Every finding on record at Avamere Transitional Care of Puget Sound

Based on interview and record review, the facility failed to consistently monitor a removable medical device for 1 of 3 sampled residents (1) reviewed for pressure ulcers. Resident 1 experienced harm when the resident's medical device had not been removed for a prolonged period of time and the resident developed foot pressure ulcers under the medical device, which required antibiotics, daily dressing changes, and wound care services. This failure placed all residents at risk for skin breakdown, pressure ulcer development, infection, and diminished quality of life. The facility has corrected the above deficiency prior to the abbreviated survey and constituted as past non-compliance (the facility was not in compliance at the time the incident occurred; however, there was sufficient evidence the facility corrected the non-compliance after it was identified) and is no longer outstanding.Findings included .Resident 1 was admitted to the facility on [DATE] after a fall that resulted in a fracture of the fibula (calf bone), as well as diagnoses of osteoporosis, generalized muscle weakness and debilitation, and was admitted for rehabilitation. The resident's fracture was treated conservatively with a CAM (controlled ankle movement) boot, a removeable orthopedic walking boot used to immobilize, protect, and support the foot or ankle during healing from fractures, severe sprains, tendon injuries, or surgery. Review of resident 1's skin assessment on admission, dated 06/04/2026, showed bruising to one lower leg, non-blanchable redness (red or discolored skin that does not turn white when pressed, which can indicate blood flow is blocked and the start of deep tissue damage) to the resident's coccyx (tailbone) area, and groin rash. Review of Resident 1's record showed that during a provider appointment on 07/08/2026, a provider removed the resident's CAM boot and noted two pressure ulcers with infection. A physician's progress note, dated 07/09/2026 at 3:29 PM, documented Resident 1 had a foot pressure ulcer with infection, noted the resident had transitioned from cast to the CAM boot approximately 2 weeks prior, noted the CAM boot had not been removed for skin checks for approximately 2 weeks and contributed to the development of pressure sores which were identified at a recent orthopedic visit, and noted that bloodwork and toe and foot x-rays were obtained to evaluate for infection or osteomyelitis (bone infection). On 07/09/2026 the provider also ordered wound care provider evaluation for sharp debridement (cutting away of dead, damaged or infected tissue) of slough and macerated tissue, to continue antibiotics for suspected infection, continued daily wound care and dressings which would keep the resident skilled, and no weightbearing on the forefoot and to use the heel only for transfers, and for the CAM boot to remain off unless the resident was transferring. A nursing note, dated 07/09/2026 at 4:25 PM, documented that on 07/08/2026 during an orthopedic provider visit, the provider noted Resident 1 had developed pressure injuries to the plantar (bottom) surface of the foot related to the CAM boot. Staff documented 2 unstageable pressure injuries to the plantar surface of the foot and blanchable redness to the top of the foot. A prescription for 14 days of antibiotics and treatment orders were written and included referral to a wound specialist. The resident was placed on alert for monitoring. The orders written 07/09/2026 documented the CAM boot caused pressure wounds to the plantar surface of Resident 1's foot, and called for daily dressing changes, oral antibiotics for 14 days, staff to check exposed skin under the CAM boot to ensure no new skin impairment every day and evening shift, use of the CAM boot for transfers and to be off when the resident was in bed, elevation of the affected leg while in bed or in the wheelchair, follow-up appointment the following week. A follow-up podiatry visit note, dated 07/16/2026, documented Resident 1's plantar foot wounds were discovered after a nearly two-week period when the boot was not removed for skin inspection or hygiene and prolonged pressure from the boot. During an interview on 08/12/2026 at 1:38 PM, Resident 1 said they were still at the facility because of some mistakes that were made while they were there. Resident 1 said facility staff had never taken off the medical (CAM) boot and looked at their skin until an orthopedic provider appointment, on 07/08/2026, when the provider removed the resident's medical boot and saw two sores on the bottom of the resident's foot where the boot had been. Resident 1 said they could not see the sores but was told they looked infected. Resident 1 said the provider was concerned about the potential of a bone infection and recommended antibiotics. On 08/12/2026, Resident 1 said after that, they were on antibiotics and had dressing changes every day, and the wound care people came once a week and it eventually got better. On 08/12/2026, Resident 1 said when they spoke to the people here (facility staff) about it, they 'quietly agreed' that's what they were supposed to do, take it off and look at my leg. Resident 1 said, 'that's what kept me here so long.' On 08/12/2026 at 4:24 PM, Staff C, a Registered Nurse, taking care of Resident 1 that day, said they checked the resident's skin under the boot at least 3 times a day and that the resident only wore it when they got up out of bed. On 08/12/2026, when asked, Staff C said staff education had been provided recently regarding the use of CAM boot and other orthotic devices, and that the skin under the devices had to be checked at least once a shift for complications and if changes were noted, to notify their manager or the DNS immediately. On 08/12/2026 at 5:13 PM, Staff B, a Registered Nurse and the Director of Nursing Services, said they had identified a system problem related to orthotic devices and had already implemented a plan of correction. Staff B said Resident 1's orders were immediately implemented and that a facility-wide review was initiated to ensure consistent, clear care protocols were active for any other residents that utilized supportive orthopedic appliances. On 08/12/2026 at 5:25 PM, Staff A, the facility Administrator, reviewed the findings and the steps that had been taken to correct the concerns. On 08/21/2026 at 4:55 PM, Staff A stated they had achieved compliance as of 07/15/2026. Review of documentation showed facility had achieved compliance as of 07/15/2026. Past noncompliance - no plan of correction required. Reference WAC 388-97-1060(3)(b).

Based on interview and record review, the facility failed to provide the necessary treatment and services consistent with professional standards of practice to prevent the development and/or promote healing of PU/PI (Pressure Ulcers/Pressure Injuries) for 1 of 3 Residents (Resident 1) reviewed for PU/PIs. Resident 1 experienced harm when the facility failed to accurately assess, develop/implement/update a resident-centered care plan (CP) for PU/PIs (that included timely interventions consistent with professional standards of care for PU/PI prevention and care), consistently monitor, and accurately follow physician orders (PO) for wound care and prevention and experienced an avoidable worsening of their two coccyx (tailbone) Stage II PU/PIs (partial-thickness skin loss) to a Stage IV PU/PI (full thickness loss of skin with exposed muscle/tendon/bone in the wound bed) and developed an avoidable Deep Tissue Injury (DTI-persistent non-blanchable deep red, maroon, or purple discoloration where the extent of tissue damage is unknown) on their right heel after admission to the facility. These failures placed residents at risk for new PU/PI development, delayed healing, unnecessary discomfort, infection, and diminished quality of life/quality of care.Findings included.<POLICY>Review of the facility's undated Skin and Wound Management policy showed the facility would provide necessary treatment and care according to professional standards of practice (cited reference: the National Pressure Injury Advisory Panel [NPIAP]) to promote healing, prevent infection, and prevent development of new ulcers. The nurse manager/designee would evaluate any new skin integrity problems and document their findings in the clinical record. To determine the risk of developing (or determine risk of worsening) PU/PIs, the facility would routinely complete a Braden Risk Assessment (a standardized assessment tool used to estimate risk of developing PU/PIs by evaluating six key criteria: sensory perception, moisture, mobility, nutrition, and friction/shear to help prioritize preventative measures for CP development). After comprehensive assessment, a resident-centered care plan would be developed. PU/PI wounds were evaluated weekly with documentation that would include measurements, wound characteristics, progress, treatments, and CP interventions/revisions. The Interdisciplinary Team (IDT) would review wounds weekly which included discussion of residents' needs and revise the CP as appropriate. According to the NPIAP Pressure Injury Prevention Points: Risk Assessment, updated 2016, use of a structured risk assessment at routine intervals (such as the Braden Risk Assessment) to identify individuals at risk for PU/PIs should be used to develop a CP based on the areas of risk, rather than on the total risk assessment score and provided potential interventions to consider based on each risk category.Review of the facility's Pressure Injuries Overview and Wound Staging policy, revised March 2020, showed PU/PIs occurred because of intense and/or prolonged pressure or pressure in combination with shearing of the skin. These could also be affected by skin temperature, moisture, nutrition, perfusion, other health problems, and other skin conditions. An avoidable PU/PI occurred when the resident developed a new or worsening PU/PI and the facility failed to perform one or more of the following: evaluate the resident's clinical condition and risk factors;, define or implement CP interventions consistent with residents needs/goals, and professional standards of practice;, monitor or evaluate of the impact of the interventions;, or revise CP interventions as appropriate. <RESIDENT 1>Review of the 12/10/2025 admission Minimum Data Set (MDS-assessment tool) showed Resident 1 admitted to the facility on [DATE], had problems with cognition, had no behaviors or rejection of care, required substantial assistance for activities of daily living (bed mobility, transfers, repositioning, and toileting), and was frequently incontinent of bowel. Resident 1's diagnoses included urinary tract infection with sepsis (systemic blood infection), anemia, malnutrition, diabetes, and dementia. Resident 1 was assessed to have no unhealed PU/PIs and was at risk of developing PU/PIs.Review of the admission Nursing Database, dated 12/04/2025, showed Resident 1 admitted with two skin tears on the coccyx. One skin tear measured 0.5 cm x 0.5 cm x no depth measured and the other skin tear measured 2 cm x 0.5 cm x no depth measured. The documentation did not provide evaluation of the wound's characteristics. Review of the 12/04/2025 Braden Scale showed Resident 1's risk score was 14 (moderate risk) due to problems with moisture, activity, mobility, and friction/shear. Review of the 12/04/2025 Skin Integrity CP showed Resident 1 had actual skin impairment due to skin tears on their coccyx. Interventions included: keeping skin clean and dry, use of lotion, encouraging good nutrition, complete weekly skin assessments, monitor/document the wound location, size, and treatment of skin injury and report abnormalities, report any new skin impairments, and complete treatments as ordered by the physician. The CP did not show resident-centered interventions to address their risk for development of PU/PIs (including problem areas identified on their Braden assessment). Review of the December 2025 Treatment Administration Record (TAR) showed a PO dated 12/04/2025, for Wound #2-coccyx skin tears, to cleanse with normal saline, pat dry, and apply foam dressing every day and as needed. The TAR showed the dressing was changed daily from 12/05/2025 to 12/17/2025, with one omission on 12/09/2025. Review of Resident 1's Progress Notes and Wound Care Evaluations between 12/04/2025 and 12/18/2025 did provide documentation to show wound monitoring was conducted weekly or that the physician evaluated the wounds on the coccyx. The progress notes showed inconsistency in documentation of skin conditions as follows: A daily skilled nursing progress note dated 12/07/2025 at 3:54 PM, showed Resident 1's skin was intact and there were no wounds present.A daily skilled nursing progress note dated 12/08/2025 at 4:14 PM, showed Resident 1 had a PU/PI with a small amount of drainage and slough on the wound bed. The documentation did not show wound measurements. A weekly skin audit note dated 12/10/2025 at 8:24 PM, showed Resident 1 had no irregularities. An SBAR (alert note to the provider) progress note dated 12/11/2025 at 5:19 AM, showed Resident 1's buttocks had excoriation that spread out on both buttocks, and they needed more aggressive treatment. A History and Physical physician note dated 12/11/2025 at 11:42 AM that showed Resident 1's skin was warm, dry, with age related changes but did not show an evaluation of the coccyx wounds or plan for treatment. A daily skilled nursing progress note dated 12/12/2025 at 9:26 PM, showed Resident 1 had no wounds present.A daily skilled nursing progress note dated 12/14/2025 at 9:11 PM, showed Resident 1 had no wound(s) present.An SBAR progress note dated 12/16/2025 at 6:04 AM, showed staff requested the provider to evaluate Resident 1's coccyx; it had worsened and needed wound team attention.A Nurse Practitioner progress note dated 12/17/2025 at 8:01 PM that showed Resident 1's skin was warm and dry but did not show an evaluation of the coccyx wounds or treatment plan. A weekly skin audit note dated 12/17/2025 at 9:50 PM that showed Resident 1 had a previously identified skin irregularity with extensive excoriation of the buttocks and open areas to the coccyx that required daily dressing changes. There were no wound measurements or characteristics documented. Review of the WCC wound evaluation, dated 12/18/2025 (14 days after admission) showed Resident 1 had one unstageable (a PU/PI that is covered with dead fat/tissue to the extent that the amount of tissue damage cannot be confirmed until removal of the dead tissue, revealing either a Stage III [full-thickness skin loss without extending to the bone/muscle/tendon/ligaments] or Stage IV PU/PI) PU/PI on the coccyx that measured 10.0 cm x 9.0 cm x no depth recorded. The wound bed contained 70 percent black eschar (dead tissue/fat). The WCC's treatment plan included: wound care orders for dressing changes twice daily, an air mattress, and to turn/reposition Resident 1 every two hours. Review of a nursing CP progress note, dated 12/18/2025, showed Resident 1 had an unstageable coccyx PU/PI that required daily skilled nursing services for ongoing assessments and monitoring of the wound, complex wound care management, and extensive staff assistance with positioning, bed mobility, and pressure offloading of the coccyx area. Review of the Skin Integrity CP, dated 12/18/2025, showed an updated intervention for an air mattress. The CP did not show documentation of Resident 1's unstageable PU/PI on the coccyx, pressure offloading interventions, repositioning every two hours, or other person-centered interventions based on the risk areas identified on Braden assessment. Review of the WCC wound evaluation, dated 12/22/2025, showed Resident 1's coccyx PU/PI remained unstageable and measured 7.5 cm x 7.0 cm. The wound bed was covered with 80 percent black eschar that required surgical removal. The WCC's treatment plan included: daily wound care with medical honey, foam dressing, and frequent turning/repositioning.Review of the Skin Integrity CP, dated 12/22/2025, showed no new revisions/updates to promote healing of the PU/PI or prevent new PU/PIs.Review of the December 2025 TAR showed a PO, dated 12/23/2025, for coccyx PU/PI wound care: cleanse with normal saline, pat dry, apply Medical Honey with foam dressing twice daily. The TAR documentation showed the PO was only scheduled for once a day at 8:00 AM and not twice a day as directed in the PO. Review of Resident 1's clinical record did not show weekly facility and/or WCC evaluations of the coccyx PU/PI for the weeks of: 12/29/2025 or 01/05/2026.Review of Resident 1's facility Wound Evaluation #1, dated 01/08/2026 at 12:51 PM (17 days after the last wound evaluation), showed Resident 1's unstageable coccyx PU/PI measured 6.5 cm x 5.2 cm, with additional recommendations for pressure relieving device for the chair, and the CP was reviewed/updated.Review of Resident 1's Skin Integrity CP, dated 01/08/2026, did not show any revisions or updates, including an intervention for pressure reduction cushion for their chair, as documented in the facility Wound Evaluation that same day. Review of the WCC wound evaluation, dated 01/15/2026, showed Resident 1's unstageable coccyx PU/PI was now a Stage IV PU/PI that measured 6.0 cm x 4.5 cm x 0.5 cm, and the wound bed contained 60% dead tissue/fat that required surgical removal at the bedside. The WCC's treatment plan showed to perform wound daily: cleanse with an acidic wound cleanser and leave on the wound for 10 minutes prior to applying a clean dressing of medical honey covered with foam dressing and turn/reposition every two hours. Review of the January 2026 TAR showed a PO dated 01/16/2026, for coccyx PU/PI wound care: cleanse with the acidic wound cleanser, pat dry, apply medical honey and foam dressing twice daily. The TAR transcription of the PO showed the wound care schedule duplicated for 8:00 AM daily. Additionally, the PO was not transcribed as recommended by the WCC to leave the acidic solution on the wound bed for 10 minutes prior to application of the clean dressing daily. Review of Resident 1's Skin Integrity CP, dated 01/15/2026, showed no new CP updates/revisions. <WORSENED COCCYX PU/PI >Review of the clinical record did not provide documentation to show a weekly wound evaluation by either the facility or the WCC for the week of 01/22/2026.Review of the WCC wound evaluation, dated 01/29/2026 showed Resident 1's Stage IV coccyx PU/PI worsened and measured 8 cm x 8 cm x 0.6 cm. The WCC treatment plan included: cleanse with the acidic wound cleanser and allow the solution to sit on the wound for 10 minutes at each dressing change, apply medical honey, cover with a foam dressing twice daily, and turn/reposition every two hours.Review of the January TAR showed a PO, dated 01/29/2026, for coccyx wound care: cleanse with the acidic wound cleanser, pat dry, apply medical honey and cover with a foam dressing twice daily and as needed. The TAR transcription of the PO order transcribed did not include leaving the Named Cleanser to sit on the wound for 10 minutes before completing the dressing as directed by the WCC.In an interview on 03/19/2026 at 1:15 PM, Staff B stated the transcribed wound care POs on December 2025 and January 2026 TARS did not match WCC's treatment plan and were incorrectly transcribed and/or scheduled. Staff B stated the POs should have been clarified and correctly transcribed but were not. Review of Resident 1's Skin Integrity CP, dated 01/29/2026, did not provide documentation to show the CP was updated or revised. < CONTINUED WORSENING OF COCCYX WOUND AND DEVELOPMENT OF NEW HEEL PU/PI>Review of the WCC wound evaluation, dated 02/05/2026 showed Resident 1's Stage IV coccyx PU/PI continued to worsen and measured 10 cm x 11 cm x 1.5 cm. The wound bed was covered with 90 percent eschar that required surgical removal at the bedside. The WCC's treatment plan was changed to a Named antimicrobial cleansing solution at 1/4 strength-soaked gauze to be placed on the wound bed and covered with a foam dressing twice daily and as needed after each stool incontinence episode and turn every two hours. Resident 1 developed a new DTI (deep tissue injury-persistent non-blanchable deep red, maroon, or purple discoloration caused by intense and/or prolonged pressure and shear forces) PU/PI on the right heel that measured 3.0 cm x 3.0 cm x no depth measured. The WCC's treatment plan included daily treatment with an unnamed skin protectant, heel protectors, and keeping the heels off the bed. Review of Resident 1's Skin Integrity CP, dated 02/05/2026, showed an intervention (dated 02/02/2026) for care staff to offer/encourage/assist with repositioning/turning frequently but did not indicate how frequently. The CP showed a 02/05/2026 intervention to elevate heels when in bed and apply Named pressure relieving boots when in bed or sitting in a chair. The CP did not show that Resident 1 had a Stage IV PU/PI on the coccyx or a DTI on the right heel. Review of a nursing progress note dated 02/10/2026 at 8:49 PM showed Resident 1 was transferred to an acute care hospital related to evaluation of their urine catheter. Review of Resident 1's 02/10/2026 Discharge Return Not Anticipated MDS showed they discharged with one Stage IV PU/PI that was not present on admission. The MDS did not show Resident 1 had a right heel DTI (not present on admission to the facility).In an interview on 03/06/2026 at 10:30 AM, Resident 1's Responsible Party (R1RP) stated they stayed with Resident 1 most days due to his cognitive decline. R1RP stated during the first month or so of Resident 1's stay at the facility, they did not observe Resident 1 repositioned every two hours, they remained in bed most of the day and were not assisted out of bed for meals. R1RP stated the facility did not change Resident 1's PU/PI dressing after each incontinent episode and stool contaminated the wound most of the time, so they discussed their concerns with the facility. R1RP stated they observed an increase in repositioning after they reported their concerns, but it was after their wounds worsened or developed. In an interview on 03/06/2026 at 2:01 PM, Staff C, Registered Nurse (RN), stated they were assigned to be the new wound team coordinator approximately three weeks ago. [NAME] asked to review the facility's wound tracking log, Staff C stated they had no information on the wound care program or log of wounds prior to three weeks ago and just started tracking facility wounds when they were assigned to lead the wound program. Staff C stated weekly wound evaluations were required for all PU/PI's and documented in the chart. Staff C stated the WCC they used during December 2025 through February 2026 did not consistently come to the facility every week, so they found a different WCC that just started seeing patients. Staff C stated their expectation was that the PU/PI CP should include all PU/PIs with their stage and include interventions that addressed positioning, moisture, shearing, offloading, nutrition, and risk for future development of PU/PIs.In an interview on 03/06/2026 at 3:00 pm, Staff B, Director of Nursing, stated they investigated Resident 1's coccyx PU/PI on 02/05/2026. Staff B determined through their investigation that the admission assessment on 12/04/2025 incorrectly identified Resident 1's two coccyx wounds as skin tears that were actually two Stage II PU/PIs on the coccyx that worsened after admission, that weekly wound evaluations were not routinely done, and progress notes contained inconsistent documentation, so they initiated a Performance Improvement Plan. Staff B stated they expected the licensed nurse staff to conduct wound evaluations for each PU/PI weekly and document their findings in the clinical record. The wound evaluations should include wound type/stage, location, measurements, wound bed characteristics, condition of skin around the wound, current treatment, CP interventions, evaluation of the effectiveness of the interventions, and wound progress. Staff B stated the wound evaluations should be completed whether the contracted WCC was in the facility or not. Staff B stated, It was just a bad start for Resident 1. REFER TO F641REFERENCE WAC: 388-97-1060 (1), (3)(b).

Based on interview and record review, the facility failed to accurately assess 1 of 3 residents (Resident 1) reviewed for assessments. The failure to ensure accurate assessments placed residents at risk for unidentified and/or unmet care needs and diminished quality of care/quality of life. Findings included . <Resident 1>Review of Resident 1's admission Nursing Database-Skin Integrity, dated 12/04/2025, showed they admitted with two wounds on the coccyx, identified as skin tears. Review of a daily skilled progress note, dated 12/08/2025 at 4:14 PM, showed Resident 1 had a PU/PI with a small amount of drainage and dead tissue on the wound bed. The documentation did not indicate the anatomical location, stage, or measurements of the PU/PI. Review of Resident 1's 12/10/2025 admission Minimum Data Set (MDS-assessment tool) showed Resident 1 was at risk of developing PU/PIs and had no unhealed PU/PIs. Review of the 12/15/2025 PU/PI Care Area Assessment (CAA-a standardized process for evaluation of each resident's functional capacity and care needs to help develop a resident-centered care plan) did not provide documentation to show the facility's rationale for care plan decisions (that included complications, risk factors, or resident centered care needs). Review of Resident 1's Significant Change MDS, dated [DATE], showed Resident 1 had one Stage IV PU/PI that was present on admission. Review of Resident 1's 12/10/2025 admission MDS modification #1, dated 01/27/2026, showed Resident 1 had one unstageable PU/PI on admission. In an interview on 03/06/2026 at 2:00 PM, Staff B, Director of Nursing, stated the admission Nursing Database-Skin Integrity was inaccurately documented, showing Resident 1 had two skin tears on the coccyx. Staff B stated Resident 1 admitted with two Stage II PU/PIs on the coccyx, and the admission MDS was incorrect. < MDS Modifications>Review of the 12/20/2025 admission MDS modification #2, dated 02/11/2026 (one day after Resident 1 discharged ), showed Resident 1 had one unhealed PU/PI but no coded number or stage of wound(s). In an interview on 03/19/2026 at 12:41 PM, Staff E, Registered Nurse-MDS Coordinator, stated they reviewed the clinical record and found no documentation to show Resident 1 had a PU/PI on admission. Staff E stated the 12/10/2025 admission MDS modification #1, dated 01/22/2026, was incorrectly coded as an unstageable PU/PI present on admit with no supporting documentation. Staff E submitted the 12/10/2025 admission MDS modification #2 on 02/11/2026 to correctly reflect Resident 1 had a PU/PI that was not present on admission. Staff E stated they could not code a stage for the wound due to insufficient wound documentation. Review of the 01/22/2026 Significant Change MDS Modification, dated 02/11/2026, showed Resident 's Stage IV PU/PI was not present on admission. In an interview on 03/19/2026 at 12:45 PM, Staff E stated the 01/22/2026 Significant Change MDS was modified on 02/11/2026, to correctly reflect Resident 1 had one Stage IV PU/PI that was not present on admission. Staff E stated the coccyx Stage IV PU/PI developed at the facility. <New PU/PI>Review of the Wound Care Consultant's (WCC) Wound Tracker Form, dated 02/05/2026, showed Resident 1 had a new DTI (deep tissue injury) PU/PI on their right heel. Review of the 02/10/2026 Discharge Return Not Anticipated MDS showed Resident 1 had one Stage IV PU/PI that was not present at admission but did not show Resident 1 had one DTI, also not present on admission. In an interview on 03/19/2026 at 12:50, Staff E stated the WCC Wound Tracker Form, dated 02/05/2026, was not in the clinical record at the time they completed the Discharge MDS. Staff E stated the MDS should accurately show coding for the new DTI PU/PI but did not. REFER TO F686 REFERENCE: WAC 388-97-1000-(1)(a)(b)(c), (2)(l).

Based on observation and interview, the facility failed to ensure treatment and medication carts were secured/locked when unattended for 4 of 4 treatment carts (Front North 200 hall, Back North 200 hall, Front South 300 hall, and Back South 300 hall) and for 4 of 4 medication carts (Front North 200 hall, Back North 200 hall, Front South 300 hall, and Back South 300 hall) when reviewed for medication storage. This failure placed residents at risk for drug diversion and potential loss of medications/treatments.Findings included. Review of the facility's policy titled, Medication Storage, dated 2007, showed, In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications (such as medication aides) are allowed access to medication carts, Medication rooms, cabinets and medication supplies should remain locked when not in use or attended by persons with authorized access. Observations on 09/23/2025 at 6:04 AM showed the Front North 200 hall treatment and medication carts, the Back North 200 hall treatment and medication carts, the Back South 300 hall treatment cart, and the Front South 300 hall treatment cart, left unlocked/unsecured while unattended (treatment carts contain medicated creams, ointments, wound cleansers, and treatment supplies such as various types of dressings, and medication carts contain residents' prescribed medications and medical supplies). Observation on 09/24/2025 at 8:02 PM showed the Front South 300 hall medication cart unlocked and unattended. Observation on 09/14/2025 at 8:04 PM showed the Front North 200 hall treatment cart and medication cart unlocked and unattended. Observation on 09/24/2025 at 8:27 PM showed the Back North 200 hall treatment cart unlocked and unattended. During an interview on 09/24/2025 at 9:40 PM regarding the Front South 300 hall medication cart, Staff P, Registered Nurse (RN), stated the medication cart should be locked when unattended. Staff P stated they usually locked the medication cart automatically and leaving it unsecured did not meet expectations and it should have been locked. During an interview on 09/24/2025 at 9:44 PM, regarding the Front North treatment and medication carts, Staff Q, RN, stated they must have forgotten to lock them, and they should always be locked when unattended. Observation and interview on 09/26/2025 at 6:58 AM showed the Back South 300 hall treatment and medication carts not locked and left unattended. Observation showed Staff K, RN, coming out of the medication room and sat at the nurses station. Staff K stated they went into the medication room to check on something but should have locked the medication and treatment carts because they should be locked when unattended. During an interview on 09/26/2025 at 11:26 AM, Staff B, Director of Nursing Services, stated the expectation was treatment and medication carts should be locked/secured when left unattended. Reference WAC 388-97-1300(2), -2340.

Based on interview and record review, the facility failed to consistently offer/provide showers and oral care for 3 of 4 sampled residents (Residents 14, 84 and 88) when reviewed for activities of daily living (ADL). These failures placed dependent residents at risk for unmet care needs, poor hygiene and diminished quality of life.Findings included . Resident 14Review of the electronic health record (EHR) showed Resident 14 admitted to the facility on [DATE] with diagnoses of failure to thrive, anxiety (feeling of fear, tension or worry) and neuropathy (nerve damage). During an interview on 09/23/2025 at 8:58 AM, Resident 14 stated they had been at the facility for over a week and had not received a shower. Review of the facility shower sheet showed Resident 14 was to receive showers twice a week. During an interview on 09/25/2025 at 11:19 AM, Staff F, Residential Care Manager (RCM), stated Resident 14 declined showers; however, it was not documented and should have been. Resident 84Review of the EHR showed Resident 84 admitted to the facility on [DATE] with diagnoses of fractured femur (breakage in the thigh bone) and anxiety. Resident 84 required staff assistance for ADLs. During an interview on 09/23/2025 at 8:35 AM, Resident 84 lay in bed with greasy unkempt hair and yellow matter on their teeth. Resident 84 stated they had not been offered a shower and staff did not provide/offer oral hygiene. Review of the facility shower sheet showed Resident 84 was to receive showers twice a week. Review of the EHR showed Resident 84 required set-up assistance with oral hygiene. During an interview on 09/25/2025 at 11:22 AM, Staff J, Certified Nursing Assistant, stated they had not assisted Resident 84 with oral care due to a therapy appointment. During an interview on 09/25/2025 at 2:11 PM, Staff F, RCM, stated the expectation was for staff to assist with oral hygiene set up or assistance daily. Resident 88Review of the EHR showed Resident 88 admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (lung condition that limits airflow) and diabetes (high blood sugar). Resident 88 required staff assistance with bathing. During an interview on 09/23/2025 at 11:37 AM, Resident 88 stated they had not had a shower in over a week. Review of the facility shower sheet showed Resident 88 was to receive showers twice a week. During an interview on 09/25/2025 at 10:18 AM, Staff F, RCM, stated Resident 88 wanted to be bathed by their caregiver who had not yet been to the facility to visit. Staff F stated the preference had not been care planned but should have been. During an interview on 09/26/2025 at 11:45 AM, Staff B, Director of Nursing Services (DNS), stated the expectation was that residents were offered showers twice per week and staff were to document whether the shower was provided and, if not, the reason why. Staff B stated residents who refused should be reapproached at a later time and that continuous refusals should be documented and discussed with the provider. Reference WAC 388-97-1060 (2)(c)

Based on observation, interview, and record review, the facility failed to ensure sufficient nursing staff were available to provide care in a timely manner and complete activities of daily living for 1 of 4 halls (300 hall) when reviewed for sufficient staffing. This failure placed residents at risk for unmet needs, decreased self-worth and a diminished quality of life. Findings included. During an interview on 09/23/2025 at 8:30 AM, Resident 67 (room [ROOM NUMBER]) stated they had turned their call light on last night and waited over an hour. Resident 67 stated they had gone out into the hall and did not see any staff in the hallways. During an interview on 09/24/2025 at 9:25 AM, Resident 32 (room [ROOM NUMBER]) stated they waited 30 minutes with the call light on to ask for pain medicine last night (09/23/2025) and then another 15 minutes for the nurse to bring it. Resident 32 stated That's a long time when you are hurting. Observation on 09/24/2025 at 9:30 AM showed Resident 51 (room [ROOM NUMBER]) in their room with a family member. The family member turned on the call light for assistance with repositioning Resident 51. Observation showed multiple staff walked by the room without answering the call light. At 10:05 AM, a nursing staff answered the call light and assisted the resident (35 minutes wait time). Observation on 09/24/2025 at 8:05 PM showed the call light system at the nurse's station was lit up for Resident 5 (room [ROOM NUMBER]) and showed it had been on for 34 minutes. Observation and interview on 09/24/2025 at 8:29 PM showed Resident 5 (room [ROOM NUMBER]) sat in their wheelchair next their bed and the call light was not on. Resident 5 stated they were upset because they had turned the light on to go to bed half an hour ago and staff turned it off and said they would return. Resident 5 turned the light back on and a certified nursing assistant (CNA) arrived at 8:30 PM and stated, Are you ready? and assisted the resident to bed (55 total minutes wait time). Review of the resident council minutes dated 09/24/2025 showed Resident 4 had reported turning on the call light in the bathroom for assistance and it took too long for staff to come so they had to use their walker without assistance. During an interview on 09/25/2025 at 2:32 PM, Staff C, CNA, stated a call light should be answered in five to ten minutes and staff should not turn the light off unless the resident's needs had been met. Staff C stated the call light did not make a sound at the nurse's station. During an interview on 09/25/2025 at 2:39 PM, Staff B, Director of Nursing Services, stated a call light should be responded to within 10 to 15 minutes and more than 30 minutes was too long. Staff B stated the call light should have a tone at the nurse's station and a light above the door. During an interview on 09/25/2025 at 3:12 PM, Staff A, Administrator, stated more than 20 minutes waiting for a call light to be answered did not meet expectations and staff should not turn the call light off unless they had met the need. Staff A stated the call light system at the nurse's station should be audible.SEE F677 FOR ADDITIONAL INFORMATION Reference WAC 399-97 -1080 (1), 1090 (1)

Based on observation, interview, and record review, the facility failed to honor a resident's request for mobility bars for 1 of 6 sampled residents (Resident 93) when reviewed for choices. This failure placed the resident at risk of fear of falling, inability to sleep, and a diminished quality of life.Findings included.Review of the electronic health record showed Resident 93 admitted to the facility on [DATE] with diagnoses to include spinal stenosis (a condition where the space within the spine that houses the spinal cord and nerve roots becomes narrowed), anxiety, and insomnia (a common sleep disorder characterized by difficulty falling or staying asleep). Resident 93 was able to make needs known. During an interview and observation on 09/23/2025 at 10:28 AM, Resident 93 stated they had fallen at home prior to coming to the facility and continued to worry about falling from their bed at the facility. Resident 93 stated they requested mobility bars be added to their bed so they could reposition themselves in bed, but facility staff had not honored this request. Observation showed Resident 93's bed was in a high position and did not have mobility bars. Review of the care plan, initiated on 09/15/2025, showed Resident 93 was at a high risk for falls with a recent fall, but did not show an intervention for mobility bars. Review of a Safety Device Evaluation and Consent, dated 09/17/2025, showed Resident 93 had a history of falls and recommended mobility bars be placed on the resident's bed. Review showed, Mobility bars are requested to improve bed mobility and independence with positioning and the care plan was reviewed and updated by Staff F, Resident Care Manager (RCM). During an interview and observation on 09/25/2025 at 10:40 AM, Resident 93 stated they kept asking every day for mobility bars and was unsure why they could not have them. Observation showed Resident 93's bed was in a high position and did not have mobility bars. Observation on 09/26/2025 at 11:04 AM showed Resident 93's bed was in a high position and did not have mobility bars. During an interview on 09/26/2025 at 11:28 AM, Staff F, RCM, stated if a resident requested mobility bars, they would be evaluated by physical therapy, a safety evaluation and consent would be completed, and maintenance would be informed of the need to install the mobility bars. Staff F stated this was usually done within 24 hours. Staff F stated they assessed Resident 93 for mobility bars on 09/17/2025, a provider's order for mobility bars was obtained on 09/25/2025, and maintenance was notified of the need for mobility bars. Staff F stated this did not meet their expectation of timely response to Resident 93's request for mobility bars. During an interview on 09/26/2025 at 12:02 PM, Staff B, Director of Nursing Services, stated when a resident requested mobility bars therapy would assess the resident, receive a provider's order, and maintenance would install them. Staff B stated mobility bars should be provided as soon as possible, and Resident 93's mobility bars should have been provided more quickly. Reference WAC 388-97-0900(1)-(4)

Based on interview and record review, the facility failed to complete a care conference meeting with a resident or responsible party for 1 of 19 sampled residents (Resident 74) when reviewed for care plans and care planning. This failure placed Resident 74 at risk for unmet needs, not being involved or informed of their plan of care, and a decreased quality of life.Findings included . Review of the electronic health record (EHR) showed Resident 74 admitted to the facility on [DATE] with diagnoses to include a broken part of the right hip socket and heart failure. Resident 74 was able to communicate needs. During an interview on 09/25/2025 at 12:35 PM, Resident 74 stated they did not recall ever going to a care conference or being asked to attend a care conference. Resident 74's adult child stated they were not invited to go to a care conference and would have liked to have gone to a care conference with their parent. Review of Resident 74's EHR showed a care conference information form dated 09/09/2025 showed the area for resident or responsible party who were present and who attended was blank/not filled out. Review showed no documentation to indicate Resident 74 or their family had attended a care conference. During an interview on 09/25/2025 at 12:53 PM, Staff L, Social Services Director, stated they were unable to tell from the documentation in the EHR if Resident 74 had attended a care conference. Staff L stated Resident 74 should have attended a care conference on 09/02/2025 and on 09/09/2025. Staff L stated Resident 74's care conference information form dated 09/09/2025 did not show who was present at the care conference and this did not meet expectations. During an interview on 09/25/2025 at 1:11 PM, Staff A, Administrator, stated Social Services were to invite the residents and/or their responsible party to care conferences via phone, email, or in person, and the care conference should be documented in the resident's EHR to include who attended. Staff A stated they were unable to tell who attended Resident 74's care conference scheduled for 09/09/2025 and this did not meet expectations. Reference WAC 388-97-1020 2(f), (4)(b)

Based on observation, interview, and record review, the facility failed to have a provider order and interventions in place for 1 of 1 sampled resident (Resident 91) when reviewed for a life vest (a device worn under clothing with an attached monitor, designed to protect a person from sudden cardiac arrest/heart stop beating, by monitoring the hearts electrical activity and automatically delivers an electrical shock to correct a dangerous heart rhythm, preventing a potentially fatal event), and failed to ensure care and services were in place to treat a non-pressure skin issue for 1 of 3 sampled residents (Resident 68) when reviewed for general and/or skin conditions. These findings placed residents at risk of unmet needs, worsening conditions, clinical complications, and a decreased quality of life.Resident 91Review of the electronic health record (EHR) showed Resident 91 readmitted to the facility on [DATE] with diagnoses to include infection and swelling reaction due to a cardiac/heart device implant/inserted into the chest area and diabetes (too much sugar in the blood). Resident 91 was able to communicate needs. Observation and interview on 09/26/2025 at 12:04 PM showed Resident 91 laid in bed with the head of the bed elevated and a life vest in place under their tank top. Resident 91 stated they had the life vest on for about two weeks, showed the attached monitor, explained how the vest and the monitor worked, and knew the phone number to call if they had any issues. Resident 91 stated they were told by the cardiologist (heart doctor) they would wear the life vest until November 26th, 2025. Review of the EHR showed Resident 91 had no provider's order for the use of a life vest and had no interventions in place in Resident 91's plan of care related to the life vest. During an interview on 09/26/2025 at 12:13 PM, Staff K, Registered Nurse (RN), stated Resident 91 readmitted to the facility with the life vest. Staff K was able to explain the use of the life vest and stated Resident 91 was fully informed on the life vest. Staff K stated the care plan mentioned Resident 91 had a life vest; however, there were no interventions in place and no provider order for the use of the life vest and there should have been. During an interview on 09/26/2025 at 12:31 PM, Staff B, Director of Nursing Services (DNS), stated Resident 91 was the only resident in the facility with a life vest. Staff B stated Resident 91 did not have a provider order for the use of the life vest or interventions in place and this did not meet their expectations. Resident 68Review of the EHR showed Resident 68 admitted to the facility on [DATE] with diagnoses to include a broken hip, muscle weakness, and was able to make needs known. Observation and interview on 09/24/2025 at 12:46 PM showed Resident 68 laid in bed with their left foot wrapped in gauze. Resident 68 stated their left foot was wrapped and their relative had brought in a cream to apply to the left foot and gave it to a nurse on Monday [09/22/2025]; however, the left foot had not been treated with the medication. During a follow up interview on 09/25/2025 at 1:57 PM Resident 68 stated their left foot was wrapped and still had not been provided with the medicated cream treatment that their relative had brought in. Review of the admission nursing database evaluation dated 09/09/2025 showed Resident 68 had a left plantar foot (the sole of the foot) wart (fleshy bump/growth on the skin caused by a virus) 9 centimeters (cm) by 8 cm in length and width. Review of Resident 68's EHR showed their medication order summary dated 09/25/2025 had no medication treatment order for their left foot. Review showed no interventions documented in Resident 68's plan of care related to the left foot plantar wart. During an interview on 09/26/2025 at 9:43 AM, Staff K, RN, stated they were not aware Resident 68's left foot was wrapped. Staff K was unable to locate a treatment order for Resident 68's left foot. Staff K unwrapped Resident 68's left foot and stated the left plantar raised growth was 6 cm in length by 6 cm in width. Staff K stated Resident 68 had an order for a medicated cream for the left foot when they were admitted to the facility; however, they were informed by the pharmacy that the medication was to be provided by Resident 68. Staff K stated they were not aware that Resident 68's relative had brought in the medicated cream. During an interview on 09/26/2025 at 11:43 AM, Staff B, DNS, stated they were not aware that Resident 68 was not provided treatment for the left foot due to medication not being available. Staff B stated the provider should have been notified and this issue should have been addressed prior to now. Staff B stated this did not meet their expectations. Reference WAC 388-97-1060 (1)

Based on observation, interview and record review, the facility failed to provide respiratory care consistent with professional standards of practice for 2 of 3 sampled residents (Residents 88 and 101) when reviewed for respiratory care. Failure to follow physician orders for oxygen (O2) therapy placed the residents at risk for unmet needs and diminished quality of life. Findings included . Resident 88Review of the electronic health record (EHR) showed Resident 88 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (lung condition that limits airflow) and diabetes (high blood sugar). Resident 88 was able to make needs known. Observations on 09/23/2025 at 11:55 AM, 09/24/2025 at 1:05 PM and 09/25/2025 at 3:10 PM showed Resident 88 received O2 set to 2 liters (L) per minute via a nasal canula (devise to deliver O2 through a tube into the nose). Review of Resident 88's care plan dated 09/15/2025 showed an intervention for oxygen settings at 1 L continuously. During an interview on 09/25/2026 at 3:15 PM, Staff S, Licensed Practical Nurse (LPN), stated Resident 88's oxygen was set at 2 L but should have been set to 1 L. During an interview on 09/25/2026 at 3:19 PM Staff F, Resident Care Manager (RCM), stated the expectation was for staff to follow the physician's orders. Resident 101Review of the EHR showed Resident 101 was admitted to the facility on [DATE] and was assessed as oxygen dependent. Observation on 09/26/2025 at 2:06 PM showed Resident 101 received O2 set to 1.5 L per minute via a nasal canula. Review of Resident 101's care plan dated 09/22/2025 showed an intervention for oxygen settings at 2 L continuously. During an interview and observation on 09/26/2025 at 2:08 PM, Staff R, Registered Nurse (RN), verified Resident 101's oxygen was set to 1.5 L and the provider's order was for 2 L. Staff R stated they were in the process of weening Resident 101 off oxygen but had not received a new order. During an interview on 09/26/2025 at 11:45 AM, Staff B, Director of Nursing Services, stated the expectation was for staff to follow the provider orders and document accurate information. Reference WAC 388-97-1060 (3)(j)(vi)

Based on interview and record review, the facility failed to conduct a timely medication regimen review on admitting to the facility for 1 of 5 sampled residents (Resident 9) when reviewed for medication regimen review. This failure placed the resident at risk of allergic reaction, receiving contraindicated medication, and a diminished quality of life.Findings included.Review of the electronic health record showed Resident 9 admitted to the facility on [DATE] with diagnoses of hepatic encephalopathy (a syndrome that occurs when the liver is unable to properly metabolize toxins, leading to their accumulation in the brain), diabetes (too much sugar in the blood), and chronic kidney disease. Resident 9 was able to make needs known. Review of a Drug Regimen Review for New Admissions and Identification of Potential Clinically Significant Medication Issues form, dated 09/03/2025, showed Resident 9 had clinically significant medication issues in the areas of Drug Allergy and Other and required a provider's review. Review showed the document was faxed to the facility on [DATE] and reviewed by the provider on 09/24/2025. During an interview on 09/26/2025 at 11:19 AM, Staff F, Resident Care Manager (RCM), stated residents newly admitted to the facility would have a drug regimen review to ensure there were no errors in their medications and the provider would review this report if there were any issues. Staff F stated the facility did not receive Resident 9's medication regimen review until 09/23/2025 and there were issues identified on the report. Staff F stated the review should be received from the pharmacy within 12 hours and, if it was not, the facility should call the pharmacy for the recommendations. Staff F stated Resident 9's medication regimen review did not meet expectations for timeliness. During an interview on 09/26/2025 at 12:04 PM, Staff B, Director of Nursing Services, stated newly admitted residents would have a medication regimen review conducted by the pharmacy and the recommendations should be received within 24 hours. Staff B stated Resident 9's medication regimen review did not meet expectation for timeliness. Reference WAC 388-97-1300 (1)(c)(iii)

Based on interview and record review, the facility failed to consistently provide non-pharmacological interventions (NPI, health interventions/approaches used instead of medication) and to have pain level parameters in place prior to giving as needed pain medication for 1 of 5 sampled residents (Resident 45) when reviewed for unnecessary medication use. This failure placed a resident at risk of receiving unnecessary medications, avoidable medication side effects, and a diminished quality of life.Findings included. Review of the electronic health record (EHR) showed Resident 45 admitted to the facility on [DATE] with diagnoses to include aftercare following knee surgery, heart failure, and diabetes (too much sugar in the blood). Resident 45 was able to make needs known. Review of the September 2025 medication administration record (MAR) from 09/01/2025 - 09/25/2025 showed Resident 45 had an order with a start date of 08/28/2025 for oxycodone hydrochloride (HCI) (medication used to treat moderate to severe pain) every four hours as needed for moderate to severe pain that included to document pain level and NPI attempted first with a code number prior to giving the pain medication. Documentation showed oxycodone HCI was provided using a pain level of 0-10 (with 0 being no pain and 10 being the worst pain) that ranged from 0 (zero) to 7 (seven). Continued review of September 2025 MAR showed Resident 45 had an order with a start date of 09/11/2025 for acetaminophen extra strength (used to treat mild to moderate pain) every four hours as needed for pain. This order showed no pain level parameters or NPI codes. Documentation showed medication was provided with pain levels ranging from 3 (three) to 7 (seven) and no NPI documented as provided prior to giving the medication. Documentation showed multiple times that acetaminophen extra strength was provided at the same time oxycodone HCI was provided. During an interview on 09/25/2025 at 11:35 AM, Staff O, Resident Care Manager (RCM), stated Resident 45's order for as needed acetaminophen extra strength had no pain level parameters and there were no NPI provided when it was provided without the oxycodone HCI and there should have been. Staff O stated Resident 45's pain management documentation did not meet their expectations. During an interview on 09/25/2025 at 12:16 PM, Staff B, Director of Nursing Services, stated NPIs were to be provided and documented prior to giving as needed pain medication. Staff B stated there should be pain level parameters written in the order to guide licensed nurses when to give as needed acetaminophen verses oxycodone for pain management. Staff B stated Resident 74's pain management documentation did not meet their expectations because there were no pain level parameters or NPI documented for the as needed acetaminophen provider's order. Staff B stated Resident 74 had inconsistent documentation regarding why acetaminophen and oxycodone was provided at the same time and did not consistently show in the progress notes that it was due to Resident 74's request. Reference WAC 388-97 -1060 (3)(k)(i)

Based on observation and interview, the facility failed to implement the appropriate use of transmission-based precautions (TBP) for 1 of 4 hallways (North front) when reviewed for TBP. This failure placed residents and staff at an increased risk for communicable diseases and a decreased quality of life. Findings included .Observation on 09/23/2025 at 6:15 AM showed room [ROOM NUMBER] with a TBP sign posted on the door. The sign instructed staff to put on an N95 mask, eye protection, a gown and gloves when entering the room and to keep the door closed. Observation and interview on 09/23/2025 at 6:15 AM showed Staff H, Certified Nursing Assistant (CNA), entered room [ROOM NUMBER] in a surgical mask. Staff H did not put on an N95 mask, gown or eye protection. Staff H remained in the room for eight minutes and exited the room with a bag of soiled linens still wearing the surgical mask. Staff H stated the resident in room [ROOM NUMBER] had Covid-19 (a highly contagious respiratory virus). Observation on 09/23/2025 at 11:53 AM showed room [ROOM NUMBER] with the door open and the resident was observed sitting in a wheelchair at the door. The resident did not have a surgical mask on, and multiple staff walked by the resident without an N95 or eye protection. Staff J, CNA, entered room [ROOM NUMBER] without putting on an N95 mask, eye protection, gloves or a gown. During an interview on 09/23/2025 at 12:03 PM, Staff J stated room [ROOM NUMBER] had a sign posted for TBP and they did not wear PPE when entering the room. They thought the resident no longer required TBP. During an interview on 09/26/2025 at 2:24 PM, Staff B, Director of Nursing Services, stated it was their expectation that staff followed the precaution signs' instructions when entering the resident rooms. Reference WAC 388-97 -1320 (2)(b)

Based on observation, interview, and record review, the facility failed to follow prepared menus and ensure any changes were reviewed with the registered dietician when reviewed for kitchen. This failure placed residents at risk of not receiving adequate nutritional intake, decrease in weight, and a diminished quality of life.Findings included.Review of the menu for lunch on 09/25/2025 showed parmesan chicken, sweet potato, cauliflower, bread roll, and seasonal fresh fruit as the main meal. Observation on 09/25/2025 at 11:47 AM showed the facility cook serving chicken breast in an orange sauce, sweet potato, green beans, and canned mandarin oranges. Observation showed bread rolls were not provided. Observation of the facility provided test lunch tray on 09/25/2025 at 12:10 PM showed chicken in a sweet orange sauce, sweet potatoes, green beans, and canned mandarin oranges. A bread roll was not provided. During an interview on 09/25/2025 at 12:43 PM, Staff N, Registered Dietician, stated they oversaw the kitchen, the kitchen should follow the provided menus when possible, and any menu changes should be reviewed with them to ensure meals met nutritional needs of the residents. Staff N stated they were unaware of the kitchen's substitution of orange chicken for parmesan chicken, substitution of canned mandarin oranges for seasonal fresh fruit, or lack of bread roll. Staff N stated the provided lunch on 09/25/2025 did not follow the planned menu. Staff N stated there had been five deviations from the menu in the last week. During an interview on 09/25/2025 at 1:18 PM, Staff M, Dietary Manager, stated the kitchen knew what items to prepare by following the facility provided menus. Staff M stated if there needed to be a deviation from the menus, Staff N, Dietary Manager, needed to be informed and agree to the deviation. Staff M stated Staff N should have been contacted regarding the deviations from the lunch menu on 09/25/2025. During an interview on 09/25/2025 at 12:58 PM, Staff A, Administrator, stated the facility's menus were provided by the corporate office. Staff A stated menus should be followed as much as possible and, in an emergency, any deviations from the menu should be discussed by Staff N, Registered Dietician, and Staff M, Dietary Manager. Staff A stated the lack of communication regarding the deviations from the menu at lunch on 09/25/2025 did not meet expectations. Reference WAC 388-97-1160 (1)(a)(b)

Based on interview and record review, the facility failed to identify and report an allegation of abuse for 1 of 3 sampled residents (Resident 1) reviewed for abuse. This failure placed all residents at risk for unidentified and ongoing abuse/neglect and lack of protection from abuse.Findings included .Review of the Nursing Home Guidelines, The Purple Book, revised in 2015, showed that facilities are to report all staff-to-resident allegations of abuse, neglect, mistreatment, sexual and/or physical abuse/assault to the State hotline, report to law enforcement and to document on the State incident reporting log within five days. Review of the facility's policy titled, Abuse and Neglect - Clinical Protocol, undated and provided to surveyor on 09/15/2025, under Assessment and Recognition, documented, The nurse will assess the individual and document related findings. Assessment data will include injury assessment (bleeding, bruising, deformity, swelling, etc.), pain assessment, current behavior, . vital signs . Under Cause Identification, the policy also showed that staff would investigate alleged abuse and neglect to clarify what happened and identify possible causes. The policy further showed that management and staff would address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations. The protocol also showed that staff would monitor individuals to address any issues regarding their medical condition, mood, and function. Review of the electronic health record (EHR) showed Resident 1 admitted to the facility on [DATE] for skilled nursing and rehabilitation after a recent hospitalization with multiple diagnoses that included a stroke, a history of back surgery and an implanted nerve stimulator (a medical device that blocked pain signals for management of pain), generalized weakness, and was able to make their needs known. On 09/10/2025 at 10:04 AM, Resident 1 said during the night shift on 08/12/2025 a facility Certified Nurse Assistant (CNA) was rough when they provided personal care and said the CNA had a hard time trying to get the resident's brief off and tried to yank the brief off. Resident 1 said the CNA tugged on the resident's brief, and yanked the resident up and down, and would not listen to the resident when they asked them to stop. Resident 1 said their whole bed was soaked and the CNA should have just gotten them up to the wheelchair to have easily changed the sheets instead of having Resident 1 roll all over the place. Resident 1 said they felt like a rag doll being tossed all over the place like that. Resident 1 said they had bruising due to the rough care. Resident 1 said they reported the incident to a provider the next morning. Resident 1 said after that, Staff B, a Registered Nurse (RN) and the Director of Nursing Services, came in and spoke to them about the incident. Resident 1 said Staff B asked them what the resident thought should be done about the staff member. Review of the facility's incident logs for August 2025 showed no allegation of abuse logged related to Resident 1. Review of a grievance form, dated 08/13/2025, signed by Staff C, a Social Services Assistant no longer at the facility, showed Resident 1 had reported that during the night shift, around 2:00 AM, they had wet themself and soiled the bed. Resident 1 said the CNA who came to assist them did so in a rough way and described them tugging on and tossing them around. Resident 1 said they tried to tell the CNA that they could help to hold themselves up and move around, the CNA disregarded the resident's words and continued to handle the brief change roughly. On 08/14/2025, Staff B documented, as resolution of the grievance, that the facility would provide education with the CNA, to pay attention to what the residents say and move slower, and take a break if needed. Staff B documented that Resident 1's care plan was updated and the resident was to be independent with bed mobility transfers and ambulation. Review of Resident 1's EHR did not show a progress note or other documentation by a provider, Staff B, or Staff C about the resident's report of rough care or documentation of any interviews with the resident. No skin assessment or evaluation was located after the allegation referenced in the grievance. On 09/11/2025 at 2:09 PM, Staff D, an RN, when asked their response to a resident report that someone had been rough with them or yelled at them, said they would get a statement, let the Resident Care Manager (RCM) know and, if it was a CNA, switch the CNA's assignment so they were not working with the resident anymore, and do a note in the resident's chart. On 09/11/2025 at 2:49 PM, Staff E, an RN, said if a resident made an allegation of rough care, they would grab a grievance form and have the resident fill it out and would let Staff B, the DNS, know. When asked whether the staff member would continue to work with the resident, Staff E said they did not think it was within their scope of practice to suspend or reassign a CNA. When asked, Staff E was unclear about notifications, reporting, and documentation of allegations in the resident's record. On 09/15/2025 at 1:38 PM, Staff F, a Licensed Practical Nurse (LPN), said if a resident told them that someone had been physically rough with them, the nurse would make sure the resident was safe and go and talk to the staff member to see what really happened, and would call the Hotline. Staff F said they would talk with the resident again because sometimes they say they did not mean something like that. Staff F said they would investigate, and if something did happen then they would call their director and let them know. When asked about protecting the resident, Staff F said they could not send an aide home, that would be the Director, so they would have to call the Director, and they would do all of that. On 09/15/2025 at 3:15 PM, Staff G, an LPN, said if a resident complained about rough care, they would make sure the resident was safe, tell the RCM and call the State. When asked what actions were taken if the staff member was still present when the resident made the allegation, Staff G said they did not know what happened after they reported but sometimes they did not see the person on the floor, would ask, and was told the person was suspended due to an investigation. On 09/15/2025 at 4:37 PM, Staff H, an LPN and the Staff Development Coordinator, said they had just done an in-service with staff members about abuse and neglect reporting because they were made aware of some wrong answers. Staff H said staff were to Rescue, Remove, Report. When asked about protection of the resident, Staff H said if it was a staff person, they needed to just to let the staff know that they needed to go until it was taken care of. On 09/15/2025 at 4:48 PM, Staff B said the facility follows the Purple Book. Staff B said when there is an allegation of abuse, they will talk to the resident to find out more information about what happened before they suspend a staff member. If it is clear, then they will suspend the staff member, assess the resident, notify the parties, and start an investigation. When asked about protection of the residents, Staff B said they needed to figure out what was going on to know whether it was a grievance or an incident and what to do after that. Staff B could not recall the name of the staff member described in the grievance by Resident 1 and could not provide documentation of the education provided to the staff as indicated on the grievance. On 09/15/2025 at 5:01 PM, Staff A, the facility administrator, said either Staff A or Staff B wanted to be called so that they knew what was going on and could decide next steps then. Reference WAC 388-97-0640(2)(b)(5)(a).

Based on interview and record review, the facility failed to ensure that the correct texture of food was served to a resident with a prescribed therapeutic diet for 1 of 1 residents (Resident 1) reviewed for prescribed therapeutic diets. This failure placed the resident at risk for choking, aspiration pneumonia (a lung infection that occurs when food, liquids, or other substances are inhaled into the lungs instead of being swallowed), hospitalization , and a decreased quality of life. The facility had corrected the above deficiency prior to the complaint survey, and it is constituted as past non-compliance (the facility was not in compliance at the time the incident occurred; however, there was sufficient evidence the facility corrected the non-compliance after it was identified) and is no longer outstanding. Findings included . Review of the admission minimum data set (MDS, a required assessment tool), dated 03/09/2025 showed Resident 1 admitted to the facility on [DATE] and had a diagnosis of dysphagia (difficulty swallowing). The MDS further showed that Resident 1 was moderately cognitively impaired (had difficulty with thinking and memory), required hands-on assistance with daily activities, dressing, moving from place to place, and hygiene, and required set-up assistance for eating meals and snacks. Review of the electronic health record (EHR) showed that Resident 1 had been in the hospital 02/24/2025 to 03/03/2025 for a change in condition which included a diagnosis of aspiration pneumonia. Review of a physician's order, dated 03/03/2025, showed Resident 1 was to receive a minced & moist texture diet (Foods that are easy to swallow because they are minced, soft, and moist and can be scooped and shaped. Food pieces should be no larger than 4 millimeters [mm] width by 15mm length). Review of a facility incident report and investigation, dated 03/06/2025, showed that on 03/06/2025 at 6:30 PM, Resident 1 had been served dinner, but requested a hamburger as an alternative to what had been served. The incident report showed that the facility staff served Resident 1 a regular texture hamburger in place of the original meal. Resident 1 began to eat the hamburger, started coughing, and staff realized that the wrong texture had been served. The hamburger was removed, and Resident 1 was assessed and sent to the hospital for further evaluation, with no negative outcome. During interview on 03/13/2025 at 9:30 AM, Staff B, Director of Nursing Services (DNS), stated that when staff removed Resident 1's dinner tray, and took it to the kitchen to get a hamburger as an alternate meal, the kitchen staff nor the nursing staff checked to ensure that the prescribed therapeutic diet was being served. Staff B, DNS, stated that this did not meet the expectations, and that both kitchen and nursing staff should have checked Resident 1's orders and care plan to ensure that the correct diet was being served. During an interview on 03/13/2025 at 11:15 AM, Staff A, Administrator, stated that after the incident was reported to them they immediately began working on and developed an internal plan of correction which included audits of all residents' diet orders, dietary slips and care plans; in-servicing (education) of staff on dietary orders and process for ensuring correct diet is being served; ongoing audits of meals being served to residents; and referral to the Quality Assurance and Performance Improvement program for ongoing monitoring. Staff A, Administrator, stated they had achieved compliance as of 03/07/2025. Review of documentation and review of current facility resident EHR showed facility had achieved compliance as of 03/07/2025. Past noncompliance - no plan of correction required. Reference WAC 388-97-1200 (1)

Based on interview and record review, the facility failed to investigate an unexpected death to rule out mistreatment for 1 of 4 sampled residents (Resident 52) and failed to investigate an allegation of abuse for 1 of 4 sampled residents (Resident 114) when reviewed for Abuse. This failure placed residents at risk of abuse, neglect, avoidable death, retaliation from staff, and a diminished quality of life. Findings included . Resident 52 Review of the electronic health record (EHR) showed that Resident 52 admitted to the facility on [DATE], discharged on [DATE] and had a diagnosis of essential hypertension (high blood pressure). Review showed that Resident 52 unexpectedly died at the facility. Review of provider's orders showed Resident 52 received amlodipine for high blood pressure to be held if the systolic blood pressure (SBP, top number in a blood pressure reading) was less than 100. Review of the [DATE] medication administrator record (MAR) showed Resident 52 had a blood pressure of ,d+[DATE] and was provided amlodipine on the morning of [DATE]. Review of the progress notes, dated [DATE] at 12:12 PM, showed that Resident 52 was very sleepy, pain medications were held, and the provider was notified of the held mediations at 12:12 PM. Review did not show that the provider was notified of Resident 52 receiving medication outside of parameters or of the resident's low blood pressure. Review of a progress note, dated [DATE] at 7:03 PM, showed Resident 52's blood pressure was measured at ,d+[DATE] with respirations of 14 at 5:00 PM, the resident continued to be sleepy, and the nurse held medications. Review showed at 5:30 PM the nurse returned, and Resident 52 was breathing more rapidly and shallowly. Review showed the nurse contacted the on-call provider and was told to monitor Resident 52's vitals every four hours. Review showed the nurse returned and Resident 52 was nonresponsive. Review showed the on-call provider was contacted again, oxygen was applied, CPR was started, and 911 was called. Review showed that Resident 52 died . During an interview on [DATE] at 11:02 AM, Staff B, Director of Nursing Services (DNS), stated deaths that were completely unexpected would be investigated to rule out abuse, neglect, or mistreatment. During an interview on [DATE] at 10:07 AM, Staff B stated the facility would investigate unexpected deaths to rule out abuse, neglect or mistreatment. Staff B stated they looked over Resident 52's medical records after the death and did not see anything wrong so there was no further investigation. During an interview on [DATE] at 9:49 AM, Staff A, Administrator, stated that unexpected deaths were investigated to rule out malpractice. Staff A stated a death after two days in the facility should be investigated and that the medication error should have been noted during the file review Staff B completed. Resident 114 Resident 114 was admitted on [DATE] with diagnoses that included multiple fractures of the pelvis. The five-day admission Minimum Data Set (MDS), an assessment tool, dated [DATE] showed that the resident was cognitively intact and able to recall. During an interview on [DATE] at 1:08 PM, Resident 114 stated they had told Staff P, Charge Nurse, about an incident they had with a staff member, and had requested that the staff member would not come back into their room. Resident 114 stated that the staff member, although not assigned to Resident 114's room, had come back to threshold of the room and acted childish. Resident 114 stated they now tried to avoid this staff member. Resident 114 was observed to be visibly upset (eyebrows furrowed) as they recalled the events. Review of the Incident Log from February 2024 to [DATE] showed no recorded incident/allegation for Resident 114. During an interview on [DATE] at 9:30 AM, Staff P stated if a resident was reporting a staff member was rude, it should still be reported so that it could be care planned. If an allegation was made against a Certified Nursing Assistant (CNA), the CNA should be sent home and should not work with that resident anymore. Staff P recalled the initial incident with Resident 114 and stated they had had a conversation in the resident's room with the resident, the CNA, and themself, where the CNA was asked to not enter the room anymore. Staff P stated they did not report this to anyone else. During an interview on [DATE] at 10:44 AM, Staff B, Director of Nursing Services, stated for allegations of abuse they should have reported the allegations to the state, investigated, suspended the perpetrator, interviewed residents and staff, and gone from there. During an interview on [DATE] at 3:08 PM, Staff A, Administrator, stated the employee should have been suspended, the resident should have been interviewed and assessed, and that staff and other residents should have been interviewed. Allegations of abuse should be reported to the Complaint Resolution Unit, the family should have been notified, and the patient should have been put on an alert if needed. On [DATE] at 11:10 AM, Staff A, Administrator, was informed of the allegations for verbal abuse for Resident 114. On [DATE] the facility provided the investigation report, which did not have any interview/witness statements by Staff P. Reference WAC [DATE](5)(a), (6)(a)(c)

Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Sets (MDS), an assessment tool, accurately reflected residents' health status and/or care needs for 2 of 12 sampled residents (Residents 107 and 307) reviewed for resident assessment. This failure placed residents at risk for unidentified and/or unmet care needs and a diminished quality of life. Findings included . Resident 107 Resident 107 admitted to the facility on [DATE] with diagnoses of congestive heart failure and atrial fibrillation (abnormal fluttering heartbeat). The resident was able to make needs known. Review of the admission nursing database assessment dated [DATE] showed the resident reported pain level at a 7 out of 10 daily. Review of the medication administration record showed the resident received tramadol (a narcotic pain medication) four times between 07/17/2024 and 07/21/2024 for a reported pain level between 6 out of 10 and 8 out of 10. Review or the providers orders showed the resident received heparin sodium (an anticoagulant/blood thinning medication) injections twice a day from 07/17/2024 through 07/22/2024. Observation and interview on 07/25/2024 at 1:25 PM showed Resident 107 sat in a wheelchair and leaned side to side and stated they were in pain. The resident had a bruise to their face and left hand. Review of the admission MDS, dated [DATE], showed Resident 107 reported no pain and was marked that the resident did not receive an anticoagulant medication. During an interview on 07/29/24 at 10:28 AM, Staff O, Registered Nurse/MDS Coordinator, stated they did not review the records to see if the resident had reported pain during the lookback period. Staff O stated if a resident received an anticoagulant medication one day of the lookback period it should be marked in the MDS. During an interview on 07/29/2024 at 12:12 PM, Staff B, Director of Nursing Services, stated Resident 107's MDS did not accurately reflect the resident's pain and anticoagulant but should have. 49926 Resident 307 Resident 307 was readmitted to the facility on [DATE] with multiple diagnoses to include heart failure and contusion to the left leg. Resident 307 was able to make needs known. Multiple observations between 07/25/2024 and 07/31/2024 showed Resident 307 in bed with a swollen left lower leg, and large dressing covering the lower part of the left leg. During an interview on 07/25/2024 at 11:44 AM, Resident 307 stated they hurt their leg at home and the nurses were applying dressings at the facility. Review of Resident 307's five-day MDS, dated [DATE], showed Resident 307 did not have any dressings. During an interview on 07/30/2024 at 1:40 PM, Staff O stated that Resident 307's MDS should have been marked yes for dressing changes. During an interview on 07/29/2024 at 2:14 PM, Staff B stated the expectations was to make sure the MDS assessment matched the resident's condition. Reference WAC 388-97-1000(1)(b)

Based on interview, observation, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 4 of 12 sampled residents (Residents 113, 44, 108, and 306) reviewed for Care Plan. This failure placed residents at risk for unidentified outcomes or goals, inconsistent or lack of interventions, and diminished quality of life. Findings included . Resident 113 Resident 113 was admitted to the facility on [DATE] with diagnoses that included a recent fall with complications, which resulted in orthopedic surgery to the right knee with external fixation (surgery that used pins and wires to keep bones from moving), and surgery to the right leg. The five-day admission Minimum Data Set (MDS), an assessment tool, dated 07/22/2024, showed the resident was cognitively intact, required the use of a wheelchair due to recent surgery, and had not been diagnosed previously with any mental health conditions. Observation and interview on 07/25/2024 at 1:54 PM showed Resident 113 was tearful as they recounted having anxiety in the facility when left alone in the bathroom. Resident 113 stated, I have started telling staff members when they try to leave (the bathroom). The resident stated they told physical therapy and occupational therapy that they believed they had anxiety or possible post-traumatic stress disorder (PTSD). Resident 113's care plan, initiated on 07/18/2024, showed no care plan for anxiety related to toileting. During an interview on 07/29/2024 at 11:30 AM, Staff L, Resident Care Manager (RCM), was unable to find any documentation related to Resident 113's anxiety with being left alone in the bathroom. During an interview on 07/29/2024 at 12:09 PM, Staff M, Occupational Therapist (OT), stated Resident 113 had told them about their fear of being left alone in the bathroom, but Staff M did not report this to anyone else. During an interview on 07/29/2024 at 1:36 PM, Staff B, Director of Nursing Services (DNS), stated their expectation for staff, once aware of the anxiety, was to stay with the resident in the bathroom and to have care planned it. Staff B stated the therapist should tell nursing so the care plan could be updated, and everyone would be aware. 40817 Resident 44 Resident 44 admitted to the facility on [DATE] with a diagnosis of essential hypertension (high blood pressure). Review of provider's orders showed an order for oxycodone (a narcotic pain medication) and acetaminophen (a pain medication). Review of Resident 44's care plan, initiated 07/01/2024, showed no focus area for pain or the use of narcotic pain medications. During an interview on 07/29/2024 at 1:53 PM, Staff CC, Registered Nurse/Resident Care Manager, stated the expectation was that residents taking pain medications would have a care plan focus area related to their use and Resident 44 did not meet this expectation. During an interview on 07/29/2024 at 2:05 PM, Staff B, Director of Nursing Services, stated the expectation was residents taking pain medications would have a care plan focus area related to their use and Resident 44 did not meet this expectation. 46148 Resident 108 Resident 108 admitted to the facility on [DATE] for aftercare of surgery for an abdominal aneurism (weak artery wall). Observation and interview on 07/25/2024 at 12:58 PM showed Resident 108 sat at the bedside and had an indwelling urinary catheter (tube placed into the bladder to drain urine). The resident stated they were not sure why they had a urinary catheter. Review of the electronic health record (EHR) showed that Resident 108 had no order or care plan for a urinary catheter. During an interview on 07/29/2024 at 9:43 AM, Staff L, Resident Care Manager (RCM), stated if a resident was admitted with a catheter, they should have a provider order and a care plan. During an interview on 07/29/2024 at 12:07 PM, Staff B, Director of Nursing Services (DNS), stated they were unable to locate an order or care plan for Resident 108's catheter and they should have had both in place. 49926 Resident 306 Resident 306 was admitted to the facility on [DATE] with multiple diagnoses to include anxiety, depression and physical deconditioning. Resident 306 was able to make needs known. Multiple observations between 07/25/2024 and 07/31/2024 showed Resident 306 appeared sad as evidenced by lowered lip corners and slanting inner eyebrows. During an interview on 07/25/2024 at 10:39 AM, Resident 306 stated they had PTSD and were afraid of falling. During an interview on 07/29/2024 at 9:34 AM, Resident 306 stated, They are hurting me trying to roll me in this tiny bed. It's terrifying to me. My fear of falling has to be one of the worst feelings. I told everyone about it. Review of Resident 306's care plan and Kardex (care directives for nursing assistants) showed no instructions on how to handle Resident 306's fear of falling and how many staff were needed for bed mobility. During an interview on 07/29/2024 at 12:33 PM, Staff R, Occupational Therapist, stated Resident 306 was a one to two persons assist in bed mobility and their fear was when they were sitting at the edge of the bed. During an interview on 07/29/2024 at 12:38 PM, Staff P, Licensed Practical Nurse, stated they were not sure how Resident 306 was turned in bed. During an interview on 07/29/2024 at 12:42 PM, Staff Q, Certified Nursing Assistant, stated Resident 306 required two men or four women to assist with bed mobility as the resident was very anxious and afraid of falling. During an interview on 07/29/2024 at 2:13 PM, Staff B, Director of Nursing Services, stated the expectations was to have instructions in the care plan about fears, and how many staff were to assist the resident in bed mobility. Reference WAC 1020(1), (2)(a)(b)

50945 46148 Surveyor: Somal, [NAME] Based on observation, interview and record review, the facility failed to follow provider's orders, ensure medications had safe monitoring and hold parameters, and notify the provider of changes in condition and medication errors for 8 of 10 sampled residents (Residents 52, 44, 206, 8, 112, 1, 107, and 9) when reviewed for Quality of Care. These failures placed residents at risk of decline in condition, lack of timely interventions to prevent death, avoidable side effects, and a diminished quality of life. Findings included . <Blood Pressure Medication Administration> Review of a policy titled Change in a Resident's Condition or Status, revised February 2021, showed the nurse would notify the resident's provider when there had been an accident or incident involving the resident or significant change in the resident's physical/emotional/mental condition. Review of a policy titled Blood Pressure, Measuring, revised [DATE], showed hypotension (low blood pressure) was defined as blood pressure less than 100 / 60 and orthostatic (postural) hypotension was defined as a 20 (or greater) decline in systolic blood pressure (top blood pressure reading) or a 10 (or greater) decline in diastolic blood pressure (bottom blood pressure reading) upon standing. Review showed that hypotension should be reported to the provider. Review of a policy titled Avamere Living: Physician Notification, dated [DATE], showed after determining that the provider needed to be contacted, the date and problem/request would be entered into the progress notes in the electronic health record (EHR) for that resident. Review showed the resident care manager (RCM) or charge nurse was responsible for placing the call or faxing the provider at the earliest possible time. Resident 52 Review of EHR showed that Resident 52 admitted to the facility on [DATE], discharged on [DATE] and had a diagnosis of essential hypertension (high blood pressure). Review showed that Resident 52 unexpectedly died at the facility. Review of provider's orders showed Resident 52 received amlodipine for high blood pressure to be held if the systolic blood pressure (SBP, top number in a blood pressure reading) was less than 100. Review of the [DATE] medication administration record (MAR) showed Resident 52 had a blood pressure of ,d+[DATE] and was provided amlodipine on the morning of [DATE]. Review of Resident 52's blood pressures and pulses from [DATE] showed: 7:24 AM - 92 / 49, 60 beats per minute (bpm) 10:25 AM - 92 / 49 1:59 PM - 90 / 48, 60 bpm 4:01 PM - 90 / 30, 61 bpm 5:07 PM - 90 / 48, 60 bpm Review of a progress note, dated [DATE] at 12:12 PM, showed that Resident 52 was very sleepy, pain medications were held, and the provider was notified of the held pain mediations at 12:12 PM. Review did not show that the provider was notified of Resident 52 receiving medication outside of parameters or of the resident's low blood pressure. Review of the progress notes on [DATE] from 12:13 PM through 5:00 PM showed no update on Resident 52's status. Review of a progress note, dated [DATE] at 7:03 PM, showed Resident 52's blood pressure was measured at ,d+[DATE] with respirations of 14 at 5:00 PM, the resident continued to be sleepy, and the nurse held medications. Review showed at 5:30 PM the nurse returned, and Resident 52 was breathing more rapidly and shallowly. Review showed the nurse contacted the on-call provider and was told to monitor Resident 52's vitals every four hours. Review showed the nurse returned and Resident 52 was nonresponsive. Review showed the on-call provider was contacted again, oxygen was applied, CPR was started, and 911 was called. Review showed that Resident 52 died . During an interview on [DATE] at 10:07 AM, Staff B, Director of Nursing Services (DNS), stated residents should not receive medications if the vital signs were outside the parameters and Resident 52 received amlodipine despite the resident's blood pressure being below parameters. Staff B stated this did not meet expectation. Staff B stated that staff should contact the provider during a change of condition as soon as the change was noticed, and Resident 52's provider should have been notified of the low blood pressure as soon as it was noticed. Review of an emailed statement, dated [DATE], showed Staff V, Medical Director, stated they were contacted by the facility regarding Resident 52's decline in condition on [DATE] at 5:30 PM. Staff V stated, There could've been better communication from the nursing home staff to me. Resident 8 Resident 8 was admitted on [DATE], with diagnoses that included chronic respiratory failure, heart failure, atrial fibrillation, and high blood pressure. The five-day admission Minimum Data Set (MDS, an assessment tool), dated [DATE], showed the resident was cognitively intact and a fall risk. Review of the EHR showed that Resident 8 had a positive orthostatic blood pressure (a change in blood pressure from moving positions, resulting in low blood pressure) during their recent prior admission, admitted [DATE]. Resident 8's orthostatic blood pressure readings were ,d+[DATE] laying down, ,d+[DATE] sitting, and ,d+[DATE] standing. A cardiology progress note showed that they adjusted Resident 8's dose of metoprolol, in response to the positive orthostatic blood pressure. Review of the EHR showed Resident 8 had an order for daily metoprolol with a start date of [DATE]. No monitoring or hold parameters for vitals were found. During an interview on [DATE] at 10:16 AM, Resident 8 stated, Once in a while I have been lightheaded since being here. The resident stated that their lightheadedness symptom was when their blood pressure was low. During an interview on [DATE] at 10:37 AM, Staff J, Certified Nursing Assistant (CNA), stated a blood pressure should be rechecked every two hours if abnormal. Observation on [DATE] showed Staff S, CNA, used a standard sheet from the facility for recording vitals, which included wording that the nurse should be notified immediately for systolic blood pressures of less than 110. During an interview on [DATE] at 12:27 PM Staff T, CNA, stated that the method to take blood pressure was, The cuff goes around the upper arm. I can't remember, pump up to 100 I believe, hear two thumps. During an interview on [DATE] at 12:29 PM, Staff U, CNA, stated they usually used the blood pressure machine, but if the blood pressure was out of range they would use the manual. When asked what a normal range was, Staff U stated, If it goes higher than 120 then that means it is high. Review of the EHR showed 93 blood pressure readings were obtained from [DATE] to the morning of [DATE]. Review of Resident 8's blood pressure readings showed 24 of 93 had a systolic value of less than 110. Of those 24 readings, 20 did not have a repeat blood pressure reading within two hours. On [DATE], a reading of ,d+[DATE] was recorded at 8:35 AM, with no repeated blood pressure read until the following morning, [DATE] at 6:34 AM. Review of the EHR showed on [DATE], [DATE], [DATE], and [DATE], the resident received their morning metoprolol without any morning blood pressure vitals being recorded. In addition, torsemide (a medication that shifts fluid from the body into urine to be excreted, with a possibility to cause a loss of too much fluid) was given on the morning of [DATE], and both the morning and afternoon of [DATE] and [DATE]. On [DATE] at 3:03 PM, the resident had a blood pressure of ,d+[DATE]. The next blood pressure was taken almost 16 hours later at 6:40 AM on [DATE]. During an interview on [DATE] at 10:48 AM, Staff K, Registered Nurse (RN), stated metoprolol should have had hold parameters, and for low blood pressures they had the expectation that staff would hold the medication and alert the provider. During an interview on [DATE] at 11:14 AM, Staff L, Resident Care Manager (RCM), stated they did not see any parameters listed for metoprolol for Resident 8, and was unable to provide any documentation that the provider was made aware of the blood pressure of ,d+[DATE] on [DATE] by staff. During an interview on [DATE] at 1:32 PM, Staff B, DNS, stated metoprolol should have had a hold parameter, that their expectation was for the CNA to have told the nurse of the low blood pressure, that the nurse should have rechecked the blood pressure, and that they would have notified the physician if the blood pressure was still low. Staff B stated it was not acceptable that the blood pressure, on [DATE], was not rechecked until the next day at 6:40 AM, and that staff should have rechecked and documented the event. Resident 206 Review of the EHR showed Resident 206 admitted to the facility on [DATE], discharged on [DATE], and had a diagnosis of paroxysmal atrial fibrillation (an irregular heart rate) and heart disease. Review of Resident 206's provider's orders showed metoprolol (a blood pressure medication) and to hold the medication for a SBP less than 110. Review of the [DATE] MAR showed metoprolol was provided to Resident 206 on [DATE] evening dose, and [DATE] morning dose, when the SBP was 101, below the hold perimeter. Resident 44 Review of the EHR showed the Resident 44 admitted to the facility on [DATE] with a diagnosis of essential hypertension. Review of Resident 44's provider's order showed isosorbide (a blood pressure medication) and metoprolol to be held if the heart rate was less than 60. Review of [DATE] MAR showed that Resident 44 was provided isosorbide on [DATE] with a heart rate of 58 and [DATE] with a heart rate of 57. Review showed Resident 44 received metoprolol on [DATE] with a heart rate of 59 and [DATE] with a heart rate of 58. During an interview on [DATE] at 10:07 AM, Staff B, DNS, stated Residents 206 and 44 received medications outside of prescribed parameters and this did not meet expectation. Resident 307 Resident 307 was readmitted to the facility on [DATE] with multiple diagnoses to include heart failure. The MDS, dated [DATE], showed the resident was cognitively intact. During an interview on [DATE] at 10:30 AM, Resident 307 stated they received medications, but they did not always know what they are taking. Review of Resident 307's [DATE] MAR showed an order for losartan (a blood pressure medication) and to hold when the SBP was less than 110. Further review of [DATE] MAR showed losartan was documented administered on [DATE] when the blood pressure was ,d+[DATE], on [DATE] when the blood pressure was ,d+[DATE] and on [DATE] when the blood pressure was ,d+[DATE]. Review of the EHR showed no documentation that the nurses notified the provider about the blood pressure being outside of parameters. During an interview on [DATE] at 2:15 PM, Staff B, DNS, stated the expectation was for the licensed nurses to follow orders and parameters of medications. Resident 1 Review of Resident 1's EHR showed they admitted to the facility on [DATE] with diagnoses including essential hypertension (HTN), syncope and collapse (dizzy spells) and fall with hip fracture. The resident was able to make needs known. Review of the EHR showed an order for metoprolol daily for hypertension with a start date of [DATE]. There were no instructions attached to the order to monitor blood pressure or pulse prior to administration or notify the provider of low blood pressure/pulse. Review of the EHR showed on [DATE] the resident had a blood pressure of ,d+[DATE]. No documentation was found in the medical record that the blood pressure was re-checked, or the provider was notified. During an interview on [DATE] at 1:12 PM, Staff B, DNS, stated that Resident 1 should have had parameters in place for antihypertensive medications and the provider should have been notified of any low blood pressures. Resident 107 Review of the EHR showed Resident 107 admitted to the facility on [DATE] with a diagnosis of congestive heart failure and atrial fibrillation. The resident was able to make needs known. Review of the EHR showed a provider order for heparin (blood thinning) injection twice a day with a start date of [DATE] and an end date of [DATE]. There was a current order to monitor for adverse effects which included bruising. Observation on [DATE] at 1:12 PM showed a large dark purple bruise to back left hand and scattered other bruises to include facial bruising to the left eye. Review of a current order to monitor for adverse side effects of anticoagulant therapy showed no bruises or adverse side effects were identified between the dates of [DATE] through [DATE]. There was no documentation found in the EHR of Resident 107's bruises. During an interview on [DATE] at 10:42 AM, Staff B, DNS, stated their expectation was that the staff document adverse side effects such as bruising from anticoagulant therapy and that they be monitored until resolved. <Bowel Care> Review of the Avamere Living Bowel Care Protocol, undated, showed if a resident had not had a bowel movement for three consecutive days, a physician order should be obtained, and the bowel protocol should be followed. The protocol showed that evening shift should do a look back report for residents who had not had a bowel movement for two consecutive days, evening shift should give milk of magnesia, and then (if no results) dayshift should give a suppository. Resident 112 Resident 112 was admitted to the facility on [DATE] with diagnoses including fracture, malnutrition, and cancer. The five-day admission MDS, dated [DATE], showed the resident was cognitively intact and had frequent pain that required pain management interventions. Review of the [DATE] MAR showed Resident 112 had been receiving morphine (a narcotic pain medication, which had a potential side effect of causing constipation) for pain since [DATE]. On admission, the resident had a bisacodyl suppository (a rectal drug that stimulates a bowel movement) ordered for every 24 hours as needed for no bowel movement in three days. On [DATE], an order was placed for daily docusate (a stool softener to help with constipation). Review of Resident 112's bowel log and hospice notes, the resident had no bowel movement from [DATE] through [DATE] and [DATE] through [DATE]. Resident 112 was given a bisacodyl suppository on [DATE] (day 6 of no bowel movement) and [DATE] (day 5 of no bowel movement). The resident had a bowel movement after each suppository. Review of the Resident 112's progress notes showed no documentation related to the resident's constipation on [DATE] through [DATE] (days 3 and 4), or [DATE] through [DATE] (days 3 and 4). During an interview on [DATE] at 11:22 AM, Staff L, Resident Care Manager (RCM), stated their expectation was for staff to monitor bowels every day, every shift, and to have started the protocol if three days without a bowel movement. During an interview on [DATE] at 1:34 PM, Staff B, DNS, stated their expectation was for staff to have documented any intervention or refusal after three to four days without a bowel movement, to have followed protocol or orders, and to have assessed the patient for any stomach pain or abdominal distention (swelling). Reference WAC [DATE](1) 49926

Based on interview and record review, the facility failed to implement interventions to prevent a fall for one of two residents (Resident 1). This failure resulted in harm when Resident 1 fell and sustained two nose fractures, a fracture around the right eye, a large blood blister behind the right eye, and pain to the face and neck. The fall required hospitalization and advanced medical attention. Findings included . According to March 2018 facility policy titled Resident -Centered approaches to managing falls and fall risks showed, 1 Facility staff with the input of the attending physician, will implement a resident- centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident or history of falls. Review of a 2021 Lippincott Procedure manual, used by the facility as a reference tool, showed if a resident was at risk for falls, the facility would take steps to reduce the danger based on the factors that created the risk. This procedure showed that one of the interventions to prevent falls for high-risk residents was to check on them every 30 minutes, and to document the times and frequency the resident was checked. This procedure also instructed the facility to consider providing close supervision. Review of a 09/19/2022 Admission Minimum Data Set (an assessment tool) showed Resident 1 admitted to the facility on [DATE] with medically complex conditions. This assessment showed staff assessed Resident 1 usually made themselves understood and understood others and had intact cognition. Staff assessed Resident 1 required limited assistance of one person assist with bed mobility, transfers, and extensive assist with dressing and toilet use. This assessment identified Resident 1 was not steady when moving from a seated to a standing position, moving on and off the toilet, or transferring between a bed and a chair or wheelchair. Review of a 09/21/2022 Care Area Assessment (an assessment showed Resident 1was at risk for falls related to poor balance, reduced mobility and physical deconditioning. This assessment showed staff identified, The nature of this problem requires close monitoring by staff and participation in skilled therapy to prevent falls and improve activity of daily living (ADL) function. Review of a 09/13/2021 Fall Risk Evaluation showed staff was instructed to initiate fall prevention interventions for score of 10 or above. Staff assessed Resident 1's fall risk score at 16 (a high risk) on 09/13/2022, and that Resident 1 required hands on to move from place to place, needed help to maintain balance, had three or more health conditions or medications that contributed to falls, and had one to two falls in the last 90 days. Review of Resident 1's comprehensive Care Plan (CP), dated 09/13/2022, showed the resident was at high risk for falls related to a history of actual fall with no injury. This CP showed Resident 1 had an activity of daily living self-care performance deficit, limited mobility related to fatigue, pain, shortness of breath and weakness. The CP showed Resident 1 required one person assist for transfer, bed mobility and toileting assistance. Review of the CP showed no documentation the staff developed and implemented interventions to prevent falls when they identified Resident 1 was a high risk for falls. Review of 09/27/2022 nursing progress notes showed, Change of condition reported on Resident 1's abnormal vital signs (low blood pressure), altered mental status, poor safety awareness, and impulsivity. Resident 1 was given Intravenous (IV) hydration to decrease risk of hypotensive episode. Review of the CP showed no documentation the staff developed and implemented interventions to prevent falls when they identified Resident 1's risk for falls increased when the staff identified, altered mental status, poor safety awareness, and impulsivity. Review of a 09/28/2022 nursing progress notes showed, at 01:00 AM Resident 1 was found on the floor along the bed in prone position, face down. Noted profuse bleeding from the resident's nose, staff noted that the right eye had started swelling, staff was not able to transfer Resident 1 to bed due to pain, and weakness. Review of a 10/03/2022 facility Investigation Report showed, According to the evening shift Certified Nursing Assistant (CNA), Resident 1 required a heavier level of assistance than normal during transfer. The resident was offered bed-level toileting but declined and stated that they wished to continue to get out of bed. The nurse educated the resident of risk of falling. Later in the evening, the resident complained of dizziness, but not to the point of passing out. Further review showed the conclusion of the resident's fall was related to poor safety awareness secondary to acute change of condition and ambulating without assistance. Review of a 09/28/2022 emergency room physician progress notes showed Resident 1 was treated for acute blood loss [CONDITION(S)], traumatic fracture around the eye, and [CONDITION(S)] (slow heart rate). On 10/17/2022 at 12:20 PM, Staff C, Resident Care Manager, stated that Resident 1 was assessed for the change of condition in altered mental status, [CONDITION(S)], and impulsivity. Staff C stated, Resident 1 was given IV hydration to treat hypotensive episode. When asked what falls safety interventions were implemented when the staff identified the altered mental status, impulsivity, and an increased need for physical support, Staff C stated that Resident 1 was educated to use a call light to call for help. On 10/17/2022 at 1:00 PM, Staff B, Director of Nursing, stated that staff should have but did not re-assess Resident 1's risk for falls with the change in condition, or update the CP accordingly. Staff B stated staff educated Resident 1 to use the call light when they needed help. Staff B acknowledged the ineffective and unrealistic intervention to educate Resident 1 when the staff assessed altered mental status and impulsivity. Staff B stated, We should have checked the resident promptly and the nurse should listen to the nursing assistant about the resident's change in care. When asked Staff B about whether the facility had changed interventions before and after Resident 1's change in condition. Staff B, said No. Although the staff knew that Resident 1 admitted to the facility with a history of falls, assessed the resident to be a high risk for falls, and identified a change of condition (altered mental status, poor safety awareness, and impulsivity) that increased an already high risk for falls, the staff failed to develop and implement interventions that effectively anticipated the resident's needs and compensated for their impaired level of awareness. These failures resulted in multiple face fractures, pain and hospitalization . Reference: (WAC) 388-97-1060 (3)(g)

Based on observation, interview, and record review the facility failed to maintain an environment free of potential hazards. The facility did not complete a comprehensive assessment of an assistive device prior to use and did not adequately supervise Resident #1. This failure caused one of four sample Residents (#1) fall from a bed fitted with a Low Air Loss Mattress (LALM) and suffer an injury. Findings included: Resident #1 Resident #1 has been discharged from the facility. According to the 9/16/2020 Minimum Data Set (MDS, a comprehensive assessment tool), Resident #1 admitted on [DATE] with [DIAGNOSES REDACTED]. Resident was on hospice (end of life care). The assessment showed Resident #1 required extensive assistance for bed mobility. According to the facility's 10/03/2020 evidence of investigation, a single direct-care staff provided personal care while resident was in bed on a LALM. The staff member asked resident to reposition, and as the resident turned she slid from the mattress and fell on the floor hitting her head. Resident #1 sustained a hematoma (collection of blood) above the left eye, right thigh bruise and left neck abrasion (superficial wound). The same incident investigation showed that on 10/01/2020 facility employee installed a Low Airloss Mattress (LALM) provided by hospice. An undated statement described the mattress was narrow and slippery. During an interview with Staff B, Director of Nursing (DNS) on 10/07/2020 at 2:22 PM it was identified there was no clinical assessment of LALM prior to its use. The DNS said the facility was investigating the incident and was evaluating the process related to LALM use. According to CMS (Centers for Medicare & Medicaid Services) an air-filled mattress compresses on the side to which a person moves, thus raising the center of the mattress and lowering the side. This may make it easier for a resident to slide off the mattress. Without device assessment by clinical team member(s) the facility cannot identify potential hazard risk and determine level of assistance and supervision necessary to ensure safe care. WAC Reference 388-97-1060(3)(g).