Every finding on record at Bethany At Pacific

Based on observation, interview, and record review the facility failed to maintain essential equipment in safe operating condition. The facility failed to adequately identify fluctuating dishwasher rinse temperatures and ensure maintenance/repairs were successful for one of one facility high temperature dishwasher. They failed to ensure Hoyer lifts (mechanical device that assists with transfer of residents from one surface to another) and sit to stand lifts (mobility device used to help residents who are partially weight bearing from sitting position to a standing position) for one of three halls (3 South) batteries were consistently monitored and repaired for safe operation. These failures placed residents at risk for food borne illness, accidents, and overall decreased quality of life. Findings included . <DISHWASHER> On 5/12/2026 at 10:13 AM, observed the rinse cycle on the high temperature dishwasher and the temperature gauge when running the rinse cycle. The rinse cycle temperature read 178 degrees Fahrenheit (F). The gauge on the dishwasher showed the temperature should be between 180-190 degrees F. In an interview on 05/12/2026 at 10:15 AM, Collateral Contact 5 (CC 5), Kitchen Manager, stated they were contracted to provide food services for the facility. CC 5 stated they had issues with their dishwasher keeping temperature in the past and was unaware of any current issues, maintenance or repairs needed. Observed CC 5 use a thermal pad (temperature pad used to go through the dishwasher cycles and measure the temperature) in the dishwasher and after the final rinse the temperature was 151.5 degrees F. CC 5 stated they would contact the maintenance and have them repair the dishwasher. In a follow up visit to the kitchen on 05/13/2026 at 12:56 PM, observed the dishwasher rinse temperature to be 179 degrees F, observed the dishwasher running an additional three trays of dishes through the dishwasher with the rinse cycle at 170 degrees F. In an interview on 05/13/2026 at 1:00 PM, CC 5 stated they had called maintenance yesterday, they came and found no issues and the dishwasher temperature was within range at 190 degrees F. CC 5 stated they would contact maintenance again. In an additional observation on 05/13/2026 at 1:10 PM the dishwasher rinse temperature was 200 degrees F. In a follow up interview on 05/13/2026 at 1:12 PM CC 5, stated they had called maintenance, and they had turned up the temperature from the boiler room. Review of work orders from maintenance for the last 15 months (February 2025 through May 2026), documented 14 instances involving the dishwasher functioning and requiring repairs/maintenance. Review of a repair estimate summary, dated 10/13/2025, documented the dishwasher was originally installed 07/11/2017 and required repair for, the unit is not heating well for the final rinse. In an interview on 05/13/2026 at 4:15 PM, Staff F, Director of Dietary Services, stated they had checked the dishwashing rinse temperature on 05/12/2026 and it was running within the temperature range. Staff F stated they were unaware the temperature of the rinse cycle was continuing to fluctuate and at times was not up to temperature. Staff F stated the contracted food service provider would need to coordinate repair of the dishwasher and they would follow up with them. <HOYER LIFT-SIT TO STAND LIFTS> In an interview on 05/13/2026 at 8:50 AM, Resident 22 stated the sit-to-stand machine battery frequently died in the middle of the transfer, and they were left hanging while nursing staff searched the facility for a working battery. In an observation and interview on 05/13/2026 at 1:53PM, Staff DD, Nursing Assistant Certified (NAC), was observed attempting to use multiple batteries on the Hoyer lift, but the machine failed to operate. Staff DD stated that although the battery charging bar indicated the batteries were fully charged, the battery still did not work. Staff DD stated this had occurred frequently for three and four months since they began working at the facility. Observed that the battery status indicator on the machine displayed a full charge, but the lift remained inoperable. In an observation and interview on 05/13/2026 at 2:25 PM, Staff EE, NAC, attempted three different batteries from the charging bases to use on the Hoyer lifting machine, but the machine failed to function. Staff EE stated that staff frequently had to go to different floors of the facility to find a working battery. Staff EE stated that this defective equipment had been an ongoing problem for over one year and had been reported to facility management. In an interview and observation on 05/14/2026 at 10:07 AM, Staff G, Maintenance Assistant, explained that a yellow light on the charging base indicated an active charge, while a green light verified the battery was fully charged and ready to use. Staff G stated the battery docked on charging base number one was ready to use as the green light was on. Staff G explained the machine also had a screen which indicated how much the battery was charged. Staff G inserted this battery into the Hoyer lift; the machine screen indicated a full charge, but the lift failed to operate. During this observation, Resident 46 approached and stated that the lift batteries were always not working. Staff G then attempted to use the same battery on another Hoyer lift machine, and it failed to operate as well. Staff G confirmed the battery was defective rather than the Hoyer machines. Staff G then tested an additional two batteries that displayed full charge indicators on both the wall charging base and the machine screen; both failed to operate the lift. Staff G confirmed that three out of the five facility batteries tested were not functional. Staff G inspected the three defective batteries and identified historical dates on the back: 11/29/2021, 03/10/2020, and 09/15/2016. Staff G stated they were unsure if these represented production or expiration dates and lacked knowledge regarding the lifespan of the battery. Staff G reported that facility administration was aware of the problem but had previously attributed it to poor battery and charging base connections. Staff G confirmed these three specific batteries were fully charged but entirely nonfunctional. In a group interview on 05/14/2026 at 2:40 PM, Resident 22 expressed concern regarding when the facility would replace the lift batteries. Resident 22 stated they had been left hanging up in the air in the middle of a transfer when the machine's battery died, forcing the nurse to run all over the places to different floors for a working battery. Resident 46, Resident 39 and Resident 7 stated the same machine failure had happened on them as well, leaving them halfway in the air due to dead batteries. Resident 46 and Resident 39 stated this equipment concern had been brought up to the Resident Council meetings several times. Resident 45 nodded their head in agreement. In an interview on 05/15/2026 at 1:19 PM, Staff A, Administrator, stated they received periodic complaints regarding the Hoyer lifts and staff had recently reported battery failures. Staff A stated they were unsure if the maintenance department had figured out the battery's problem and stated the facility had begun renting a Hoyer lift the previous week. In a follow-up interview on 05/18/2026 at 9:03 AM, Staff G stated they had reported to Staff A about two to three months ago that the batteries required replacement. Staff G stated the nonfunctional batteries should be removed from the charging station. On 05/18/2026 at 11:03 AM, Resident 22 approached the surveyor and reported they had been stuck in the air again during sit to stand transfers on 05/16/2026 and 05/17/2026. Resident 22 stated they were very worried about using the sit to stand lift and was sure something would happen or someone would get hurt if there was no change. Refer to WAC 388-97-2100 (1)

Based on interview and record review, the facility failed to provide a follow up response to concerns voiced by 1 of 1 resident groups (Resident Council). The failure to respond to the Resident Council about their concerns left the issues unresolved and resulted in the Resident Council process being ineffective at improving resident quality of life. Findings included .Review of the facility policy titled, Resident Council Meetings, revised date 01/2026, documented the facility shall act upon concerns of the Council and communicate the decision to the Council. Review of the facility policy titled, Resident and Family Grievances, revised date [DATE], documented that grievances could be voiced via verbal complaints during resident council meetings. The policy documented the staff member receiving the grievance would record the nature and specifics of the grievance on the designated form and take any immediate actions needed. The policy showed all staff should make prompt efforts to resolve the grievance. In a group interview on [DATE] at 2:40 PM, Resident 2 and Resident 7 stated that some nursing assistants talked very loudly in the hallways at night and noted this was a consistent concern. Resident 45 nodded their head to acknowledge agreement. Resident 2 stated they frequently received other residents' clothes from the laundry department. Resident 35 stated they received Resident 7's clothes, and Resident 22 stated they received Resident 35's clothes. Resident 7 and Resident 35 stated this laundry concern was brought up during Resident Council meetings, but no change occurred. During the same group interview, Resident 22 asked when the batteries for the Hoyer lift (machine that lifts persons from one surface to another) would be replaced, stating they had been left hanging up in the air in the middle of a transfer when the machine's battery died. Resident 46, Resident 39 and Resident 7 stated the same machine failure had happened on them as well, leaving them halfway in the air due to dead batteries. Resident 46 and Resident 39 stated this equipment concern had been brought up to the Resident Council meetings several times. Resident 45 nodded their head to acknowledge agreementReview of Resident Council Meeting minutes for [DATE] documented there was a concern regarding staff talking loudly in the hallways. There was no documentation of resolution or facility follow-up on the minutes. Review of the Grievance Resolution Log for [DATE] showed no documentation or resolution to the noted concerns from Resident Council from [DATE].Review of Resident Council Meeting Minutes for [DATE] documented there was a concern regarding staff talking in different languages in the hallways and laughing loudly. There was no documentation of resolution or facility follow-up on the minutes. Review of the Grievance Resolution Log for [DATE] showed no documentation or resolution to the noted concerns from Resident Council from [DATE].Review of Resident Council Meeting Minutes for [DATE] documented there were concerns regarding staff talking in different languages in the hall, and laundry/clothes being returned to the incorrect rooms with bleach stains. There was no documentation of resolution or follow-up on the minutes. Review of the Grievance Resolution Log for [DATE] showed no documentation or resolution to the noted concerns from Resident Council from [DATE].Review of Resident Council Meeting Minutes from [DATE] to [DATE], show no documentation about concern regarding the Hoyer lift. In an interview on [DATE] at 10:11AM, Staff X, Director of Activity, stated they filled out grievance forms for the Resident Council's concerns and passed them to the Director of Nursing and the Administrator. Staff X stated they were not following up with the outcomes. In an interview on [DATE] at 9:34 AM, Staff Y, Laundry, stated they were not aware of the concern from the resident council meeting regarding the clothes being returned to the wrong residents.In an interview on [DATE] at 1:03 PM, Staff A, Administrator, stated that the facility did not log group concerns from Resident Council meetings into the formal Grievance Log, nor did they file official grievance reports. Staff A stated the facility had conducted in-service trainings regarding staff talking loudly in the hallways and would provide documentation of the training.In a follow-up interview on [DATE] at 12:07 PM, Staff A stated they were unable to find any in-service training records corresponding to the concerns about staff talking in the hallways, nor any training or resolution documentation related to clothes being returned to the wrong residents.Reference WAC 388-97-0920

Based on interview and record review, the facility failed to provide instructions upon discharge, evaluate the need for home health support or equipment needs, and make arrangements for home medications to ensure a safe discharge for 1 of 2 residents (Resident 88) reviewed for discharge to the community and failed to provide appropriate notifications in writing to the resident/representative and the ombudsman (neutral resident advocate) for 3 of 4 residents (Residents 9, 11, and 88) reviewed for discharge process. These failures placed residents at risk of an unsafe discharge, risk of medical complications, and risk of not being informed of their rights regarding the transfer/discharge process.Findings included.<RESIDENT 88>Review of a progress note, dated 03/26/2026, showed Resident 88 discharged home Against Medical Advice (AMA). The note did not document any instructions that were provided or document any services or equipment needs for Resident 88. Review of Resident 88's Electronic Medical Record (EMR) showed no record of a discharge summary, discharge instructions or Notice of Transfer form.During an interview on 05/14/2026 at 11:42 AM, Staff D, social service assistant, stated when a resident was discharged , they ordered services and equipment and provided the Notice of Transfer form to the resident. Staff D stated that if a resident left AMA, the facility sets up services and provided instructions the same as a regular discharge. Staff D stated Resident 88 discharged without any notice, so they had not set up any services. Staff D stated they had not contacted Resident 88 after discharge to offer services.During a joint interview on 05/14/2026 at 3:35 PM with Staff C, Assistant Director of Nursing Services, and Staff B, Director of Nursing Services; Staff C stated that services and discharge instructions were provided for residents that left AMA. Staff B reviewed Resident 88's EMR and stated there was no documentation that any instructions were provided or that any services were set up for Resident 88 upon discharge.During a follow up interview on 05/14/2026 at 3:43 PM, Staff C reported they contacted the nurse that was working when Resident 88 was discharged and they could not remember what information had been provided to the resident upon discharge.During an interview on 05/14/2026 at 3:45 PM, Staff A, Administrator, stated social services kept the completed Notice of Transfer forms and they would provide a copy for Resident 88.In a follow up interview on 05/14/2026 at 4:32 PM, Staff A reported that the social service staff had not been providing Notice of transfer forms for residents that left AMA. <RESIDENT 11>Review of a progress note dated 05/02/2026 at 7:20 AM, showed Resident 11 was transferred to the hospital.Review of Resident 11's EMR showed no record of a Notice of Transfer form being provided to the resident or resident's representative. <RESIDENT 9>Review of a progress note dated 04/24/2026 at 3:51 PM, showed Resident 9 was sent to the hospital Emergency room.Review of the progress notes from 04/24/2026 through 05/01/2026 showed Resident 9 did not return from the hospital and their significant other picked up all personal belongings.Review of Resident 9's EMR showed no record of a Notice of Transfer form being provided to the resident or resident's representative.During a joint interview on 05/14/2026 at 3:45 PM, with Staff B and Staff A, Staff B stated the facility staff should be including the Notice of Transfer form with the transfer instructions. Staff A stated they would follow up with social services.In a follow up interview on 05/14/2026 at 4:32 PM, Staff A reported that they could not find any Notice of transfer forms for Resident 11 or Resident 9. Staff A reported that the facility staff had not been providing notices to residents that were transferred to the hospital. Refer to WAC 388-97-0080 (5),(7) & 388-97-0120 (5)(b)(i)

Based on observation, interview and record review, the facility failed to ensure expired medications were discarded in one of two medication room refrigerators and sharps containers emptied after reaching the full line, temperatures were documented and monitored for vaccines located in one of two medication room vaccine refrigerators, and failed ensure medications were secured and not accessible to the public or residents for one of one residents (Resident 93) whose medications were at their bedside. These failures place all residents at risk for receiving compromised and/or ineffective medications and medical solutions, which potentially result to the residents not receiving the therapeutic effect of the medications, and or possibly experience adverse side effects.Findings included . Review of the facility policy titled, Storage of Medication Requiring Refrigeration, reviewed documented the facility would assure proper and safe to prevent storage of medications requiring refrigeration and the potential alteration of medication by exposure to improper temperature controls by monitoring temperature daily to ensure proper temperature control and documented on the temperature log located outside of the refrigerator provide safe and effective storage of medications through proper temperature controls consistent with professional standards of practice. According to the facility policy titled Bedside Medication Storage dated 01/2023 documented, a written order for the bedside storage of medication is present in the resident's medical record. According to the Center for Disease Control and Prevention (CDC), The Epidemiology and Prevention of Vaccine-Preventable Diseases also known as the Pink Book, Chapter 5 documented if temperatures could not be recorded digitally, they should be checked and recorded a minimum of two times each workday. In an observation on 05/14/2026 at 9:13 AM of the sixth-floor medication room, the vaccine refrigerator contained vials of flu vaccine. Review of the temperature logs for: -05/01/2026 through 05/14/2026 documented temperatures/initials recorded for AM Temp and PM Temp were blank. -04/01/2026 through 04/30/2026 documented temperatures/initials missing for AM Temp for 04/01/2026 and 04/10/2026 and missing temperatures/initials for PM Temp for the entire month except for 04/01/2026. -03/01/2026 through 03/30/2026 documented missing temperatures/initials for AM Temp on 03/17/2026 and PM Temp for 03/04, 03/05, 03/08, 03/09, 03/11, 3/18, 3/19. 3/20 and 3/23 through 3/30/2026. In an observation on 05/14/2026 at 9:13 AM observed the refrigerator in the medication room contained a bottle of liquid Amoxicillin and Clavulanate Potassium for Oral Suspension 400 milligrams/57mg per 5 milliliters (an antibiotic) with a filled date of 05/01/2026 and expiration date of 05/11/2026 on the pharmacy label. In an observation on 05/14/2026 at 9:13 AM observed the sharps container located on the wall adjacent to the vaccine refrigerator filled past the full line. The container was hanging in an unlocked wall mount. In an interview on 05/14/2026 11:07 AM Staff V, Licensed Practical Nurse/Nurse Manager stated the refrigerator temperatures for vaccines should be checked and documented twice daily and would be completing education with the nursing staff. Staff V stated that the nurses at night were responsible for maintaining the medication room and refrigerator to ensure expired medications and products were disposed of as required. <MEDICATIONS AT BEDSIDE> <RESIDENT 93> Resident 93 was admitted to the facility on [DATE]. In an observation and interview on 05/12/2026 at 2:28 PM, Resident 93's overbed table had 2 nasal sprays – Fluticasone Nasal Spray (over the counter medication (OTC) to treat allergy) and Ipratropium Bromide (prescription medication to treat allergy) and 2 tubes of Triamcinolone Cream 0.5% (a prescription medication to treat skin problems). The resident stated they administered the nasal sprays once a day and used the cream for itchiness. In an observation and interview on 05/13/2026 at 8:17 AM, Resident 93 stated the nurse took their nose sprays. Observed Vicks VapoRub container (OTC medication to treat congestion) and Systane eyedrops (OTC eye lubricant) by their windowsill. Resident stated they use the Vicks for stuffy nose and the eyedrops for dry eyes. In an observation on 05/14/2026 at 9:26 AM, Resident 93 was eating their breakfast and observed Vicks VapoRub, Systane eyedrops, 3 different brands of OTC antifungal creams, and 2 tubes of Triamcinolone creams on their over bed table. Record review of Resident 93's order summary with a print date of 05/13/2026 did not contain an order that the resident may keep medications at bedside. In an interview on 05/14/2026 at 10:44 AM, Staff M, Licensed Practical Nurse stated that any medications and creams such as antifungal creams were not supposed to be at resident's bedside. Staff M stated they saw the creams on Resident 93's bedside and will take them out of the resident's room. Reference WAC 388-97-1300 (2)

Based on observation, interview and record review, the facility failed to allow residents to make choices about daily routines for 1 of 2 residents (Resident 12) reviewed for choices. The facility's failure to accommodate resident choices placed residents at risk for a diminished quality of life.Findings included. Resident 12 was admitted to the facility on [DATE]. According to the admission minimum data set assessment (MDS-an assessment of care needs), dated 12/30/2025, the resident was cognitively intact.<FOOD>In an interview on 05/12/2026 at 10:46 AM, Resident 12 reported experiencing weight loss because the facility repeatedly provided food items they disliked. The resident stated they disliked pineapple but the facility provided pineapple in the fruit cup. The resident further stated they did not like chicken but almost every meal contained chicken. Resident 12 stated the facility should have been aware of these preferences. In an interview on 05/13/2026 at 3:04 PM, Staff I, Nursing Assistant Certified (NAC), reported Resident 12 disliked chicken and certain green vegetables. In an observation and interview on 05/14/2026 at 12:36 PM, Staff J, NAC was observed assisting Resident 12 with lunch. The beef on the lunch tray was observed to be approximately 10 percent consumed. When asked if they liked beef, Resident 12 stated, No. Staff J stated that Resident 12 disliked chicken and most beef dishes. Staff J further stated that Resident 12 disliked pineapple, but the kitchen occasionally provided it anyway, even though the resident's meal tray card documented no pineapple. Staff J stated the dietary manager needed to be informed to update the resident's food preferences.Review of Resident 12's lunch tray card on 05/14/2026 documented Resident 12 disliked pineapple, but not other food restrictions or dislikes. The tray card showed an order for health shake (high protein drink), but this was manually crossed out with the word out written next to it.In an observation and interview on 05/15/2026 at 9:23 AM, Staff K, NAC, was observed assisting Resident 12 with breakfast. Resident 12 consumed all of the eggs and almost all of the sausages but left the oatmeal untouched. Resident 12 stated they liked eggs and sausages but disliked oatmeal. Resident 12 reiterated that they disliked chicken and beef, but the facility always provided those items. Staff K stated that Resident 12 disliked oatmeal and refused to eat it. Staff K reported the resident also disliked pineapple but the kitchen still served to Resident 12. Staff K stated they had never seen the resident eat steaks (beef) or diced chicken and noted it was challenging for the resident because the kitchen frequently served chicken and beef for lunch. Staff K stated that Resident 12 did not like the available substitutes and would usually finish the rest of the meal, leaving them with no protein source. Staff K stated they had reported the resident's preferences to the nurse.In an observation and interview on 05/15/2026 at 1:06 PM, Staff K was observed assisting Resident 12 with lunch. Staff K stated that the resident did not like chicken or the ordered health shakes. The chicken inside a hot pie was observed to be almost untouched, and the health shake remained unopened. Staff K stated the resident preferred chocolate milk over the health shake, and Resident 12 nodded their head in agreement.In a follow-up interview and observation on 05/15/2026 at 1:37 PM, Resident 12 stated they did not like chicken and had only eaten a couple of bites. The resident stated they did not like the health shake and chose not to drink it. The lunch tray was observed in the dietary cart with the chicken left in the bowl and the health shake untouched.In a phone interview on 05/16/2026 at 3:51PM, Collateral Contact 3 (CC3), spouse of Resident 12, stated that the resident used to eat all types of meat before suffering a stroke, but no longer did. CC3 stated that Resident 12 disliked chicken and fish due to their textures, and ate a very limited amount of beef, specifically disliking hamburgers. CC3 confirmed they had seen pineapple served to the resident despite the resident's strong dislike for it.Review of Resident 12's diet order, dated 04/28/2026, documented that the resident required a high-protein diet.Review of Resident 12's body weight record showed that the resident's weight decreased from 205.1 pounds on 12/23/2025 to 182 pounds on 05/05/2026, which was a loss of 23.1 pounds and 11.26 percent weight decline in less than six months.Review of a facility form titled, FOOD PREFERENCES RECORD FORM, date 12/23/2025, documented yes for all types of meat and listed no foods under the dislikes section. The form failed to indicate what type of milk Resident 12 preferred.Review of Resident 12's Electronic Health Record (EHR) showed that no further food preferences assessments were conducted after the initial admission date.Review of Resident 12's physician order summary documented an order dated 04/04/2026 to offer a health shake once per day due to reduced meal intake.In a joint interview on 05/15/2026 at 10:49 AM with Staff F, Director of Dietary, and Staff H, Dietitian, Staff F stated they had not spoken with Resident 12 about food preferences since the initial admission assessment. Staff F stated that if the tray card indicated the resident disliked pineapple, the kitchen should not have provided it. Staff H stated they had recently updated the tray card to reflect that Resident 12 disliked pineapple and liked cottage cheese. Both Staff F and Staff H stated they were unaware that the resident disliked chicken, beef, or any other items. Staff H stated that Staff F regularly attended resident care conferences to provide opportunities for updating food preferences.Review of the care conference records dated 12/29/2025 and 01/16/2026, showed no documentation about diet or food preferences discussed in the meetings. Review of the care conference record dated 03/09/2026 showed that Staff F did not sign the attendance log. In a follow-up interview on 05/18/2026 at 9:23 AM, Staff F confirmed they did not attend Resident 12's last care conference on 03/09/2026.In an interview on 05/15/2026 at 12:47 PM, Staff B, DNS (Director of Nursing), stated the expectation was for nursing staff to communicate directly with the dietary manager to update resident food preferences.In an interview on 05/15/2026 at 1:19 PM, Staff A, Administrator, stated they expect food preferences to be updated during scheduled care conferences. <Bed Time>In an interview on 05/12/2026 at 10:46 AM, Resident 12 stated they did not get enough sleep at night and was always getting disturbed by staff which made them sleepy and tired during the day. In an interview on 05/14/2026 at 9:39 AM, Resident 12 stated they were awakened in the early morning and middle of the night for medications, vital signs check (blood pressure, heart rate, amount of oxygen percentage in the blood, and temperature), and care of urinary device. Resident 12 stated they had told the staff about not wanting to be awakened at night, but no changes were made.Review of a facility psychosocial assessment and history, dated 12/24/2025 at 10:58 AM, documented Resident 12 complained about not getting enough sleep because staff were bugging them every two hours.Review of the Grievance Resolution Log for December 2025 showed no documentation or resolution to the concern about being awakened at night for Resident 12. Review of a facility form titled, [NAME] AT PACIFIC, dated 12/23/2025, under section of preferences, documented Resident 12 preferred to wake up at 11AM. Review of a quarterly MDS assessment dated [DATE], documented it was very important for the resident to choose their own bedtime routine. Review of Resident 12's Medication Administration Record from 05/01/2026- 05/13/2026 showed a physician order for a thyroid medication scheduled to be administered daily at 6AM. Review of Resident 12's V2 Survey Report (documentation of care provided) from 05/01/2026 to 05/13/2026 documented the night shift staff routinely drained the resident's urinary device at 12 AM (midnight) and 5 AM. In an interview on 05/14/2026 at 10:05 AM, Staff Z, NAC, stated that facility routine required staff to check residents' vital signs at the beginning of every shift at 6AM, 2 PM and 10PM. In an interview on 05/18/2026 at 10:47 PM, Staff D, Social Service Assistant, confirmed that no facility grievance had been generated regarding the sleeping concerns documented on the initial 12/24/2025 psychosocial assessment, and was not sure if any adjustment had been made to Resident 12's night-time care routine. In an interview on 05/18/2026 at 11:37 AM, Staff E, Registered Nurse/Nurse Manager, stated staff generally discuss resident preferences during care conferences. Staff E acknowledged that Resident 12's personal preferences were not being followed. In an interview on 05/18/2026 at 12:01 PM, Staff A, Administrator, stated that if a resident requested not to be awakened at night, the facility expectation was for the nurse manager to update the care plan, rearrange tasks, and adjust medication administration time to accommodate the resident's choices. Reference WAC 388-97-0900 (1)

Based on interview and record review, the facility failed to ensure speech therapy services were provided for 1 of 2 residents (Resident 91) reviewed for specialized rehabilitative services. This failure prevented residents from attaining and maintaining their highest practicable level of physical, functional and psycho-social well-being.Findings included.Resident 91 was admitted to the facility on [DATE] with diagnoses to include stroke. According to the admission Minimum Data Set (an assessment tool) dated 05/14/2026, the resident had intact cognition.In an interview on 05/12/2026 at 9:52 AM, Resident 91 stated they had not seen a speech therapist since they were admitted to the facility. According to the resident, they had to wait for the speech therapist to evaluate them first before they could upgrade the diet texture of their meals.Review of Resident 91's orders documented Speech Therapy evaluation and treatment for swallow and cognitive evaluation, order date 05/07/2026.Review of Resident 91's therapy service log matrix report with a print date of 05/13/2026 had no documentation of minutes for speech therapy.In an interview on 05/13/2026 at 1:12 PM, Staff Q, Resident Care Manager, stated when they received an order for a resident to see a speech therapist, the resident would normally be seen within 24-48 hours after the order was placed in resident's chart. Staff Q could not provide notes that Resident 91 was seen by speech therapist.In an interview on 05/14/2026 at 8:47 AM, Staff R, Rehab Director, stated after verifying the therapy (Physical Therapy/Occupational Therapy/Speech Therapy) order, they schedule the therapist to see the resident within 24-48 hours. Staff R confirmed that Resident 91 was not seen by speech therapist within 24-48 hours after the order was placed. Staff R stated they had no available speech therapist at that time. Staff R stated they did not inform the provider about the delay with speech therapist evaluating Resident 91. Refer to WAC 388-97-1280(1)(a)

Based on interview and record review, the facility failed to provide medically related social services and to advocate for 1 of 4 cognitively impaired residents (Resident 81) reviewed for advanced directives. The facility failed to advocate and educate the resident of legal options for an advanced directive and failed to identify other family that may be an alternative decision maker per state law which placed the resident at risk of not having their rights and wishes honored.Findings included.Resident 81 admitted to the facility on [DATE] with diagnoses to include fall with wedge compression fracture (spinal break where the front part the vertebrae collapse while the back remains intact) of the upper/middle back.Review of Resident 81's care plan dated 05/08/2026 documented they were primary language was Mandarin.Review of Resident 81's admission documents dated 05/01/2026, to include advanced directive options/information, showed they were all signed by their Collateral Contact 4 (CC 4) as Resident Surrogate.Review of Resident 81's preferences dated 04/30/2026 showed they were completed and signed by CC 4.In an interview on 05/15/2026 at 9:50 AM CC 4, Resident 81's daughter stated they had a brother and no other siblings, CC 4 stated Resident 81 had no power of attorney, no spouse, and had relied on them to make decisions for them as needed. CC 4 stated Resident 81 was cognitively intact and was able to make decisions, however they were used for translation needs.Review of Resident 81's progress notes dated 05/04/2026 documented an interpreter was used to conduct the brief interview for mental status (assessment used to determine memory loss) and scored 11/15 indicative of moderate cognitive impairment.In an interview on 05/15/2026 at 10:24 AM Staff CC, Social Services Director, stated they were aware Resident 81 had a son but did not have their contact information. Staff CC reported CC 4 and Resident 81 had lived together for many years and CC 4 had been wanting to take care of everything themselves, and Resident 81 had been a little confused.In review of Resident 81's progress notes dated 04/30/2026 through 5/12/2026 documented no discussions with Resident 81 about advanced directives, their preferences, or they had any other family members.Reference WAC 388-97-0960

Based on observation, interview and record review the facility failed to ensure 1 of 1 resident (Resident 55) reviewed for respiratory care received their physician ordered Continuous Positive Airway Pressure machine (CPAP -a machine that sends a steady flow of pressurized air into the nose and mouth to keep the airways open and helps you breath normally while sleeping). This failed practice placed the residents at risk of respiratory distress, lack of restful sleep and diminished quality of life.Findings included. According to facility policy titled Noninvasive Ventilation (CPAP, BiPAP, AVAPS, Trilogy) with revised date of 07/2025 documented, document use of the machine, resident's tolerance, any skin, respiratory or other changes and response(s).Resident 55 was admitted to the facility on [DATE] with diagnosis to include obstructive sleep apnea (disruption of breathing during sleep due to airway blockages).Review of Resident 55's physician orders documented CPAP to be on at bedtime and off in the morning, and to cleanse mask with mild soap and water, air dry every day. Order was dated 04/21/2026.In an observation and interview on 05/14/2026 at 12:10 PM, Resident 55's CPAP machine was not at their bedside. The resident stated that their CPAP was at their daughter's home and was not using it.Review of Resident 55's April and May 2026 Medication Administration Record and Treatment Administration Record (TAR) had no documentation of the order to put the CPAP on at bedtime and off in the morning however, cleaning of the CPAP mask daily was in the TAR, and it was signed daily by Licensed Nurses.In an interview on 05/14/2026 at 12:25 PM, Staff L, Certified Nursing Assistant, stated they had not seen a CPAP machine in Resident 55's room.In an interview on 05/14/2026 at 12:25 PM, Staff M, Licensed Practical Nurse stated that they had not seen the CPAP machine in Resident 55's room. Showed Staff M the May 2026 TAR that staff had been signing that they were cleaning the CPAP mask daily. Staff M looked at the TAR and responded, oh God and walked away. In an observation and interview on 05/14/2026 at 12:31 PM, Staff N, Social Services Assistant, stated Resident 55's CPAP machine was in their room. Observed Staff N looked inside the bedside table cabinet and then looked in the drawer by resident's closet and pulled out a plastic bag that had the resident's CPAP machine. Resident 55 stated they did not know that it was in there and had not been using their CPAP machine.In an interview on 05/14/2026 at 2:23 PM, Staff O, Resident Care Manager stated Resident 55's daughter took the CPAP machine home, and they were not aware that the daughter brought it back. They added that the resident had history of refusing to use the CPAP machine. Staff O could not provide documentation of resident's refusal to use the CPAP machine and documentation that staff had offered the resident to use the CPAP machine.Review of Resident 55 admission Minimum Data Set (MDS-an assessment tool) dated 04/28/2026 documented the resident used CPAP.In an interview on 05/18/2026 at 11:15 AM, Staff P, MDS Nurse, stated they could not find documentation that Resident 55 used their CPAP machine during the look back period and they will modify the MDS to reflect that. Refer to WAC 388-97-1060 (3)(j)(vi)

Based on observation, interview, and record review, the facility failed to ensure 1 of 2 sampled residents (Resident 44) reviewed for use and care of a catheter (a flexible tube inserted into the bladder to drain urine), received appropriate care and services, to minimize the risk of associated urinary tract infections. This failure placed residents at risk for discomfort, loss of dignity, continued urinary tract infections and other health complications.Findings included . Review of the facility policy titled, Catheter Care, reviewed 03/2026 documented the facility would ensure residents with indwelling catheters received appropriate catheter care. Resident 44 admitted to the facility on [DATE] with diagnoses to include acute prostatitis (severe bacterial infection in the prostate gland) and urine retention (inability to completely empty the bladder).Review of Resident 44's care plan, dated 04/29/2026, documented they had a catheter related to urinary retention with the goal for them not to have any catheter related trauma.Review of Resident 44's progress notes, dated 04/29/2026, through 05/12/2026 documented the following:-On 05/08/2026 a urine sample was collected to check urine osmolality (laboratory test that provides information on how well the kidneys are functioning).-On 5/11/2026 they were found to have blood-tinged urine in their catheter bag.-On 5/12/2026 they were found to have a fever; a urine sample was collected and sent to the laboratory.-On 05/13/2026 they were found to have a urinary tract infection (UTI) and was started on antibiotics.On 5/13/2026 at 10:40 AM Resident 44 was observed in their room, sitting upright in their wheelchair, the catheter tubing on the floor, and was dragging across the floor as they moved themselves in the wheelchair.In an interview on 05/13/2026 at 10:40 AM Resident 44 stated they had just been tested for a UTI and had fever yesterday.On 05/18/2026 at 10:50 AM, observed Resident 44 sitting upright in their wheelchair, with their catheter tubing resting on top of their left wheelchair wheel.In an interview on 05/18/2026 at 10:50 PM Resident 44 stated their catheter bag had recently been covered with the privacy bag, the catheter bag had often been left on the floor throughout their stay, and described a situation from a few nights prior that a staff had emptied the catheter bag, which was full, and overfilled the urinal causing urine to spill all over the floor, catheter bag and tubing.On 05/18/2026 at 10:54 AM, observed Staff BB, Nursing Assistant Certified, empty Resident 44's catheter. Staff BB was observed to unhook the catheter tubing from the wheelchair, take the catheter bag out of the privacy bag, and place it on the floor. Observed Staff BB place the urinal on its side, on the floor, open the catheter spout (without use of a surface disinfectant), and empty the contents of the catheter into the urinal. Staff BB then closed the spout (without the use of a surface disinfectant) on the catheter bag and place it into the privacy bag then they hung it back on the wheelchair.In an interview on 5/18/2026 at 11:00 AM, Staff BB stated space was limited and thus the reason for them to place the catheter bag on the floor. Staff BB stated it was difficult because Resident 44 was sitting in the wheelchair and if they were in their bed they could have used the bed frame to hold the catheter bag. When asked about using a disinfectant to clean the catheter bag spout before or after emptying the contents, Staff BB stated they do use a disinfectant sometimes, but not always.In an interview on 05/18/2026 at 11:08 AM Staff V, Licensed Practical Nurse/Nurse Manager stated the expectation of catheter care was for it to be completed every shift, the spout of the catheter bag to be disinfected, and the catheter tubing and catheter bag should never be on the ground.Reference WAC 388-97-1060(3)(c)

Based on observation, interview and record review the facility failed to provide a call light (a device to request help as needed) within reach for one of one resident (Resident 20) reviewed for call light accessibility and failed to ensure one of two residents (Resident 41) were comprehensively assessed and interventions implemented to prevent an avoidable fall with injury. These failures placed residents at risk for accidents, avoidable falls, and diminished quality of life.Findings included . Review of the facility policy titled, Call Lights: Accessibility and Timely Response revised 3/2026 documented their policy included the call system would be accessible to residents while in their bed or other sleeping accommodations within the resident's room.Review of the facility policy titled, Fall Risk Assessment revised 3/2026 documented it was the facility's policy to provide an environment free from accident hazards over which the facility has control, and provides supervision and assistive devices to each resident to prevent avoidable accidents. A fall risk assessment would be completed at admission to identify, evaluate, and analyze environmental hazards and individual risk, including the need for supervision. <RESIDENT 20>Resident 20 were admitted to the facility on [DATE] with diagnoses to include stroke affecting their left side.Review of Resident 20's Kardex (derived from the care plan with resident specific information/directions to provide care) as of 05/14/2026, documented under safety, to ensure their call light was within reach and encourage them to use if for assistance.In a continuous observation starting on 05/14/2026 at 10:30 AM Resident 20 was lying in their bed, their door open and their call light on the floor on the left side of their bed. At 10:36 AM Collateral Contact 1 (CC 1), provider for Resident 20, entered their room and then exited the room at 10:39 AM. In a brief interview with CC1, they stated they were the provider for Resident 20 and could not complete a visit as they wanted them to return tomorrow. CC 1 stated they did not observe Resident 20's call light on the floor. CC 1 left the area after the interview and did not reenter Resident 20's room. At 10:51 AM Staff S, Registered Nurse, and Staff T, Nursing Assistant Certified, walked past Resident 20's room while their call light remained on the floor. At 10:56 AM Staff U, Certified Occupational Therapy Assistant, knocked on Resident 20's door and explained they would be removing a piece of equipment from their bathroom. Observed Staff U remove and clean an over the toilet commode in Resident 20's doorway until 11:02 AM. At 11:23 AM Staff V, Licensed Practical Nurse (LPN)/Nurse Manager, entered Resident 20's room and informed them they were closing their door for a fire drill and closed their door. Staff V returned at 11:36 AM and opened Resident 20's door and picked up their call light from the floor and provided it to them. In an interview at 11:36 AM Staff V stated they were unaware Resident 20's call light was on the floor until they reentered their room after the fire drill.<RESIDENT 41>Resident 41 was admitted to the facility on [DATE] with diagnoses to include stroke with an affected right side and removal of brain tumor.In an interview on 05/12/2026 at 10:46 AM Resident 41 stated they had a fall while in the facility from rolling out of bed and suffered an abrasion to their head. Resident 41 stated they had been in a smaller bed and since the fall was placed in a larger bed. In an observation at 10:46 AM, Resident 41 was lying in a bariatric bed with bolsters to define the border of the mattress and fall mats on each side of their bed. Resident 41 stated they were left hand dominant.Review of Resident 41's hospital physical and occupational therapy (PT, OT) notes dated 04/04/2026, showed they were a fall risk and their bed was in the lowest position for safety.Review of Resident 41's hospital speech and language evaluation dated 04/01/2026 documented they were left hand dominant.Review of Resident 41's facility fall risk assessment dated [DATE], scored a 14, and documented they were a high fall risk. The assessment and accompanying progress note failed to fully identify, evaluate, and analyze environmental hazards and individual risk for Resident 41. Review of Resident 41's admission Care Area Assessment (used to create care plan) dated 04/21/2026 documented they were at risk for falls related to their incontinence. There was no input documented from family or residents and they were noted to have decreased balance, dependence on staff for assistance, and if they were to fall placed them at risk for further decline.Review of Resident 41's care plan for falls dated 04/10/2026 documented they were to have their call light within reach, assist them in keeping frequently used items in reach, ensure appropriate footwear when in their wheelchair, and their room close to the nurse's station for increased visibility.Review of Resident 41's PT notes dated 04/23/2026 documented they required maximum assistance from two staff for bed mobility.In an interview on 05/14/2026 at 3:30 PM Collateral Contact 2 (CC 2) stated they had been concerned about Resident 41's positioning in their bed and a week prior to the fall and had spoken to staff about positioning them in the middle of the bed. CC 2 stated they had asked about bed rails at the time and were told they were not allowed to use them.Review of the incident report dated 04/23/2026 documented Resident 41 rolled out of their bed onto the left side, hit their head and sustained an abrasion at 7:30 PM. The root cause analysis documented Resident 41 had been having involuntary movements which caused the fall. The witness statement by the aide that was assigned to and found Resident 41 documented they had repositioned them on their side and changed their brief prior to the fall at 6:15 PM. Interventions implemented after the fall included a bariatric mattress with perimeter (to have increased surface area to move), bed in lowest position, bolsters to define the sides of the mattress, and fall mats on each side of the bed. The investigation failed to determine which side Resident 41 was positioned and no other witness statements were included even though they required two-person assistance.Review of a grievance dated 04/17/2026 documented CC 2 had filled out a grievance regarding an observed transfer of Resident 41 from their wheelchair to their bed and the position in which Resident 41's was left, their head was pressed up against the headboard of the bed.Review of progress notes from 04/10/2026 through 05/12/2026 showed no documentation of involuntary movements as described in the incident report.In an interview on 05/18/2026 at 11:12 AM Staff V, LPN/ Nurse Manager stated they were not part of the investigation or admission process for Resident 41 and had no knowledge of the details related to their fall. Staff V deferred to Staff B, Director of Nursing Services.In an interview on 05/18/2026 at 12:22 PM and 2:51 PM Staff B stated they did not know which side Resident 41 was repositioned to prior to their fall, had consulted with the provider and there was no notation of involuntary movements or treatments for it, all residents were at risk for falls, Resident 41 was right hand dominant and was repositioned prior to their fall.Reference WAC 388-97-1060(3)(g)

Based on observation, interview, and record review, the facility failed to ensure quality of care were met for 1 of 2 residents (Resident 12) reviewed for vision, and 1 of 5 residents (Resident 84) reviewed for unnecessary medication review. The facility failed to place essential items including the call light and television remote control within the resident's unaffected vision field; failed to ensure physician-ordered parameters were followed for blood pressure medication administration. These failures placed the residents at risk for medication errors, unmet needs, and decreased quality of life. Findings included . <Resident 12>Resident 12 was admitted to the facility on [DATE] with diagnoses to included right side hemiplegia (paralysis of one side) and hemiparesis (weakness of one side) following cerebral infarction (stroke). According to the admission minimum data set assessment (MDS-an assessment of care needs), dated 12/30/2025, the resident was cognitively intact.In an interview and observation on 05/12/2026 at 10:46 AM, Resident 12 stated their left eye was blind and could not see items placed on their left side. Observed the resident's call light was placed beside their left upper arm; the television remote control was on the bedside table; and both the bedside table and the nightstand situated at the left side of the bed within the resident's left blind side. In an interview and observation on 05/13/2026 at 1:27 PM, Resident 12 asked the surveyor where their call light was located. Observed the call light lying on the bed to the resident's left. The resident reiterated that they could not see the call light when placed on their left side. Review of the initial admission nursing assessment dated [DATE] at 3:48 PM, documented Resident 12 had impaired vision due to left eye blindness. Review of Resident 12's care plan, initiated on 12/30/2025, documented the resident had impaired visual function related to left eye blindness. However, there was no corresponded intervention directing staff to position the call light and other essential items within the resident's unaffected right visual side. Review of Resident 12's admission MDS assessment, dated 12/30/2025, in visual function care area assessment, showed no documentation about left eye blindness, any contributing risk factors to the care, or clinical rationale to guide care planning. In an interview on 05/14/2026 at 12:36PM, Staff J, Nursing Assistant Certified, confirmed Resident 12 could not see their left side due to left eye blindness. Staff J stated they should place the call light, television remote control and other essential items on the resident's right side. In an interview on 05/15/2026 at 11:45 AM, Staff E, Nurse Manager, confirmed Resident 12 had an impairment of their left visual field and the care plan lacked instructions to position the call light and essential items on the right side. In an interview on 05/15/2026 at 12:47 PM, Staff B, Director of Nursing, stated that staff were expected to place all essential items, especially the call light, within the resident's unaffected visual field; and the intervention should have been documented in the care plan. <RESIDENT 84>Resident 84 was admitted to the facility on [DATE] with diagnoses to include high blood pressure.Review of Resident 84's from 05/01/2026 to 05/13/2026 MAR, showed a physician order for a blood pressure medication to be given twice a day. The order directed nurses to hold the medication for a heart rate below 60 beats per minute (bpm). However, the medication was administered when the resident's heart rate was below 60 bpm on the morning of 05/03/2026. Review of Resident 84's April 2026 MAR, showed the medication was administered when the resident's heart rate was below 60 bpm on the mornings of 04/17/2026, 04/18/2026, 04/25/2026, 04/26/2026, and the evenings of 04/13/2026 and0 4/25/2026. In a record review and interview on 05/15/2026 at 12:03 PM, Staff E, Nurse Manager, stated the nurse needed to follow the order instruction and hold the medication when the heart rate was below 60 bpm. In a record review and interview on 05/15/2026 at 12:47 PM, Staff B, Director of Nursing, stated the expectation was to follow the provider's order, to read the parameter, and to hold the medication if the parameter was out of range. Refer to WAC 388-97-1060(1)(3)(k)

Based on observation, interview and record review, the facility failed to ensure oral hygiene was performed for 1 of 1 resident (Resident 41) reviewed for Activities of Daily Living (ADLs). This failure placed the resident at risk for poor oral hygiene, dental complications, decreased self-esteem, and diminished quality of life.Findings included . Review of the facility policy titled, Activities of Daily Living (ADL's), reviewed 3/2026 documented, the facility would ensure residents would receive the care and services to include oral care based on their choices and comprehensive care plan. A resident who was unable to carry out activities of daily living would receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.Resident 41 was admitted to the facility on [DATE] with diagnoses to include stroke with an affected right side and removal of brain tumor.Review of Resident 41's care plan dated 04/10/2026 documented they were totally dependent on staff for oral care.Review of Resident 41's V2 Documentation Report (Nursing Assistant charting) for 05/01 through 05/17/2026 documented NA (Not Applicable) during evening shift on 05/03, 05/04, 05/07, 05/08, 05/09, 05/13, 05/14/2026 (total of 7 out of 18 opportunities on evening shift).In an interview on 05/12/2026 at 11:05 AM Resident 41 stated they were not always offered to brush their teeth. Resident 41 stated their preference was to brush their teeth twice daily and this was their routine at home prior to being hospitalized . Resident 41 stated they observed a toothbrush and toothpaste in a basin located above the sink in their room.In an interview on 05/14/2026 at 11:39 AM Resident 41 stated they had not had their teeth brushed since the night before last and had not been offered.In an interview on 05/18/2026 9:19 AM Resident 41 stated they had not brushed their teeth or been offered to for several days. Resident 41 stated they had eaten breakfast already and had not been offered to have their teeth brushed.In an interview on 05/18/2026 at 9:27 AM Staff W, Nursing Assistant Certified (NAC), stated oral care for residents was expected to be done at least once a shift, usually after meals. Staff W stated they encouraged Resident 41 to brush their teeth, required set up, and at times encouraged them to use mouthwash versus brushing their teeth. Staff W stated they had not offered Resident 41 oral care that day. Staff W stated they were unaware of Resident 41's routine prior to their admission regarding oral care and relied on information provided in the care plan.Reference WAC 388-97-1060(2)(c)

Based on interview and record review, the facility failed to notify the State PASRR (Pre-admission Screening and Resident Review-an assessment used to identify residents with Serious Mental Illness [SMI] or intellectual disabilities (ID) were not inappropriately placed in a nursing facility for long term care) Coordinator after a significant change in behavior status for 1 of 5 residents (Resident 40) reviewed for PASRR. This failure placed the resident at risk for unmet mental health services necessary to obtain the resident's highest level of psychosocial well-being and a diminished quality of life.Findings included.Resident 40 was initially admitted on [DATE] and most recently readmitted on [DATE].Review of Resident 40's Level 1 PASRR, dated 11/11/2024, showed no indicators of SMI or ID.Review of Resident 40's diagnosis list showed dementia with psychotic disturbance (decline in mental ability that often includes visual hallucinations or paranoid beliefs) was added on 08/13/2025.Review of Resident 40's quetiapine (medication to treat paranoia and/or hallucinations) physician order history showed medication was initiated on 08/28/2025.Review of the minimum data set (an assessment tool), dated 03/09/2026, documented that Resident 40's current behavior status was worse compared to the prior assessment.Review of Resident 40's electronic medical record (EMR) showed no record of an updated Level 1 PASRR.During an interview and record review on 05/14/2026 at 12:11 PM, Staff D, Social Service Assistant, stated if a resident had a change in behavior status or had a new diagnosis added for a mental health condition, a new Level 1 PASSR should be done. Staff D reviewed Resident 40's EMR and reported an updated Level 1 PASSR was not completed when they had a new diagnosis of dementia with psychotic disturbance and medication for that condition had been started. Refer to WAC 388-97-1975(9)

Based on observation, record review and interviews, the facility failed to ensure that 1out of 5 residents (Resident 84) reviewed for Preadmission Screening and Resident Review (PASRR - a federally required screening of all individuals for Intellectual Disability or Related Condition and a Serious Mental Illness prior to admission) process. The facility failed to incorporate PASRR Level II recommendations into the comprehensive care plan and failed to implement individualized activities to meet the resident's specialized behavioral health needs. This failure placed the resident at risk for psychological decline, unmet psychosocial needs, and lack of specialized services. Findings included. Review of the facility policy titled, Resident Assessment -Coordination with PASARR (PASRR) Program, revised date 04/2025, documented any recommendations included specialized services, from a PASARR level II determination and/or PASARR evaluation report would be incorporated into the resident's assessment, care planning, and transitions of care. Resident 84 was admitted to the facility on [DATE] with diagnoses to include bipolar disorder (a mental health condition characterized by extreme, cyclical shifts in mood, energy, and activity levels). Review of Resident 84's PASRR Level II Initial Psychiatric Evaluation Summary, dated 08/14/2025, documented under the sections of Recommendations for Nursing Facility and Activities that Resident 84 had specific specialized preferences for artwork including drawing, painting and Play-Doh. Review of Resident 84's care plan, initiated on 07/03/2025, showed no interventions that Resident 84 did artwork for activity. In an interview on 05/15/2026 at 9:43 AM, Staff AA, Activity Assistant, confirmed that Resident 84 was not provided with individualized artwork activities. In an interview on 05/15/2026 at 9:53 AM, Resident 84 stated they really liked artwork, painting, drawing and Play-Doh, but there was not much in the facility. The resident stated they needed more supplies and assistance to set up. In an interview on 05/15/2026 at 10:11 AM, Staff X, Director of Activity, confirmed that Resident 84 did not have individualized art activities structured and did not engage in drawing, painting or Play-Doh. Staff X stated the resident attended general group ceramics occasionally and stated they were unaware that Resident 84 had specific PASRR activity recommendations or documented preferences. In an interview on 05/15/2026 at 12:13 PM, Staff D, Social Service Assistant, stated they forwarded PASRR Level II evaluations to other departments via email upon receipt. Staff D stated PASRR Level II recommendations should be implemented into the resident's care plan. Refer to WAC 388-97-1975(8)(10)

Based on interview and record review the facility failed to coordinate Home Health (HH) services, provide a medication list, and complete discharge instructions for 1 of 3 sampled residents (Resident 1) reviewed for discharges. Failure to arrange HH services and provide a medication list placed residents at risk of unmet care needs, and diminished quality of life. Findings included . Review of a facility policy titled DISCHARGE OF A RESIDENT, last reviewed on January 25th, 2025, showed: Discharge to lesser level of care (home/ALF/AFH) 3. Nurse manager and social services will complete Discharge Instruction Form in PCC to include: any follow up appointments, pharmacy to pick up prescriptions, DME ordered, HH services ordered, any special instructions for the patient after discharge and a summary of their stay. Additionally, a complete list of their medications will be provided. -On the day of the patient's discharge: a. Discharge Instruction Form and completed medication list will be reviewed by a licensed nurse with the patient and family representative (if present) and signed by patient or representative accompanying the patient. c. A copy of the signed discharge instruction and medication list is kept with their medical record. <RESIDENT 1> Resident 1 admitted to the facility on [DATE] with diagnoses including subluxation (partial dislocation) of left shoulder, history of falling, difficulty walking, and chronic pain. Review of Resident 1's medical record showed they required set up for showers and supervision for walking. Review of the medical provider Discharge summary dated [DATE], documented Resident 1 would discharge home with HH services for physical and occupational therapies and Registered Nurse (RN) services. Review of an assessment titled Discharge Instructions Form dated 04/25/2025, documented Resident 1 would have HH services for physical therapy and nursing but did not include any HH agency or contact information. Review of Resident 1's medical record did not show a physician signed medication list. In an interview on 06/09/2025 at 12:55 PM, Staff C, RN, stated Social Services (SS) was responsible for arranging HH services. Staff C stated that the floor nurse on duty will review the discharge instruction form and ensure that the HH information is documented to include name of the HH company, phone number, and what services were ordered and if that information is missing SS would be notified. Staff C stated the nurse would review medications with the resident or resident representative at the time of discharge and send the medication list with the resident, and copies would be scanned into the resident's medical record. In an interview and record review on 06/09/2025 at 1:27 PM, Staff D, Licensed Practical Nurse, nurse manager, stated SS arranges HH services. Staff D stated the day before a resident is scheduled to discharge, they would review the discharge form and make sure it was completed and on the day of discharge the floor nurse would review the discharge form to make sure it was complete. Staff D stated that there was no documentation of an HH company or contact information listed for Resident 1's discharge. In an interview on 06/09/2025 at 1:39 PM, Staff E, SS Assistant, stated SS would send information to the HH company to coordinate care after discharge. Staff E stated HH information would be documented on the Discharge Instruction Form. Staff E stated they were not working at the facility at the time of Resident 1's discharge. In an interview and record review on 06/09/2025 at 2:50 PM, Staff B, RN, Director of Nursing, stated when a resident discharges from the facility, the Discharge Instruction Form would be completed. Staff B acknowledged the Discharge Instruction Form for Resident 1 was incomplete, and the HH agency information was not documented. Staff B stated they would attempt to find documentation of a signed medication list and documentation that HH services had been arranged for Resident 1. Staff B was unable to provide any further information or documentation. Reference WAC 388-97-0120(3)(a)

Based on interviews and record review, the facility failed to ensure medically related social services were provided for 8 of 8 residents (Residents 20, 28, 39, 277, 278, 324, 325, and 329) reviewed for social services. The facility failed to ensure residents received support with care planning process (Residents 28, 39, 325, and 329), failed to ensure residents were provided support to formulate their advanced directive options (Residents 325, and 329), failed to ensure residents received support with discharge planning (Residents 277, and 278), and failed to ensure referrals and recommendations for appropriate mental health services were completed (Residents 20 and 324). This failure placed residents at risk of unmet social service needs, unsafe care, psychosocial decline, and a diminished quality of life. Findings included . <RESIDENT 20> Resident 20 admitted to the facility on [DATE] with diagnoses that included depression, and insomnia. The Admission Minimum Data Set (MDS- an assessment tool) dated 03/04/2025 showed the resident had moderately impaired cognition, with moderate depression. Review of Resident 20's progress notes, on 03/28/2025 the resident had been seen for a psychological evaluation and recommendations of treatment and follow-up care. Review of Resident 20's medical record on 04/15/2025 no update to the plan of care had been completed by social services related to the resident mental health recommendations and approaches. <RESIDENT 28> Resident 28 admitted to the facility on [DATE], diagnoses that include Alzheimer's, and cognitive communication deficit. The quarterly MDS dated [DATE], showed the resident had sever impaired cognition. In a phone interview on 04/15/2025 at 2:13 PM, Collateral Contact (CC) 1 stated they were the power of attorney for Resident 28. CC1 stated in the past, they had received regular communication with the facility on updates, and plan of care for Resident 28, lately they have not had any. CC1 stated they had requested a care conference and updates with the previous social services and were told that unless something was wrong, they would not be able to provide regular updates to them. CC1 stated Resident 28 has been declining, losing weight and they were really worried about them. Review of Resident 28's medical record on 04/15/2025, the resident had a care conference document dated 10/21/2024, the form was blank and not completed. The last documented care conference for Resident 28 was dated 06/26/2024. Review of Resident 28's care plan on 04/15/2025 showed a focus area revised on 06/20/2024 that the resident and family wished the resident to remain at the facility with an intervention that staff will offer care meetings and reviews as the family desires in addition to quarterly, annually and any change in conditions. <RESIDENT 39> Resident 39 admitted to the facility 05/15/2024 with diagnoses that included major depression, cognitive communication disorder (difficulty communicating), and osteoarthritis (inflammation and pain to joints) in both hands. The quarterly MDS dated [DATE] documented that the resident had intact cognition, with moderate depression In an interview on 04/15/2025 at 1:49 PM, Resident 39 stated they have been trying to get assistance from social services regarding a letter that they received from Medicaid. Resident 39 stated they have tried to write back to them, but the pain in their hands just will not allow them to write anymore. Resident 39 expressed they were frustrated and worried. Resident 39 was asked if they had told anyone they needed to speak with social services, they stated they tell the nurse all the time, I don't think we even have one anymore. The resident stated they had not had a care conference for a long time. Review of Resident 39's medical record on 04/15/2025, there were no care conferences documented in the last 6 months. Review of the facility assessment dated [DATE] documented that the facility average census was 72 residents. The average weekly admissions and discharges were six to eight. The facility requires a social services director and assistant to manage the resident case load and requirements to meet their needs. In an interview on 04/17/2025 at 11:38 AM, Staff B, Director of Nursing Services (DNS) stated the social service director and assistant were no longer employed at the facility and they were currently interviewing for new candidates. They are receiving some support from another facility for social services tasks. In an interview on 04/17/2025 at 2:15 PM, CC 2 stated they were from another facility and were assisting with social work tasks. CC2 stated they were doing there best to assist and help cover things. 50725 <RESIDENT 277> Resident 277 was admitted to the facility on [DATE]. According to the quarterly MDS, dated [DATE], resident had moderate cognitive impairment. In an interview on 04/15/2025 at 3:39 PM. Resident 277 stated that they had a care conference once but nobody from the facility had updated them regarding their discharge (dc) plan. Review of Resident 277's Electronic Health Record (EHR), under progress notes for Social Services showed on 04/02/2025, it stated that resident's payor changed to Medicaid effective 04/05/2025 and that niece was notified. The other note from Social Services dated 03/27/2025 stated, referral was made to Case Worker for an Adult Family Home (AFH) Assessment. There were no other notes regarding resident's dc plan. In an interview on 04/18/2025 at 10:50 AM, Staff E, Licensed Practical Nurse (LPN)/Resident Care Manager (RCM) stated that they were not assigned to the 3rd floor as the RCM but was only there to orient a newly hired RCM. They added that one Social Worker (SW) no longer works at the facility and the other SW was on emergency leave so the SW's from another facility were helping them. Staff E stated that Resident 277's discharge plan was to go to an AFH, but they were waiting on the assessment from DSHS. Staff E was not sure why resident was not updated regarding the dc plan. They will go and talk to the resident to update them. <RESIDENT 278> Resident 278 was admitted to the facility on [DATE]. According to the admission MDS, dated [DATE], resident had moderate cognitive impairment. In an interview on 04/15/2025, Resident 278 stated they were worried about when the facility will start taking money from her. They had not been updated about their discharge plan. Review of Resident 278's EHR under progress note for Social Services dated 04/07/2025, documented: Discharge 04/10/2025. Daughter is figuring out who will pick up. Also called Case Worker about Caregivers. Daughter will call too. No other notes from Social Services after this. In an interview on 04/21/2025 at 10:24 AM Staff B, DNS stated that dc planning process was challenging at this time due to changes in the Social Services Department. Every Wednesday, their team review residents and determine who will be able to dc back to the community, they review the therapy notes and if a resident plateau, and no nursing needs they initiate dc plan. Staff B stated, SW from another facility were helping them with the dc process. Staff B stated they will investigate Resident 278's dc plan. 51551 <RESIDENT 324> Resident 324 admitted to the facility on [DATE] with a diagnosis of recurrent and unspecified major depressive disorder (constant feeling of sadness). According to the MDS assessment dated [DATE], Resident 324 had a diagnosis of depression and was using antidepressant. Review of April 2025 Medication Administration Record showed Resident 324 had been taking an antidepressant medication daily started from 04/03/2025. Review of Resident 324's Level I PASARR (Preadmission Screening and Resident Reviews -an assessment to ensure individuals with Serious Mental Illness [SMI] or intellectual/Developmental Disabilities [ID/DD]) dated 04/01/2025, showed no level II evaluation referral because of no depression marked under SMI indicator. In an interview on 04/18/2025 at 09:35 AM, Staff E, Licensed Practice Nurse/Resident Care Manager, social services reviewed PASARR forms for accuracy and update if necessary. In an interview on 04/22/2025 at 10:24 AM, Staff B, Director of Nursing, stated Resident 324's level I PASRR was not accurate and should be reviewed, updated and sent for level II evaluation prior to admission. <RESIDENT 325> Resident 325 admitted to the facility on [DATE]. According to the Admission Minimum Data Set (MDS-an assessment tool) assessment dated [DATE], Resident 325 had minimal cognitive impairment. In an interview on 04/15/2025 at 12:10 AM, Resident 325 stated they were not sure about their discharge planning. Resident 325 stated they were not told of a care plan meeting. Review of Resident 325's electronic health record (EHR) showed no documentation about the initial care planning conference. Review of Resident 325's electronic health record (EHR) showed no AD documentation or Resident 325 had been provided with assistance to formulate an AD. Review of Resident 325's care plan, print date 04/20/2025 did not document a focus area addressing an AD or discharge planning. <RESIDENT 329> Resident 329 admitted to the facility on [DATE]. According to the admission nursing assessment dated [DATE], Resident 329 was alert and oriented. In an interview on 04/15/2025 at 11:31 AM, Resident 329 stated they were not told of a care plan meeting and were not involved in discussions regarding the goals of their person-centered care and not sure about their discharge planning. Review of Resident 329's EMR since admission to 04/17/2025, revealed no correlating documentation of any interdisciplinary care plan meeting with the resident. Review of Resident 329's electronic health record (EHR) showed no AD documentation or Resident 329 had been provided with assistance to formulate an AD. Review of Resident 329's care plan, dated 04/20/2025, revealed no focus area of addressing discharge planning or AD. In an interview on 04/18/2025 at 9:35 AM, Staff E, Licensed Practical Nurse/Resident Care Manager, stated social service was responsible for arranging initial care plan meetings for newly admitted residents during the first 72 hours. Staff E stated the social service would follow up on AD during the first initial care conference as well. Staff E stated the social service should document the initial care plan meeting in electronic health record. In a record review and interview on 04/22/2025 at 10:24 AM, Staff B, Director of Nursing, stated they expected social service to set up the first initial care plan meeting within three days of admission and to follow up on AD during the first initial care conference. Reference WAC 388-97-0960(1) This is a repeat deficiency from 06/12/2024.

Based on interview and record review the facility failed to have a system in place that ensured grievances were addressed and resolved in response to residents' verbal conveyance of concerns for 2 of 3 resident council's (February and March 2025), who verbalized complaints during a Resident Council (RC) meeting and failed to follow the grievance process for 2 of 2 residents (Resident 12 and 35) who voiced grievances. These failures led to residents repeatedly reporting the same care issues without resolution and placed them at risk of feeling frustrated, unimportant, with diminished self-worth and decreased quality of life. Findings Included . Review of the facility policy titled Resident and Family Grievances dated October 2024 showed the social services director was designated as the Grievance Official and was responsible for overseeing the grievance process. The grievance procedure showed staff members who received the grievance would record the nature and specifics of the grievance on the designated grievance form and a written decision regarding the grievance would be provided at the conclusion of the investigation. All staff involved in the grievance investigation or resolution should make prompt efforts to resolve the grievance. Prompt efforts include acknowledgment of complaint/grievances and actively working toward a resolution of that complaint/grievance. <RESIDENT COUNCIL> Review of resident council minutes for February and March 2025 showed there were complaints of the garbage not being routinely emptied in their rooms. There was no documented resolution to this grievance. Review of resident council minutes for March 2025 showed there were several residents who inquired as to the time frame of the refresh (painting) of resident rooms. There was no documented resolution to the question. There were other residents who voiced concern/request to have their rooms picked up and clothing put away by the nursing assistant staff. There was no documented resolution. In an interview on 04/16/2025 at 2:41 PM Staff S, Activity Director, stated if there is a grievance or an issue that is brought up in Resident Council then they would do a grievance but if it was something for like maintenance, they would write a note and give it to maintenance. Staff S stated they discuss grievances in the morning meetings. <RESIDENT 35> Resident 35 admitted to the facility on [DATE] with diagnoses to include depressive disorder and high blood pressure, and atrial fibrillation (rapid/irregular heartbeat). In an interview on 04/16/2025 at 10:02 AM Resident 35 stated their [NAME] blanket had been missing almost a year and was given to them by their family member. Resident 35 stated they had told their nursing aide (NAC) at the time, Collateral Contact 3 (CC3) and they looked everywhere for the blanket and were not able to find it. Resident 35 stated the blanket had not ever been returned to them and they had not been reimbursed or replaced. In a review of the grievance logs from October 2024 through March 2024 showed no entries related to Resident 35. In an interview on 04/17/2025 at 11:30 AM Staff A, Administrator, stated they were unable to find any grievances related to Resident 35 and would initiate one for their missing blanket. In an interview on 04/21/2025 at 10:25 AM CC3, Resident 35's previously assigned NAC, stated they recalled Resident 35 missing two blankets: a gray one and a blue one. CC3 stated they were able to locate the gray blanket but not the blue blanket. CC3 stated they informed the nurse manager at the time. CC3 stated they did not fill out a grievance form related to the missing blue blanket and would have only done so if the resident needed the item replaced right away or was upset over it. 51551 <RESIDENT 12> Resident 12 readmitted to the facility on [DATE] with diagnoses to include bilateral osteoarthritis of hips (a degenerative joint disease affects both side of hips) and morbid obesity with alveolar hypoventilation (a severe form of obesity leads to chronic inadequate breathing). According to the annual Minimum Data Set (MDS - an assessment tool) assessment, dated 03/18/2025, the resident had moderate cognitive impairment, both upper and lower extremities impairment and was dependent on shower and bathe. Review of resident council meeting minutes, date 02/26/2025, documented Resident 12 complained they had not received a shower for four weeks. The meeting minutes also documented the grievance form was completed and sent to social services. Review of Resident 12's grievance form date 02/26/2025, documented the resident had not had a shower for four weeks for a variety of reasons which included no staff available and no shower chair available. Under grievance resolution, it documented shower to be given on 02/27/2025 and if Resident 12 missed a shower in the morning would be reoffered for the evening shift or other day by different staff. The date of resolution was 02/27/2025. Review of the electronic health record (EHR) showed Resident 12 had no documentation the resident had received a shower on 02/27/2025. In an interview on 04/21/2025 at 9:07 AM, Resident 12 stated they did not have a shower on the following day but waited for a couple of weeks after they complained during the resident council meeting. Resident 12 stated they were told the facility had no shower aide and no shower bench available. In a record review and interview on 04/21/2025 at 10:24 AM, Staff B, Director of Nursing, stated the expectation of grievance resolution should occur within 24 to 48 hours if it occurs on a weekend. Staff B stated the shower record showed Resident 12 did not receive a shower until 03/04/2025 (7 days after the grievance occurred). Staff B stated the resident should not have had to wait that long to receive a shower. Reference WAC 388-97-0460(2)

Based on interview and record review, the facility failed to ensure residents were informed in writing of their potential liability for payment related to Medicare services ending for 1 of 3 sampled residents (Resident 45) reviewed for Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). This failure placed the residents at risk of not having adequate information to make care and financial decisions during their continued stay. Findings included . Resident 45 was admitted to the facility and was receiving skilled services under their Medicare Part A benefit. Review of the most recent Minimum Data Set assessment (a required assessment tool) dated 03/09/2025 (end of Med A stay) showed the resident had mild cognitive impairment. The resident record showed they had an Advance Directive in place designating Collateral Contact 5 (CC5) as their representative. Review of Resident 45's record documented a Notice of Medicare Non-Coverage (NOMNC) was communicated by phone to CC5 on 03/07/2025, which informed the resident and the representative that skilled nursing services would end on 03/09/2025. The notice informed the resident Medicare would probably no longer cover skilled services, and they may have to pay for any services occurring after 03/09/2025. Further review of the record documented the SNF/ABN was not issued to the resident or representative as required. This form would have explained the amount the resident would be liable to pay if they remained in the facility for long-term care after 03/09/2025. In an interview on 04/18/2025 at 12:21 PM, CC5 was in Resident 45's room visiting, and stated the facility had called them and stated the resident was done with therapy and would be transitioning off of Medicare. CC5 stated they were not told about the right to appeal that decision, and they were not told about any other specific costs or asked to sign any forms. CC5 stated they came to visit every week and would have been available. Resident 45 confirmed that they prefer CC5 to be the one to sign forms for them. In an interview on 04/18/2025 01:56 PM, Staff A, Administrator, stated the forms should be provided to the resident or representative in person when possible, and if they were communicated by phone, the facility should still provide a copy by mail or email, and obtain a physical signature as soon as possible. Staff A stated Resident 45 should have been provided with both the notice of non-coverage and the ABN notice. Reference WAC 388-97-0300 (1)(e)(5)(6)

Based on interview and record review, the facility failed to ensure an advance directive (a written instruction, such as a living will or Durable Power of Attorney [DPOA] for health care [a document delegating to an agent the authority to make health care decisions in case the individual delegating the authority subsequently becomes incapable to do so]) was obtained and completed for 3 of 24 residents (Residents 325, 329 and 55), reviewed for advance directives. This failure placed the residents and/or their representatives at risk for losing their right to have their preferences honored to receive or refuse/discontinue care according to their choice. Findings included . Review of the facility policy titled, Advance Directive Policy and Procedure, dated 2017, showed the Social Services, at the time of admission, will ask if there are any current Advance Directives. If so, copies will be obtained and placed in the resident's chart under the admission tab and scanned into PC documents. <RESIDENT 325> Resident 325 was admitted to the facility on [DATE]. According to the Admission Minimum Data Set (MDS-an assessment tool) assessment dated [DATE], the resident had minimal cognitive impairment. Review of Resident 325's medical record document titled Advance Directive Receipt of Information in admission package dated 04/16/2025 documented Resident 325 was unsure if they had a living will or directive to physician. Review of Resident 325's electronic health record (EHR) showed no AD documentation or Resident 325 had been provided with assistance to formulate an AD. Review of Resident 325's care plan, print date 04/20/2025 did not document a focus area addressing an AD. <Resident 329> Resident 329 admitted to the facility on [DATE]. According to the admission nursing assessment dated [DATE], Resident 329 was alert and oriented. Review of Resident 329's medical record document titled Advance Directive Receipt of Information in admission package dated 04/15/2025 documented Resident 329 had no Durable Power of Attorney and was unsure if they had a living will or directive to physician. Review of Resident 329's electronic health record (EHR) showed no AD documentation or that the resident had been provided with assistance to formulate an AD. Review of Resident 329's care plan, print date 04/20/2025 did not document a focus area addressing an AD. In an interview on 04/16/2025 at 11:23 AM, Staff K, Medical Records stated they could not locate any AD documentation in Resident 329's EHR. <RESIDENT 55> Resident 55 was admitted to the facility on [DATE]. According to the quarterly MDS assessment dated [DATE], the resident had moderate cognitive impairment. Review of Resident 55's medical record document titled Advance Directive Receipt of Information in the admission packet dated 10/03/2024, showed that the resident had a DPOA. Review of Resident 55's EHR showed no copy of the DPOA form. Review of Resident 55's care conference notes dated 10/08/2024 showed no mention of AD or DPOA. In an interview on 4/17/2025 at 3:10 PM, Staff C, Assistant Director of Nursing Services stated that they were not able to find any documentation regarding resident's DPOA. They stated that Social Services were supposed to follow up on AD. In an interview on 04/18/2025 at 9:35 AM, Staff E, Licensed Practical Nurse/Resident Care Manager, stated the admission staff asked resident and/or family to bring in the AD during admission and the AD would be uploaded into EHR once the facility received it. Staff E stated if there was no AD, the social service would follow up during the first initial care conference which happened the first 72 hours after admission. Staff E stated they were not sure why no AD documentation. In a record review and interview on 04/22/2025 at 10:24 AM, Staff B, Director of Nursing, stated they could not find copy of AD copy or information/documentation that an AD was reviewed or residents were assisted in formulating an AD for Resident 325 and Resident 329 in their EHRs. Staff B stated they expected the admission nurse to request a copy of AD and upload it into EHR once received and social services would follow up during the first initial care conference within the first three days of admission. This is a repeat deficiency from 06/12/2024. Reference WAC 388-97-0280 (1) (3)(a)(c)(ii)

Based on interview and record review, the facility failed to ensure residents and/or their representatives were offered the opportunity to participate in care conferences (a collaborative care plan meeting where a resident's care is discussed and coordinated by a team of health care providers, family members and residents) for 2 of 6 sampled residents (Residents 325 and 329) reviewed for participation in care planning. This failure placed residents at risk of not being allowed to be involved and informed about care and services and a diminished quality of life. Findings included . Review of the facility policy titled, Care Planning-Resident Participation, revised date January 2025, documented the facility will encourage and assist the resident and/or resident representative to participate in choosing care and treatment options including initial decisions about treatment .The facility will honor the resident's right to participate in establishing the expected goals and outcome of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care. <RESIDENT 325> Resident 325 was admitted to the facility on [DATE]. According to the Admission Minimum Data Set (MDS-an assessment tool) assessment dated [DATE], the resident had minimal cognitive impairment. In an interview on 04/15/2025 at 12:10 PM, Resident 325 stated they were not sure about their discharge planning. The resident stated they were not told of a care plan meeting and were not involved in discussions regarding their person-centered care and unsure what the goal was for their care. Review of Resident 325's Electronic Medical Record (EMR) since admission to 04/20/2025, documented no correlating documentation of any interdisciplinary care plan meeting with the resident or representative to discuss the initial comprehensive admission care plan or to establish resident specific goals of care or initiate discharge planning. Review of Resident 325's care plan, dated 04/20/2025, documented no focus area addressing discharge planning. <RESIDENT 329> Resident 329 was admitted to the facility on [DATE]. According to the admission nursing assessment dated [DATE], the resident was alert and oriented. In an interview on 04/15/2025 at 11:31 AM, Resident 329 stated during admission, no one explained to them about their medications, treatment or care. The residenrt stated they were not told of a care plan meeting and were not involved in discussions regarding the goals of their person-centered care and not sure about their discharge planning. Review of Resident 329's EMR since admission to 04/17/2025, documented no correlating documentation of any interdisciplinary care plan meeting with the resident or representative to discuss the initial comprehensive admission care plan or establishing resident specific goals of care or initiating a discharge planning. Review of Resident 329's care plan, dated 04/20/2025, revealed no focus area addressing discharge planning. In an interview on 04/18/2025 at 9:35 AM, Staff E, Licensed Practical Nurse/Resident Care Manager, stated social service was responsible for arranging the initial care plan meetings for newly admitted residents and the initial care plan meeting was supposed to be conducted with the resident and/or their resident representatives and multidisciplinary team during the first 72 hours. Staff E stated the initial care plan meeting should be documented under assessments in EMR and they were not sure why there was no documentation of the initial care plan meeting for Resident 329. In a record review and interview on 04/22/2025 at 10:24 AM, Staff B, Director of Nursing, stated they reach out to residents and/or their representatives to set up the initial admission care plan meeting within the first three days. Staff B stated the initial care plan meeting included discussing the resident and family's needs, the baseline functional level, the goals of care and discharge planning. Staff B stated they could not see the documentation of the initial care plan meetings for Resident 325 or Resident 329 during the first three days of admission. Reference WAC 388-97-1020 (2)(f)(4)(d)(e)

Based on observation, interview, and record review, the facility failed to assess dietary preferences, maintain accurate documentation of nutritional intake of meals and supplements, consistently offer substitutes or replacement meals when residents ate less than 50% of a meal, notify the physician of significant weight loss, perform consistent and accurate weights, assess and offer culturally appropriate meals, and follow and update care plans as needed, for 1 of 2 sampled residents (Resident 46) reviewed for nutrition/weight loss. Resident 46 experienced severe weight loss of 11.8% weight loss in 34 days. This failed practice placed residents at nutritional risk and diminished quality of life. Findings included . Review of the State Operations Manual, Appendix PP - Guidance to Surveyors for Long Term Care Facilities, dated 02/03/2023, defined severe weight loss greater than five percent in one month, and greater than 7.5% in three months. Review of the facility policy titled, Weight Monitoring, dated 05/01/2024, showed, facility to accurately assess weight on admission, create a care plan to include resident's goals and preferences, monitor and modify interventions appropriately according to resident's preferences and goals, and professional standards in nutritional status, communicate care instructions to staff and notify physician for any significant weight changes. Significant weight changes defined as: five percent change in weight in one month, 7.5 percent change in weight in three months and ten percent change in weight in six months. Review of the facility policy titled, Nutrition/(Impaired)/Unplanned Weight Loss-Clinical Protocol, dated September 2017, showed the staff to report to the physician any significant weight loss, the nursing staff to monitor and document weight and dietary intake of residents in a format that shows comparison over time, staff and physician to identify resident's risk for impaired nutrition, and identify interventions based on causes and overall condition, prognosis and wishes of the resident. Resident 46 admitted to the facility on [DATE] with diagnosis to include sepsis (life threatening complications of an infection), urinary tract infection, diabetes, muscle wasting, and atrophy (partial or complete wasting away of a part of the body). According to the Admission Minimum Data Set (an assessment tool) assessment, dated 05/05/2024, the resident had no cognitive impairment, and could feed themselves after setup assistance. Review of the physician's History and Physical, dated 04/30/2024, showed Resident 46's weight was 200.2 (no units given) on 04/30/2024. The review of Resident 46's weights (a mechanical lift was used to obtain the resident's weight) showed: - On 04/29/2024, there was no admission weight documented. - On 05/01/2024 at 1:24 PM, the resident weighed 193.1 lbs. - On 05/13/2024 at 7:32 AM, the resident weighed 182.0 lbs., a weight loss of 11.1 lbs. in 12 days. - On 05/29/2024 at 1:41 PM, the resident weighed 174.0 lbs., a significant weight loss of 19.1 lbs. or 9.9% in four weeks. - On 06/04/2024 at 7:53 AM, the resident weighed 170.2 lbs., a significant weight loss of 22.9 lbs. or 11.9% in about five weeks. Review of a dietician's weight change note, dated 06/06/2024, showed: -Resident 46's current weight was 170.2 lbs. -The resident's weight continued to trend down in the past week from 173 lbs. (05/30/2024), and an overall weight loss from 193.1 lbs. (05/01/2024). -Recommended to notify the physician of the significant weight loss of 12% in one month. -The resident's weight changes likely due to scale differences with moves to different units, weight methods and measurement differences and variable meal intakes. Review of the resident's weight record, dated 04/29/2024 to 06/04/2024, showed 13 out of 16 weights, Resident 46 was weighed using a mechanical lift. Reviewed of Resident 46's care plan for nutrition, dated 06/06/2024, showed an intervention to notify the physician for weight loss of more than three lbs. in one week, more than five percent of their body weight in one month, and to weigh the resident at the same time of day. The care plan did not identify any food preferences for the resident. In an interview on 06/05/2024 at 2:59 PM, Resident 46 stated they received the same food all the time and they felt they had lost weight. Resident 46 stated they had experienced weight loss from 215 lbs. (pounds) to 170 lbs. in three weeks. In an observation and interview on 06/07/2024 at 1:03 PM, Resident 46 in bed with their lunch tray in front of them and untouched, there was an unopen carton of chocolate health shake observed next to their plate. They stated their weight loss was making them lose their strength. The resident stated they were from another country and had specific food preferences that they were not receiving at the facility. In an interview on 06/07/2024 at 2:29 PM, Resident 46 was asked about why they did not drink the chocolate shake, they stated it was too sweet and they preferred vanilla. Resident 46 stated that staff had not asked them about their food preferences. Review of the Medication Administration Record, dated 06/07/2024, showed the licensed nurse had documented Resident 46 consumed 100% of their health shake for lunch on 06/07/2024. In an interview on 06/07/2024 at 2:24 PM, Staff P, Licensed Practical Nurse (LPN), was asked about the health shake documentation that was on Resident 46's lunch tray and was observed unopened. Staff P stated that they gave Resident 46 a health shake that morning and resident drank 237 milliliters and counted that for lunch. Staff P stated they would go give the resident the health shake right now. In an interview on 06/10/2024 at 9:03 AM, Staff Q, Dietary Manager, was asked how they assessed residents' food preferences. Staff Q stated the nurse aides were good about informing them of residents' food preferences. In an interview on 06/10/2024 at 9:06 AM, Staff R, Dietician, stated the Resident Care Manager (RCM) were the ones that notified the physician regarding any weight loss and if they notice weight loss, they will start the resident on a health shake which comes on the resident's tray. In an interview on 06/10/2024 at 9:20 AM, Staff M, LPN/RCM, stated they had not notified Resident 46's physician regarding their weight loss. They have interdisciplinary meetings every Thursdays, where they review residents' weights, attendees were RCM, Dietician, and the Director of Nursing Services (DNS). In an observation/interview on 06/11/2024 at 8:50 AM, Resident 46 stated they only ate a small amount of their breakfast because they did not like the food. The resident stated they liked black beans. Resident 46 stated they ate one piece of bacon and one of the three pancakes. The pancake syrup, butter, salsa, and chocolate health shake were observed unopened on the tray. When asked about the health shake, the resident stated they did not like chocolate, so they told the staff to not even open it as they preferred vanilla. In an observation and interview on 06/11/2024 at 9:05 AM, Staff L, Nursing Assistant Certified (NAC), was observed to pick up Resident 46's breakfast tray and did not offer the resident any alternate/replacement food when they had not eaten more than 50% of their meal. Staff L was asked about not offering the resident an alternate or a meal replacement when they had eaten less than 50% of their breakfast, Staff L stated they felt the resident had eaten enough so they did not ask them. Review of Resident 46's breakfast meal intake in electronic chart, dated 06/11/2024, showed staff documented the resident consumed 75-100% of their meal. In an interview on 06/11/2024 at 9:46 AM, Staff M stated the dietician was responsible for monitoring weight trends, and if there were weight fluctuations, the resident would be put on alert charting (residents' chart is tagged to indicate that special charting procedures/precautions need to be initiated and followed for a specified time). Nursing assistants were supposed to weigh residents between 6:00 AM to 10:00 AM, if there were more than three lbs. of weight loss, the nursing assistant should re-weigh the resident the next day. Staff M did not know why Resident 46 was not re-weighed for four days when they had an 11 lbs. weight loss on 05/13/2024 nor why the nursing assistant did not notify the nurse for Resident 46 of the weight loss. Staff M stated that room changes should not affect the weights because maintenance was supposed to calibrate the scales so there's no differences of the weights on all the scales. If there was a big difference on the weight, around three lbs., then they notify the maintenance staff to re-calibrate the scale. Staff M stated that if a resident does not like the meal, the staff can call the kitchen to get something different, staff don't document if residents were offered snack or replacement. In an observation on 06/11/2024 at 12:23 PM, Resident 46's was observed in bed, their lunch tray was set in front of them, and was uneaten. In an interview on 06/11/2024 at 12:38 PM, Staff S, NAC, stated Resident 46 had eaten less than 50% of their lunch. When asked what they do if a resident ate less than 50%, they stated they offered a snack, provided food choices to the resident, and offered a health shake. Staff S stated the resident does not like chocolate so they would offer Resident 46 vanilla shake. When asked what Staff S does if a resident does not like a certain food or flavor, Staff S stated they would notify the Dietary Manager so it could be put on the tray slip (piece of paper placed on residents' tray with their diet information, allergies, food dislikes) so the resident would no longer get that food/flavor on their meal trays. In an interview 06/11/2024 at 12:43, Staff S stated they had forgotten to go back to Resident 46's room to offer them a food replacement. In an interview on 06/11/2024 at 1:51 PM, Staff B, Registered Nurse/DNS, stated the doctor needed to be notified no matter what for residents with a weight loss of three to five lbs., and placed on alert charting for weight loss. Staff B could not find if Resident 46's had been placed on alert charting for their weight loss. Staff B stated staff were supposed to weigh residents before breakfast, and if a resident ate less than 50% the staff were supposed to offer an alternate meal or food. Staff B stated the dietician were supposed to assess residents for their food preferences. In a phone interview on 06/11/2024 at 2:25 PM, Collateral Contact 1, Advance Registered Nurse Practitioner, on call, reviewed Resident 46 medical record. CC1 was asked about Resident 46's weight loss from 193 lbs. on 05/01/2024 to 170.2 lbs. on 06/04/2024. CC1 stated that was a lot of weight loss and was not able to locate if the resident's provider had been notified. Refer to WAC 388-97-1060 (3)(h)

Based on observation, interview, and record review, the facility failed to ensure staff used the planned/safe transfer technique for one of three residents (1) reviewed for injuries. This failure caused harm to Resident 1 who was transferred using the wrong method, injured their leg during the transfer, sustained an infection and fractures, and experienced emotional distress. This failure additionally placed other residents at risk for potential harm and injury. Findings included . Resident 1 admitted to the facility on [DATE] with diagnoses to include osteoarthritis of right knee and morbid obesity. Review of the resident's admission Minimum Data Set assessment (an assessment tool) dated 07/03/2022, showed the resident had mild cognitive impairment. Review of Resident 1's care plan for transfer status, revised 07/08/2022, showed the resident required limited assist of one staff to transfer between surfaces with a slide board (a board used for a person to slide across to transfer from one surface to another) transfer. Review of the facility investigation dated 07/21/2022, showed Resident 1 was oriented to person, place, time, and situation. The investigation revealed that while Resident 1 was being transferred from the recliner to a wheelchair (w/c) by two nursing assistants (NAs), their right foot slipped, and their leg hit the bedside table/nightstand. The NA's were able to hold the resident up and transfer the resident with a stand-pivot (transfer in which NA's hold each side of gait belt and pivot the resident) transfer to the w/c. The incident resulted in a reddened area which progressed to bruising to the resident's right lower leg. Review of witness statement dated 07/21/2022, signed by Staff A, NA, showed during a transfer from the recliner to the w/c the resident struggled to stand on their right leg but with staff support was able to stand. In the process, their right foot slipped and bumped into their bedside table. Review of a witness statement dated 07/21/2022, signed by Staff B, NA, revealed they helped Resident 1 stand and the resident's foot slipped. Review of a statement dated 07/21/2022 signed by Staff C, NA, showed Resident 1 stated during the transfer their foot slipped out from under them and their right leg hit the nightstand causing a bruise. Review of skin check form dated 07/21/2022 showed Resident 1 had a nine centimeter (cm) by seven cm bruise to their right lower leg. Review of facility provider (P1), a medical doctor, note dated 07/23/2022, revealed the resident had worsening knee and ankle pain the last few days and had hit their shin against a piece of furniture. The assessment showed the resident had a moderate size bruise on their right shin. Review of Physiatrist (P2) (doctor who specializes in physical medicine and rehabilitation) note dated the morning of 07/25/2022, showed the resident had a large, reddened patch with mild swelling at the right shin, consistent with cellulitis (bacterial skin infection). Due to the cellulitis, the provider deferred the planned knee steroid injections until the cellulitis resolved. Review of facility provider (P3), a medical doctor, note dated the afternoon of 07/25/2022, showed the resident hit their right shin and had bruising extending to the back of their leg with redness and warmth on almost the entire leg, and was reported by the resident to be painful. P2 diagnosed cellulitis and started the resident on an antibiotic and diuretic (water pill for the swelling). Review of facility investigation summary dated 08/15/2022, revealed Resident 1 was sent to the hospital on 08/04/2022, two weeks after the initial injury, for an unrelated issue. Upon the facility staff review of the resident hospital records when they returned from the hospital, it was noted that due to right leg injury which was not healing, the resident had an MRI (magnetic resonance imaging-scan that produces detailed images of the inside of the body) which showed right tibia (shin bone) and fibula (calf bone) fractures related to the injury on 07/21/2022. Review of Resident 1's right knee x-ray results dated 08/07/2022, showed comminuted (break in at least two places) and a displaced (pieces of bone moved leaving a gap around the fracture) tibia fracture and fibular neck fracture. In an interview on 10/27/2022 at 2:05 PM, Resident 1 stated on 07/21/2022 they requested assistance to transfer from their recliner. When asked about how they were transferred, Resident 1 stated as on many prior occasions, the NA's assisted them to stand, moved the recliner or whatever they were currently sitting on, and then would slide the commode (or whatever they were transferring to) behind them and assisted them to sit. Resident 1 stated on this occasion their right foot slipped due to gripper sock being on sideways, and they bumped their shin against the corner of the nightstand causing discomfort. Resident 1 was visibly upset and stated that this happened due to no fault of theirs and was very upsetting to them. They stated had it not happened, the original plan of steroid injections and a brace to their right knee would have been completed and they would have been home by the end of August 2022. The resident stated they ended up using their Medicare days because of the injury and stated now was using all their money and were very concerned. On 11/03/2022 at 1:55 PM, Staff A, NA stated they did not recall details about Resident 1's incident on 07/21/2022, however stated the process for transferring Resident 1 was that the resident would direct the NA's. They would assist the resident to stand then one of them would move the recliner away and slide the w/c or commode behind the resident and assist the resident to sit. On 11/03/2022 at 2:30 PM, Anonymous Staff-1 (AS-1), stated some NA staff had not consistently followed the rules or the care plan for transfers. AS-1 stated for example some NA's had not always had two staff for Hoyer (a type of mechanical lift) transfers and had taken other short-cuts. On 11/29/2022 at 12:02 PM, Resident 1 was observed lying in bed. The resident stated since diagnosis of their right lower leg fractures, they had limited weight-bearing on their right leg. Resident 1 was asked again about their transfer process on 07/21/2022, the date they injured their right leg. Resident 1 repeated the same thing as on their initial interview on 10/27/2022. When asked if they were sure they had not been using a slide board for transfers, the resident became visibly emotional, and appeared upset and angry. The resident stated they had used slide board for transfer practice with therapies only, however when the NA's transferred them, they had not used the slide board to transfer them. When this investigator explained their care plan showed they were to have been using a slide board for transfers, Resident 1 appeared very upset (elevated tone of voice, facial flushing, eyes watered). Resident 1 stated they were not aware they were supposed to transfer with staff and use a slide board. On 11/29/2022 at 12:25 PM, Staff D, NA, stated when assigned to resident care, the NA's used Point of Care (an electronic charting system) to view how to transfer and provide care for each individual resident. When asked what they were to do if they were asked to do something different than the care plan, or if other NA's were not following the care plan, Staff D stated they would stop and clarify with the nurse to ensure proper care. On 11/29/2022 at 12:45 PM, when the Director of Nursing Services (DNS) and the Administrator were informed of the failed practice due to failure of NAs to perform a slide board transfer on 07/21/2022, the DNS stated they wanted to review and attempt to find records to support the resident was transferred per the care plan. They were unable to provide documents to disprove resident reports of the transfer and the staff witness statements written immediately following the incident. (WAC) Reference: 388-97-1060(3)(g)

Based on observation, interview and record review the facility failed to ensure safe hot liquid temperatures for one of three residents (#1) reviewed for accidents and hazards. This failure resulted in harm in the form of a burn to Resident #1 requiring treatment. Findings included . Review of a facility policy, titled, Hot Liquid Safety, dated 09/23/2019, showed the following: - The temperature of hot liquids would be checked in the dietary department prior to distribution to the nursing units. If the temperature was greater than 140-150 degrees Fahrenheit, hold the liquid in the dietary department until it reached a more appropriate temperature; - All residents were assessed for their ability to handle containers and consume hot liquids. Residents with difficulties received appropriate supervision and use of assistive devices in order to consume hot liquids. Interventions would be individualized and noted on the resident's plan of care. Interventions included but not limited to: a. Wide based cups; b. Cups with lids and handles; c. Limit Styrofoam cups to residents with no difficulties; d. Aprons; and e. Disallow hot liquids while lying in bed. - General safety precautions when serving hot liquids included but not limited to: a. Make sure resident was alert and in proper positioning to consume hot liquids; b. Use cups, mugs or other containers that were appropriate for hot beverages; c. Do not overfill containers; d. Regulate temperature of hot liquids to which residents have direct access; e. Place filled containers directly on table. Do not hand them directly to residents; f. Keep hot liquids away from edges of the table; and g. Do not refill containers while the resident is holding the container. - Time and Temperature Relationship to [MEDICAL CONDITION] showed if the water temperature was 155 degrees it would take 1 second for a 3rd degree burn to occur. If the water was 148 degrees, it would take 2 second for 3rd degree burn to occur. If the water was 140 degrees, it would take 5 second for a 3rd degree burn to occur. -[MEDICAL CONDITION] occur even at water temperatures below those identified in the table, depending on an individual's condition and the length of exposure. The policy was updated on 04/16/2020 and showed the following: The temperature of hot liquids would be checked in the dietary department prior to distribution to the nursing units. If the temperature is greater than 140 degrees Fahrenheit plus or minus five degrees, hold the liquid in the dietary department until it reached a more appropriate temperature. Resident #1 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set (MDS) assessment, dated 02/28/2020, showed the resident was independent with eating with set up help only. The MDS showed the resident scored 09/15 on the Brief Interview for Mental Status (BIMS) assessment, indicating moderate cognitive impairement. Review of a Nutrition Risk Assessment, dated 03/03/2020, showed the resident drank a lot of coffee. A note in the assessment stated, per last assessment: He sometimes eats quite quickly, causing coughing, which then impairs his PO (by mouth) intake overall . The assessment showed the resident was independent/supervision in the dining room with set up. Under the nutritional summary of the assessment, it showed the resident's PO intake was generally fair to poor, and nursing was to provide encouragement of PO intake during meals. Review of a Skin Check- Non-Pressure Weekly assessment, dated 04/08/2020, showed the resident had chronic excoriation/redness to his perineal area and buttocks due to refusing at times to be changed. Review of an incident report, dated 04/10/2020, showed the resident was sitting up in bed for breakfast around 9:30 AM. The incident report showed the resident had placed his coffee cup to his right side on the bed. The resident's coffee spilled and caused a reddened area to the right side of the hip, measuring approximately 13 cm (centimeters) x 13 cm, and later developed into a blister, measuring 3 cm x 2 cm and was noted to be painful to the touch. The incident report showed the coffee cup had a lid on it prior to being spilled. Review of a Skin Check- Non-Pressure Weekly assessment, dated 04/10/2020, showed the resident had a burn to the right thigh (front) measuring 13 cm x 13 cm. The resident's right trochanter (hip) was noted as a site of the burn as well. The notes read approximately 13 cm x 13 cm scattered red right lateral upper thigh, treatment as ordered [MEDICATION NAME] (a topical medication) twice daily. Review of a Skin Check- Non-Pressure Weekly assessment, dated 04/13/2020, showed the right trochanter (hip) had a burn measuring 13 cm x 13 cm. The notes showed the right side of the hip was noted to have a reddened area approximately 13 cm x 13 cm, and later developed a blister to the proximal end that measured approximately 4 cm x 4.5 cm x 0.1 cm. No other skin issues identified. Review of the Hot Beverage Temperature Log, dated April 2020, showed on 04/10/2020 the hot beverage temperature for breakfast was 140 degrees. The log showed the temperatures of hot beverages were consistently between 140 degrees Fahrenheit and 150 degrees Fahrenheit for 04/01/2020 - 04/14/2020. Review of an occupational therapy note, dated 03/06/2018, showed the resident had no difficulty feeding himself, but did not mention handling of hot fluids or beverage containers. Review of the comprehensive care plan, review date 04/16/2020, showed the resident had the potential to be verbally aggressive related to dementia with poor impulse control. The care plan showed the resident had impaired cognitive function/dementia or impaired thought process related to dementia caused by [MEDICAL CONDITION]'s (stokes). Interventions included providing the resident with necessary cues, and the resident needed assistance with all decision making. The care plan indicated under the fall care plan focus area interventions that the resident had no or poor safety awareness, and that the resident did not use his call light. Review of the medical record, review date 04/17/2020, showed that prior to 04/14/2020, the resident did not have an assessment for his ability to handle containers and consume hot liquids. In an interview on 04/16/2020 at 10:27 AM, Resident #1 stated when asked about the coffee spill incident, that his coffee cup did not have a lid on it. The resident stated when he spilled the coffee it burned him and it was painful. The resident was observed to have steady hands with no concerns for dexterity. In an interview on 04/16/2020 at 10:33 AM, Staff B, Nursing Assistant Certified (NAC), stated she had never been asked to heat up coffee for a resident. In an observation on 04/16/2020 at 10:38 AM, with Staff A, Registered Nurse (RN)/Resident Care Manager (RCM), showed the 3rd floor nourishment cart with coffee poured into a coffee cup and the temperature was observed to test at 157 degrees Fahrenheit. Staff A stated the coffee was made in a separate machine on each floor in the nourishment room. In an observation and interview on 04/16/2020 at 10:45 AM, Resident #1's coffee burn wound was observed with Staff A. The wound was observed to be covered with a 4 inch x 4 inch white dressing. The wound was on the lateral right hip and upper right thigh. An open area measuring approximately 5 cm x 4 cm was observed to be red and raw. An area adjacent to the open area was observed to be red and measuring approximately 3 cm x 3 cm. Staff A stated they were using [MEDICATION NAME] ointment to treat the burn. In an observation on 04/16/2020 at 10:55 AM, Staff A took the temperatures of the liquids on the 3rd floor nourishment carts. Cart 1 was observed to have two coffee pots. The coffee temperature was measured at 155 degrees Fahrenheit and 151 degrees Fahrenheit and the hot water temperature was 140 degrees Fahrenheit. Cart 2 was observed to have one coffee pot temperature at 155 degrees Fahrenheit, a pot of decaf coffee temperature at 140 degrees Fahrenheit, and hot water temperature of 130 degrees Fahrenheit. The temperature log for the carts only allowed for one temperature to be recorded. Staff A was asked how she knew which temperature was recorded on the log, she stated she did not know specifically, but did state all of the hot water came out of the same coffee maker. In an observation and interview on 04/16/2020 at 11:10 AM, Staff C, Dietary Manager, stated she wrote a new hot drinks policy in January 2020 and that hot drinks were supposed to be between 140-150 degrees Fahrenheit. Staff C took the temperature of the coffee thermos container on the 5th floor nourishment room, and the temperature read 150 degrees Fahrenheit. Staff C made a fresh pot of coffee and took the temperature, which read 150 degrees Fahrenheit. Staff C stated she knew Resident #1 liked his coffee hot, and prior to COVID closing the dining rooms, the resident would ask staff to heat up his coffee for him. In an interview on 04/17/2020 at 11:14 AM, Staff D, CNA, stated sometimes residents ask for their coffee to be heated up and they use the microwave. Staff D denied temping the fluids after microwaving, and stated she would feel the cup with her hand to check temperature and inform the resident it was hot. Staff D stated they typically only put lids on coffee if the resident is traveling for example from the dining room to their room, but if serving from the drink cart right outside of a resident room, they would not necessarily put a lid on it unless the resident asked for a lid. In an interview on 04/17/2020 at 11:19 AM, Staff E, NAC, stated the NAC's do not check the temperatures of fluids, but the dietary aides did. Staff E stated they typically only put lids on hot beverages if the resident was travelling with it, for example from the dining room to the resident's room, but if serving the resident in their room, they do not usually put a lid on it unless the resident asked. In an interview on 04/17/2020 at 11:50 AM, Staff A stated the floor staff do not warm up beverages, but dietary prepared the hot beverages and took the temperatures. Staff A stated the temperature should be between 140 degrees Fahrenheit and 150 degrees Fahrenheit, and on 04/10/2020, the day of the incident, the temperature log for the morning hot beverages was 140 degrees Fahrenheit. In an interview on 04/17/2020 at 12:01 PM, Staff F, weekend dietary supervisor, stated when coffee comes out of the coffee machine, it usually comes out at 150-160 degrees Fahrenheit, and with the lag time before going on the floor, it was usually 150 degrees Fahrenheit by the time it was being served. Staff F stated there was no hard rule on what a safe temperature was to prevent scalding. Staff F stated there were a few residents that on occasion would ask staff to heat their hot beverages up because they preferred the hotter temperatures. Staff F stated when she did this, she would check the temperature with great care to make sure it was not too hot, and inform the resident that it was hot. Staff F stated if taking the nourishment cart/beverage cart to the floor and serving to residents in their rooms, they do not typically put lids on hot beverages unless the resident asks or will be traveling with their fluids, for example going from the dining room to the resident's room. In an interview on 04/17/2020 at 12:37 PM, Staff G, Dietary Aide, stated the process was to brew the coffee in the nourishment room and the temperature was typically 150 degrees Fahrenheit or higher. In an interview on 04/17/2020 at 12:53 PM, Staff H, Dietary Aide, stated when making hot beverages like coffee or preparing the hot water, the temperature was usually between 150 - 155 degrees Fahrenheit. Staff H stated she put lids on hot beverages if a resident had shaky hands, or if the resident requested one. In an interview on 04/20/2020 at 10:49 AM, Staff I, CNA, stated that on the morning Resident #1 spilled his coffee and burned himself, he was working with the resident. Staff I stated he had helped the resident to prepare for breakfast, brought the resident his breakfast tray, and the resident requested coffee. Staff I stated he provided the resident with coffee in a cup with a lid on it, and proceeded to go help other residents. Staff I stated a short time later he went to collect Resident #1's breakfast tray, and the resident stated calmly that he had accidently burned himself with his coffee. Staff I stated the resident's coffee cup still had the lid on it but was upside down on the bed on the resident's right side. Staff I stated the resident stated he did not feel it at first. Staff I stated he immediately got a cold cloth and the nurse to assess the resident. Staff I stated the resident does not usually remember his name and can be forgetful, but was mostly alert and oriented. Staff I denied hearing the resident call out in pain or using call light to call for help. Staff I stated the resident was calm following the incident, and stated the next day the resident had forgotten about the incident when Staff I asked about it. In an interview on 04/20/2020 at 2:32 PM, the Director of Nursing (DNS), stated the resident was alert and oriented and able to express needs. The DNS stated she found out from staff interviews the resident preferred his coffee hot. The DNS stated the resident was able to move all extremities, and that his [MEDICAL CONDITION]/[MEDICAL CONDITION] did not impact the resident's movement. The incident report for Resident #1's burn and the hot liquid policy were reviewed with the DNS. The DNS acknowledged based on the way the policy was written, the appropriate temperature of the coffee was confusing. The DNS stated the resident was assessed for handling hot beverages upon admission. The facility policy stated hot liquid temperatures should be cooled if between 140-150 degrees Fahrenheit, and staff stated that the appropriate temperatures were between 140-150 degrees. The morning of the incident, the temperature log showed hot beverages were at a temperature of 140 degrees Fahrenheit. The resident reported the coffee cup had no lid, and Staff stated they do not typically place a lid on hot beverages unless transporting or a resident requests a lid. The incident report indicated there was a lid on the coffee cup. The resident received a burn forming into a blister as a result of a coffee burn. The facility failed to ensure safe and appropriate temperatures for hot fluids, failed to implement the hot fluid policy, and failed to assess the resident for handling container and consuming hot fluids resulting in harm in the form of a burn, requiring treatment. Reference: (WAC) 388-97-1060 (3) (g)

Based on observation, interview and record review, the facility failed to ensure a resident received adequate assistance to prevent accidents for one of three residents (Resident #1) reviewed. Failure to ensure that a facility employee, who provided direct care for Resident #1, followed the plan of care resulted in an avoidable accident resulting in harm. Findings included . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had impaired cognitive function and [MEDICAL CONDITION], and was only able to answer questions with a yes or no response. On 8/5/19 at 11:30 AM, the resident was observed lying in bed, watching television. The resident had a sling on her right arm. Review of the residents care plan dated 4/16/19, documented, the resident required extensive assistance by two staff for transfers. Review of the facility investigation dated 7/25/19, documented Staff A, Nursing Assistant, attempted to transfer the resident from her wheelchair into her bed by herself, although, the resident's care plan stated the resident required two person extensive assist for transfers. The resident fell while being transferred and sustained a fracture to her shoulder. During the facility investigation Staff A was interviewed. Staff A stated she was aware of the resident's transfer status even though Resident #1 required two person extensive assistance for transfers. On 08/08/19 at 1:00 PM, the Director of Nursing Services (DNS) and Assistant Director of Nursing Services (ADNS) were interviewed. The DNS and ADNS stated understanding that the actions of Staff A caused harm to Resident #1. Reference: (WAC) 387-97-1060(3)(g)

Based on interview and record review the facility failed to ensure one of one residents (#9) reviewed was free from verbal abuse. The facility failed to protect the resident from continued verbal abuse from a licensed staff member. This failure caused the resident to feel intimidated and reluctant to ask for care. Additionally, by allowing the verbal abuse to continue, all the residents on the unit were left vulnerable to abuse. Findings included . Review of the facility's abuse policy, dated 02/04/19, showed the facility management had zero tolerance for abuse or any mistreatment of [REDACTED]. Abuse was defined as willful infliction of injury, unreasonable confinement, intimidation, or punishment on a vulnerable adult with resulting physical harm or pain or mental anguish. Resident #9 admitted to the facility 06/18/17 with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated 02/09/19, showed the resident was cognitively intact and required extensive assistance with most activities of daily living. During an interview on 02/25/19 at 12:41 PM, Resident #9 stated there was one nurse who yelled a lot at you, .every day. Resident #9 stated the nurse was kind of a bully. If you had any ideas or thoughts about anything she squashed them. Resident #9 stated she had not told anyone about it. I don't like it, it makes me feel bad. The resident did not want to ask the nurse for anything or for any help and stated I've heard her yell at other residents too. The surveyor immediately reported this allegation of verbal abuse to the facility's administration staff. Review of the facility Incident Review, dated 03/01/19, showed an alleged abuse occurrence on 02/24/19 outside of the dining room at dinner time. The resident was in the dining room eating dinner and waiting for her medications. The resident stated Staff I, Licensed Practical Nurse (LPN), kept stating I'm working on your meds, I'm coming, I'm coming. The resident left the dining room after waiting for 30 minutes and Staff I then said I told you to wait. The resident responded why should I wait? She has no regard for my time. The resident stated Staff I then said to her you're yelling at me and the resident replied you yelled at me first. The resident stated that all Staff I does was put people down. Staff I stated Resident #9 had been angry prior to the incident. The investigation documented Staff I neither confirmed or denied yelling at the resident during the incident. The incident review had additional resident interviews. Resident #78 stated Staff I was stressed and hollered at other residents. Resident #78 stated Staff I told residents she could not listen or talk to them (the residents). Staff I always said I'm going to have a [MEDICAL CONDITION], and would get onto people. The resident was unable to elaborate what get onto people meant. The investigation documented Staff I had been working several extra shifts, which included a double shift on 02/21/19 and on 02/24/19, the day of the allegation, which may have been a contributing factor in her increased stress level. The investigation included resident and staff interviews but the facility did not substantiate abuse had occurred. Review of the (MONTH) 2019 Medication Treatment Sheet behavior monitor documented Resident #9 had no outbursts of anger or episodes of restlessness/agitation on 02/24/19, the day of the alleged incident, as Staff I had indicated. Review of Staff I's employee file revealed Staff I had been counseled and had written and verbal warnings six times from 2007-2019 for an unprofessional communication style. The incidents including using loud verbalizations and foul language at the nurse's station, getting defensive with families, talking over and not listening to residents, and not being responsive to resident's needs. The documentation stated residents had stated Staff I seemed overworked and they were reluctant to ask for things. During an interview on 03/04/19 at 11:14 AM, Resident #78 stated she had heard Staff I was yelling at residents before and it had gotten worse lately. The resident stated Staff I was usually good with me, but Staff I could get kind of harsh when she got overwhelmed. The resident felt Staff I was busy with to much to do. The resident felt it was time for Staff I to retire. The resident observed Staff I talking with a resident, get frustrated and turn away and say oh, I am going to have a [MEDICAL CONDITION]! During an interview on 03/04/19 at 1:40 PM, Staff J, Nurse Manager/Registered Nurse, stated she had talked to Resident #9 on 03/01/19 and the resident had not mentioned her concern regarding Staff I. Staff J stated staff were monitored for care concerns by observing them throughout the day and asked the residents randomly about care concerns. During an interview on 03/04/19 at 2:33 PM, Resident #9 stated everyone came to talk to me after I told you about Staff I yelling at me. I wasn't expecting it to get taken care of so quickly. Resident #9 stated It is a relief to not have her here anymore. She would yell every day she worked. I didn't want to ask her for anything. I would feel intimidated sometimes by her yelling and just felt bad. During an interview on 03/05/19 at 10:00 AM Staff K, Nursing Assistant, stated Staff I was a regular nurse on the unit that she worked. Staff K that Staff I would get very anxious at times. I think she was just getting tired. During an interview on 03/05/19 at 1:02 PM, the Director of Nursing Services (DNS) stated the facility management had counseled Staff I in the past on her verbal communication. The DNS stated they did educate Staff I on communication, abuse and would monitor her. The DNS stated she would check in with Staff I weekly to see how she was doing and the nurse manager was on the floor and would observe her interactions daily. The DNS stated she would check in with certain residents that she knew would be honest and ask general questions about care, but not specifically about Staff I. The DNS stated this was not documented and she would have to get better at documenting when she followed. The DNS was unable to provide information on any further measures put in place to protect residents after past incidents involving Staff I, or if staff was monitored or observed for signs of burnout. In summary, Staff I had a pattern of aggressive verbal behaviors, including yelling, talking over residents, and using unprofessional language, per review of her employee file. This was also supported by resident and staff interviews. The facility had failed to put measures in place to protect residents from the continued verbal abuse by Staff I. This failure to protect caused Resident #9 to feel intimidated and reluctant to ask to have her care needs met. Reference: WAC 388-97-0640(1)

Based on observation, interview and record review, the facility failed to assess for and implement necessary range of motion (ROM) services to prevent further decrease in ROM for 1 of 3 residents (35). Additionally, the facility failed to monitor, report functional issues with the resident's right upper extremity to a Physician or a qualified healthcare professional. These failures caused harm, decline, in the use of the resident's right upper extremity, a decrease in her ROM and overall quality of life. Findings included: The National Stroke Association defines [MEDICAL CONDITION] or one-sided (hemi) weakness (paresis) as weakness or the inability to move one side of the body. Side effects of [MEDICAL CONDITION] include: Muscle [DIAGNOSES REDACTED] (weakness in the muscles), [MEDICAL CONDITION] (loss of muscle strength) and pain. Rehabilitation treatments, ROM exercises and assistive devices can help improve mobility and recovery. RESIDENT 35 The resident admitted to the facility in February 2015 with [DIAGNOSES REDACTED]. The resident's Minimum Data Set (MDS) from February 2015 to November 2017 indicated the following: 1. Section I of the resident's MDS dated for February 2017 showed the resident had [MEDICAL CONDITION]. 2. Section G of the MDS dated [DATE], August 2017 and November 2017 showed the resident was coded as not having any upper extremity impairments. Review of the progress notes showed the resident was alert and oriented and was able to make her needs known. Review of the resident's admission Care Area Assessment (CAA) for Functional Status, showed the resident had right sided [MEDICAL CONDITION] with decreased mobility. The CAA did not identify the resident's right upper extremity ADL (Activities of Daily Living) functional/rehabilitation potential or causal factors for decline, potential for decline or lack of improvement. Review of the resident's Occupational Therapy (OT) evaluation and Plan of Treatment showed, the resident was seen and evaluated by Occupational Therapy on 03/04/15. The note showed the resident was right handed and had a Right [MEDICAL CONDITION]. The notes showed the resident was able to use both hands for self-feeding but had right upper extremity shoulder ROM impairment. The note also showed the resident had a pain level of 8/10 (0 being no pain and 10 being the most extreme pain) intermittent pain in both shoulders with whole right shoulder area to touch. The note revealed the right upper extremity ROM was impaired for Active/Passive ROM with the resident complaining of pain. Description or type of pain showed the resident stated It hurts and was unable to elaborate further. Recommendations made by OT stated The resident was not appropriate for the Restorative Nursing Program (RNP), due to shoulder pain and needed further assessment from the Nurse Practitioner. Review of the Restorative Nurse's Aide sheet showed the resident received Restorative Nursing services from 03/27/15 to 04/26/15 for Dysphagia (difficulty swallowing). The document showed the resident did not receive Restorative services, therapies, ROM exercises, splint placement or other interventions for her right upper extremity. Review of the residents care plan showed the resident had right [MEDICAL CONDITION], however did not include monitoring, identifying the risks for decline in ROM or preventative measures to prevent a decline in ROM. Also interventions of when to report complications to a Physician or qualified healthcare professional related to the resident's right sided [MEDICAL CONDITION], were not included in the care plan. Review of the resident's RNP Quarterly Assessment on 08/17 showed the resident was being seen by OT for strengthening of the right hand due to increased weakness. Review of the resident's OT Discharge Summary dated 08/31/17, showed the resident was assessed by OT to have 100% impairment with no use of her right hand for functional tasks and pain in her right shoulder. A note dated 09/05/17, showed the resident had 0% use of her right upper extremity during functional task performance. Pain was reported at 10/10, on attempts to actively use the extremity. Review of the facility RNP policy stated, RNP would be initiated when: 1. When a resident was discharged from a formalized physical, occupational or speech rehabilitation therapy. 2. Restorative program flowsheet was utilized to track progress, participation and refusals for each individual resident. In an interview on 11/15/17 at 10:47 AM, Staff P, Restorative Aide (RA), stated when a resident refused to participate in daily restorative therapy it was documented on a sheet in the chart. When asked what was done if the resident refused the program, she stated it was documented why the resident did not want to participate in the program, reported to her manager then the nurse manager will be notified. Staff P was not sure what happened after that. At 10:58 AM, Staff O, Restorative Manager, stated that OT/ Physical Therapy (PT) would do an initial functional assessment of the resident and a referral was made to restorative. When asked what happened when a resident refused the program, she stated she would speak to the resident to find out why, reduce the frequency of sessions and if they insisted on refusing the program, Staff O stated she would discontinue the resident from the program. She also stated would speak to the nurse manager to discuss the issue and nursing would then monitor the resident for any declines in ROM. At 1:43 PM, Staff O stated the resident refused restorative services back in 2015. When she was asked to show any documented refusals, reasons for refusals she stated there was no documentation available. Staff O stated that OT had not written a program for restorative or made any recommendations, therefore, the resident was never on the program and nothing was implemented until the resident started having increased right hand weakness in 2017. When asked how the resident was being monitored for any worsening contractures, she stated nursing was responsible for the monitoring. Staff O stated the resident admitted in 2015 and had not been on any restorative program for ROM. At 2:13 PM, Staff Q OT, stated the resident was recently placed back on OT due to increased weakness and decrease in her right hand function. At 2:21 PM, Staff J, Registered Nurse (RN), stated there were no recommendations made from the restorative department. Therefore no interventions were implemented from October 2015 to August 2017, when the resident's right hand function declined. Staff J was asked if the resident's right hand contracture was care planned for goals and interventions, she stated it was probably not. When asked if there was any monitoring for any worsening contractures from the time the resident was discharged from OT in 2015 for Dysphagia, to the most recent decline in ROM, she stated Not really. When asked how the resident's most recent decline was identified she stated, The daughter reported that she felt the resident had increased weakness and that is what triggered for the resident to be referred back to OT. Staff J also stated the resident was also having right hand and arm pain. In a follow up interview with the resident at 2:44 PM, the resident was asked what hand she used to eat with and she stated I use my left because I can't use my right anymore. In an interview on 11/16/17 at 9:40 AM, Staff N, RN, MDS Coordinator stated the resident's admission, significant change and annual MDS; showed the resident was documented to have right sided [MEDICAL CONDITION] but was not marked to have functional limitations in the MDS. Staff N stated she did not complete the MDS and was not sure why the MDS was not coded with right sided functional limitations and the nurse who completed the MDS would have more information. In a joint review of the CAA with Staff N, showed the resident had right sided weakness but did not identify which part of the body had functional limitations. At 9:51 AM, Staff J, RN stated the reason why Section G of the MDS did not identify the resident to have right sided weakness or functional limitations, was because the resident had use of her right hand to eat. When asked if she thought the resident could have benefited from Restorative therapy to prevent any declines, she stated It could have helped. At 11:50 AM, Staff O stated If the resident had received Restorative Therapy, the increase in the resident's right hand weakness could have been prevented if not slowed down. In an observation on 11/16/17 at 12:55 PM, observed the resident up in her wheelchair eating lunch using her left hand with her right hand tucked under a blanket. In an interview on 11/17/17 at 9:44 AM, the Director of Nursing Services (DNS) stated in moving forward they would be looking at improving the process of how residents transition from OT to RNP. Summary Interviews conducted and records reviewed showed the resident was evaluated by Occupational Therapy shortly after her admission to the facility in 2015. However due to high levels of pain in her right upper extremity, OT determined the resident was not eligible for a RNP and made a recommendation for the resident to be evaluated by the Nurse Practitioner (NP). Review of the entire clinical record from March 2015 to August 2017, did not show any evidence the resident's right upper extremity issues related to her Right sided [MEDICAL CONDITION] or pain, were reported or evaluated by a Physician, NP or qualified professional. Quarterly MDS reviews completed failed to identify functional limitations related to the resident's [MEDICAL CONDITION]; As a result, no interventions or monitoring of the Right upper extremity for functional decline were care planned or implemented and ultimately resulted with the resident unable to use her right hand. Reference (WAC): 388-97- 1060 (3) (d)

Based on interview and record review, the facility failed to promote care in a manner that maintained a resident's individual dignity and self-worth for 1 of 1 sample residents(1). Failure of staff to immediately stop administration of a newly ordered medication upon the resident's verbal request and/or upon signs of discomfort resulted in psychological harm for Resident 1. Findings include: Resident 1 resided in the facility from October - November 2015. The resident was assessed as cognitively alert and oriented, and able to speak clearly and understand others. Throughout Resident 1's stay at the facility, the resident had an ongoing rash for which she received treatments of antifungal powder and cream externally applied to skin folds and private area. On 11/20/15, a medical provider note indicated the resident was having much burning pain in the vaginal area, and ordered a medication/cream to be inserted via an applicator into the area once a day for 3 days. Documentation Review: An Occupational Therapist (OT) documented onn 11/22/15, Resident 1 reported to the OT, that a night shift person, Staff B, a Licenced Nurse (LN) had went into the resident's room to apply a cream. The resident had great difficulty understanding Staff B, LN, because of a language barrier. The resident reported that Staff B, LN parted her legs, and the resident said she then told Staff B, LN, not to do that, but that the LN proceeded with the treatment anyway. The resident told the OT that she felt violated because she clearly said 'No' to Staff B, LN. Staff B, LN, documented: On 11/22/15 at approximately 5 a.m., she went to the resident's room to administer the first dose of a vaginal cream, accompanied by Staff C, Certified Nursing Assistant (CNA). Staff B, LN, documented that she explained the procedure to the resident and the resident agreed to it. However, during the procedure, Resident 1 shouted aw when touched on the insertion site. Staff B, LN, documented that she stopped and asked Resident 1 if she needed pain medication, instead of stopping and the resident declined the offer, and Staff B, LN, continued with the procedure. The Nurse Manager (NM) documented: On 11/23/15, Resident 1 told the NM that she had initially agreed to getting the vaginal cream, but while Staff B, LN was touching the insertion area, 'it hurt'. The resident said she told Staff B to get her hands off her, but Staff B, LN, continued with the cream insertion without saying anything to the resident. The resident told the NM that she cried for almost an hour afterwards. The Social Worker (SW) documented: On 11/23/15, Resident 1 told the SW that during the cream application, she was 'screaming and crying because it hurt, and had told Staff B, LN to get her hands off of her, Staff B, LN did not listen and continued to apply the cream.' The CNA who accompanied Staff B, LN, documented: that Staff B did explain to Resident 1 what she was going to do prior to starting the procedure. However, Staff C, CNA, documented the resident looked 'hurt' while Staff B kept trying to locate the correct area and insert (the cream) until the resident 'screamed.' Interviews: During an interview on 12/2/15 at 11:15 a.m., Staff D, a Nurse Manager (NM) said he talked to Resident 1 regarding the incident, She said it was really uncomfortable and told Staff B, LN, to stop and that's what she was upset about, (Staff B) not stopping. The resident did say she had initially said ok to treatment. Staff D, NM, also indicated that Staff B spoke English as a second language. During an interview on 12/2/15 at 1 p.m., the SW said she had asked Resident 1 about the alleged incident. The resident stated that she had told Staff B No to the treatment during the procedure, but that the LN continued anyway. The resident told her it really started to hurt when Staff B, LN, applied the medicine, and she told Staff B, LN, to stop, but Staff B, LN didn't stop the procedure. The main issue was that Staff B, LN didn't stop (doing the procedure) when asked to stop. In an interview on 12/2/15 at 1:30 p.m., the Director of Nursing stated there may have been a communication issue between the resident and the LN during the procedure. The DNS stated that she talked to Staff B regarding the incident and Staff B told her the resident never said to stop. Staff B did state that the resident was grimacing during the procedure, so Staff B briefly stopped and asked if Resident 1 was in pain, but the resident seemed okay so Staff B finished the medication administration. Staff B told the DNS that she never heard the resident say 'No' or 'stop', and that she would have immediately stopped if that was so. Staff B, LN and Staff C, CNA or the resident were not available for interview.

Based on observation, interview and record review, the facility failed to prevent an avoidable injury to 1 of 9 sampled residents (Resident 1). This resulted in Resident 1 experiencing pain and a bruise to her left foot, which later developed an infection, and declining an exercise modality for increasing her strength. Findings include: Resident 1 was alert and oriented, with multiple medical conditions, admitted on [DATE] for rehabilitation after falling at home. On 08/13/14 at 12:25 p.m., the resident was observed in her room, sitting in a recliner with her swollen legs elevated on the foot rest. The top of her left foot had a reddened raised area, circled with a black pen mark. The resident stated that the redness on the top of her foot started when she received a "bruise" during physical therapy on 07/31/14. She stated that Staff C, a physical therapist, "shoved my feet into the bike pedals. She made me pedal. She said 'If you don't pedal I'm going to put leg weights on you.' Now I have cellulitis (an infection of the tissue under the skin) and they put me on antibiotics today." She stated that the injury was "really painful," and that she refused to use the exercise bicyle after this incident. On 08/13/14 at 1:50 p.m., Staff B, a nurse manager, was asked about the resident's left foot. She said the injury happened because "the strap was too tight" on the bike pedal in physical therapy. Staff B stated that the injury was being monitored once a week on the Wound/Skin Condition Evalution Report. On 08/01/14 the wound was a "superficial bruise," measuring 4 cm x 6 cm, red in color. On 08/05/14, the wound was 2.8 cm x 1.8 cm, " with red edges and white in the middle." On 08/12/14 the wound masured 2.8 cm x 1.8 cm, but with "increasing redness" noted. During an interview with the resident and her family member on 08/13/14 at 3:30 p.m., the family member stated that he had observed the physical therapy session on 07/31, and that the therapist "tried ot force it (the foot) in." Then Resident 1 said that her sock had been too thick, and that "I said 'stop' but she kept shoving with her fingers. It hurt." On 08/01/14, Staff D, an advanced practice nurse, documented that the resident herself stated, "I ended up shoving my left foot into the strap of the pedal of the stationary bike and it really hurt and now I have pain and swelling in that foot. I am not going to ride the bike anymore." Staff D documented, "Left foot pain due to trauma from stationary bike. Ordered ice pack every 2 hours PRN (as needed). Will continue to monitor for infection." Staff C, the physical therapist working with the resident on 07/31/14, documented on 07/31/14, "Pt (patient) in tears during the session and reported inability to continue therapy. Pt decline(d) strengthening w/WTs (with weights). Pt attempted paddle bike but inability to do that due to L (left) knee pain and weakness." Staff C did not document information regarding the bike pedal or that the resident reported pain in her left foot from the bike pedal. Staff H, an occupational therapy assistant who saw the resident on 08/01/14, documented that she removed the resident's sock and noted a "large bruised area on top of left foot, that was very red and half white, like it had been pinched. Patient reports it (is) from foot strap on foot bike from previous day's session with PT." Record review revealed that on the evening of 08/12/14 the resident's foot had increased redness and warmth, signs of infection. On 08/13/14 she was started on antibiotics to treat cellulitis, an infection of the tissue under the skin. Staff J, a physical therapist, noted that on 08/13 the resident was "upset about new [DIAGNOSES REDACTED]. During an interview on 08/18/14 at 8:45 a.m., Staff members G and F, rehabilitation manager and assistant manager, respectively, were asked about the incident. They stated they had not witnessed the incident. Staff G said "I assume the strap would have caused it," and that if the resident's feet were swollen, "I can see why that would cause a bruise." Staff F produced the bike pedals she said Staff C had used in the therapy session with Resident 1. They were pedals with non-adjustable plastic straps that went over the top of the foot. According to Staff F: "You have to slide the foot in."

Based on interview and record review, the facility failed to ensure 1 of 5 sample residents (1) was free of any significant medication errors. Failure to administer the correct medications as ordered by a physician resulted in Resident 1 experiencing an acute change in condition which resulted in harm and required hospitalization . Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/22/14, the resident had a consultant physician appointment scheduled for 10:30 a.m. At approximately 8:30 a.m., a licensed nurse (LN) administered medications to Resident 1, and then the resident left the facility for her appointment. Documentation indicated Resident 1 had received medications which included [MEDICATION NAME] (narcotic [MEDICATION NAME]), beta-blocker (blood pressure), [MEDICATION NAME] (corticosteroid), and [MEDICATION NAME] (anticonvulsant, also used to treat nerve pain). During an interview with Staff 1 on 2/11/13 at approximately 11 a.m., Staff 1 said that on 1/22/14, the LN mistakenly administered another resident's medications to Resident 1 prior to the resident leaving the facility for her appointment. Shortly after Resident 1 left, the LN realized a medication error had been made and notified the facility physician. The LN then notified the consultant physician's office that Resident 1 had been given the wrong medications. The resident had a change of condition (vomiting, altered mental status, low blood oxygen level) while at the consultant's office and was sent to a hospital emergency department. Review of hospital records for 1/22/14 revealed Resident 1 was admitted to the hospital for cardiac monitoring of sedation and [MEDICAL CONDITION] (slow heart rate) related to an unintentional medication overdose.

Based on observations, interviews and record review, it was determined the facility failed to ensure continued use of quarter side rails was based on a thorough and individualized assessment. Continued use of quarter side rails after Resident 1 was known to have behaviors placing her at risk for entrapment resulted in harm for this resident. Failure to assess if the use of quarter side rails was safe after residents (1 & 2) displayed unsafe behaviors placed 2 of 38 residents identified with falls/injury at risk for harm. Findings include: Observation of facility beds on 10/21/10 revealed that each bed in the facility was equipped with bilateral quarter side rails and multiple side rails were elevated on the beds observed during rounds conducted at 4:00 PM. Interview with the facility nursing director revealed the bed controls were located in the side rail and that is why the residents used the side rails; however not all of the residents had the cognitive status to enable them to use the side rail controls. 1. Resident 1 had discharged to home on 10/19/2010. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Staff documented the resident as confused and disoriented. On 10/6 staff documented the resident was continuously climbing out of bed. On 10/8 staff documented the resident was confused and " her extremities keep on tangling all over the bed." Review of the resident ' s record revealed the resident had 7 falls from 9/25 to 10/17/2010. On 9/30/10 staff documented the resident was restless, climbing out of bed, throwing her legs over the upper side rail and attempting to straddle the side rail. Staff documented bruises were noted to her inner right thigh matched up with how the resident was observed climbing out of the rails. There was no indication staff had considered assessing the side rails as a contributing factor for injury. Three of the falls were observed falls from her wheelchair and 4 of the falls were unwitnessed falls from her bed. On 10/3/10 @ 11:00 AM the resident was found hanging on to her side rail with her knees on the floor. Staff documented last seeing the resident laying in bed at 10:30 AM. Staff documented the resident was attempting to self-transfer out of bed and documented the resident was impulsive and lacked safety awareness. There was no indication staff had considered assessing the side rails as a contributing factor for injury. On 10/8/10 @ 0935 the resident was observed sitting next to her bed on the floor mat. Staff documented last seeing the resident laying in bed at 9:15 AM. Later that day @11:30 AM staff documented walking by and seeing the resident holding onto the side rail trying to pull herself up. Staff documented they were able to get to the resident in time to assist her fall to the floor. The resident had been last seen before 11:00 AM sitting in her chair. Follow up documentation indicated the resident later presented with facial bruising with an edematous right eye and her inner thigh was reddened and purple. Interview with staff revealed they had not considered assessing the side rails as contributing factors for injury. The resident was found again on 10/11/10 @ 11:20 AM sitting on the mat on the floor next to her bed. The resident had last been seen at 11:00 Am sitting with her husband. Record review and interview indicate the facility had implemented fall prevention measures including low bed, frequent checks and 1:1 supervision at times but they had failed to consider reassessment to determine if the side rail may contribute to injury. 2. Resident 2 was admitted to the facility on ,[DATE] with [DIAGNOSES REDACTED]. The resident was observed lying in a bed that was in low position, with the left side of the bed against the wall and the right side rail up. The mattress had slid over and a large gap was present between the mattress and the right rail which created a risk for limb entrapment. The resident was unable to respond verbally. Review of interdisciplinary notes revealed the resident presented at times with behaviors described as agitation and restless. A weekly skin assessment dated [DATE] documneted "resident continues to have multiple bruises from being active during care." Review of the assistive device assessment dated ,[DATE] indicated the resident used the side rail for use of the bed control panel to enable enhance sitting balance and positioning. However, the MDS dated [DATE] identified the resident as being totally dependent in bed mobility and transfers. The resident had advanced dementia and would not have known how to use the bed controls. Interview with the director of nursing, unit manager, and assistant director of nursing revealed they had not considered assessing the use of the side rails with residents identified with fall risks and cognitive decline to determine if the use of the device assisted assisted them to be more safe or created an additional risk for the residents.