Based on interview and record review, the facility failed to ensure 1 of 8 out of state licensed nurses (Staff C) reviewed had a multistate license authorizing practice in the state the facility was located. This failure placed residents at risk of receiving care from an unlicensed and unqualified individual.Findings included . On [DATE] Resident 1 experienced a change in condition, and coded. CPR (Cardiopulmonary Resuscitation) was started, 911 notified, medics continued CPR and pronounced Resident 1 deceased . The assigned nurse, Staff C, Registered Nurse (RN),was suspended pending investigation. On [DATE] at 6:55 PM, Staff A, Administrator documented the facility investigation substantiated that Staff C did not meet the standard of care when responding to a reported change in condition. …
F839 citations in Washington
Administration Deficiencies
Employ staff that are licensed, certified, or registered in accordance with state laws.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Washington cites F839 more often than its own record predicts
1.24 times the share F839 takes of citations nationally.
Of every deficiency written in Washington in 2025, this is the portion that was F839.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Washington surveyors wrote
F839 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.
What else Washington surveyors cite →
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