Every finding on record at Avamere Rehabilitation of Issaquah

Based on interview and record review, the facility failed to complete comprehensive assessments within the regulatory timeframes for 2 of 3 sample residents (Residents 1 & 7) reviewed for change in condition. The failure to ensure a comprehensive Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS - an assessment tool) was completed timely delayed the residents' care planning process necessary to provide the appropriate care and services, and placed residents at risk for unidentified care needs, delayed services, and a decreased quality of life. Findings included. <Facility Policy>The facility policy titled, MDS Completion and Submission Timeframes, revised July 2017, showed timeframes for completion and submission was based on the current requirements published in the Resident Assessment Instrument (RAI) Manual. <Resident Assessment Instrument (RAI - instructional guidelines for MDS completion) Manual>The October 2025 RAI Manual outlined a SCSA must be completed no later than the 14th calendar day after a determination that a significant change in a resident's status occurred.<Resident 1>Review of Resident 1's 05/12/2026 SCSA MDS showed the resident admitted to Hospice (end of life care) services on 05/06/2026. The assessment showed the Registered Nurse (RN) Coordinator completed the assessment on 05/27/2026, seven days past the required regulatory timeframe. <Resident 7>Review of Resident 7's 05/13/2026 SCSA MDS showed the resident was determined to have a change in condition because they needed increased staff assistance with their activities of daily living. The assessment showed the RN Coordinator completed the assessment on 05/30/2026, three days past the required regulatory timeframe. In an interview on 06/30/2026 at 12:51 PM, Staff J (MDS Coordinator) stated it was important to ensure MDS assessments were completed timely because it drove the care planning process, .late assessments equated to late care plans. Staff J reviewed Resident 1 and Resident 7's SCSA MDS assessment and stated they were completed late. Refer to F644- Coordination of PASARR and Assessments. REFERENCE: WAC 388-97-1000(b)(c)(ii), (3)(a).

Based on interview and record review, the facility failed to refer and coordinate assessments with the Pre-admission Screening And Resident Review (PASARR) program after a Significant Change in Status Assessment (SCSA) was completed in accordance with the Social Security Act for 3 of 3 sample residents (Residents 1, 7, & 57) reviewed for change in condition. This failure placed residents with a mental disorder, intellectual disability, or a related condition at risk for unidentified mental health care needs and a decreased quality of life. Findings included. <Facility Policy>The facility policy titled, PASARR Completion, revised 08/2025, showed the facility would ensure residents had the appropriate PASARR completed. The policy showed either admissions or social services was designated to conduct the referrals and that the PASARR form and correspondence were retained in the resident's medical record.<Resident 1>Review of Resident 1's 05/12/2026 SCSA MDS showed the resident admitted to Hospice (end of life care) services on 05/06/2026. Review of Resident 1's progress notes from 05/06/2026 until 06/30/2026 did not show a PASARR referral was sent to the appropriate state agency after the resident had a significant change in condition. <Resident 7>Review of Resident 7's 05/13/2026 SCSA MDS showed the resident was determined to have a change in condition because they needed increased staff assistance with their activities of daily living. Review of Resident 7's progress notes from 05/13/2026 until 06/30/2026 did not show a PASARR referral was sent to the appropriate state agency after the resident had a significant change in condition. <Resident 57>Review of Resident 57's 04/20/2026 SCSA MDS showed the resident was determined to have a change in condition because they needed increased staff assistance with their activities of daily living. Review of Resident 57's progress notes from 04/20/2026 until 06/30/2026 did not show a PASARR referral was sent to the appropriate state agency after the resident had a significant change in condition. In an interview on 07/01/2026 at 12:42 PM, Staff C (Social Services Director) stated PASARR coordination was important because it ensured residents' mental health needs were identified and met through the evaluator's assessment and recommendations. Staff C stated the social services department was responsible for sending the PASARR referral in line with a resident's SCSA. Staff C reviewed Residents 1, 7, and 57's medical records and stated there was no PASARR referral sent for all three residents as required. Refer to F636- Comprehensive Assessments & Timing. REFERENCE: WAC 388-97-1975(7)(8)(10).

Based on observation, interview, and record review the facility failed to: follow physician's orders for 2 of 21 sample residents (Residents 57 & 1), notify the physician when the resident refused care for 1 of 12 sample residents (Resident 7), ensure an order was in place prior to care for 3 of 21 sample residents (Residents 5, 9, & 23), and sign only for care provided for 1 of 1 residents (Resident 12) reviewed for intravenous (IV) therapy. This failure placed residents at risk for missed care opportunities, inappropriate care, infection, and other negative health outcomes. Findings included. <Following Physician Orders> <Resident 57> According to the 04/20/2026 Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS – an assessment tool), Resident 57 had medical conditions including memory deficits and difficulty with swallowing. The MDS showed Resident 57's weight was dashed, indicating there was no information from which to base the assessment. The revised 01/21/2025 nutrition Care Plan (CP) showed Resident 57 was at risk for nutritional problems due to their chewing difficulty, from not wanting to wear their dentures, and refusals to follow their prescribed diet. A 01/25/2024 CP intervention directed staff to weigh Resident 57 as ordered by the physician. In an observation and interview on 06/26/2026 at 9:07 AM, Resident 57 was observed sitting at the edge of the bed while eating breakfast. Resident 57 stated they had a specific and routine order for breakfast because most of the lunch and dinner menus served did not appeal much to them. Observation on 06/30/2026 at 12:46 PM showed Resident 57 took one bite of the squash side vegetable served on their lunch tray and did not eat anything else. Review of Resident 57's physician orders showed a 08/25/2024 order to weigh the resident monthly. Review of Resident 57's weights log from 06/2025 until 06/2026 showed there was no documented weight obtained for the resident for the month of April. In an interview on 07/01/2026 at 1:03 PM, Staff T (Resident Care Manager - RCM) reviewed Resident 57's medical records and confirmed there was no documented weight for the month of April. Staff T stated weight monitoring was important for assessing a resident's nutritional status and should be done as ordered by the physician to ensure any unplanned weight loss/gain was addressed accordingly. <Resident 1> According to the 05/12/2026 SCSA MDS, Resident 1 was not capable of meaningful communication due to their mental health and memory deficits. The MDS showed Resident 1 readmitted back to the facility on [DATE] after hospitalization and had medical conditions including sepsis pneumonia (a severe, life-threatening immune response to a lung infection), other chronic respiratory diseases, and failure to thrive syndrome. The revised 04/20/2026 respiratory CP showed a 05/12/2026 CP intervention directing staff to monitor Resident 1 for any signs and symptoms of respiratory compromise and to notify the physician. Review of Resident 1's medical records showed a 04/16/2026 physician note instructing the nursing staff to follow up on Resident 1's blood culture results from the hospital to determine the need for continued antibiotic treatment in line with the resident's recent severe lung infection. A 04/19/2026 physician note showed Resident 1 was feeling sick to their stomach and documented that the resident's blood culture results were still not available for review. In an interview on 06/29/2026 at 8:58 AM, Staff B (Director of Nursing) reviewed Resident 1's medical records and stated the nursing staff should have followed up and obtained the blood culture report as ordered by the physician but they did not. Staff B stated it was important to have Resident 1's critical hospital laboratory results available for physician review for continuity of care at the facility. <Care Coordination - Refusal of Treatment> <Resident 7> According to the 04/22/2026 Discharge Return Anticipated MDS, Resident 7 had medical conditions including memory deficits, mental illness, and age-related degeneration of the spine. The MDS showed Resident 7 had a major injury fall while at the facility and was discharged to the hospital. The revised 05/04/2026 CP showed Resident 7 had a spine fracture between their neck and lower back. A 05/04/2026 CP intervention showed a medical spinal brace must be worn by the resident when they get out of bed for stabilization and to follow up with the spine physician. Observations on 06/25/2026 at 9:37 AM, on 06/26/2026 at 10:26 AM, and on 06/30/2026 at 8:35 AM, Resident 7 was observed sitting in the recliner and was not wearing the spinal brace; the brace was observed sitting on top of Resident 1's wheelchair inside their room. Review of the June 2026 Treatment Administration Record (TAR) showed a 05/04/2026 physician order instructing the staff to put the spinal brace on Resident 7's upper body whenever out of the bed and to document the resident's compliance with the treatment. The TAR showed the nurses documented Resident 7's refusals on 06/12/2026, 06/13/2026, and 06/26/2026. Review of Resident 7's progress notes from 06/12/2026 until 06/30/2026 showed no documentation to support the nursing staff followed up and communicated Resident 7's refusals to wear the spinal brace with the spine physician. In an interview on 06/30/2026 at 8:39 AM, Staff W (Certified Nursing Assistant - CNA) stated Resident 7 had refused to wear the spinal brace on multiple occasions including that morning. In an interview on 06/30/2026 at 8:42 AM, Staff T reviewed Resident 7's medical records and confirmed there was no documented coordination with the spine physician regarding Resident 7's refusals to wear the spinal brace. Staff T stated the physician needed to be notified to ensure continuity of care in healing Resident 7's spine fracture. <Care Without an Order> <Resident 5> According to the 05/30/2026 Quarterly MDS, Resident 5 was dependent on staff for hygiene, bathing, and dressing and required substantial/maximal assistance with bed mobility. The MDS showed Resident 5 had medically complex diagnoses including heart failure, difficulty walking, and a need for personal care. Observation on 06/25/2026 10:24 AM showed Resident 5 lying in bed. Resident 5's heels rested directly on the mattress. Between Resident 5's heels and the end of the bed was a blue, U-shaped, rubberized foam pad. Resident 5's feet did not reach the foam pad. Review of Resident 5's physician's orders showed no order for a U-shaped foam pad to be placed at the foot of Resident 5's bed. According to Resident 5's 01/08/2026 Self Care Performance deficit CP, Resident 5 should wear special boots when in bed to protect their heels. Observation on 06/29/2026 at 8:40 AM showed the U-shaped pad again at the foot of Resident 5's bed. The pad did not affect Resident 5's positioning in any way. Observation on 06/30/2026 at 12:48 PM showed the U-shaped pad at the foot of Resident 5's bed, not touching the resident's feet. In an interview on 07/01/2026 at 12:57 PM, Staff G (RCM) looked at the blue, u-shaped pad on Resident 5's bed. Staff G stated they did not know what its purpose was, or what to call it but would find out. In an interview on 07/02/2026 8:17 AM, Staff G stated the U-shaped pad was called heal lift and should be placed under Resident 5's heals for support but was not. Staff G stated Resident 5 did not use the special boots for their heal anymore. Staff G stated an order should have been obtained for the heel lift prior to use of the heal lift but was not. <Resident 9> According to the 06/03/2026 Annual MDS, Resident 9 required partial/moderate assistance with rolling from their back to their left or right side and back and refused to perform any further mobility assessment. The MDS showed Resident 9 admitted to the facility with no pressure wounds and had two Stage II (partial-thickness skin loss) pressure wounds. The MDS showed Resident 9's left leg was amputated and the resident had diagnoses including peripheral vascular disease (a condition restricting blood flow) and gangrene. Observation on 06/29/2026 at 8:23 AM showed Resident 9 lying on their back. A pressure-reducing boot was placed on their left leg. According to a 03/23/2026 facility investigation, on 03/23/2026 at 3:00PM a nurse noted Resident 9 with two foam dressings on their right and left buttocks. This nurse removed the dressings and assessed Resident 9 with two stage II pressure wounds. The nurse noted Resident 9's brief was soiled with feces and offered to change the resident, who replied did I put my light on to be changed? In an interview on 07/02/2026 at 8:23 AM, Staff G stated Resident 9's pressure wounds were unavoidable due to their diagnoses and persistent refusals of care. Staff G stated they did not know which nurse originally dressed the wounds but the nurse should have notified the physician and obtained an order for the dressings but did not. <Resident 23> According to the 05/08/2026 admission MDS, Resident 23 had intact memory, clear speech, and was able to understand others. Review of Resident 23's physician orders showed a 04/15/2026 order for prescription grade antifungal powder for application to Resident 23's abdomen and buttocks. This order was discontinued on 05/18/2026. No more recent orders for the powder were found in Resident 23's record. Observation and interview on 07/01/2026 at 10:22 AM showed a bottle of over-the-counter anti-fungal foot powder on Resident 23's bedside table. Resident 23 was observed to have white powder under their stomach fold and on their back, buttocks, and groin areas. Staff U (CNA) stated they frequently applied the over-the-counter antifungal powder following incontinence care and bathing. Staff U stated the powder was frequently stored on Resident 23's bedside cabinet. In an interview on 07/01/2026 at 10:25 AM, Resident 23 stated the medication was always left in their room at bedside and administered by the aides. Resident 23 stated they felt the aides bathed them in the powder under their stomach fold, groin, back and buttocks. Resident 23 stated the amount of powder used felt uncomfortable and they did not want so much of the powder used. In an observation, interview, and record review on 07/01/2026 at 10:42 AM, Staff F (Charge Nurse, Licensed Practical Nurse) confirmed the over-the-counter antifungal powder was unsecured at Resident 23's bedside, should be locked in the medication cart, and administered by licensed nursing staff. Staff F reviewed Resident 23's record and stated no antifungal powder was ordered, and the powder should not have been applied to Resident 23's skin. In a record review and interview on 07/02/2026 at 10:36 AM, Staff B stated they expected all medications to be locked in the medication carts and administered under the direction of licensed nursing staff. Review of Resident 23's physician orders showed no order to keep medications at bedside, and the prescription anti-fungal powder order had been discontinued on 05/18/2026. Staff B confirmed the antifungal powder ordered and the antifungal powder being applied were different medications with different indications. Staff B stated staff were expected to only use medications as ordered and not use alternate medications without consulting the physician. <Signing For Care Not Completed> <Policy> Review of the facility's undated Central Venous Catheter (CVC) Care and Dressing Changes policy showed the facility would ensure staff change CVC dressings at least every seven days. <Resident 12> According to the 04/24/2026 admission MDS, Resident 12 admitted to the facility on [DATE] with diagnoses of a bone infection, a bladder infection, and a blood infection. The MDS showed Resident 12 had IV access and received antibiotics. Review of Resident 12's health records showed 06/17/2026 physician orders to change the CVC dressing every seven days. Review of the 04/20/2026 IV therapy CP showed Resident 12 had a CVC for the administration of antibiotic medications and had interventions to change the dressing on the CVC per the physician's orders. Review of Resident 12's June 2026 TAR showed that the dressing was signed off as changed on 06/19/2026 and 06/26/2026. During an observation on 06/29/2026 at 7:07 AM Staff Q (Registered Nurse - RN) administered Resident 12's IV antibiotic and the CVC dressing was seen loose and peeling and was dated 06/19/2026. In an interview on 06/29/2026 at 7:51 AM, Staff Q stated that Resident 12's CVC dressing should have been changed every seven days to prevent infection but was not. In an interview on 06/29/2026 at 11:38 AM Staff G (RCM) stated that Resident 12's CVC dressing needed to be changed every week to prevent infections and to prevent the CVC from becoming dislodged from the body. Staff G stated that the CVC dressing should not have been documented as completed if it was not done, and that further education would be completed with staff. REFERENCE: WAC 388-97-1620(2)(b)(i)(ii)(6)(b)(i)

Based on observation, interview, and record review the facility failed to provide quality skin care based on professional standards of practice for 3 of 5 residents reviewed for non-pressure skin conditions. The facility failed to implement care plan interventions to prevent skin conditions (Resident 5); failed to follow physician's orders to protect the skin (Resident 10); and failed to notify the physician for a newly identified skin rash (Resident 47). These failures placed residents at risk for avoidable bruising, skin breakdown, and worsening skin condition. Findings included. <Facility Policy>According to the facility's 11/2025 Skin and wound management policy the facility would ensure residents had a comprehensive assessment on admission and then would develop a Care Plan (CP) based on the residents' skin condition and the risks present for the treatment and prevention of skin conditions. The policy states that newly identified skin conditions will be reported to the physician to obtain orders for treatment. <Resident 5> According to the 05/30/2026 Quarterly Minimum Data Set (MDS – an assessment tool) Resident 5 had medically complex diagnoses including heart failure and a disorder of the heart rhythm with an associated risk for blood clots. The MDS showed Resident 5 took a blood thinner medication. The MDS showed Resident 5 had moderate cognitive impairment and no behavior. Record review showed a 01/08/2026 order for a blood thinner medication, and a 01/08/2026 order to monitor, document, and report any side effects of the blood thinner medication, including bruising. The 01/08/2026 blood thinner order showed the medicine was needed to treat Resident 5's heart rhythm disorder. In an interview on 06/25/2026 at 10:19 AM, Resident 5 stated they got bruised all the time. At that time a quarter sized bruise was observed on Resident 5's right hand and their left shin. Resident 5's right leg was covered at the time and Resident 5 stated there was a bruise on that shin too. Observation on 06/26/2026 at 8:28 AM showed purple, quarter-sized bruises on Resident 5's right hand and both shins. In an interview on 06/29/2026 at 8:40 AM Resident 5 they felt nursing staff did not use adequate caution when transferring them or repositioning them, they just come in and do stuff and they got bruised. Review of Resident 5's comprehensive CP showed the facility developed a 01/08/2026 CP addressing Resident 5's blood thinner use. This CP included a goal for Resident 5 to be free from discomfort or adverse reactions of the blood thinner. This CP showed to watch for side effects of the blood thinner including bruising. Review of Resident 5's as of 06/26/2026 Kardex (nurse aide instructions) showed there was no instruction provided to nurses' aides related to Resident 5's elevated risk for bruising. In an interview on 06/30/2026 at 10:31 AM Staff I (Certified Nursing Assistant - CNA), stated they did not know of any residents on their unit (where Resident 5 was a resident) required extra precaution due to bruising risks. In an interview on 06/30/2026 at 10:33 AM Staff H (CNA) stated they did not know of any residents on their unit (where Resident 5 was a resident) required extra precaution due to bruising risks. In an interview on 06/30/2026 at Staff G (Resident Care Manager - RCM) stated residents taking blood thinner medications were at risk for adverse side effects including bruising and bleeding. Staff G stated nursing staff should be careful when transferring and/or repositioning residents who took blood thinners to avoid unnecessary bruising. Staff G stated they expected nurses' aides to know which residents were at risk for side effects of their medications and stated that information should be on the Kardex. <Resident 10> According to the 04/08/2026 Quarterly MDS, Resident 10 had severe cognitive impairment and disorganized thinking. The MDS showed Resident 10 was dependent on staff for assistance with Activities of Daily Living (ADL – grooming, personal hygiene, dressing, etc.) The MDS showed Resident 10 had brain degeneration associated with advanced aging. Review of Resident 10's physician's order showed 01/22/2026 physician's order directing nurses to apply Tubi Grip (an elasticated, tube-shaped bandage) to both of Resident 10's arms. The order showed this was needed for skin protection. Observation on 06/30/2026 at 12:13 PM showed Resident 10 in the dining room nearest to their room waiting for lunch. Resident 10's arms were bare, with no tube-shaped bandage applied. Observation on 07/01/2026 at 10:44 AM showed Resident 10 in bed relaxing. Resident 10's arms were bare, with no tube-shaped bandage applied. In an interview on 07/01/2026 at 12:57 PM, Staff G stated they were unsure why Resident 10 needed the tube-shaped bandage but would find out. Staff G stated if there was an order, the bandages should be in place. In an interview on 07/02/2026 at 8:42 AM, Staff G stated Resident 10 needed the bandages because they scratched at their skin. <Resident 47> According to the 06/08/2026 admission MDS, Resident 47 was alert and oriented, with clear speech, and needed assistance with personal care. The MDS showed Resident 47 has moisture associated skin damage during the assessment period. The revised 06/11/2026 skin CP showed Resident 47 was at risk for skin breakdown. A 06/01/2026 intervention directed the nursing staff to complete weekly skin assessments, monitor/document the skin issue's location, size, and treatment, and to notify the physician. In an observation and interview on 06/25/2026 at 10:06 AM, Resident 47 was observed sitting at the edge of their bed; they were wearing a gown on top and a pair of pants underneath. Resident 47 stated they were waiting for the nurse to bring them some medicated powder for a rash they had under their left breast before they put on their blouse. Observation of Resident 47's left breast area showed the skin was red and inflamed. Resident 47 stated their rash was recurrent, .it [rash] would come and go. Review of Resident 47's physician orders showed a 06/01/2026 order for medicated powder for 10 days to treat fungal rash; this order was discontinued on 06/11/2026. The physician orders did not show a new order was obtained to treat Resident 47's current rash. Review of Resident 47's progress notes from 06/20/2026 until 06/29/2026 did not show the nurse notified the physician regarding the reoccurrence of Resident 47's rash and/or to request any medical treatment. In an interview on 06/30/2026 at 12:19 PM, Staff G stated the nursing staff were expected to complete a skin assessment, monitor, and evaluate any new or worsening skin condition(s) identified among residents. Staff G stated the nurse was expected to notify the physician and to obtain the appropriate treatment to help heal and/or resolve the skin issue. In an interview on 07/02/2026 at 8:11 AM, Staff K (Charge Nurse- Licensed Practical Nurse) stated Resident 47 told them about the rash underneath their left breast on 06/25/2026 but they forgot to notify the physician and/or ask for any skin treatment to provide the resident. Staff K stated they did not complete a skin assessment for Resident 47 or put the resident on alert for skin monitoring after they identified the rash. REFERENCE:WAC 388-97-1060(1)-(3)

Based on observation, interview, and record review the facility failed to ensure residents were free of accident hazards for 4 of 7 residents reviewed for accidents (Residents 1, 2, 10, & 49). The failure to keep fall mats unobstructed (Resident 1), ensure mattresses were secured (Resident 2), implement fall interventions (Resident 10), and implement the facility's smoking policy (Residents 49) placed residents at risks for falls, burns, and other negative health outcomes. Findings included. <Facility Policy>According to the facility's 10/2025 Managing Falls and Fall Risk policy, the facility would assess each resident's risk for fall upon admission, quarterly, and with changes in condition. The policy showed a resident-centered fall prevention plan would be implemented for all residents with a history of falling. The facility policy titled, Smoking Policy- Residents, approved 01/2026 (excerpt included in the facility's admission Packet), showed the facility would establish and maintain safe resident smoking practices. The policy showed a resident's ability to smoke safely was re-evaluated quarterly, upon a significant change (physical or cognitive), and as determined by the staff. The policy showed residents who had independent smoking privileges were not permitted to keep smoking materials such as ignition sources in their possession or inside their room and only the nursing staff could give smoking materials to residents; there were no exceptions. <Obstructed Fall Mats> <Resident 1> According to the 05/12/2026 Significant Change in Status Minimum Data Set (MDS- an assessment tool), Resident 1 had medical conditions including memory deficits and involuntary muscle movements. The MDS showed Resident 1 sustained a fall during the assessment period. The revised 05/12/2026 fall Care Plan (CP) showed Resident 1 was high risk for falls due to their impaired mental state and mobility. A 05/20/2026 CP intervention showed a padded floor mat was put in place to minimize injury should Resident 1 roll out of the bed. Observation on 06/25/2026 at 11:26 AM showed Resident 1 was lying in bed; the left side of the bed was pushed against the wall, and a fall mat was observed in place on the floor to the right side of the bed. The overbed table was observed on top of the floor mat. Observations on 06/26/2026 at 12:18 PM and on 06/29/2026 at 5:36 AM and 9:22 AM showed the overbed table remained on top of the fall mat and was situated against the bed frame when Resident 1 was left unattended inside their room. In an observation and interview on 06/29/2026 at 9:25 AM, Staff T went to Resident 1's room, saw the overbed table situated on top of the fall mat, and stated it was an accident hazard because the resident could hit the metal part in the event they roll out of the bed, .it [fall] would create more serious injuries. Staff T stated the fall mat should be clear of things at all times for resident safety. <Mattress Safety><Resident 2> According to the 06/11/2026 admission MDS, Resident 2 had moderate cognitive impairment and medically complex diagnoses including a heart rhythm disorder and respiratory failure. The MDS showed Resident 2 needed substantial/maximum assistance with moving in bed and had a fall two-to-six months prior to admission. According to the 6/04/2026 Morse Fall Risk evaluation, Resident 2 was at high risk of falling. This evaluation showed Resident 2 had a history of falling and a weak gait. The evaluation showed Resident 2 overestimated or forgot their abilities. Observation on 06/26/2026 at 9:54 AM showed Resident 2 in bed with the head of their bed elevated. Resident 2's mattress was noted to not align exactly with the frame beneath, with the top left (from the resident's perspective) corner of the mattress lower than the right and extending two inches past the frame on the resident's left. In observations on 06/29/2026 at 10:51 AM, on 06/30/2026 at 9:02 AM, and on 06/30/2026 at 11:26 AM the mattress was observed to have the same lean on the left-hand side In an interview on 06/30/2026 at 11:26 AM, Resident 2 stated they knew the mattress slipped a little. Resident 2 stated they felt the mattress shift under them when being transferred recently. In an interview on 07/01/2026 at 12:59 PM, Staff G stated it was important for mattresses to be secured for safety. Staff G looked at Resident 2's mattress and stated it was not placed correctly and needed to be secured. <Falls> <Resident 10> According to the 04/08/2026 Quarterly MDS Resident 10 had severely impaired cognition and fluctuating attention and altered level of consciousness and rarely understood others in conversation. The MDS showed limited range of motion in both legs, used a wheelchair, and was dependent on staff for most mobility. The MDS showed Resident 10 had diagnoses including brain dysfunction and brain degeneration associated with old age. The MDS showed Resident 10 did not fall in the prior quarter. Review of Resident 10's physician's orders showed a 05/14/2026 order for a fall mat to be placed on both the left and right side of Resident 10's bed. The order showed this was to minimize the risk of injury if Resident 10 fell from bed. According to the revised 05/07/2026 resident is Moderate risk for falls . CP, Resident 10 had a history of attempting to roll out of bed forgetting [their] limitations and surroundings. and had decreased safety awareness. The CP included a revised 05/12/2025 intervention showing a floor mat should be placed on each side of Resident 10's bed. According to the 05/07/2026 Morse Fall Risk evaluation, Resident 10 was at high risk for falls. This evaluation showed Resident 10 had a history of falling, an impaired gait, and overestimated or forgot their physical limitations. Observation on 06/26/2026 at 8:09 AM showed Resident 10 lying in bed, resting. One fall mat was placed on the floor by the bed to Resident 10's left. There was no mat to Resident 10's right. Similar observations were made of Resident 10 with only fall mat placed to their left on 06/26/2026 at 10:19 AM and 12:10 PM, on 06/30/2026 at 9:00 AM and 10:35 AM, and on 07/01/2026 at 12:51 PM when Resident 10's over-bed table was noted to be placed on top of the mat. In an interview on 07/01/2026 at 12:57 PM, Staff G (Resident Care Manager – RCM) observed the one fall mat to Resident 10's left only and stated there should two mats in place if the order and CP state two mats were required for fall risk management. Staff G stated an over-bed table should not be placed on top of the fall mat as that created a safety risk. <Unsecured Smoking Materials> <Resident 49> According to the 04/01/2026 Quarterly MDS, Resident 49 was alert, oriented, and had clear speech. The MDS showed Resident 49 had medical conditions including stimulant use, traumatic brain injury, loss of mobility and function on the left side of their body, chronic pain, and dependence on a controlled substance. Review of Resident 49's revised 03/30/2025 Smoking CP showed the resident was capable of safe independent smoking. A 03/25/2025 CP intervention directed the staff to educate Resident 49 regarding the facility's non-smoking policy. In an observation and interview on 06/25/2026 at 1:39 PM, Resident 49 stated they were an independent smoker and they managed the safe keeping of their own smoking materials. Resident 49's smoking materials were observed kept inside a locked drawer in their room. On 06/26/2026 at 12:02 PM, review of Resident 49's smoking assessment log showed the resident was last assessed for safety on 11/25/2025 and the required frequency in completing the smoking safety assessment was not followed by staff. In an interview on 06/26/2026 at 12:07 PM, Staff T (Resident Care Manager) stated they were responsible for completing the smoking safety assessment. Staff T reviewed Resident 49's smoking assessment log and stated they missed doing it for the past quarter. Staff T stated it was important to ensure the smoking safety assessment was completed according to facility expectations to capture any changes in the resident's condition that could compromise their safety. Staff T stated they were aware Resident 49 was keeping their own smoking materials in their room. In a joint interview on 06/26/2026 at 12:28 PM with Staff A (Administrator) and Staff B (Director of Nursing), Staff A stated Resident 49 should not be allowed to keep their own smoking materials in their room for the resident's safety and that of the entire facility. REFERENCE: WAC 388-97-1060(3)(g).

Based on interview and record review, the facility failed to ensure the medical care of each resident was supervised by a physician or that another physician supervised the medical care of residents when their attending physician was unavailable for 4 of 4 sample residents (Residents 57, 49, 5, & 4) whose monthly drug regimen review contained pharmacy consultant recommendations that were not reviewed or acted upon as required. This failure placed residents at risk of unnecessary medication use, avoidable adverse effects, negative health outcomes, and a decreased quality of life. Findings included. <Facility Policy>The undated facility policy titled, Medication Monitoring: Medication Regimen Review [MRR] and Reporting, showed the nursing care center would follow up on the pharmacy consultant's recommendation and verify that appropriate action was taken within 30 calendar days. The policy showed, for those issues that required physician intervention, the attending physician would either accept and act upon the report and recommendations or reject all or some of the report; a rationale of why the recommendation was rejected must be documented in the resident's medical record. The policy showed, if there was potential for serious harm and the attending physician did not concur or refused to document an explanation, the Director of Nursing (DON) and the consultant pharmacist would contact the medical director and arrange a meeting to discuss the identified MRR issue(s). The policy showed all parties must come to an agreement in order to ensure no actual resident harm would occur. <Resident 57>Review of the 02/17/2026 Consultant Pharmacist Recommendations to Prescribers form showed: (1) Resident 57's antidepressant use was due for a gradual dose reduction assessment per the Centers for Medicare and Medicaid Services (CMS) guidelines; (2) a recommendation to update the affiliated medical diagnosis of Resident 57's antidepressant use to include both Major Depressive Disorder (MDD) and insomnia (difficulty sleeping); and (3) a recommendation to decrease the Melatonin (an oral supplement that promote sleep) dose from 9 milligrams (mg) to 3mg due to observed persistent daytime sleepiness as reported by the nursing staff. The form did not show the attending physician reviewed and/or acted upon the pharmacist's recommendations within 30 days; there was no written rationale if/when the physician declined the pharmacist's recommendation as required by CMS. Review of Resident 57's practitioner notes log on 07/01/2026 at 2:28 PM showed there were no documented physician visits for the month of February 2026. The 03/04/2026, 03/05/2026, 03/10/2026, and 03/20/2026 physician visit notes did not indicate they acted upon or rejected (with a written rationale) the pharmacy consultant's recommendations. Review of Resident 57's June 2026 Medication Administration Record (MAR) showed there were no changes made regarding the resident's antidepressant and Melatonin dosing and use. The antidepressant order did not include the MDD diagnosis as an appropriate indication for its current use as recommended. <Resident 49>Review of the 02/17/2026 Consultant Pharmacist Recommendations to Prescribers form showed: (1) a recommendation to discontinue Resident 1's current insulin (an injectable medication used to treat unstable blood sugar levels) use due to low blood sugar level readings that indicated over-treatment; and (2) a recommendation to consider the initiation of an oral medication to treat Resident 49's unstable blood sugar levels instead of the injectable format. The form did not show the attending physician reviewed and/or acted upon the pharmacist's recommendations within 30 days; there was no written rationale if/when the physician declined the pharmacist's recommendation as required by CMS. Review of Resident 49's practitioner notes log on 07/01/2026 at 2:33 PM showed a 03/04/2026 physician note that did not indicate Resident 49's ongoing use of insulin was reviewed. The note did not show the physician acted upon or rejected (with a written rationale) the pharmacy consultant's recommendation. Review of Resident 49's June 2026 MAR showed the insulin was discontinued on 06/29/2026, more than four months after the recommendation was made. The MAR showed Resident 49 was not taking any oral medications for their unstable blood sugar levels. <Resident 5>Review of the 02/17/2026 Consultant Pharmacist Recommendations to Prescribers form showed a recommendation to review Resident 5's use of oral steroids to treat their chronic lung disease because the oral capsule formulation was not indicated for the management of respiratory illnesses. The recommendation showed the physician was asked to include the appropriate indication for its use by soliciting additional medical history from the resident/representative or to discontinue the medication if there was no pertinent medical condition identified. The form did not show the attending physician reviewed and/or acted upon the pharmacist's recommendations within 30 days; there was no written rationale if/when the physician declined the pharmacist's recommendation as required by CMS. Review of Resident 5's practitioner notes log on 07/01/2026 at 2:41 PM showed the 03/05/2026, 03/12/2026, and 03/15/2026 physician visit notes that did not indicate Resident 5's ongoing oral steroid use was reviewed. The notes did not show the physician acted upon or rejected (with a written rationale) the pharmacy consultant's recommendation. Review of Resident 5's June 2026 MAR showed the indication (medical diagnosis) for Resident 5's oral steroids use was changed to liver inflammation on 05/22/2026, more than three months after the recommendation was made. <Resident 4>Review of the 02/17/2026 Consultant Pharmacist Recommendations to Prescribers form showed a recommendation to re-evaluate and potentially discontinue Resident 4's use of Scopolamine (a drug used to treat post-operative nausea/vomiting and for prevention of motion sickness) patch that was initiated since 12/05/2025 due to the risks affiliated with its prolonged use including adverse side effects such as delirium and agitation. The form did not show the attending physician reviewed and/or acted upon the pharmacist's recommendations within 30 days; there was no written rationale if/when the physician declined the pharmacist's recommendation as required by CMS. Review of Resident 4's practitioner notes log on 07/01/2026 at 2:47 PM showed a 03/10/2026 physician note regarding Resident 4's complaints of intermittent nausea. The note showed Resident 4 was prescribed a short, five-day course of an oral anti-nausea medication but it did not indicate the physician reviewed Resident 4's ongoing Scopolamine patch use. The note did not show the physician acted upon or rejected (with a written rationale) the pharmacy consultant's recommendation. Review of Resident 4's June 2026 MAR showed the Scopolamine patch order remained the same and the resident continued to receive the medication. In an interview on 06/30/2026 at 9:15 AM, Staff B (DON) reviewed the MRR binder and confirmed all Consultant Pharmacist Recommendations to Prescribers forms for residents identified with pharmacy recommendations for the month of February 2026 were blank. Staff B stated the attending physician at that time injured their shoulder and needed to take a leave of absence. In a phone interview on 07/02/2026 at 12:03 PM, Staff X (Medical Director) confirmed Staff Y (Medical Practitioner) was the assigned attending physician working with them for the month of February 2026 based on Staff A's (Administrator) provider schedule list. Staff X stated they were not aware the pharmacy consultant's MRR report for February 2026 containing recommendations for several residents were not reviewed or acted upon by the attending physician as required. In a joint interview on 07/02/2026 at 12:19 PM with Staff A and Staff B, Staff A stated the attending physician was responsible for reviewing the MRR report and they were expected to act on the recommendation timely and to document the rationale for their declination in the resident's medical record. Staff A stated the pharmacy consultant provided Staff X a copy of the monthly MRR report for oversight. Staff A stated it was important for the attending physician to review and act upon the pharmacy consultant's MRR recommendation(s) because the facility was serving a vulnerable population and medication use was a critical component in safeguarding the residents' health and well-being. Refer to F605- Right to be Free from Chemical Restraints. Refer to F756- Drug Regimen Review, Report Irregular, Act On. REFERENCE: WAC 388-97-1260(3)(a).

Based on observation, interview, and record review the facility failed to ensure residents were served meals they found palatable for 4 of 7 residents (Residents 47, 5, 66, and 23) reviewed for food. The failure to ensure the meals were served adequately palatable placed residents at risk of frustration, weight loss, and a diminished quality of life.Findings included .<Facility Policy> According to the facility's undated Food and Nutrition Services policy, staff were to provide each resident with a nourishing, palatable, well-balanced diet to meet their daily nutritional and special dietary needs. Staff were to take into consideration the preferences of each resident. <Resident 47> Review of the 06/25/2026 lunch menu showed the facility was serving pork loin, corn on the cob, coleslaw, and a biscuit. In an interview on 06/25/2026 at 9:55 AM, Resident 47 stated they were given cold foods when it was supposed to be served hot and specified the waffles being served during breakfast. In an observation, interview, and record review on 06/25/2026 at 12:26 PM, Resident 47 was observed eating their lunch inside their room; their meal tray was observed to have a scoop of soft, watered-down green beans that were left untouched. Resident 47 stated the green beans were mushy and did not taste good. Review of Resident 47's meal tray ticket (that came with their lunch tray) showed the resident disliked corn. In an interview on 07/01/2026 at 3:08 PM, Staff L (Dietary Manager) stated, during lunch service on 06/25/2026, the alternate vegetable menu option for corn was green beans. In an observation and interview on 07/02/2026 at 8:32 AM, Resident 47 was observed eating breakfast inside their room; their meal tray was observed to have waffles that were pale and limp. Resident 47 stated the waffles were served cold once again. <Resident 5> According to the 05/30/2026 Quarterly MDS, Resident 5 was moderately cognitively impaired and had diagnoses including difficulty swallowing. According to the 01/09/2026 Food Preferences evaluation Resident 5 wanted cornflakes once or twice a week and only wanted milk when served cornflakes. In an interview on 06/25/2026 at 10:13 AM Resident 5 stated they did not enjoy the food they were served and felt the facility could do a lot more to improve the food. Resident 5 gave an example that their breakfast earlier that morning included waffles. Resident 5 stated the waffle was not heated. Resident 5 stated the following day sausage, and biscuits would be served and they hoped that would be satisfying. In an interview on 06/26/2026 at 8:28 AM, Resident 5 stated they got biscuits and sausage that morning, but the biscuit was dry and needed more gravy and the eggs were awful. Observation at that time showed the biscuit looked dry. Resident 5 stated breakfast was better than usual. In an interview on 06/29/2026 at 8:40 AM, Resident 5 stated they got one bacon strip and one piece of toast the prior morning and was not satisfied. Resident 5 stated they calculated they could budget for two breakfasts and two lunches a month to be delivered from outside to enhance their satisfaction with the food they ate. In an interview on 06/30/2026 at 12:48 PM Resident 5 stated they had chicken and rice for lunch that day and found it inedible. Observation of a test tray on 07/01/2026 at 8:36 AM showed the soft and bite sized preparation of the hash browns lacked texture and color, negatively affecting the palatability. In an interview on 07/01/2026 at 8:24 AM, Resident 5 stated they enjoyed their breakfast that morning, but the hashbrown they were served lacked texture. Observation showed the hashbrown half eaten on Resident 5's plate In an interview on 07/02/2026 at 8:04 AM Resident 5 stated they chose not to get the waffles served that morning as they did not like how they were prepared. Resident 5 stated they asked for cereal and it was served without milk, which was frustrating. Observation at that time showed cereal and no milk on Resident 5's tray. In an interview on 07/02/2026 at 8:35 AM, another resident (Resident 97) stated they returned the waffles they were served that morning for reheating as they were not warm at all. Resident 97 stated the two waffles they were served were slightly warm on one side and cold on the other. Resident 97 stated when the waffles were returned, they were still not warm enough and the texture was lacking but they planned to eat them as they were hungry. Two waffles were observed on Resident 97's plate. In an interview on 07/01/2026 at 1:01 PM Staff L (Dietary Manager) stated it was important to serve palatable meals to residents to help ensure they had nutrition and were satisfied with their food. Staff L stated it was important for food to be served at a temperature and texture that enhanced the flavor of the meal. Staff L stated Resident 5 should have been served milk with their cornflakes but was not. <Resident 66> According to the 06/15/2026 admission MDS, Resident 66 had intact cognition and needed supervision when eating. The MDS showed Resident 66 had difficulty swallowing and needed an altered texture meal. In an interview on 06/25/2026 9:26 AM Resident 66 stated they had swallowing difficulty and needed their food to be cut up. Resident 66 stated they did not like the food they were served and might as well be at home if I am not eating. Resident 66 stated they admitted a couple of weeks prior and remembered preferring the food they were served at the hospital. Observation of breakfast preparation on 07/01/2026 at 7:15 AM showed Staff V (Cook) helping serve breakfast. Staff V was using a measuring spoon to serve portions of the bite sized preparation of hashbrowns. The bite sized hashbrowns in the pan from which Staff V was serving were processed in such a manner that the hashbrowns were not in pieces but more mashed together. The manner in which Staff V measured the hash browns pressed them into the measuring spoon. Observation of a test tray on 07/01/2026 at 8:36 AM showed the soft and bite sized preparation of the hash browns lacked texture and color, negatively affecting the palatability. The bite sized hash browns were served in a lump, without observable texture, or bite sized pieces. Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. <Resident 23> According to the 05/08/2026 admission Minimum Data Set (MDS – an assessment tool), Resident 23 had intact memory, clear speech, and multiple medically complex diagnoses including diabetes, heart failure and obesity. According to the 04/16/2026 Food Preferences evaluation, Resident 23 had no protein dislikes but preferred a limited salt and carbohydrate diet. In an interview and observation on 06/26/2026 at 8:42 AM, Resident 23 was lying in bed and eating breakfast. Resident 23's breakfast plate contained a toasted bagel with cream cheese and 2 sausage patties which appeared dark brown and dry. Resident 23 stated the sausage patties did not taste good because they were plant-based and frequently dry and overcooked. Resident 23 stated they had completed a request to receive scrambled eggs with every breakfast but rarely received them. In an interview and observation on 06/26/2026 at 8:46 AM, Staff E (Resident Care Manager – 200 Unit) entered Resident 23's room and observed their plate contained the two sausage patties and no scrambled eggs. Staff E removed the tray and returned it to the kitchen. In an interview and observation on 06/26/2026 at 9:06 AM, Staff E returned to Resident 23's room with a new breakfast tray which included scrambled eggs and 2 sausage patties. Resident 23 stated they were happy with the new breakfast. In an interview and record review on 07/01/2026 at 1:32 PM, Staff L (Dietary Manager) stated Resident 23 had no protein dislikes but disliked cream sauce and gravy. Staff L stated the planned breakfast item for 06/26/2026 was biscuits and gravy with scrambled eggs listed as the alternative. Staff L stated Resident 23's dislike for cream sauce and gravy should have prompted staff to offer them scrambled eggs as an alternative, but they did not. Staff L stated food palatability was important to enhance residents' quality of life and increasing dietary proteins aided them in recovering from illnesses and injuries. REFERENCE: WAC 388-97 -1100(1)(2).

Based on observation and interview, the facility failed to ensure food was prepared and stored in sanitary conditions for 1 of 1 facility kitchens. The failure to ensure food preparation equipment was cleaned between use, and ensure food was stored in sanitary conditions placed residents at risk for contaminated food and food-borne illness. Findings included . <Facility Policy>According to the facility's May 2025 Sanitation Policy the food service would be maintained in a clean and sanitary manner. The policy showed equipment would be kept clean.<Facility Kitchen>Observation of the facility's kitchen on 06/25/2026 at 8:28 AM showed the base of the food processor encrusted with dirt and grime. The large stand mixer was observed to have a grate at the top to help keep dough in the bowl. An area of beige, dough-like film was dried on the stand mixer's grate and stretched between several bars of the grate.Observation of the dry storage room on 06/25/2026 at 8:32 AM showed the floor under and around the wire rack nearest the exit encrusted with dirt and a sticky substance. On another shelf there was an open box of powdered sugar that was not properly closed and was not marked with an open date.Observation of the facility's freezer on 06/25/2026 at 8:42 AM showed a clear, open bag of sweet potatoes in freezer. The bag of frozen sweet potatoes did not have an open date, and a light accumulation of freezer burn was noted on the sweet potatoes.In an interview on 06/25/2026 at 11:26 AM Staff L (Dietary Manager) stated it was important to maintain a clean kitchen for food safety. Staff L stated they expected kitchen equipment to be kept clean and food to be stored in a way that ensured it was fresh when used.In an interview on 07/01/2026 at 1:01 PM, Staff L stated they looked through the kitchen after the prior conversation and confirmed the concerns discussed.REFERENCE: WAC 388-97-1100(3), -2980.

Based on interview and record review, the facility failed to ensure the pharmacy consultant recommendations were followed up and acted upon as required for 1 of 5 residents (Resident 57) whose medication regimens were reviewed and 1 supplemental resident (Resident 66). The failure to ensure the physician used the most current information when addressing pharmacist recommendations (Resident 57) and provide adequate rationale when not adopting recommendations (Resident 66) placed residents at risk for incorrect dosing, unnecessary medications, and other negative health outcomes. Findings included. <Facility Policy>The undated facility policy titled, Medication Monitoring: Medication Regimen Review (MRR) and Reporting, showed the MRR was a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication use. The policy showed the facility would follow up on the pharmacy consultant's recommendation(s) and verify they were reviewed and acted upon within 30 calendar days.<Resident 57> According to the 04/20/2026 Significant Change in Status Assessment Minimum Data Set (MDS - an assessment tool), Resident 57 had medical conditions including memory deficits, depression, and insomnia (difficulty sleeping). The MDS showed Resident 57 was administered an antidepressant medication during the assessment period. Review of the 02/17/2026 Consultant Pharmacist Recommendations to Prescribers form showed Resident 57's antidepressant and Melatonin (an oral supplement that promote sleep) use were due for a gradual dose reduction assessment per the Centers for Medicare and Medicaid Services guidelines. Review of resident 57's medical records from 02/17/2026 until 03/17/2026 showed no documentation to support the attending physician reviewed and acted upon the pharmacy consultant's recommendation within 30 days. Review of Resident 57's July 2026 Medication Administration Record showed a 10/27/2025 order for an antidepressant 50 milligrams (mg) to be given daily at bedtime. Review of the 06/27/2026 Consultant Pharmacist Recommendations to Prescribers form showed the pharmacy consultant recommended to decrease Resident 57's antidepressant dosing from 100mg to 75mg; this recommendation conflicted with Resident 57's current dosing of 50mg (a lower dose) as shown in the July 2026 MAR. The form showed the attending physician agreed with the pharmacy consultant's recommendation and signed the form on 06/28/2026 despite the drug regimen review being erroneous. In an interview on 07/01/2026 at 3:07 PM, Staff B (Director of Nursing) reviewed Resident 57's medical records and stated the MRR regarding the resident's antidepressant use was incorrect and was based on old information. Staff B stated the attending physician should have caught the error during their review before they agreed with the recommendation, but they did not. Staff B stated it was important to ensure the pharmacy reviews were conducted thoroughly using current medication information so the residents would receive the correct and appropriate treatment. <Resident 66> According to the 06/15/2026 admission MDS, Resident 66 had intact cognition and fluctuating disorganized thinking. The MDS showed Resident 66 had medically complex diagnoses including depression and took an antidepressant medication. Review of the 06/18/2026 Consultant Pharmacist Recommendations to Prescribers form showed the pharmacist identified none of the three as-needed antianxiety orders had end dates. The pharmacist noted the as-needed medications required a rationale for use beyond 14 days. On 06/24/2026, the physician noted on the pharmacist's recommendation addressing 0.5mg antianxiety orders that Resident 66 had severe anxiety and wanted to avoid routine medications and indicated they would add a 60-day duration. On 06/24/2026, the physician noted on the pharmacist's recommendation addressing the 25mg antianxiety order that Resident 66 had severe anxiety and indicated they would add a 60-day duration. In an interview on 07/02/2026 at 9:50 AM, Staff B reviewed Resident 66's record and noted neither medication was given at any dose. Staff B stated the physician's rationale for extending the as-needed orders for psychotropic medications was not appropriate as the resident did not use the medications. Staff B stated it didn't make sense to continue the orders. In an interview on 07/02/2028 at 9:58 AM, Resident 66 stated they were not interested in using antianxiety medications. Refer to F605- Right to be Free from Chemical Restraints. Refer to F710- Resident's Care Supervised by a Physician. REFERENCE: WAC 388-97-1300(4)(c).

Based on observation, interview, and record review, the facility failed to ensure the Advance Directives (AD) for 2 of 4 residents (Residents 57 & 47) reviewed were in place in the event residents became incapacitated to make medically related healthcare decisions. The facility failed to educate and follow up AD status (Resident 57) and failed to ensure the AD was accessible to staff as required (Resident 47). These failures placed residents at risk of losing their right to have their stated preferences and decisions honored regarding medical treatment and/or end-of-life care. Findings included . <Facility Policy>The facility policy titled, AD, revised 12/2025, showed the resident had the right to formulate an AD. The policy showed, prior to or upon admission of a resident, the Social Services Director (SSD) or designee would inquire about the existence of any written AD. The policy showed, if the resident did not have an AD, the facility would offer assistance in establishing one and the resident's decision whether to accept or decline assistance would be documented in the medical records. The policy showed, if the resident had an AD, copies of these documents were obtained and maintained in the resident's medical records and were readily retrievable by any facility staff.<Resident 57>According to the 04/20/2026 Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS - an assessment tool), Resident 57 had memory deficits including inattention and disorganized thinking. The MDS showed Resident 57 had medical conditions including a viral liver infection, heart, kidney, and respiratory diseases. The MDS showed only Resident 57 participated in their assessment and goal setting process. The revised 06/23/2026 AD Care Plan (CP) showed Resident 57 elected full code for their life-sustaining treatment. A 03/04/2024 CP intervention directed staff to review AD status with the resident and/or their representative quarterly and as needed with any change in condition. In an observation and interview on 06/26/2026 at 8:56 AM, Resident 57 was observed lying in bed and would fall asleep during the conversation. Resident 57 stated they did not have an AD and did not know the importance of having one. Resident 57 stated they could not remember if the facility provided them any education or asked if they were interested (or not) in formulating an AD. Review of Resident 57's medical records showed a 01/24/2024 acknowledgment form indicating the resident was provided AD information at that time. There was no other documentation to support Resident 57's AD status was reviewed and followed up by the facility after the resident experienced a significant change in condition as indicated in Resident 57's CP. In a joint interview on 06/30/2026 at 2:38 PM with Staff C (SSD) and Staff D (Social Services Assistant), Staff D reviewed Resident 57's medical records and stated there was no care conference documentation to show the facility revisited the resident's preference to offer/formulate an AD when the SCSA was completed. Staff C stated it was important to ensure a resident's AD status was evaluated after a significant change in condition to determine the appropriate medical decision-making route to take in line with the resident's wishes/preference. <Resident 47>According to the 06/08/2026 admission MDS, Resident 47 admitted to the facility on [DATE]; they were alert, oriented, and had clear speech. The MDS showed Resident 47 had multiple medical conditions including an immune system disorder, blood diseases, heart and kidney failure, bleeding inside their stomach, and a fracture related to a fall within the last six months prior to their admission. The revised 06/24/2026 AD CP showed Resident 47 elected full code for their life-sustaining treatment and listed family members as their representatives. On 06/25/2026 at 10:16 AM, Resident 47 stated they had an AD in place and their son was their designated Durable Power of Attorney for both Financial and Health Care. Resident 47 stated the facility did not ask them for a copy of their AD paperwork during admission. Review of Resident 47's medical records on 06/25/2026 at 2:50 PM showed the resident's AD documentation was not accessible and/or readily available for any facility staff as required. In an interview on 06/30/2026 at 2:44 PM, Staff C stated Resident 47's AD paperwork should be, but was not on file. REFERENCE: WAC 388-97-0280 (3)(c)(i-ii).

Based on observation and interview, the facility failed to ensure residents were provided with a safe, homelike environment for 3 of 4 units (Units 200, 300 and 400) and 1 of 1 resident (Resident 47). The failure to provide necessary maintenance and repairs in common areas and resident rooms for damaged walls, dirty rooms, and excess noise left residents at risk for a diminished homelike environment.Findings included .Observations on 06/25/2026 at 12:35 PM in the Unit 400 weight room showed mismatched and missing wall tiles. In an observation on 06/26/2026 at 9:29 AM, room [ROOM NUMBER] had large scratches on the wall near the headboard. Observations in room [ROOM NUMBER] on 06/29/2026 at 9:23 AM and 07/01/2026 at 2:46 PM showed deep scratches on the wall near the headboard which exposed the drywall plaster. In the hallway outside room [ROOM NUMBER], several dark scratches were observed along the bottom of the walls. In an observation and interview on 06/30/2026 at 11:16 AM Resident 47's room had a persistent vibrating noise in the room that could be heard from the hallway. Resident 47 stated that they could not sleep at night due to the noise despite the use of ear plugs. Resident 47 stated that they had notified maintenance staff, but the noise had not been fixed. In an interview on 07/02/2026 at 8:47 AM Staff R (Maintenance Lead) stated they were aware of the issue in Resident 47's room, but they had not fixed it yet. In an observation and interview on 07/02/2026 at 9:19 AM, Staff S (Maintenance Supervisor) observed large scratches on the walls behind the bed in room [ROOM NUMBER] and room [ROOM NUMBER], dirt and grime on the Unit 400 weight room scale and missing wall tiles, and scratches at the base of the walls in the 200-unit hallway. After touring the facility, Staff S stated these concerns should have been identified and entered into the facility maintenance reporting system, but they were not. Staff S stated the noise complaint for Resident 47 should have been addressed when reported but was not. Staff S stated completing the repairs was important to ensure residents a safe and homelike environment. REFERENCE: WAC 388-97-0880

Based on observation, interview, and record review the facility failed to ensure residents' medication regimens were free from unnecessary chemical restraints for 1 of 7 residents reviewed for mood/behavior (Resident 66) and 1 of 5 residents reviewed for unnecessary medications (Resident 57). The failure to ensure as-needed psychotropic medication orders lasted no longer than 14 days (Resident 66) and the failure to ensure alternative treatments, such as behavioral (non-pharmacological) interventions were attempted (Resident 57) placed residents at risk for unnecessary use of psychotropic (any drug that alters brain function, affecting a person's mood, thoughts, feelings, or behavior) medications, unwanted/avoidable adverse side effects, and other negative health outcomes. Findings included . <Facility Policy> According to the facility's 11/2025 Psychotropic Medication Use policy, as-needed psychotropic medication orders should last no longer than 14 days. The policy showed as-needed psychotropic medication use after 14 days required a rationale from the physician and an expiration date. The policy showed psychotropic medication use may be considered appropriate when non-pharmacological approaches (if not clinically contraindicated) were attempted but did not relieve the medical symptoms presenting a danger or significant distress. <Resident 66> According to the 06/15/2026 admission Minimum Data Set (MDS - an assessment tool) Resident 66 had intact cognition and fluctuating disorganized thinking. The MDS showed Resident 66 had medically complex diagnoses including depression and took an antidepressant medication. Review of the June 2026 Medication Administration Record (MAR) showed Resident 66 had three as-needed orders for two different antianxiety medications: a 06/08/2026 order for an antianxiety medication, give one 25 Milligram (MG) capsule to be given every six hours as needed for anxiety, a 06/08/2026 order for an antianxiety medication, give one 0.5 MG tablet as needed every eight hours as needed, and a 06/08/2026 order for an antianxiety medication, give two 0.5 MG tablets as needed every eight hours as needed. The MAR showed no record Resident 66 was offered, received, or refused either medication since admission. Review of the 06/18/2026 Consultant Pharmacist Recommendations to Prescribers showed the pharmacist communicated to the physician that none of the three as-needed antianxiety orders had end dates for use. The pharmacist noted the as-needed medications could be continued if a rationale was provided and a duration added. On 06/24/2026 the physician noted on the pharmacist's recommendation addressing 0.5 MG antianxiety orders that Resident 66 had severe anxiety and wanted to avoid routine medications and indicated they would add a 60-day duration. On 06/24/2026 the physician noted on the pharmacist's recommendation addressing the 25 MG antianxiety order that Resident 66 had severe anxiety and indicated they would add a 60-day duration. In an interview on 07/02/2026 at 9:50 AM, Staff B (Director of Nursing) stated for residents in nursing homes, it was not permissible to have as-needed orders for psychotropic medications lasting longer than 14 days without a rationale. Staff B reviewed the June 2026 MAR and noted there were no occasions since admission where Resident 66 was offered or took either medication. Staff B stated it didn't make sense to continue the orders, and there was no reason for them to still be active. In an interview on 07/02/2028 at 9:58 AM, Resident 66 stated they were not interested in using antianxiety medications. Resident 66 stated antianxiety medications had too many side effects. Resident 66 stated they hoped to return home when stronger where they would have less stress and did not want to depend on something they would not need in the future. <Resident 57> According to the 04/20/2026 Significant Change in Status Assessment MDS, Resident 57 had medical conditions including memory deficits, depression, and insomnia (difficulty sleeping). The MDS showed Resident 57's mood interview indicated the presence of depression symptoms. The MDS showed Resident 7's behavior, including their rejection of care, was worse compared to the prior assessment. The revised 06/22/2026 CP showed Resident 57 was taking an antidepressant to manage their depression and difficulty sleeping. The June 2026 Medication Administration Record showed Resident 57 was administered an antidepressant for their insomnia. Review of Resident 57's medical records showed the 10/27/2025 physician order to provide the resident non-pharmacological interventions for depression was discontinued on 01/29/2026. There was no current provision of any non-pharmacological interventions in line with Resident 57 antidepressant use as required. In an interview on 07/01/2026 at 2:34 PM, Staff T (Resident Care Manager) reviewed Resident 57's medical records and stated the physician order to provide Resident 57 non-pharmacological interventions in managing their depression should not be discontinued. Staff T stated non-pharmacological interventions were important and necessary to decrease the need for using high risk medications including antidepressants. Refer to F710- Resident's Care Supervised by a Physician. Refer to F756- Drug Regimen Review, Report Irregular, Act On. REFERENCE: WAC 388-97-1060(3)(k)(i).

Based on observation, interview, and record review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR - a mental health screening required before the transfer to a nursing home) assessment was timely and accurate to reflect the residents' mental health conditions for 2 of 6 residents (Residents 22 and Resident 4) reviewed for PASRR. This failure placed residents at risk for inappropriate nursing home placement and/or not receiving timely and necessary services to meet their mental health needs.Findings included .<Facility Policy>According to the facility's August 2025 PASRR Completion Policy, staff would coordinate resident assessments with the PASRR program to ensure individuals with mental disorders or related conditions received services in the most integrated setting appropriate to their needs. The policy required a Level I screening prior to admission and Level II evaluation for positive screens to determine appropriate placement and specialized services.<Resident 22> According to the 04/29/2026 Annual Minimum Data Set (MDS, an assessment tool), Resident 22 had diagnoses including opioid use disorder and homelessness. The MDS showed Resident 22 was admitted to the facility on [DATE]. Review of Resident 22's record showed Level I PASRR was entered by Staff D (Social Services Assistant) on 04/28/2025. This PASRR was completed for a different person and not Resident 22. No other Level 1 PASRR was entered prior to admission. Record review showed a Level I PASRR was completed for Resident 22 by Staff C (Social Services Assistant) on 09/18/2025. No serious mental illness or functional limitations were indicated. In an interview on 06/26/2026 at 10:34 AM, Resident 22 stated they had been homeless due to substance use disorder prior to admission. Resident 22 stated they did not know where they would live after discharge and were concerned about future homelessness. In an interview and record review on 07/02/2026 at 10:06 AM, Staff C (Social Services Director) stated Resident 22's Level I PASRR should have been completed accurately and prior to admission but was not. Staff C stated Resident 22's substance use disorder and homelessness status should have been indicated, but it was not. <Resident 4> According to the 03/25/2026 Quarterly MDS, Resident 4 had medically complex diagnoses including: anxiety; a mental health condition characterized by unpredictable shifts in mood, energy, and activity levels; a brain disorder affecting the ability to interpret reality, causing disruptions in thought processes, perceptions, emotional responsiveness, and social interactions; a mental health condition characterized by difficulty with emotional regulation, unstable moods, and impulsive behavior. The MDS showed Resident 4 took antianxiety medication. Record review showed Resident 4's brain disorder affecting the ability to interpret reality diagnosis was added to their record on 05/13/2025. Record review showed Resident 4's anxiety disorder and mental health condition characterized by difficulty with emotional regulation diagnoses were present on admission on [DATE]. Record review showed the most recent Level I PASSR screening was signed on 10/8/2025 by Staff D. This Level I PASRR screening identified Resident 4's condition associated with shifts in mood as a Serious Mental Illness (SMI) indicator, but did not capture the resident's anxiety diagnosis, brain disorder affecting the ability to interpret reality, or mental health condition associated with characterized by difficulty with emotional regulation. In an interview on 06/30/2026, Staff C stated Level I PASRR screenings were an important step in the admissions process and helped facilities determine if they could meet a resident's mental health and/or intellectual disability needs. Staff C stated when a resident's mental health status changed, such as having a new diagnosis or a change in psychotropic medication change the facility should complete a new Level I PASRR screening to ensure the resident's needs were addressed. Staff C stated the 10/8/2025 Level I PASRR screening should have identified all four of Resident 4's SMI indicators to capture the totality of the resident's mental health status, rather than just one but did not and stated the 10/8/2025 screening was inaccurate. REFERENCE: WAC 388-97-1915(1)(2)(a)-(c).

Based on observation, interview, and record review, the facility failed to ensure communication between the dialysis (a life-sustaining treatment to filter the blood of waste when kidneys can no longer do so naturally) center and the facility met professional standards for 1 of 1 residents reviewed for dialysis (Resident 2). This failure placed residents at risk for poorly managed dialysis, unwanted fluid gain, and other negative health outcomes. Findings included . <Facility Policy>According to the facility's 10/2025 dialysis policy, the facility would send a dialysis communication form with the resident each time they went to dialysis. The policy showed both the dialysis center and the facility would complete their portions of the form and a copy of the form would be kept in the resident's record.<Resident 2>According to the 06/11/2026 admission Minimum Data Set (an assessment tool) Resident 2 had medically complex diagnoses including end stage renal (kidney) disease. The MDS showed Resident 2 required dialysis while a resident at the facility. Review of the physician's orders showed a 06/04/2026 order to ensure a dialysis communication form was sent with Resident 2 to dialysis every Tuesday, Thursday and Saturday. This order showed a nurse should assess Resident 2 per the communication form upon return. According to the 05/20/2026 dialysis Care Plan (CP) Resident 2 had dialysis on Tuesdays, Thursdays, and Saturdays. In an interview on 06/26/2026 at 10:24 AM, Resident 2 stated they went to dialysis three times a week. Resident 2 stated they noticed the communication sheets they came back with from the dialysis center were incomplete. Observation at that time showed a fistula (tubing to allow blood flow for dialysis) on Resident 2's left arm and a sign on the wall reminding nursing staff not take Resident 2's blood pressure in their left arm.Review of the dialysis communication book kept at the nurse station showed a 05/07/2026 Dialysis Communication Report with a section to be completed by the Dialysis Center staff and returned to the facility with the resident and a section beneath to be completed by the Nursing staff upon resident's return to the facility. The section to be completed by the facility was incomplete and did not show Resident 2 was assessed as per the 06/04/2026 order. On 05/26/2026, 05/28/2026, 06/09/2026, 06/18/2026, and 06/27/2026 the Dialysis Communication Reports were not completed by the dialysis center. The 06/16/2026 and 06/20/2026 Dialysis Communication Reports were not completed by either the facility or the dialysis center. Record review showed dialysis run sheets (a log of the dialysis session) for 05/06/2026 and 06/06/2026. No other run sheets were scanned in. In an interview on 07/02/2026 at 8:33 AM, Staff G (Resident Care Manager - 400 Unit) stated the Dialysis Communication Reports were important in order to ensure there was good communication and coordination of care between the dialysis center and the facility. Staff G stated they expected facility nurses to complete the facility's portion upon return from dialysis and contact the dialysis center if the center did not complete their portion. Staff G stated the Dialysis Communication Reports should be complete but were not. Staff G stated the facility practice was to upload dialysis run sheets weekly. Staff G stated the facility should but did not keep a complete record of the run sheets.REFERENCE: WAC 388-97-1900(1)(6)(a-c).

Based on observation, interview, and record review, the facility failed to ensure residents were free of significant medication errors for 1 of 19 (Resident 12) sample residents. The failure to ensure blood pressure medications were discontinued when necessary placed residents at risk for low blood pressure, lightheadedness, and other negative health outcomes. Findings included . <Resident 12>According to the 04/24/2026 admission Minimum Data Set, Resident 12 admitted to the facility on [DATE] and had moderate cognitive impairment and was usually understood and understood by others in conversation. The MDS showed Resident 12 had diagnoses including anemia and high blood pressure.Review of the 04/20/2026 hospital discharge summary, showed the hospital medical staff directed the facility to discontinue Resident 12's 40 Milligram (MG) dose of a blood pressure medication. The discharge summary showed Resident 12's blood pressure was measured within normal range when they admitted to the hospital. Review of the April 2026 Medication Administration Record showed a 04/21/2026 order for the blood pressure medication, give 40 MG in the morning for high blood pressure. The April 2026 MAR showed the medicine was given daily from 04/21/2026 through 04/30/2026.Review of the May 2026 MAR showed the blood pressure was given daily from 05/01/2026 through 05/19/2026.According to the facility's 05/19/2026 investigation, a nurse identified on that date that the blood pressure medication should have been discontinued upon admission but was not. The investigation noted Resident 12 had no signs or symptoms of low blood pressure and Resident 12 denied dizziness or lightheadedness. The investigation showed a nurse misread the admission paperwork from the hospital and mistakenly added in the order to Resident 12's medication regimen. Review of the blood pressure records showed Resident 12's SBP averaged 107 in the 31 blood pressure measurements taken from admission through 05/19/2026. The blood pressure records showed Resident 12's SBP averaged 118.3 in the ten measurements taken after the blood pressure medication was discontinued. In an interview on 07/01/2026 at 9:50 AM, Resident 12 stated they did not feel ill effects from the unneeded blood pressure medication. Resident 12 did not show concern when discussing the situation.In an interview on 07/02/2026 at 9:43 AM, Staff B (Director of Nursing) stated the nurse responsible for admissions should have identified the blood pressure medication should not be given to Resident 12 but did not. Staff B stated the physician should have identified the blood pressure medication should not be given to Resident 12 on admission but did not. Staff B stated Resident 12 did not require the blood pressure medication upon admission. Staff B reviewed the blood pressure records and stated Resident 12's blood pressure was in a better range since the discontinuation of the blood pressure medication. REFERENCE: WAC 388-97-1060(3)(k)(iii).

Based on observation, interview, and record review, the facility failed to ensure each resident was treated with dignity and respect and cared for in a manner and in an environment that promoted their sense of well-being while providing eating assistance for 1 of 1 residents (Resident 10) observed during dining. This failure placed residents at risk for undignified existence and a decreased quality of life. Findings included. <Facility Policy>The facility policy titled, Resident Rights- Dignity, revised October 2025, showed residents were to be treated with dignity and respect at all times. The policy showed each resident was cared for in a manner that promoted and enhanced their individuality, sense of well-being, satisfaction with life, and feelings of self-worth and self-esteem. The policy showed, when assisting with care, the staff would support the residents in exercising their right to dignity.<Resident 10>According to the 04/08/2026 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 10 had medical conditions including memory impairment, communication deficits, and a mental health illness. The MDS showed Resident 10 was assessed to require one-person physical assistance with eating. The revised 01/22/2026 activities of daily living Care Plan (CP) showed Resident 10 had self-care performance deficits due to their limited mobility and memory impairment. A 06/07/2026 CP intervention directed staff to provide Resident 10 feeding assistance. In an observation on 06/25/2026 at 12:48, Staff H (Certified Nursing Assistant) was observed serving Resident 10's meal tray inside the resident's room. Staff H placed the tray on top of the overbed table, placed the clothing protector on Resident 10 without asking, and started feeding the resident while standing up next to the bed. Staff H remained standing up for the entire duration they were assisting Resident 10 with their lunch. In an interview on 06/25/2026 at 12:58 PM, Staff H stated it was important to sit down and be eye-to-eye with a resident when providing dining assistance. Staff H stated they should have lowered Resident 10's bed and sat down while helping the resident eat instead of standing up, but they did not. In an interview on 06/30/2026 at 8:57 AM, Staff G (Resident Care Manager) stated they expected staff to promote and enhance a resident's dignity with every care interaction for quality of life. REFERENCE: WAC 388-97-0180(1)-(4).

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases. The facility failed to ensure staff performed Hand Hygiene (HH) before and after resident care and failed to follow a contact precaution sign for a resident with Transmission Based Precautions. The facility failed to establish a water management program that assessed and monitored measures to prevent the growth of Legionella (bacteria that could cause a serious lung infection), and other opportunistic waterborne pathogens in the facility's water systems. These failures placed residents at risk for the development of contagious, communicable diseases, and an unclean environment. Findings included . <Water Management Program> In an interview on 03/25/2025 at 10:41 AM, Staff L (Maintenance Director) was unable to provide documentation supporting the facility had a water management plan. Staff M (Infection Preventionist) provided a Legionella Water Management Program policy which showed the facility would have water management committee and staff would review the plan quarterly. Staff L stated they were unaware of a committee or a meeting that discussed the water management plan. Staff L stated they thought the facility performed a Legionella test prior to Staff L being hired but Staff L was unable to provide testing documentation. Staff L did not have a facility water flow diagram and was unaware of high-risk areas in the facility's water systems where Legionella had the potential to grow. Staff L stated each week they checked hot water temperatures in random resident rooms, kitchen, laundry, rehab gym, and showers. Staff L confirmed they should have a water management plan to prevent water borne pathogens, but they did not. In an interview on 03/26/2025 at 11:44 AM, Staff A (Administrator) stated the facility should have a water management plan in place to prevent Legionella, but they did not have one at this time. <HH> <Resident 40> According to a 02/19/2025 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 40 received 51% or more calories through tube feeding (tube inserted into the stomach and provided artificial nutrition). The MDS showed Resident 40 was incontinent of bowel and bladder and was dependent on staff for oral care, toileting, transferring, and bathing. Observation on 03/25/2025 at 9:23 AM showed Staff N (Certified Nursing Assistant - CNA) and Staff K (CNA) were providing incontinence care to Resident 40. Staff N and Staff K had a gown and gloves on. Resident 40 had a bowel movement and Staff K cleaned Resident 40 with wipes. Staff K grabbed a clean brief, placed the brief on the resident, grabbed clean linens and placed them under Resident 40 with the same soiled gloves used to clean the bowel movement. Staff K did not remove their gloves or perform HH before touching the resident's clean brief and clean linens. Staff K grabbed a clean pillow and placed it under Resident 40's legs with the same contaminated gloves. Staff N removed the dirty linens from Resident 40's bed, rolled the linens up and put them on top of a bed side table. Staff N removed their personal protective gown with their soiled gloves on. Staff N removed their soiled gloves last and sanitized their hands. In an interview on 03/25/2025 at 9:38 AM, Staff K stated they forgot to change their gloves in between the care from dirty to clean area. Staff K stated they should remove dirty gloves after the incontinence care was provided and stated they should wash their hands, but they did not. In an interview on 03/25/2025 at 9:41 AM, Staff N stated they should change their gloves in between the care from a dirty to clean area. Staff N stated they should not put the dirty linens on the bed side table. Staff N stated they should put the dirty linens in a bag and wash their hands, but they did not. In an interview on 03/25/2025 at 11:28 AM, Staff M (Infection Preventionist) confirmed staff should perform HH and change their gloves when going from dirty to clean. Staff M stated staff should not put the dirty linens on the resident's bed side table and should put dirty linens in a bag. 46479 <Following Transmission Based Precautions> Observation on 03/25/2025 showed resident room [ROOM NUMBER] had a sign on their door showing the resident was on Contact Precautions and instructed staff to perform HH and put on a gown and gloves prior to entering the resident's room. The sign instructed staff to wash their hands prior to leaving the room. At that time, Staff E (Activity Assistant) entered room [ROOM NUMBER] without performing HH, or putting on a gown and gloves. Staff E handed paperwork to the resident and left the room without washing their hands. In an interview at that time, Staff E looked at the contact precautions sign on the door of room [ROOM NUMBER] and acknowledged they did not follow the sign as directed. In an interview on 03/25/2025 at 11:30 AM, Staff M stated staff should follow the instructions on the sign posted on the resident's doors. Staff M stated staff should wear gown and gloves as instructed on the sign before entering the resident's room but they did not. REFERENCE: WAC 388-97-1320 (1)(a)(c), (5)(c).

Based on interview and record review, the facility failed to ensure a Pre-Admission Screening and Resident Review (PASRR - a process to determine if a potential nursing home resident had mental health/intellectual disability needs which required further assessment/treatment) assessment was accurate to reflect the residents' mental health conditions and/or obtained prior to admission for 4 of 6 (Residents 56, 16, 32, & 8), and 1 supplemental (Resident 61) residents reviewed for PASRR. This failure placed residents at risk for inappropriate nursing home placement and/or not receiving timely and necessary services to meet their mental health needs. Findings included . <Resident 61> According to a 02/11/2025 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 61 admitted on [DATE] with multiple medically complex diagnoses including a bipolar disorder (a mental illness characterized by extreme mood swings). This MDS showed Resident 61 required the use of an antipsychotic medication during the assessment period. Record review showed Resident 61 was admitted from the hospital with a 10/30/2024 Level 1 PASRR that showed the resident had a Serious Mental Illness (SMI) indicator of a mood disorder. There was no referral or evaluation completed due to Resident 61's identified SMI prior to Resident 61's admission to the facility as required. Review of 01/20/2025 Level 1 PASRR, completed over two months after Resident 61's admission, showed staff identified the resident had a mood disorder, but marked no Level 2 evaluation was indicated due to an exempted hospital discharge. The exempted hospital discharge section was blank on the 01/20/2025 Level 1 PASRR form. Staff documented on the form that Resident 61 did not discharge within 30 days and there was no anticipated discharge at this time. In an interview on 03/27/2025 at 9:22 AM, Staff C (Social Services Coordinator) reviewed Resident 61's records and stated if the Level 1 PASRR completed on 10/30/2024 indicated Resident 61 had a SMI, then a Level 2 evaluation should be completed prior to the resident's admission to the facility as required. Staff C stated the 01/20/2025 Level 1 PASRR should have identified a Level 2 referral was required as Resident 61 had a SMI identified and did not have a pending discharge in progress. <Resident 56> According to a 12/20/2024 Quarterly MDS, Resident 56 admitted on [DATE] with multiple medically complex diagnoses including anxiety and depression, and required the use of antianxiety and antidepressant medications during the assessment period. Record review showed Resident 56 was admitted from the hospital with a 09/20/2024 Level 1 PASRR that showed the resident had SMI indicators of a mood disorder and anxiety. There was no referral or evaluation completed due to Resident 56's identified SMIs prior to Resident 56's admission to the facility as required. In an interview on 03/27/2025 at 9:22 AM, Staff C reviewed Resident 56's records and stated if the 09/20/2024 Level 1 PASRR indicated Resident 56 had a SMI, then a Level 2 evaluation should be completed prior to the resident's admission to the facility as required. <Resident 16> According to a 02/18/2025 Annual MDS, Resident 16 had multiple medically complex diagnoses including a bipolar disorder and depression, and required the use of antipsychotic and antidepressant medications during the assessment period. Review of a 06/17/2024 Level 1 PASRR showed staff identified Resident 16 had a SMI indicator of a mood disorder and required a referral for a Level 2 evaluation. No Level 2 evaluation was found in Resident 16's records. On 01/20/2025, seven months later, staff completed a second Level 1 PASRR with a SMI indicator of a mood disorder and indicated a referral for a Level 2 evaluation was required for a significant change. Record review showed no Level 2 was found in Resident 16's records. In an interview on 03/27/2025 at 9:22 AM, Staff C reviewed Resident 16's records and stated a Level 2 evaluation should be completed as required with the 06/17/2024 and 01/20/2025 referrals. Staff C was unable to locate a Level 2 form that showed a referral was completed and stated the evaluators were behind schedule. When asked to provide documentation the evaluators were behind schedule, Staff C did not provide any further data. <Resident 32> According to a 01/28/2025 Annual MDS, Resident 32 had multiple medically complex diagnoses including dementia and depression, and required the use of an antidepressant medication during the assessment period. Review of a 12/28/2024 Level 1 PASRR showed staff identified Resident 32 with a SMI indicator of a mood disorder and required a Level 2 referral for the SMI. This form was not signed or dated by staff and no Level 2 evaluation was found in Resident 32's records. In an interview on 03/27/2025 at 9:22 AM, Staff C reviewed Resident 32's records and stated their expectation was for the form to be complete, signed, and with a Level 2 evaluation obtained as required. 46479 <Resident 8> Review of Resident 8's 04/26/2024 Significant Change in status MDS showed the resident's most recent entry to the facility was 04/19/2024. This MDS showed Resident 8 had diagnosis of anxiety, depression, bipolar disorder, and post-traumatic stress disorder. This MDS showed Resident 8 experienced inattention, disorganized thinking, suicide attempt, and rejected care during the assessment period. The MDS showed Resident 8 received antipsychotic, antianxiety, and antidepressant medications during the assessment period. Review of a 04/19/2024 Level 1 PASRR showed Resident 8 had SMI indicators including mood disorders, anxiety disorders, and post-traumatic stress disorder. The PASRR showed Resident 8 required a referral for a Level II PASRR due to having a significant change in their health status. Record review showed Resident 8 was not referred for a Level II PASRR until 12/27/2024, eight months after their significant change in health status occurred. In a joint interview on 03/27/2025 at 11:47 AM Staff A (Administrator) and Staff C reviewed Resident 8's records and confirmed the Level II PASRR referral was not sent timely. REFERENCE: WAC 388-97-1915(1)(2)(a-c). 45941 51791

Based on interview and record review, the facility failed to ensure funds were reimbursed to the resident and/or representative or the state Office of Financial Recovery (OFR), within 30 days of resident discharge or death, for 4 (Residents 234, 235, 237, & 236) of 7 discharged residents reviewed. This failure caused a delay in reconciling residents' accounts within 30 days as required. Findings included . <Facility Policy> According to an undated facility Trust Standards policy, balances in the trust would be disbursed upon discharge according to state regulations. This policy identified trust funds would be disbursed in seven days for discharged residents and 30 days for expired residents. <Resident 234> Review of an [DATE] Discharge Minimum Data Set (MDS - an assessment tool) showed Resident 234 discharged from the facility on [DATE] with their return not anticipated. Review of Resident 234's trust transaction history showed their balance of $6.00 was not closed out and disbursed until [DATE], 64 days after Resident 234 discharged from the facility. <Resident 235> Review of an [DATE] Discharge MDS showed Resident 235 discharged from the facility on [DATE] with their return not anticipated. Review of Resident 235's trust transaction history showed their balance of $28.00 was not closed out and disbursed until [DATE], 59 days after Resident 235 discharged from the facility. <Resident 237> Review of a [DATE] Discharge MDS showed Resident 237 discharged from the facility on [DATE]. Review of Resident 237's trust transaction history showed their balance of $303.66 was not closed out and disbursed until [DATE], 34 days after Resident 237 discharged from the facility. <Resident 236> Review of a [DATE] Discharge MDS showed Resident 236 discharged from the facility on [DATE] with their return not anticipated. Review of Resident 236's trust transaction history as of [DATE], showed their balance of $60.00 was still active in the facility trust and was not disbursed yet, 33 days after Resident 236 discharged from the facility. In an interview on [DATE] at 8:52 AM, Staff P (Business Office Manager) stated the facility needed to ensure trust funds were distributed within 30 days of a resident's discharge. Staff P stated Resident 234, 235, 237, and 236 trust accounts should have, but were not disbursed as required. REFERENCE: WAC [DATE](5).

Based on observation, interview, and record review the facility failed to initiate, log, investigate, and/or resolve grievances identified for 2 (Residents 14 & 56) of 2 sample residents reviewed for grievances. Staff failure to oversee the grievance process and track grievances through to their conclusions, placed residents at risk for unmet care needs. Findings included . <Facility Policy> The facility's May 2000 Grievance Policy showed formal grievances would be submitted in writing by outlining the concern on the grievance communication form. Staff would assist in completion of the form and submit it to the administrator, who would forward it to the appropriate department manager for action within 72 hours of receipt. <Resident 14> According to the 07/22/2024 Annual Minimum Data Set (MDS - an assessment tool), Resident 14 had moderate cognitive impairment, loosely fitting dentures, broken teeth, and experienced pain when chewing. Review of the February 2025 Grievance Log showed Resident 14 verbalized in the resident council meeting their dentures did not fit and were returned to the dental provider. This log showed Resident 14 understood that new [dentures] would take about two months, but it's already been six months. Staff I (Activities Director) completed the grievance communication form on 02/20/2025 for Resident 14 and submitted the form to Staff A (Administrator). On 02/20/2025, Staff C (Social Services Coordinator) documented they reached out to the provider for an update. Staff C concluded the investigation by attaching the contracted provider's email response and added they would ask Resident, if they would like extractions. Review of the 03/03/2025 dental evaluation showed the provider noted, patient does not have any upper denture at facility. In a phone interview with the dental provider on 03/27/2025 at 9:25 AM, the provider stated they emailed Staff C to report the dentures were missing on 03/05/2025. In an interview on 03/27/2025 at 11:16 AM, Staff C stated they received an email from the provider regarding Resident 14's missing dentures. Staff C stated they did not complete a grievance communication form addressing Resident 14's missing dentures. Staff C could not recall whether they informed Staff A of the email from the provider. In an interview on 03/27/2025 at 12:54 PM, Staff A stated they were unaware Resident 14's dentures were missing. Staff A stated they expected staff to follow the grievance policy, when residents' belongings were reported as missing. Staff A stated it was the residents' right to voice concerns and have those concerns thoroughly investigated and resolved. Staff A stated an important part of the process was to communicate the results of the investigation to the resident and concerned representatives. 45941 <Resident 56> According to the 12/20/2024 Quarterly MDS, Resident 56 had minimal difficulty with hearing and used hearing aids. According to the 03/19/2025 Quarterly MDS, Resident 56 had moderate difficulty with hearing and did not use hearing aids. Observation and interview on 03/20/2025 at 1:44 PM showed Resident 56 had a hearing aid in their left ear only. Resident 56 stated they could not hear well since they lost their right hearing aid. In an interview on 03/21/2025 at 10:43 AM, Resident 56's representative stated Resident 56 went to the hospital on 12/06/2024 and came back to the facility on [DATE] with both hearing aids. A week after Resident 56 came back from the hospital, they lost their right ear hearing aid in the facility and the facility did not resolve the missing hearing aid yet. Observations on 03/21/2025 at 11:34 AM, on 03/24/2025 at 1:01 PM, and on 03/25/2025 at 8:58 AM, showed Resident 56 lying in bed and only had their left ear hearing aid in. Resident 56 stated they could not hear well ever since they lost their hearing aid. Resident 56 stated their daughter talked to the staff about getting new hearing aid. Review of a 09/20/2024 admission assessment showed staff documented Resident 56 had both hearing aids and had difficulty with hearing. Review of the facility's November 2024, December 2024, January 2025, February 2025, and March 2025 grievance logs and investigation logs showed no documentation Resident 56's missing hearing aid was acknowledged or investigated. In an interview on 03/25/2025 at 2:01 PM, Staff C stated the facility process for missing items was to file a grievance form on the resident's behalf and the facility would investigate. Staff C stated if the facility could not find the resident's items, the facility would replace the items. Staff C stated they did not recall anything regarding Resident 56's missing hearing aid. In an interview on 03/25/2025 at 2:15 PM, Staff F (Resident Care Manager) stated they were aware Resident 56 was missing one of their hearing aids. Staff F stated Resident 56 came back from the hospital with both hearing aids and they lost the right ear hearing aid in the facility. Staff F stated they reported to social services that Resident 56 was missing their hearing aid. In an interview on 03/25/2025 at 2:32 PM, Staff U (Charge Nurse) stated they knew about Resident 56 missing hearing aid since Resident 56 came back from hospital in December 2024. Staff U stated they reported Resident 56's missing hearing aid to Staff F and Staff C. Staff U stated they reported the missing items to Staff C, and Staff C was supposed to fill out the grievance form. In an interview on 03/27/2025 at 10:16 AM, Staff F stated the facility's provider notified staff regarding Resident 56's missing hearing aid. In an interview on 03/27/2025 at 11:30 AM, Staff H (Outside Provider) stated Resident 56 lost their hearing aid after they came back from the hospital. Staff H found out about the missing hearing aid from the resident. Staff H provided the documentation showing they notified Staff C in February 2025 regarding Resident 56's missing hearing aid. In an interview on 03/27/2025 at 12:08 PM, Staff A stated they were unaware Resident 56 was missing a hearing aid. Staff A stated they expected staff to follow the grievance policy, when residents' belongings were reported as missing. Staff A stated it was the residents' right to voice concerns and have those concerns thoroughly investigated and resolved. Staff A stated staff should initiate a grievance form when they found out about Resident 56 missing hearing aid and provided an alternate device to the resident for hearing, but they did not. REFERENCE: WAC 388-97-0460.

Based on observation, interview and record review, the facility failed to implement their abuse and neglect policy for 1 of 1 resident (Resident 35) reviewed for injuries of unknown origin. Facility failure to identify, report, and investigate, multiple bruisesof unknown origin to Resident 35's upper/middle/lower back, both breasts, and knee placed Resident 35 at risk for potential continued abuse and psychosocial harm and all residents at risk for abuse, and psychosocial harm. An Immediate Jeopardy (IJ) was called on 01/31/2024 at 5:15 PM related to CFR 483.12 F-607, Develop/Implement Abuse/Neglect Policies. The IJ was determined to have begun 01/24/2024 when the bruises were initially identified by staff. The IJ was removed on 02/05/2024 when an on-site inspection confirmed the facility removed the immediacy by providing training to staff, skin assessments for all residents and suspending the concerned staff. Following the removal of the immediacy, noncompliance remained at isolated, no actual harm with potential for more than minimal harm. Findings included . According to the Nursing Home Guidelines The Purple Book The Code of Federal Regulation (CFR) defines abuse as, the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish . Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. The obligation of nursing homes is to protect the health and safety of every resident, including those that are unable to express themselves. <Facility Policy> The facility's 07/01/2020 Abuse Prevention Policy defined abuse to include intimidation or punishment with resulting physical, emotional or psychological harm, pain or mental anguish. The policy showed all suspected or alleged cases of resident abuse, including injuries of unknown origin, should be thoroughly and completely investigated, and reported according to State and Federal regulations. The Prevention section of the facility policy showed all incidents and injuries of unknown origins such as bruising, or skin tears would be identified through the 24-hour report and incident report to initiate an investigation. The Administrator and the Director of Nursing (DNS) would be notified. The Reporting section of the facility policy instructed mandated reporters to immediately report to their supervisor and the State Hotline when they had reason to suspect abuse and neglect. <Resident 35> Failure To Identify/Report/Investigate According to the 10/27/2023 Quarterly MDS (Minimum Data Set - an assessment tool) Resident 35 admitted to the facility on [DATE] and was cognitively impaired. The assessment showed Resident 35 was an English language learner and understood very little English. Resident 35 was assessed to be visually impaired and required extensive physical assistance with transfers, personal hygiene, dressing, and bathing. Resident 35 used a wheelchair (w/c) for mobility during the assessment period and required assistance with propelling. Review of the 10/06/2024 Self-Care Deficit CP showed Resident 35 had a range of motion limitations and instructed staff to transfer Resident 35 with two person total assistance. Observation on 01/30/2024 at 9:38 AM showed Resident 35 was sitting in a w/c by the nursing station in 200 Hall. Resident 35 was wearing a hospital gown and a small light green yellowish bruise to their left upper back, 3 fingerprint-like, light green-yellowish bruises to their middle back, and a small light yellowish bruise to lower back was observed. Observation on 01/30/2024 at 12:23 PM showed Resident 35 was dressed in a purple sweatshirt and was lying in bed. Observation on 01/31/2024 at 9:19 AM and 12:13 PM showed Resident 35 was awake, lying in their bed in a hospital gown. Observation on 01/31/2024 at 12:19 PM showed Staff P (Certified Nursing Assistant - CNA) providing care to Resident 35 in their bed. When Staff P removed Resident 35's hospital gown, multiple bruises were observed: light green yellowish bruise to Resident 35's left upper back, left middle back; left lower back; dark purple bruise to their right breast; dark purple bruise to left lateral breast; and light green yellowish bruise under their left breast. Staff P removed the blanket from Resident 35's legs, a dark purple bruise with a bump under Resident 35 right knee was observed. When Staff P transferred the resident from the bed to the w/c by grabbing Resident 35 from under their arms. Staff P did not follow the Care Plan (CP) to have another staff for assistance and no gait belt was used while Resident 35 was transferred from the bed to the w/c. In an interview on 01/31/2024 at 12:28 PM, Staff P Stated they reported the new bruises to their supervisor, but they did not report the bruises to the nurse today because the bruises to Resident 35's breast and back were not new. Staff P stated Resident 35 crawled on the floor and easy to get the bruises. Staff P stated they worked with Resident 35 since last week and the bruises were reported to Staff L (Registered Nurse - RN) on 01/24/2024. Review of 01/30/2024 weekly skin assessment completed by the nurse showed no irregularities were discovered during skin check. Review of January 2024 Physician Orders (POs) showed no orders to monitor bruises on Resident 35's back and breast area as of 01/31/2024. Review of Resident 35's nursing progress notes for 01/24/2024, 01/25/2024, 01/26/2024, 01/27/2024, 01/28/2024, 01/29/2024, and 01/30/2024 showed no documentation about Resident 35's bruises to their back and breast areas. Review of facility's January 2024 Incident log showed no entry for Resident 35's bruising. In an interview on 01/31/2024 at 12:41 PM, Staff X (CNA) stated they worked with Resident 35 on 01/29/2024 and did not notice any bruise to their back or breast area. In an interview on 01/31/2024 at 12:49 PM, Staff Q (RN) stated they worked on 200 Hall with Resident 35 two days a week and did not check Resident 35's skin. Staff Q did not know about any bruising to Resident 35's back or breast area. Staff Q Stated Resident 35 usually crawled on the floor out of bed and could get bruised easily. In an interview on 01/31/2024 at 12:53 PM with the interpreter assistance, Resident 35 stated they did not know how they got the bruises. In an interview on 01/31/2024 at 1:05 PM, Staff E (Resident Care Manager - RCM) stated nurses complete a weekly skin check as ordered and document skin issues in the resident's record. Staff E stated if staff note any bruises on resident's breast, thighs, or between legs, staff should report to their supervisor immediately. Staff E stated the supervisor and DNS would then assess the resident and call the State and responsible party. Staff E stated the facility would ensure the resident was safe and complete a thorough investigation to rule out abuse and neglect. Staff E stated none of the staff reported Resident 35's bruises on the back and breast area to them. Staff E stated they would go and check Resident 35's skin. On 01/31/2024 at 1:15 PM, Staff E and Staff Q performed a skin check on Resident 35 and measured the bruises; left upper back 6 centimeter (cm) by 4cm in green brown color; left middle back green brownish color bruise 1cm by 1.5cm; left lower back 4cm by 6.5cm brown color bruise; left breast 3cm by 2cm brown color bruise; under left breast 2cm by 7cm yellow greenish color bruise; right breast 3cm by 2.5cm brown color bruise; and under right knee 4cm by 3cm brown color bruise with a bump. In an interview on 01/31/2024 at 1:25 PM, Staff E stated direct care staff should have reported these bruises to the RCM. Staff E stated the facility should have reported these bruises to State Hotline and initiated an investigation to rule out abuse but they did not. In an interview on 01/31/2024 at 1: 28 PM, Staff B (DNS) stated they have not heard about any skin issues for Resident 35. Staff B stated the staff should have reported the bruises to their supervisor as they were a mandatory reporter. Staff B stated the facility should have reported to State Hotline, medical provider, and responsible party. Staff B stated the facility should have identified, reported, and investigated the bruises to rule out abuse and neglect but they did not. In an interview on 2/2/2024 at 11:23 AM, Staff L stated the staff assigned to Resident 35 did not report any bruises to them. Staff L stated that when they conducted skin check on 01/30/2024, Resident 35 did not want the room light on. Staff L stated they were unable to see any bruises on Resident 35's body because the room was dark. Reference: WAC 388-97-0640(2)(a)(b)5(b).

Based on observation, interview, and record review the facility failed to ensure 1 of 5 sampled residents (Resident 61) reviewed for Pressure Ulcers (PUs), received the necessary treatment and services, consistent with professional standards of practice to prevent new ulcers from developing. Resident 61 experienced harm when they developed a facility acquired coccyx (tailbone) and inner left knee PU when staff did not consistently implement ordered pressure offloading measures and the resident was not consistently repositioned in bed. This failure placed all other residents at risk for PU development, and a diminished quality of life. Findings included . According to the CMS PU coding guide, a PU is defined as an observable, pressure-related alteration of intact skin with non-blanchable redness of a localized area usually over a bony prominence; may include changes in skin temperature, tissue consistency and/or sensation. A Stage II PU presents as a partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising. <Resident 61> According to the 11/21/2023 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 61 was usually able to make themselves understood and usually able to understand others. The assessment showed Resident 61 was totally dependent on two staff for physical assistance with moving to and from a lying position, turning side to side, and positioning the body while in bed. The MDS showed Resident 61 had a diagnosis of a long term degenerative neurological disorder that affected both the motor system and non-motor systems. According to the MDS, Resident 61 was at high risk for developing PUs. Review of Resident 61's Physician Orders (PO), dated 08/21/2023, showed an order for heel protective boots to both feet on at all times while in bed for pressure relief and for staff to check the placement of the boots every shift. Review of Resident 61's PO dated 12/15/2023, showed an order to place a rolled blanket between legs to offload pressure. Review of a 01/31/2024 weekly skin assessment showed Resident 61 had a new 1-centimeter (cm) X 2.5 cm Stage II PU on their coccyx. Record review of Resident 61's revised Care Plan (CP), dated 02/06/2024, showed a new Stage II PU coccyx wound developed on 01/31/2024. The CP showed interventions for staff to assist Resident 61 to re-position in bed frequently to reduce pressure, place a pillow or rolled blanket between legs to reduce pressure from crossed legs, and apply heel protective boots on both feet, when in bed. Observations on 01/30/2024 at 10:08 AM, 12:09 PM, and 2:21 PM, on 01/31/2024 at 8:38 AM, 10:26 AM, and 3:22 PM, and on 02/01/2024 at 8:28 AM, 10:55 AM, 12:18 PM, and 2:20 PM showed Resident 61 lying on their back, unable to turn and reposition on their own to offload pressure. Resident 61's legs were crossed with their knees pressed together and no rolled blanket was present to prevent pressure. Resident 61 did not have pressure reduction boots on as ordered by the physician during the observations on 01/30/2024 and 01/31/2024. Resident 61 was not observed to independently shift their weight or move their body on their own. A wound care observation and interview on 02/05/2024 at 11:15 AM showed Resident 61 lying in bed on their back with their legs crossed and no blanket between their knees to reduce pressure. Staff L (Registered Nurse) stated Resident 61 should have a pillow or rolled blanket between their knees and their protective boots on, but they did not. During wound care, Staff L and Staff N (Certified Nursing Assistant) observed a new pressure area developed to Resident 61's inner left knee. Staff N stated Resident 61 often refused care, refusals should be documented in Resident 61's medical records, and they should notify the Resident Care Manager (RCM) of refusals. Staff N stated they did not document or notify the RCM of Resident 61's refusals but should have. During an interview on 02/05/2024 at 8:26 AM Staff E (RCM) stated Resident 61 should have a rolled blanket between their knees, be repositioned every two to three hours, and protective boots should be on at all times. Staff E stated the CNA was responsible for carrying out these tasks and the Nurse would check to ensure they were done each shift. Staff E stated there was no documentation to support Resident 61 refused, so they were unsure if interventions were implemented. Staff E stated if residents refuse cares the floor staff is expected to document that and notify the assigned nurse or RCM. Reference WAC: 388-97-1060 (3)(b).

Based on observation, interview, and record review the facility failed to ensure 1 of 6 sampled residents (Resident 61), reviewed for Pain Management received the necessary treatment and services as ordered to manage pain with wound care. Resident 61 experienced harm and self-reported severe levels of pain during wound care when the facility failed to consistently premedicate the resident with ordered as needed pain relieving medication 30-60 minutes prior to dressing changes. This failure placed all other residents at risk for potentially unnecessary pain during wound care, and a diminished quality of life. Findings included . <Facility Policy> Review of the facility policy titled Pain Assessment and Management, dated October 2022, showed pain management included recognizing the presence of pain, and developing and implementing approaches to pain management. This policy showed that behaviors such as resisting care, yelling out, or decreased participation in physical/social activities were included when recognizing pain. <Resident 61> According to the 11/21/2023 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 61 was usually able to make themselves understood and usually able to understand others. The assessment showed Resident 61 was totally dependent on two staff for physical assistance with moving to and from a lying position, turning side to side, and positioning the body while in bed. The MDS showed Resident 61 had a diagnosis of a long term degenerative neurological disorder that affected both the motor system and non-motor systems. According to the MDS, Resident 61 was at high risk for developing PUs. This assessment showed Resident 61 did not receive their as needed (PRN) pain medication during the assessment period. Record review of a Physician Order (PO) initiated upon admit to the facility on [DATE] showed an order for Resident 61 to receive a PRN pain medication 30-60 minutes prior to their wound dressing change. Record review of Resident 61's 01/10/2024 Care Plan (CP) showed Resident 61 had acute pain related to wound. This CP showed staff were instructed to Pre-medicate Resident 61 with PRN pain medication 30-60 min prior to a wound dressing change with a goal of Resident 61's satisfaction with pain management by decreased or no vocalizations related to pain. Record review of Resident 61's medication and treatment administration records showed Resident 61 was not premedicated with pain medication prior to wound care for 24 of the 31 wound dressing changes done in August 2023, 15 of the 21 wound dressing changes in September 2023, 13 of the 16 wound dressing changes in October 2023, 23 of the 24 wound dressing changes in November 2023, 16 of the 19 wound dressing changes in December 2023, and 23 of the 24 wound dressings changed in January 2024. During an interview on 01/30/2024 at 12:08 PM Resident 61 stated they did not experience constant pain but experienced severe pain when the staff would change their wound dressings. Review of Resident 61's MARs for August 2023 to January 2024 showed greater than 286 behavioral episodes which included yelling out, cursing, feeling anxious, agitation, and restlessness for Resident 61 were documented. In an observation and interview on 02/05/2024 at 11:15 AM, Resident 61 appeared calm without any signs of pain during their wound dressing change. Staff L (Registered Nurse) and Staff N (Certified Nursing Assistant) repeatedly stated this is so unusual for them, they are never this calm and compliant with their wound dressing changes. Staff L and Staff N stated Resident 61 normally yelled out and would often refuse care. Staff L stated the pain medication must have helped that they gave them an hour ago. Both Staff L and Staff N stated when a resident yells out and refuses care, those are signs that they were in pain. During an interview on 02/05/2024 at 8:23 AM Staff E (Resident Care Manager) stated the nurse should premedicate Resident 61 30-60 minutes prior to their wound care as directed in Resident 61's CP and PO's. Staff E stated Resident 61 was not receiving the PRN pain medication prior to wound care as directed by the PO's but should have been. Reference WAC: 388-97-1060(1).

Based on observation, interview, and record review the facility failed to provide supervision and ensure care was provided to residents at the level of care they were assessed to require for 2 of 3 residents (Residents 33 &34) reviewed for falls. The facility failed to ensure incident investigations were completed thoroughly to identify the root cause of the incident, update the incident investigations and incident log to reflect when an injury occurred, for 3 of 3 residents (Resident 33, 34 & 35) reviewed for falls. These failures caused harm to Resident 33 who fell out of bed and experienced a fractured nose, required stitches to a lacerated forehead, bruising and a cervical spine injury that required surgical repair, and caused harm to Resident 34 who sustained a fractured sternum and clavicle from a fall, and placed all residents at a potential risk of harm related to avoidable falls, the potential for continued incidents, injury, pain and diminished quality of life. Findings included According to the facility policy titled, Falls and Fall Risk Management, revised 03/2018, facility staff would implement a resident centered fall prevention plan to reduce specific risk factors for each resident identified at risk or with a history of falls. When underlying causes of falls could not be identified facility staff were to try various interventions, based on the nature of the fall, until falls were reduced, stopped, or the reason for the continued falls was identified as unavoidable. Facility staff with the physician's input would identify and implement interventions to minimize serious consequences of falls. Facility staff would monitor each resident's response to interventions implemented and re-evaluate current interventions, change interventions, and include the physician to determine possible causes for falls that was not previously identified. According to the facility policy titled, Reporting and Investigating - Abuse, Neglect, Exploitation or Misappropriation, revised 09/2022, showed the individual who conducted the investigation should review documents and evidence, review the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and after the incident, observe the alleged victim, interview the staff reporting the incident, interview any witnesses to the incident, interview the resident and/or the resident's representative, interview staff members on all shifts who had contact with the resident during the incident, interview the resident's roommate, review all events leading up to the incident and document the investigation completely and thoroughly. A follow up investigation report would provide sufficient information to describe the results of the investigation, and indicate any corrective actions taken. <Resident 33> According to the 05/02/2023 Quarterly Minimum Data Set (MDS), an assessment tool, Resident 33 was able to make their own decisions and needs known, had diagnoses including severe narrowing of the cervical spinal canal causing muscle weakness and new onset quadriplegia (paralysis of all limbs), arthritis of the right shoulder, and carpal tunnel syndrome (pain and numbness in the hands, wrists and forearms) affecting both wrists. The MDS assessed Resident 33 to require extensive assistance of two staff members for bed mobility, transfers, and dressing. Resident 33 was assessed to require extensive assistance of one staff member for personal hygiene and eating, and was totally dependent on two staff members for toileting and transfers. Review of a 02/14/2023 facility Fall Risk Evaluation showed Resident 33 was assessed at moderate risk for falls due to certain medication use and had no history of falls. A 02/14/2023 fall Care Plan (CP) showed the goal for Resident 33 was to have no falls in the facility and injuries would be minimized if the resident sustained a fall. Interventions directed staff to monitor the resident's need for toileting, encourage the resident to wear non-skid socks, and to call for assistance when transferring. A self-care deficit CP, dated 02/14/2023, was reviewed on 06/02/2023 and showed Resident 33 required two person total dependence for bed mobility and one person total assist for toileting. Review of Resident 33's CP showed revisions were made on 03/21/2023 that changed Resident 33 from a two person extensive assist with bed mobility to a one person extensive assist with bed mobility. The facility provided no documentation that supported Resident 33 had a drastic improvement in condition to require less staff assistance with bed mobility on 03/21/2023, the date Resident 33's CP was changed to a one person extensive assist with bed mobility. The same self-care deficit CP was reviewed on 06/05/2023 and showed that on 05/15/2023, two days after Resident 33 experienced a fall, the bed mobility status was changed to one person extensive assistance with bed mobility and toileting. Review of a provider encounter note, dated 03/21/2023 showed Resident 33 was evaluated for mobility and ADL (Activities of Daily Living) dysfunction, worsened pain to their right shoulder that was aggravated by a recent hospitalization and immobility. The note showed Resident 33 would continue to work with occupational therapy (OT) on ADL functional mobility training (helps improve overall coordination and mobility). Review of a 03/21/2023 Nursing Progress Note (NPN) showed facility staff documented Resident 33 had swelling to their right hand, was being monitored for pain medication effectiveness, and recently started on two medications to help with their increased right shoulder pain. Review of a 04/21/2023 Physical Therapy (PT) discharge summary showed Resident 33 had a goal to safely perform bed mobility tasks with minimal assist. The resident's baseline performance for bed mobility on admission was total dependent on staff, and as of 04/21/2023, their discharge date from PT, Resident 33 required moderate assistance. The discharge summary showed Resident 33 was discharged from PT for maximum potential achieved and the resident would be referred for a restorative program. Review of a provider encounter note, dated 04/21/2023, showed Resident 33 had a recent illness, continued feeling fatigued, and their therapy progress was slow and interrupted by their illness. Resident 33 told the provider they were frustrated that their insurance, cut me off, of therapy services. Review of 04/24/2023 facility Restorative Referral Form showed Resident 33 was at risk for decline in functional mobility and precautions included that Resident 33 was unable to use their bilateral (both) upper extremities functionally and the restorative goal was to increase Resident 33's function with repetitive movement and to maintain upper extremity strength. Review of a facility Therapy Screen document, dated 04/25/2023 ,five days after Resident 33 was discharged from PT services, showed, Resident 33 was screened for recent declines in ADL's, self-feeding, and ROM (range of motion) and strength. Therapy documented they would pursue evaluation and treatment orders for OT and start restorative services. Review of a provider encounter note, dated 05/09/2023, showed Resident 33's progress was slow and interrupted by a recent illness, and recommendations to continue therapy services with goals for modified independence with mobility, ADL's, and transfers. Review of a NPN, dated 05/13/2023, showed at 9:05 AM that day Staff E (Registered Nurse) heard a loud crash and screaming, and found Resident 33 face down on the floor. Staff D (Nursing Assistant Registered) told Staff E they tried to change Resident 33's brief, turned them, and the resident rolled out of the bed and fell to the floor. Resident 33 was observed with a nosebleed and a laceration to their forehead. Resident 33 was sent to the hospital for further evaluation. Review of the May 2023 facility incident reporting log showed no documentation of Resident 33's fall with injury on 05/13/2023. Review of a facility investigation, dated 05/18/2023 showed Staff B (Director of Nursing) documented Resident 33 was at risk for falls and required one person extensive assistance with toileting and bed mobility. Staff B concluded the fall on 05/13/2023 was unavoidable because the staff member could not break the fall as they were standing on the opposite side of the bed. The investigation did not determine if the Staff D (Nursing Assistant Registered) was following the CP or the MDS when the fall occurred, or if the MDS or the CP were accurate. MDS showed Resident 33 required two person assist with bed mobility and was dependent on staff for toileting and the CP showed two person assist with bed mobility and one person assist with toileting. In an interview on 05/24/2023 at 12:51 PM Resident 33's Collateral Contact (CC) stated the resident broke their nose and required stitches to their forehead due to the laceration. An x-ray at the hospital showed swelling in the neck area, where Resident 33 had surgery a few months prior. The CC stated that facility staff always used two people when changing the resident in bed and now suddenly the resident was a one person, that was not accurate the resident was pretty much a quadriplegic and could barely move. During an interview on 05/25/2023 at 12:05 PM Staff F (Shower Aide) stated Resident 33 was a two person assist with bed mobility and transferred out of bed with a mechanical lift. Staff F stated the resident would try to help but still required assistance from staff for daily tasks like eating. In an interview on 05/25/2023 at 12:07 PM Staff B stated Resident 33 sustained a nosebleed and a laceration to the forehead, but no nose fracture was identified at the hospital. Staff B stated they did not speak with hospital staff or obtain hospital records. Review of the May 2023 bed mobility ADL documentation by Certified Nurses Assistants (CNA) showed on 05/04/2023, 05/05/2023, 05/06/2023, 05/07/2023, 05/09/2023, 05/11/2023, and 05/12/2023 staff documented Resident 33 required total staff assistance with bed mobility. In an interview on 06/14/2023 at 1:30 PM Staff D stated they worked with Resident 33 for almost two weeks and on 05/13/2023 they checked Resident 33's CP and it showed one person assist for toileting the resident in the bed. Staff D gathered their supplies and Resident 33 wanted to turn towards their stronger right side and while providing incontinence care the resident raised their left leg to turn and rolled off the bed. During an interview on 06/05/2023 at 3:00 PM, Staff B stated Resident 33 was a one person extensive assist with toileting since the middle of February 2023. When asked who assessed the resident or changed the CP, Staff B stated it changed the date when the record was closed on 05/15/2023. Staff B was asked why there were differences between the MDS, which showed Resident 33 was two person assist with bed mobility and dependent on staff for toileting and the CP showed the resident was a two person assist for bed mobility, and a one person assist for toileting, and that CNA's documented using two staff members for bed mobility and toileting. Staff B stated Resident 33 toilets by being changed in the bed. When asked if bed mobility occurs when staff change a resident in bed, and Staff B replied, yes. Staff B was asked if the MDS was wrong and replied, no. Staff B was asked if the CP was wrong and stated, no. Staff B stated if I were the staff I would change them by myself. Staff B was asked why Staff D didn't turn the resident towards them when rolling them in bed, instead of away from them, and Staff B replied that Staff D should have but didn't turn the resident safely. Staff B stated the MDS and CP should match and be updated. Observations and interview on 06/12/2023 at 3:30 PM showed Resident 33 in bed, was unable to use their arms to call for staff assistance, and had to use a voice command on their cell phone to call for the nurse. Resident 33 stated It all started in January when I fell at home, after repeated falls and the fire department responding multiple times to pick me up from the floor they took me to the emergency room . I went to the facility from the hospital, on the day of my fall [05/13/2023], I requested staff assistance to have my wound dressing changed and possibly use the bedpan, one staff member responded but they didn't go get a second person to help, and I should have said something. The staff member turned me to the right, I am not sure how I fell but I landed on my face. Resident 33 stated the facility used two people to turn/change them in the bed from the beginning, was never told the CP changed to only one person assistance, and thought they should always use two people because I am not a small person. Resident 33 stated after the fall they required a surgical repair of the neck and now can't hold anything or barely move. Resident 33 was observed attempting to lift their left arm but was unable to significantly lift their left arm. Review of hospital documents, dated 05/25/2023, showed Resident 33 presented to the hospital on 05/13/2023 with significant signs and symptoms of a central cord syndrome (most common form of an incomplete spinal cord injury), had a severe fall with a flexion/distraction type (horizontal fracture of spine) of injury and a cervical spinal cord bruise. Resident 33 underwent surgical repair on 05/22/2023 for central cord syndrome with possible cervical fracture of C4-C5. <Resident 34> According to the 02/16/2023 Quarterly MDS Resident 34 was able to make their own decisions and needs known, admitted to the facility after a fall from a ladder that resulted in left humerus (upper arm) fracture. Resident 34 had diagnoses including a left tibia (larger bone in lower leg) and left leg fibula (smaller bone in lower leg) fracture, unsteadiness on feet, and cancer. The MDS assessed Resident 34 to require supervision of one staff member when ambulating in their room, supervision and set up help from staff when walking in the facility. The MDS showed the resident used a walker and was assessed as not steady but able to self stabilize their balance when walking. Review of a self-care deficit CP, dated 11/09/2022, showed Resident 34 was a fall risk and was independent with their walker for ambulation. Review of a facility Fall Risk Evaluation, dated 05/11/2023, showed Resident 34 scored a low risk for falls as staff documented the resident had no history of falls. This was the first fall risk evaluation completed for Resident 34, after experiencing a fall at home and after being admitted to the facility for a fall six months ago. Review of a NPN dated 05/11/2023 at 1:20 PM showed Resident 34 had a witnessed fall in the parking lot when the resident tried to walk on the grass with their walker, got stuck and fell . Review of a Provider note, dated 05/11/2023, showed Resident 34 was walking outside alone with their walker, lost their balance and fell . Resident 34 complained of occasional pain in their left leg and the pain was managed with pain medications. Review of the May 2023 facility incident reporting log showed Resident 34 had a fall that occurred on 05/11/2023 and sustained no injuries. Review of a NPN, dated 05/11/2023, showed Resident 34 was observed with swelling to the left clavicle and complained of increased pain when moving or touching the area. A physicians order (PO) was received for a two view x-ray of the left clavicle. A witness statement, dated 05/11/2023, showed a staff member was sitting in their car, heard a noise, and saw Resident 34 laying on the road next to their walker. A second witness statement, dated 05/11/203, showed a staff member saw Resident 34 outside a window walking by themselves and it looked like the walker got stuck and they fell . A third witness statement, dated 05/11/2023, showed Resident 34 was found sitting on the ground of the parking lot with the walker next to them. Review of the facility investigation, dated 05/12/2023, showed Resident 34 fell to their bottom while ambulating outside by themselves. Staff B documented that Resident 34's left shoulder is not painful and is moving per their normal, x-ray findings were similar to the previous x-ray and resident's old fracture .a second x-ray was requested and findings were similar to the previous x-ray. Staff B documented Resident 34's ambulatory status remained the same and Resident 34 was seen ambulating the halls with family or staff as usual. Staff B concluded that the x-ray revealed the chronic fracture from admission and the resident's pain, range of motion remain unchanged from prior to the fall. Review of a provider note, dated 05/12/2023, showed Resident 34 complained to the provider they could not bear weight on their left leg and had a grating sound heard when moving the left clavicle. The provider assessed the left clavicle area to be swollen and confirmed a grating sound was heard when the clavicle area was touched. The provider ordered a urgent x-ray of the left clavicle and pelvis to rule out a fracture. Review of multiple NPN's showed on 05/13/2023 Resident 34 continued to complain of pain with movement. On 05/14/2023 Resident 43 was assessed with swelling and pain to the left clavicle. On 05/15/2023 Resident 34 continued to complain of pain. Review of a Provider note, dated 05/16/2023, showed Resident 34's chief complaint was left sided sternum and clavicle pain and assessed the resident with a soft bulky area in the left sternum/clavicle region that was mildly tender to touch. The note showed the x-ray of the clavicle that was previously done was of the shoulder and recommended a new x-ray of the sternum be obtained. Review of the 05/20/2023 sternum x-ray results provided by the facility, showed an acute, non-displaced sternum fracture and an acute mildly displaced fracture of the left clavicle. Review of a Provider note, dated 05/22/2023, showed Resident 34 would need to see an orthopedic (bone) doctor, use a left arm sling, and limit physical and occupational therapy to only the legs and right arm movements. Review of a facility incident reporting log, requested on 06/07/2023 showed no indication the log was updated to reflect Resident 34's two fractures, no addendum to the original incident report to include the injures sustained on 05/11/2023, and no report was made to required entities about the substantial injury of two fractures that were identified on 05/20/2023. In an interview on 06/14/2023 at 2:10 PM, Staff B stated the facility reviewed the NPN in morning meetings, knew about the fractures but did not update the fall investigation or the facility log to reflect the two new sustained fractures from the fall. When asked how Resident 34 sustained a sternum and left clavicle fracture, Staff B stated they fell to their bottom and rolled to their side. Review of the facility investigation did not show if Resident 34 had been assessed for safety to ambulate alone or outside, and did not document the new fractures as a result of the fall, thoroughly determine circumstances and put preventative measures in place. <Resident 35> According to the 04/04/2023 Quarterly MDS Resident 35 was able to make their own decisions and needs know, had diagnoses including a brain bleed, diabetes, arthritis, abnormality of gait, muscle weakness, and a seizure disorder. The MDS assessed Resident 35 to require one person staff assistance with bed mobility, transfers, toilet use, and personal hygiene. Review of a 09/30/2022 fall CP directed staff to check on the resident between 10:00 PM-11:00 PM and offer assistance with toileting and bedtime routine, encourage the resident to call for assistance before transferring, and monitor the resident's need for toileting. The CP had interventions of a fall mat at the bedside and the bed in the lowest position to minimize injury from falls. Review of the May 2023 facility incident reporting log showed on 05/09/2023, 05/10/2023, and 05/24/2023 Resident 35 had falls, without injuries. <Fall 05/09/2023> Review of a NPN, dated 05/09/2023, showed at 12:45 AM on 05/09/2023 the nurse heard a loud noise and found Resident 35 on their back in front of their bed and the bedside table was observed flipped over to the side. Review of a Fall Scene Investigation Report, dated 05/09/2023, showed Staff H (Licensed Practical Nurse) documented NA- non applicable for question 14 which asked where the fall occurred, options included; next to the transfer surface (assess for postural hypotension- drop in blood pressure when changing posture), 10 feet from the transfer surface (assess balance), and greater than 15 feet from the transfer surface (assess strength and endurance). Review of a facility incident investigation, dated 05/11/2023, showed Staff B documented Resident 35 preferred to sit at the edge of the bed, fell asleep, and slids down to the floor. There was a fall mat to prevent injury placed by the bed. Staff B concluded that the fall was unavoidable and related to the resident's condition, a therapy referral was made to evaluate for a possible chair for them to sit in or bolsters to the bed to help identify the edge of bed. The investigation did not provide details of how Resident 35 fell on the floor mat or the floor, where in front of the bed were they found, how many feet from the transfer surface, or how the bedside table ended up flipped over on the floor. <Fall 05/10/2023> Review of a NPN, dated 05/10/2023, showed around 10:00 AM on 05/10/2023 Resident 35 was found lying on their left side on the fall mat next to their bed. Resident 35 complained of mild pain to their left shoulder and left knee. An abrasion was found on the resident's left knee and Resident 35 told the staff it was from the fall on 05/09/2023. A 05/11/2023 PO showed an order for a half bolster (a long pillow to provide support) to be used when Resident 35 was lying down in bed. Review of the facility incident investigation, dated 05/11/2023, showed Staff B documented the investigation as the therapy director evaluated the resident for multiple falls over the last quarter and the therapy director wrote a note which explained the root cause of the falls, the way the resident lays down backwards from a sitting position and their feet are over the edge of the bed causing them to slip down. I like the idea of the half bolster, we will try it to ensure that it fits in a way that they can easily get out. Staff B concluded the investigation that the resident was evaluated by therapy and will have a half bolster to assist in identifying edges of the bed and avoid falls. The investigation did not address or determine the cause of the bruise found to Resident 35's knee. Review of provider note, dated 05/22/2023, showed Resident 35 complained of pain to the left knee that got worse with movement. Review of Resident 35's record showed 14 days after staff were aware of the abrasion to the left knee on 05/10/2023, a PO was placed on 05/24/2023 to monitor the abrasion for signs of infection or worsening. <Fall 05/24/2023> Review of a NPN, dated 05/24/2023 at 12:45 AM, showed the nurse heard a loud noise and found Resident 35 lying on their back in front of the bed. A skin assessment showed a scab from the old abrasion to the left knee broke off partially leaving an open area to the knee. Resident 35 told staff they were not sure if they hit their head. A provider note, dated 05/24/2023, showed Resident 35 was having severe pain to the left knee that radiated down the leg due to a fall, the resident fell asleep by watching television and fell forward, sustaining the abrasion to the knee. Review of the facility incident investigation, dated 05/24/2023, showed Staff B documented the investigation as; the resident preferred to sit on the edge of the bed, fell asleep, then slid down to the floor. Staff B concluded the resident experienced an unavoidable fall where they slid from the bed. The resident was non-compliant with how they sit in regard to safety. The investigation did not determine if Resident 35 fell on the floor mat or the floor, where in front of the bed were they found, and how many feet from the bed surface. A Pain Evaluation, dated 05/24/2023, showed Resident 35 had severe pain in the left lower extremity. The resident was often heard to have loud vocalization of pain when rising from a lying to sitting position. Review of a NPN, dated 05/25/2023, showed Resident 35 continued to complain of left leg pain. Review of a requested and updated incident reporting log on 06/07/2023 showed no updates to Resident 35's fall on 05/09/2023 with the abrasion to the left knee, after multiple complaints to staff about pain and documentation from providers assessing the residents pain. No addendum to the incident reports were observed to include the left knee abrasion. During an interview on 06/14/2023 at 2:30 PM, when asked where Resident 35 fell when staff documented in the front of the bed, Staff B replied, they fell on the fall mat. When asked how Resident 35 sustained a bruise to the left knee on the 05/09/2023 fall if they slid from the bed, Staff B stated there was a bed side table and maybe scrapped their knee. When asked how a half bolster would prevent the resident from sliding down if the PO was to be used only when lying in bed. Staff B replied that the bolster would help the resident identify the bed edges. The investigation did not address or determine how Resident 35 sustained a bruise on the knee, where the resident was found in accordance with the bed, and how the tray table was knocked over. REFERENCE: WAC 388-97-1060(3)(g)

Based on observation, interview and record review the facility failed to ensure one (#1) of two residents reviewed for abuse, was free from abuse. The facility failed to ensure residents care planned interventions were followed, residents were adequately supervised and abuse was identified. Failure of the facility resulted in Resident #2 punching Resident #1, causing a nose bleed and resultant psychological distress, which constitutes harm. Findings included . According to a 11/22/2020 facility reported incident, there was an altercation involving Resident #1 and Resident #2 in the dining room on 11/22/2020 at 6:57 PM. Review of Resident #2's Behavior disturbance Care Plan dated 08/21/2020 showed Resident #2 had a history of [REDACTED]. Interventions included, Avoid situations that may provoke an aggressive response, Monitor for excessive stimulation and make necessary changes. Review of a 11/17/2020 3:18 PM Provider Note regarding Resident #1 showed, Per nursing he yells out most of the day. Review of a 11/23/2020 statement written by Staff C, Licensed Practical Nurse showed that Resident #2 stated, He was screaming when asked why he punched the other resident. Review of the facility undated investigation showed that dinner was done, trays were picked up and residents were watching football on the television. Staff were attending to other residents in their rooms at the time of the incident. During an interview on 12/03/2020 at 2:28 PM, Staff B, Director of Nursing confirmed there were no staff monitoring in the dining room at the time of the abuse. Review of a 11/23/2020 statement written by Staff C showed that on 11/22/2020 around 6:57 PM, Staff C went to the dining room and noticed Resident #1's nose was bleeding. There was mild redness on his nose, but not other injuries noted. On 12/03/2020 at 12:40 PM, Resident #1 was observed in bed. During an interview at that time, when asked if he had any concerns with any other residents, Resident #1 stated, one hit me in the nose and I had blood. Resident #1 repeatedly stated expletives in relation to the resident who hit him. When asked if he felt safe, Resident #1 stated, I'd like to hit him back!. When asked if he felt protected, Resident #1 stated, the only way is with you and the people here. Review of an interview on 11/22/2020 at 8:20 PM, by Staff M, Registered Nurse of Resident #3, a witness to the incident, showed Resident #3 stated, The one guy was sitting in the w/c (wheelchair) and he was talking -he likes to talk- and then I saw the other guy punching him in the face and I noticed he was bleeding. Review of the undated facility investigation of the altercation involving Resident #1 and Resident #2 on 11/22/2020 showed the facility concluded, that it was reasonable to believe Resident #2 hit Resident #1 without any intentional provocation because Resident #2 was likely irritated that Resident #1 was talking while Resident #2 was watching football on the Television. During an interview on 12/03/2020 at 2:28 PM when asked what happened, Staff B stated that Resident #2 got irritated, while they were watching football, Resident #2 went to Resident #1 and hit him. When asked what constituted physical abuse, Staff B stated, Cause a physical injury. When asked if one had to sustain an injury, Staff E, Staff Development stated, No. When asked if it was reasonable to be punched in the face, Staff B stated, No. Review of the undated facility investigation showed the Facility ruled out abuse and neglect. When asked why the investigation did not identify abuse occurred, Staff B stated that Resident #2 did not mean to punch Resident #1, he was likely telling him to stop talking .it wasn't intentional. REFERENCE: WAC 388-97-0640(1)