in resident rights protection.
Industry Standards and Required Protocols
Federal nursing home regulations require comprehensive discharge planning that begins at admission and involves the interdisciplinary care team, resident, and resident advocates. Discharge decisions must be based on documented assessments showing the resident can safely transition to their new environment.
For behavioral concerns leading to discharge, facilities must document specific incidents, interventions attempted, and evidence that the resident's continued presence endangers others. This documentation standard exists because inappropriate discharges can leave vulnerable individuals without necessary care.
Regarding ombudsman notification, state regulations require nursing homes to report various resident events to maintain transparency and accountability. The ombudsman system was established specifically to protect nursing home residents' rights and investigate potential abuse or neglect.
Proper social services should have ensured the discharged resident's medical records supported the safety concerns cited for removal. The interdisciplinary team should have documented specific behavioral incidents and interventions attempted before resorting to discharge. Additionally, the discharge location should have been evaluated for appropriateness given the resident's medical complexity and care needs.
Additional Issues Identified
Beyond the major social services failures, the inspection documented concerning patterns in staff documentation and training. Multiple staff members interviewed were unaware of incidents that allegedly supported the discharge decision, suggesting communication breakdowns within the care team.
The resident's former roommate reported never feeling unsafe around the discharged resident, while nursing staff described only minor irritability rather than dangerous behaviors. This disconnect between staff observations and the documented discharge rationale raises questions about decision-making processes.
The facility's behavior monitoring system, while present, appears to have been ineffectively implemented. Despite orders to document all concerning behaviors, staff either failed to observe problematic conduct or failed to properly record observations that would support discharge decisions.
Staff interviews revealed knowledge gaps regarding regulatory requirements, particularly around ombudsman notification procedures. The administrator expected ombudsman notifications for hospital transfers, but the social services coordinator responsible for such notifications was unaware of this requirement, indicating inadequate training and oversight.
These deficiencies collectively suggest systemic problems in social services delivery, staff training, and administrative oversight that could affect multiple residents' care and rights protection.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Prestige Care & Rehabilitation - Pinewood Terrace from 2025-05-23 including all violations, facility responses, and corrective action plans.
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