Based on observation, interview and record review, the facility failed to provide a complete discharge summary to the resident and their primary care physician and failed to implement a process to reconcile pre-discharge medications with the resident's post-discharge medications for 2 of 6 sampled residents (#1 & 2) reviewed for community discharge. This failure placed residents at risk of unmet care needs, medical complications, and a diminished quality of life. This caused harm to Resident #1. Findings include 1) Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool, dated 11/18/18, documented Resident #1 was discharged from the facility to the community on 11/28/18 and return to the facility was not anticipated. …
F661 citations in Washington
Resident Assessment and Care Planning Deficiencies
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Washington cites F661 more often than its own record predicts
2.19 times the share F661 takes of citations nationally.
Of every deficiency written in Washington in 2025, this is the portion that was F661.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Washington surveyors wrote
F661 findings written in Washington, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on interview and record review, the facility failed to ensure the discharge summary was completed and included a recapitulation (overview) of the resident's stay for 1 of 1 resident (Resident 96), reviewed for discharge summary. This failure placed the resident at risk for unsafe discharge, complications and a diminished quality of life. Findings included . Review of the facility's policy titled, Discharge Planning Process, revised in May 2024, showed, The evaluation of the resident's discharge needs and discharge plan will be completely documented on a timely basis in the clinical record. The results of the evaluation and the final discharge plan will be discussed with the resident or resident's representative. …
The short window
Recent years
| Year | Share of Washington citations | vs expected |
|---|---|---|
| 2023 | 0.22% | 0.83× |
| 2024 | 0.30% | 1.33× |
| 2025 | 0.14% | 2.19× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Washington surveyors cite →
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