Every finding on record at Cedar River Healthcare Center

Based on interview and record review, the facility failed to ensure medications were available from the pharmacy as ordered for 1 (Resident 2) of 5 residents whose medication regimens were reviewed. The failure to ensure medications were available placed Resident 2 at risk for unnecessary pain and other negative health outcomes.According to the 07/23/2026 admission Minimum Data Set (MDS), an assessment tool, Resident 2 had recently undergone surgery for a leg fracture and required postoperative care, pain management, and surgical wound care.During an interview on 08/18/2026 at 3:30 PM, Resident 2 stated on the day of admission to the facility, 07/21/2026 in the late afternoon, the facility did not have their pain medication available until after 11:00 PM. Resident 2 stated that, due to the transfer from the hospital, they experienced increased pain and needed their medication for severe pain but were told the medication was not available.Review of Resident 2's physicians' orders showed a 07/21/2026 order for a long-acting pain medication to be administered every six hours as needed for severe pain.Review of Resident 2's medical record showed the facility's provider documented on 07/21/2026 at 7:00 PM, Resident 2 stated pain medication was helpful when given on time.Review of a 07/21/2026 nursing progress note showed nursing staff documented at 11:23 PM Resident 2 requested their long-acting pain medication. The progress note showed the pharmacy did not have a valid prescription for the pain medication. Staff documented they called the on-call physician, received a verbal order for the pain medication prescription,the medication was out of stock in the facility's emergency medication supply and therefore was not available to be administered to Resident 2.Review of the July 2026 Medication Administration Record (MAR) showed the long-acting pain medication was not administered on 07/21/2026, the day Resident 2 was admitted to the facility.During an interview on 08/21/2026 at 4:05 PM, Staff B, Director of Nursing (DON), stated the pain medication was not administered to Resident 2, although other medications, such as a muscle relaxer and over-the-counter-strength pain medication, were administered. Staff B stated all medications should have been available when a new resident was admitted to the facility. Staff B stated if medications were not available, staff were expected to use the facility's emergency supply or contact the pharmacy to obtain the medications as soon as possible.Staff B stated that the emergency supply of the pain medication was out of stock at the time Resident 2 was admitted to the facility and the facility was working with the pharmacy on a plan to maintain sufficient supplies of emergency medications. Staff B stated it was important for residents' safety and care that all medications were available upon admission to the facility.REFERENCE: WAC 388-97-1620(2)(b)(i)(ii), (6)(b)(i)(ii).

Based on interview and record review the facility failed to promptly follow up on a STAT (immediate) x-ray (medical imagining of the body) results and to promptly notify the ordering provider of the STAT x-ray results for one (Resident 1) of one resident reviewed for radiology services. This failure resulted in a delay in the identification of a broken bone, delayed treatment and diminished quality of life.Findings included .<Resident 1>According to the 07/28/2026 admission Minimum Data Set (MDS-An assessment tool) Resident 1 had diagnoses that included adult failure to thrive, history of falls and memory impairment.Review of a 08/07/2026 nursing progress note showed a STAT x-ray was ordered for Resident 1 due to left leg pain, the x-ray order was processed and sent to the imagining company. The note showed the imaging company did not have an on-call radiology technologist (x-ray tech) available on 08/07/2026 and the x-ray would be completed on 08/08/2026.Review of a 08/08/2026 Xray report showed Resident 1 had a fracture on their left lower leg.Review of the 08/08/2026 x-ray report showed Resident 1 had a fracture in their lower left leg. The x-ray showed it was completed on 08/08/2026 at 4pm in the afternoon and results were faxed to the facility on [DATE] at 12:09 AM.Review of a 08/09/2026 progress note showed physical therapy staff consulted with the facility's registered nurses on multiple occasions throughout the day to obtain Xray results but was still awaiting results before providing physical therapy to Resident 1. Review of a 08/11/2026 nursing progress note showed on 08/11/2026 at 8:19 PM staff received the x-ray results three days after the x-ray was obtained on 08/08/2026.In an interview on 08/21/2026 at 1:55 PM a representative from the imaging company stated an x-ray was completed on 08/08/2026 in the afternoon and results were called to the facility on [DATE] at 9:52 PM. The representative stated no one answered the call placed to the facility at the phone number listed on the x-ray order and the x-ray results were faxed to the facility's fax number on file. The representative stated on 08/09/2026 an unidentified nurse from the facility called and stated they did not receive the faxed x-ray results and provided a new fax phone number to send Resident 1's results and on 08/11/2026 a different unidentified facility nurse called to request x-ray results and a third fax containing the x-ray results was sent to the facility on [DATE] at 3:21 PM.In an interview of 08/21/2026 at 4:05 PM, Staff B (Director of Nursing) stated Resident 1 was assessed on 08/07/2026 by the facility provider for left leg pain, the provider ordered additional pain interventions and a STAT x-ray of Resident 1's left leg. Staff B stated the facility did not receive the x-ray results until 08/11/2026 and they would expect staff to call the x-ray company and follow up on the results of the x-ray and notify the provider promptly after the x-ray was completed. Staff B stated once Resident 1's x-ray results were received by the facility; Resident 1 was sent to the hospital for a left leg fracture. Reference WAC 388-97-1620 (6)(a)(b)(i)(ii)

Based on observations, interviews, and record review the facility failed to ensure physician's orders were followed, failed to ensure medications were available from the pharmacy and failed to notify the provider of not giving medications as ordered for 1 of 5 residents (Resident 1) whose medication regimens were reviewed. The failure to ensure orders were followed and medications were made available, placed residents for unnecessary pain, and other negative health outcomes. Findings included . <Facility Policy>Review of the facility's 01/2025 Medication Ordering and Receiving from the Pharmacy policy showed timely delivery of new orders is required so that medication administration is not delayed.According to the 06/25/2025 admission Minimum Data Set (MDS - an assessment tool) Resident 1 had medically complex diagnoses including orthopedic conditions, pain in right hip, and anxiety. The MDS showed Resident 1 needed after care for orthopedic surgery, pain management and surgical wound care. In an interview and observation on 06/25/2026 at 2:15 PM, Resident 1 stated they just recently admitted to the facility and have been having troubles with nurses getting their medications to them on time or at all. Resident 1 stated when they admitted , they had a pain medication that did not get to them until late and thought the facility should have their medications available when they admitted . Resident 1 stated they had a breathing treatment but had not received it since admission and stated the facility was also not providing their skin treatment care as ordered. Record review showed Resident 1 physician's orders included the following:- a 06/19/2026 order to apply skin cream for a skin infection one time daily. - a 06/19/2026 order to apply external powder medication to affected area twice a day for a rash.-a 06/23/2026 order for a muscle relaxer medication to be given three times daily for pain and to hold for oversedation.- a 06/19/2026 order for long-acting pain medication to be given every 12 hours for moderate to severe pain.-a 06/19/2026 order for an inhaler to be provided through a breathing treatment device twice daily for asthma. Review of the June 2026 Medication Administration Record (MAR) showed on 06/20/2026, 06/21/2026, 06/22/2026, 06/23/2026 and 06/24/2026, the cream for the skin infection was not provided to Resident 1. Review of Resident 1's progress notes from 06/20/20/2026 through 06/24/2026 showed no documentation of why the cream was not provided to Resident 1 and did not show the provider was notified the skin cream was not given as ordered. Review of the June 2026 MAR showed on 06/23/2026 and 06/24/2026, showed the muscle relaxer medication was not given to Resident 1. Review of Resident 1's progress notes from 06/23/2026 through 06/24/2026 showed no documentation of why the muscle relaxer was not given and showed no documentation the provider was notified the muscle relaxer was not given as ordered. <Medications not available>Review of the June 2026 MAR showed on 06/20/2026 and on 06/21/2026 the external powder for the skin rash was not given to Resident 1. Review of Resident 1's progress notes showed on 06/20/2026 the external powder was not given because they were waiting for the delivery from the pharmacy. Review of the progress notes showed no documentation the provider was notified the external powder was not given as ordered. Review of a 06/20/2026 progress note showed the long-acting pain medication was to be administered at 9:00 PM, however Resident 1 did not receive the medication until 11:30 PM, more than two hours later because the pain medication was not available by the pharmacy. There was no documentation that showed the provider was notified of the late medication administration. Review of the June 2026 MAR showed the inhaler medication for breathing was not given on 06/19/2026, 06/20/2026, and 06/21/2026. Review of a 06/20/2026 progress note showed the nurse was waiting for the pharmacy to deliver the medication. There was no documentation that showed the provider was notified about Resident 1 not receiving their inhaler medication as ordered. In an interview on 06/25/2026 at 3:00 PM, Staff D (Registered Nurse) stated the skin cream, muscle relaxer, and long-acting medication were not given to Resident 1. Staff D stated these medications showed as pending confirmation and the medications should have been given or the pharmacy and provider should have been called but could not find documentation in the record. Staff F stated the nurses should have documented why the medication was not given as ordered but did not. In an interview on 06/25/2026 at 4:50 PM, Staff C (Resident Care Manager-RCM) stated nurses should provide medications as ordered and were to notify the provider and document when a medication was not provided but did not. In an interview on 06/25/2026 at 5:02 PM, Staff B (Director of Nursing) stated medications should be available and if not, staff were to use the emergency kit or call the pharmacy to get medications as soon as possible. Staff B stated it was important for residents' safety and care to document why medications were not given and to notify the provider of medications not being provided as ordered. REFERENCE: WAC 388-97-1620(2)(b)(i)(ii),(6)(b)(i)(ii).

Based on observation, interview and record review, the facility failed to ensure specialized rehabilitative services were provided as determined by the physician's order and the residents' plan of care for 2 of 3 residents (Residents 1 & 2) reviewed for Occupational Therapy (OT) services. This failure placed residents at risk of not attaining, maintaining, or restoring their highest practicable level of physical, mental, functional, and psychosocial well-being. Findings included . <Facility Assessment>Review of the updated February 2026 Facility Assessment showed the facility would conduct, document, and review their facility-wide assessment to consider their resident population and the resources needed to care for these residents. The assessment showed OT services were provided seven days per week, and the hours provided per day varied depending on the facility census. The assessment showed the facility resources needed to provide competent support and care for their resident population during day-to-day operations was based on a staffing plan and that the facility would take steps to ensure they had sufficient staff to meet the needs of their residents at any given time. <Facility Policy>The undated facility policy titled, Specialized Rehabilitative Services, showed the facility would provide rehabilitative services to patients as indicated by the Minimum Data Set (MDS - an assessment tool). The policy showed specialized rehabilitative services included OT and was provided upon the written order of the attending physician.<Resident 1>According to the 02/03/2026 admission MDS, Resident 1 admitted to the facility on [DATE], was alert and oriented, with clear speech, had medical conditions including fractures on their right shoulder and leg, and was assessed to require extensive staff assistance with Activities of Daily Living (ADLs). The MDS showed Resident 1 required therapy services and OT was provided during the assessment period. On 04/02/2026 at 10:38 AM, Resident 1's representative reported the resident was not provided OT services as indicated in the plan of care. The representative stated OT was supposed to come three times a week but only came two or three times since the resident admitted . In an observation and interview on 04/14/2026 at 1:55 PM, Resident 1 was observed lying in bed with limited range of motion/movement on both their right arm and right leg. Resident 1's right shoulder was observed supported by a pillow and they had a right leg brace on. Resident 1 stated they felt the rehabilitation services provided to them was not enough to get them back to their prior level of function. Review of Resident 1's physician orders showed a 01/31/2026 order for skilled OT services- evaluation and treatment. Review of Resident 1's skilled therapy documentation showed a 02/03/2026 OT evaluation indicating the resident's plan of care was to provide OT treatment sessions three times a week. Review of Resident 1's OT treatment session notes showed: Resident 1 was only seen once on 02/15/2026 during the week of 02/10/2026 - 02/16/202; and twice on 02/20/2026 and 02/21/2026 during the week of 02/17/2026 - 02/23/2026. In an interview on 04/20/2026 at 12:16 PM, Staff D (Director of Rehabilitation) stated it was important to provide skilled therapy services to residents according to the assessed plan of care to follow and meet treatment goals, increase resident strength and mobility, promote resident independence in doing their ADLs, and to prepare the residents for a safe discharge wherever the next level of care would be. Staff D stated they expected the therapy staff to follow the plan of care that was determined during assessment based on resident needs. Staff D reviewed Resident 1's OT treatment sessions and stated the resident was scheduled for OT on 02/16/2026 and 02/23/2026 but the visits were missed. Staff D stated there was no documentation found in Resident 1's therapy records to show why the OT visits were missed besides the remark: Others. Staff D stated Resident 1's OT plan of care was not followed and the resident did not receive the therapy services required as assessed because of OT staffing issues, .staffing for our OT needs is a struggle. In an interview on 04/20/2026 at 1:29 PM, Staff A (Administrator) stated they were aware of the facility's OT staffing issues. <Resident 2>According to the 03/10/2026 admission MDS, Resident 2 was alert and oriented, with clear speech, had medical conditions including a left arm fracture with muscle injury, and was assessed to require staff assistance with ADLs. The MDS showed Resident 2 required therapy services and OT was provided during the assessment period. In an observation and interview on 04/14/2026 at 2:18 PM, Resident 2 was observed sitting up in their wheelchair and was unable to fully extend their left arm. Resident 2 stated they were receiving therapy and exercises to regain their arm function. Review of Resident 2's physician orders showed a 03/04/2026 order for skilled OT services- evaluation and treatment. Review of Resident 2's skilled therapy documentation showed a 03/06/2026 OT evaluation indicating the resident's plan of care was to provide OT treatment sessions three times a week. Review of Resident 2's OT treatment session notes showed Resident 2 was only seen twice on 03/27/2026 and 03/31/2026 during the week of 03/27/2026 - 04/02/2026. In a phone interview on 04/21/2026 at 10:42 AM, Staff D stated Resident 2 was scheduled for OT on 04/02/2026 but it was missed. Staff D stated there was no documentation found in Resident 2's therapy records to show why the OT visit was missed. REFERENCE: WAC 388-97-1280(1)(a-b), (3)(a-b)

Based on interview and record review, the facility failed to maintain a Quality Assessment and Assurance (QAA) committee that included the required participants. This failure put residents at risk for unmet care needs due to ongoing non-compliance with federal regulations and detracted from the interdisciplinary effectiveness of the team. Findings included . <Facility Policy> According to a December 2024 facility Quality Assurance and Performance Improvement [QAPI] Committee policy, the committee would meet monthly and listed the staff to serve on the committee which included the: Administrator; Director of Nursing Services; Medical Director, and infection control representative. Review of the 07/11/2024 QAPI committee meeting sign-in sheet showed the Medical Director did not attend. Review of the 08/29/2024 QAPI committee meeting sign-in sheet showed the Medical Director, Director of Nursing, and Infection Preventionist did not attend. Review of the 09/26/2024 QAPI committee meeting sign-in sheet showed the Medical Director and Infection Preventionist did not attend. Review of the 10/10/2204 QAPI committee meeting sign-in sheet showed the Infection Preventionist did not attend. Review of the 11/14/2024 QAPI committee meeting sign-in sheet showed the Infection Preventionist did not attend. Review of the December 2024 tab of the binder showed no QAPI paperwork or sign-in sheet. Review of the 01/16/2025 QAPI committee meeting sign-in sheet showed the Administrator, Director of Nursing, and Medical Director did not attend. Review of the 02/27/2025 QAPI committee meeting sign-in sheet showed the Administrator and Medical Director did not attend. Review the March 2025 tab of the binder showed no QAPI paperwork or sign-in sheet. In an interview on 04/21/2025 at 11:24 AM, Staff A (Administrator) stated it was their expectation that QAPI meetings be held monthly per their policy and indicated the last one they could find in the binder was from 02/27/2025, almost two months prior. Staff A stated they were recently hired as the administrator of the facility and were unsure why the QAPI meetings were not held in December 2024 or March 2025 as directed in their policy. Staff A stated it was their expectation the required committee members attend the monthly QAPI meetings to ensure the key players are a part of the data review and the planning process which can affect resident outcomes and care. REFERENCE: WAC 388-97-1760(1)(2).

Based on observation, interview, and record review the facility failed to ensure residents' medical information was maintained in a manner to ensure privacy and confidentiality when staff failed to properly secure medical records for 3 of 16 sampled residents (Resident 59, 7, & 50) reviewed for privacy and confidentiality and 7 supplemental residents (Residents 30, 66, 264, 9, 38, 56, & 55). The failure to ensure residents' medical appointment and weight information were stored in a secure manner placed residents at risk for a loss of privacy and a diminished quality of life. <Findings> <Facility Policy> Record review of the facility's December 2016 Resident Rights policy showed facility staff were prohibited from disclosing Protected Health Information (PHI - any information that could be used to identify someone and their health care status). The policy directed staff to make reasonable efforts to protect residents' PHI. <Resident 30> Observations on 04/14/2025 at 10:59 AM and 04/14/2025 at 1:10 PM showed a folder placed upright on the counter at the 3rd floor nurses station. The folder, facing away from the nurse's station and viewable to anyone walking by, had an appointment arrangement form attached to it showing Resident 30's name. This form showed Resident 30 had an appointment at 3:40 PM for oncology (a branch of medicine that specializes in the diagnosis and treatment of cancer) and hematology (the study of blood and blood disorders). <Resident 66> Observations on 04/15/2025 at 8:27 AM showed a folder placed upright on the counter at the third-floor nurse's station. The folder, facing away from the nurse's station and viewable to anyone walking by, had an appointment arrangement form attached to it showing Resident 66's name. This form showed Resident 66 had an appointment at an orthopedic (a medical specialty clinic focused on the diagnosis, treatment, and prevention of diseases, injuries, and deformities of the musculoskeletal system) clinic. Observations on 04/18/2025 at 9:08 AM showed a folder sitting upright on the counter at the third-floor nurse's station. The folder, facing away from the nurse's station and viewable to anyone walking by, had an appointment arrangement form attached to it showing Resident 66's name. This form showed Resident 66 had an appointment at a urology (a medical specialty focused on diagnosing and treating disorders of the urinary system and the male reproductive organs) clinic. <Resident 264> Observations on 04/16/2025 at 3:16 PM, 04/17/2025 8:09 AM, and 04/17/2025 at 12:38 PM showed a folder placed upright on the counter at the third-floor nurse's station. The folder, facing away from the nurse's station and viewable to anyone walking by, had an appointment arrangement form attached to it showing Resident 264's name. This form showed Resident 264 had an appointment at an orthopedic (a medical specialty clinic focused on the diagnosis, treatment, and prevention of diseases, injuries, and deformities of the musculoskeletal system) clinic. <Resident 9> Observation on 04/16/2025 at 1:14 PM showed an appointment sheet for Resident 9 was placed in an upright document stand on the corner of the second-floor nurse's station. The appointment sheet was easily viewed by passersby. The appointment sheet included Resident 9's name and showed the resident had an orthopedic appointment that day at 1:30 PM. The form showed Resident 9 would see an external orthopedic provider. <Resident 59> Observation on 04/17/2025 at 8:20 AM showed an appointment sheet that included Resident 59's name, was placed in an upright document stand on the corner of the second-floor nurse's station. The appointment sheet was easily readable by anyone passing the station. The sheet showed the resident had an external orthopedic appointment at 10:20 that day. <Resident 38> Observations on 04/18/2025 at 7:57 AM showed a folder sitting upright on the counter at the third-floor nurse's station. The folder, facing away from the nurse's station and viewable to anyone walking by, had an appointment arrangement form attached to it showing Resident 38's name. This form showed Resident 38 had an appointment at a pulmonary (lung) and sleep clinic. <Resident 56> Observation on 04/18/2025 at 9:57 AM showed an appointment sheet including Resident 56's name for a blood draw placed in the same upright document stand on the corner of the second-floor nurse's station. The appointment sheet was easily readable. <Resident 7> Observations on 04/21/2025 at 7:58 AM showed a folder sitting upright on the counter at the 3rd floor nurses station. The folder, facing away from the third-floor nurse's station and viewable to anyone walking by, had an appointment arrangement form attached to it showing Resident 7's name. This form showed Resident 7 had an appointment at radiology (a medical specialty clinic that uses medical imaging to diagnose and treat diseases). <Resident 55> Observation on 04/21/2025 at 9:27 AM showed an appointment sheet for Resident 55 for an external urology appointment placed in the same upright document stand on the corner of the second-floor nurse's station. The appointment sheet was easily readable. <Resident 50> In an interview on 04/14/2025 at 12:48 PM, Resident 50's family member stated they received an email on 04/10/2025 from the facility which included some information about insurance coverage for another resident, rather than for Resident 50. Resident 50's family member stated they notified the facility of the error. Review of the 04/10/2025 email showed an attached letter which included the name, admitted , pending amount of co-pay due per day, and the name of the supplemental insurance company of another resident at the facility. A follow up email was sent from the facility with the corrected information for Resident 50 on 04/11/2025. <Resident Weight Information> Observation on 04/16/2025 at 1:19 PM showed a list of nine resident beds with corresponding weights left on the second-floor nurse's station. The list of resident weights was easily readable by passersby and because the names of all nine residents were shown on signs placed outside the residents' rooms, passersby could determine the nine residents' weight. In an interview on 04/21/2025 at 11:54 AM, Staff B (Director of Nursing) stated it was their expectation staff always maintain privacy and confidentiality of a resident's information. Staff B stated staff were to ensure their computer screens were not visible to others, carts were locked, report sheets and information not be out visible in public areas and should not divulge any information to others. Staff B stated the residents were entitled to their privacy and helped maintain dignity. REFERENCE: WAC 388-97-0360. 43642 50511

Based on interview and record review, the facility failed to ensure Pre-Admission Screening and Resident Review (PASRR - a mental health screening required prior to admission to a nursing home) assessments were completed as required for 2 of 5 residents (Resident 45 & 50) reviewed for PASRR screening. The failure to ensure PASRR screenings were complete and accurate left residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health care needs. Findings included . <Facility Policy> According to the undated facility PASRR policy, the facility would screen for mental disorders prior to admission by completing a Level I PASRR form. The policy showed the facility would ensure the Level I PASRR was complete and accurate prior to admission. Individuals who had or were suspected to have a mental disorder would not be admitted to the facility unless: a Level II invalidation was completed by the state-designated authority, a Level Il evaluation was completed, or by hospital exemption (the resident admits directly from an acute inpatient hospitalization for an anticipated stay of fewer than 30 days in the home). <Resident 45> According to the 04/08/2025 Admission Minimum Data Set (MDS - an assessment tool) Resident 45 admitted to the facility on [DATE] from the hospital. The MDS did not indicate Resident 45 had any psychiatric or mood conditions. According to a 04/02/2025 Daily Skilled Charting progress note, Resident 45 had a diagnosis of anxiety. According to a 04/08/2025 Social Services progress note, the Level I PASRR received from the hospital did not include Resident 45's anxiety diagnosis and was inaccurate. The note showed a correct Level I PASRR was completed. Review of the corrected 04/03/2025 Level I PASRR showed an anxiety disorder was included in the Serious Mental Illness (SMI) indicators section. The form showed a Level II PASRR referral was not required. In an interview on 04/21/2025 at 8:48 AM Staff I (Social Services Director) stated they completed a new Level I PASRR after identifying the PASRR completed by the hospital omitted the resident's anxiety diagnosis. Staff I reviewed the 04/03/2025 Level I PASRR and stated as the PASRR included an SMI indicator, a referral for a Level II evaluation should have been, but was not made. 43642 <Resident 50> According to a 04/07/2025 Admission MDS, Resident 50 admitted on [DATE] with multiple medically complex diagnoses including depression. This MDS showed Resident 50 required the use of an antidepressant medication during the assessment period. Record review showed Resident 50 was admitted from the hospital with a 04/02/2025 Level I PASRR. Section 1 of this Level I PASRR showed the resident was marked as having no SMI indicators, but in a subsection underneath, the SMI indicator for a mood disorder of depression was selected. The last section of the form showed Resident 50 did not require a Level II evaluation as they did not show indicators of an SMI, even though Resident 50 was identified with depression in the SMI indicators of Section 1. In an interview on 04/21/2025 at 10:10 AM, Staff I stated it was their expectation a Level I PASRR was accurate, and Level II evaluations obtained as required so residents could be evaluated for any needed services. Staff I reviewed Resident 50's records and confirmed the resident was identified with an SMI and did not receive a Level II PASRR prior to admission to the facility. REFERENCE: WAC 388-97-1915 (1)(2)(a-c).

Based on observation, interview, and record review the facility to ensure comprehensive Care Plans (CPs) were developed to address all identified resident care needs for 4 (Residents 58, 214, 14, & 45) of 16 residents whose CPs were reviewed. This failure placed residents at risk for unmet care needs and frustration. Findings included . <Facility Policy> According to the facility's December 2016 Care Plans, Comprehensive Person-Centered policy, facility staff would develop and implement a comprehensive CP in conjunction with the resident and/or their representative. The policy showed CPs should include measurable goals and describe the care and services the resident should be provided. <Resident 58> According to the 03/27/2025 Admission Minimum Data Set (MDS - an assessment tool) Resident 58 medical conditions including spinal cord dysfunction, spinal stenosis (a narrowing of spinal cord space that compressed nerves of spine) and muscle weakness. The MDS showed Resident 58 had frequent pain. Review of history and physical admission paperwork dated December 2024 showed Resident 58 had a total knee replacement in December 2024 Review of Resident 58's revised 03/28/2025 Pain Management CP showed Resident 58 was at risk for pain or discomfort due to lower back disorders and other complications. The CP showed staff were to assess pain every shift and showed Resident 58 preferred to lie on their side due to pain in their lower back. The CP did not show Resident 58 had pain in their right knee. Review of 03/28/2025 Musculoskeletal Disorder CP showed Resident 58 was at risk for pain or fracture related to a pinched nerve in the resident's lower back area and spinal stenosis. The CP showed staff were to encourage mobility and handle the resident gently when turning/repositioning. The CP did not show Resident 58 had a right knee total replacement in December 2024 which caused them to have pain and limited mobility. In an interview on 04/15/2025 at 8:45 AM, Resident 58 stated they had pain in their back and their knee because of their prior surgery. In an interview on 04/18/2025 at 8:28 AM Resident 58 stated they were always in pain and their medications helped somewhat but because of their spinal stenosis and knee surgery, they had ongoing chronic pain. Resident 58 stated they could reposition themselves and staff did not help them with this, but they had to be careful with repositioning because of their knee surgery as their doctor told them their knee should be kept straight for better healing. In an interview on 04/18/2025 at 11:00 AM Staff E (Resident Care Manager - RCM) stated nurses should have captured Resident 58's knee pain and included it on the CP but did not. Staff E stated the pain from the knee replacement should have been put on the CP for Resident 58's quality of life and for appropriate pain interventions and therapy. <Resident 214> According to the 04/10/2025 Admission MDS, Resident 214 had conditions including osteoporosis, hypertension (high blood pressure), reduced mobility, impairment to both shoulders, and a right shoulder fracture. Review of the 04/05/2025 Musculoskeletal Disorder CP, showed Resident 214 had a potential risk for pain due to a right shoulder fracture. The CP did not show Resident 214 had a fracture on the left shoulder. Review of interdisciplinary team care conference notes dated 04/05/2025 showed Resident 214 had both right and left fractures to their shoulders. Review of admission paperwork Hospital discharge problem list dated 4/1/2025 showed Resident 214 had fractures to both left and right shoulders. In an interview on 04/15/2025 at 8:11 AM Resident 214 stated they would have surgery in two days' time to fix the fracture on their left shoulder first because they were left-handed. Resident 214 stated their right shoulder would be addressed after two weeks recovery from left shoulder surgery. Resident 214 stated they had to wear slings on both shoulders, and sometimes when they received a shower, the staff got their slings wet. In an observation on 04/16/2025 at 9:41 AM, Resident 214 told the two care staff who were helping them to transfer to the shower chair to exercise caution with both shoulders when they transferred them. In an interview on 04/18/2025 at 10:56 AM Staff E confirmed Resident 214 had fractures to both shoulders. Staff E reviewed Resident 214's CP and confirmed that the CP showed only the right shoulder fracture was identified. Staff E stated both shoulder fractures should be on the CP because Resident 214 had pain in both shoulders and the same precautions should be employed on both shoulders, but the left shoulder was not. In an interview on 04/21/2025 at 12:38 PM Staff A (Administrator) stated it was important for assessments to be accurate and if there was a significant change to a resident's conditions, the MDS, assessments, and CPs were to be updated using our tools and hospital notes for accuracy. Staff A stated this was important for accuracy of residents' care. 42203 <Resident 14> According to the 03/18/2025 Admission MDS, Resident 14 had intact memory and experienced pain that frequently affected their sleep. The MDS showed Resident 14 had medically complex conditions. Record review showed Resident 14 had a 03/13/2025 physician's order for a medication to treat gout (a form of arthritis characterized by sudden, severe attacks of pain, swelling, redness, and tenderness in one or more joints - most often in the big toe). Record review did not show a CP was developed by facility staff to address Resident 14's gout. There were no directions for nursing staff such as what signs and symptoms to watch for, what interventions, if any, were appropriate if Resident 14 had an acute episode of gout-related pain, etc. In an interview on 04/21/2025 at 12:30 PM Staff C (RCM) stated there should be a CP developed for each diagnosis or condition for which a resident received treatment. Staff C reviewed Resident 14's comprehensive CP and determined there was not but should be a gout CP. <Resident 45> According to the 04/03/2025 Admission MDS, Resident 45 had medically complex diagnoses including Gastroesophageal Reflux Disease (GERD). Record review showed a 04/03/2025 physician's order for a proton-pump inhibitor (PPI - a medicine that decreases the amount of acid produced in the stomach). This medication was ordered to treat Resident 45's GERD condition. Record review did not show that a CP was developed to address Resident 45's GERD and PPI medication use. In an interview on 04/21/25 at 12:24 PM Staff C reviewed Resident 45's chart. Staff C stated they could not find a GERD CP but there should be one for Residents 45. REFERENCE: WAC 388-97-1020(1),(2)(a).

Based on observation, interview, and record review the facility failed to provide care and services in a manner that maintained and promoted dignity for 1 of 16 sample residents reviewed (Resident 214). This failure placed residents at risk for a diminished sense self-worth and overall well-being. Findings included . <Facility Policy> According to the facility's revised February 2021 Dignity Policy each resident would be cared for in a manner that promoted or enhanced their sense of well-being. The policy showed when staff helped with care, residents should be supported and provided with a dignified dining experience. <Resident 214> According to the 04/10/2025 Admission Minimum Data Set (MDS - an assessment tool) Resident 214 needed substantial/maximal assistance with eating due to fractures to right and left shoulders. In an interview and observation on 04/15/2025 at 8:20 AM, Resident 214 stated they had to be fed because they could not move their arms due to their shoulder fractures. Staff G (Certified Nursing Assistant) assisted Resident 214 with four large bites of oatmeal and then left the room. Resident 214 stated they thought the staff were very busy with other residents. Staff G did not return to assist Resident 214 until 8:31 AM, 11 minutes later. In an interview on 04/15/2025 at 8:20 AM Staff G stated they would give Resident 214 only four bites of food and then would come back after they finished passing out the rest of the food trays to other residents. In an interview on 04/21/2025 at 11:10 AM Staff B (Director of Nursing) stated they were aware that care staff needed help with tray services and requested that leadership begin helping with meal trays. In an interview on 04/21/2025 at 12:41 PM Staff A (Administrator) stated their expectation was for staff to only place a tray in front of a resident when they were ready to assist that resident with eating the whole meal to help promote dignity to the resident. REFERENCE: WAC 388-97-0180(1-4).

Based on interview and record review, the facility failed to ensure a system by which residents received required written notices at the time of transfer/discharge, or as soon as practicable for 3 (Residents 63, 23, & 29) of 4 residents reviewed for hospitalizations. Failure to ensure written notification was provided to the resident and/or the resident's representative, in a language and manner they understood, placed residents at risk for not having an opportunity to make informed decisions about transfers/discharges. Additionally, the facility failed to ensure a system by which the Office of the State Long-Term Care Ombudsman (LTCO, an advocacy group for individuals residing in nursing homes) received required resident discharge/transfer information for 3 (Residents 63, 23, & 29) of 4 residents reviewed for hospitalization. Failure to ensure the required notification was completed, denied the LTCO the opportunity to educate residents and advocate for them regarding the discharge process. Findings included . <Facility Policy> Review of the facility's undated Transfers and Discharge Notices policy showed facility staff were required to provide residents and/or resident representatives with a thirty-day written notice prior to the transfer or discharge. In the event the transfer was necessary for the resident's welfare, the notice would be provided as soon as it was practicable. Written notice would include the reason for transfer, the effective date, where the resident was transferred, a statement of the resident's rights to appeal, a copy of the facility's bed-hold policy, and contact information for the Washington State LTCO advocate. The policy showed the facility should also send a copy of the written notice to the Washington State LTCO. <Discharge Notices> <Resident 63> Review of Resident 63's 01/03/2025 Discharge Minimum Data Set (MDS - an assessment tool) showed the resident was transferred to an acute care hospital on [DATE], with their return anticipated. Record review showed no documentation staff provided written notification to Resident 63 and/or the resident's representative regarding their discharge as required. <Resident 23> Review of Resident 23's 02/18/2025 Discharge MDS showed the resident was transferred to an acute care hospital on [DATE], with their return anticipated. Record review showed no documentation staff provided written notification to Resident 23 and/or the resident's representative regarding their discharge as required. <Resident 29> Review of the 02/19/2025 Discharge MDS showed Resident 29 was transferred to an acute care hospital on [DATE], with their return anticipated. Record review showed no documentation staff provided written notification to Resident 29 and/or the resident's representative regarding their discharge as required. In a joint interview with Staff I (Social Services Director) and Staff J (Social Services Coordinator) on 04/17/2025 at 12:40 PM, Staff I stated they split the building up with each other and Staff I stated they do not complete discharge notices for residents sent to the hospital. Staff I stated they believed the nurses complete the forms. Staff J stated social services was responsible for completing the discharge notices and indicated they do them for the residents they cover. Staff J reviewed their discharge binder and Resident 63 and Resident 23's records and confirmed a discharge notice should have been but was not completed and provided to the resident and/or representative for their transfers to the hospital. <LTCO Notification> <Resident 63> According to a 01/03/2025 Discharge MDS, Resident 63 was discharged emergently to an acute care hospital on [DATE] with return anticipated. Review of facility and resident records showed no documentation indicating the LTCO was notified of the 01/03/2025 transfer as required. <Resident 23> According to a 02/18/2025 Discharge MDS, Resident 23 was discharged emergently to an acute care hospital on [DATE] with return anticipated. Review of facility and resident records showed no documentation indicating the LTCO was notified of the 02/18/2025 transfer as required. <Resident 29> According to a 02/19/2025 Discharge MDS, Resident 29 discharged emergently to an acute care hospital on [DATE] with return anticipated. Review of facility and resident records showed no documentation indicating the LTCO was notified of the 01/03/2025 transfer as required. In a joint interview with Staff I and Staff J on 04/17/2025 at 12:40 PM Staff J stated they sent notifications to the LTCO monthly based on the completed discharge notices. Staff J reviewed their facility binder and was unable to locate any documentation of notification to the LTCO for Resident 63, 23, or 29 as required. REFERENCE: WAC 388-97-0120 (2)(a-d), -0140 (1)(a)(b)(c)(i-iii).

Based on interview and record review, the facility failed to ensure physician's orders were followed for 1 of 5 (Resident 45) residents whose medication regimens were reviewed. The failure to ensure orders were followed placed residents for unneeded treatment, and other negative health outcomes Findings included . <Facility Policy> Review of the facility's July 2016 Administration Orders policy showed facility staff should administer medications in accordance with the physician's orders. Review of the facility's undated Weight Assessment and Intervention policy showed facility staff should monitor residents for undesirable or unintended weight loss or gain. <Resident 45> According to the 04/08/2025 Admission Minimum Data Set (MDS - an assessment tool) Resident 45 had medically complex diagnoses including heart disease and heart failure. The MDS showed Resident 45 had high blood pressure. Record review showed Resident 45's physician's orders included the following: - a 04/03/2025 order to weigh Resident 45 daily and notify the physician for a weight gain of more than two Pounds (lbs) in a day or five lbs in a week. - a 04/03/2025 order for a medication to treat high blood pressure. The order included directions to hold the medication if Resident 45's pulse was less than 60 Beats Per Minute (BPM). Review of the April 2025 Medication Administration Record (MAR) showed on 04/04/2025 Resident 45's weight was measured at 152.6 lbs and 156.8 lbs on 04/05/2025, an increase of 4.2 lbs in one day. Resident 45's weight was measured again on 04/06/2025 and their weight remained at 152.5 lbs, and again on 04/07/2025 for a weight of 156.6 lbs. The 04/06/2025 and 04/07/2025 weights indicated the 04/05/2025 4.2 lbs weight gain was not the result of an inaccurate measurement. Record review showed no indication the physician was informed of the 4.2 lbs weight gain. Review of the April 2025 MAR showed on 04/15/2025 Resident 45's pulse was measured at 57 BPM. The nurse gave Resident 45 their blood pressure medication instead of holding the medication as ordered (which placed the resident at risk of a further lowering of their pulse). In an interview on 04/21/2025 at 12:24 PM Staff C (Resident Care Manager) reviewed Resident 45's record and stated they did not see any evidence the physician was notified as the order directed. Staff C stated because Resident 45's pulse was measured at 57 on 04/15/2024 their blood pressure medication should have been, but was not held that day (to ensure the resident's pulse stayed within a desirable range). Staff C stated it was important to follow the physician's orders. REFERENCE: WAC 388-97-1620(2)(b)(i)(ii),(6)(b)(i). 43642

Based on observation, interview, and record review the facility failed to provide assistance with Activities of Daily Living (ADLs - daily hygiene and other self-care tasks) for 2 (Residents 13 & 7) of 6 sample residents reviewed for ADLs. The failure to provide ADL assistance residents were assessed to require placed residents at risk for poor hygiene, diminished feelings of self-worth, and other negative health outcomes. Findings included . <Facility Policy> Review of the facility's revised March 2018 Activities of Daily Living, Supporting policy, showed residents who were unable to carry out ADLs independently would receive the services necessary to maintain good nutrition, grooming, personal hygiene, and oral hygiene. <Resident 13> Review of the 03/07/2025 Admission Minimum Data Set (MDS - an assessment tool) showed Resident 13 needed moderate assistance with showering/bathing and had a compression fracture in their spine. Review of 03/01/2025 ADL/Mobility Care Plan (CP) showed Resident 13's bathing/showering was to be done per the shower schedule. Review of second floor shower schedule binder located at the nurse's station showed Resident 13 was scheduled for showers every Monday and Friday. In an observation and interview on 04/16/2025 at 9:22 AM, Resident 13 stated staff frequently told them they would get a shower tomorrow when they ask for one. Resident 13's nails were observed to extend one quarter inch past their nail beds. At that time Staff K (Certified Nursing Assistant) entered the room from the bathroom and Resident told Staff K that they needed a shower. Staff K stated they thought the resident's shower was scheduled for the following day. Resident 13 stated they really needed to be cleaned up. In an interview on 04/17/2025 at 10:55 AM, Resident 13 stated they missed their shower on Monday 4/14/2025 and stated they did not understand why. Resident 13 stated they hoped they would get a shower the following day. In an interview on 04/18/2025 at 10:43 AM Resident 13 stated they did not get a shower that day and was told they would receive a shower the following day. Review of caregiver task sheets showed from 04/11/2025 through 04/18/2025 showed Resident 13 did not receive a shower over that period. In an interview on 04/18/2025 at 11:08 AM Staff E (Resident Care Manager) stated staff should approach the approach residents on their shower days and should document if Resident 13 refused. Staff E stated if staff were not able to get to the resident on the day the shower was scheduled, then a shower should be provided the next day. Staff E said it was important for residents to look presentable for their dignity. In an interview on 04/21/2025 at 11:00 AM Staff B stated staff should have offered showers twice per week and for resident refusals, should try again the next day. Staff B stated fingernails should be trimmed on shower days and stated the provision of showers was important so residents would feel presentable. 43642 <Resident 7> According to a 03/31/2025 Admission MDS, Resident 7 had multiple medically complex diagnoses including diabetes, had clear speech, was understood, and able to understand others. This MDS showed Resident 7 was assessed to be dependent on staff for rolling from side to side in bed, upper and lower dressing, and had no rejection of care during the assessment period. Review of a revised 03/25/2025 ADL/Mobility CP showed a goal that staff would anticipate and meet Resident 7's needs with interventions identified for a nurse to provide diabetic nail care. Review of Resident 7's physician's orders showed a 03/25/2025 order for diabetic nail care to be done weekly on Tuesdays by a licensed nurse. Observations on 04/14/2025 at 9:43 AM showed Resident 7 with long toenails to both feet that extended past the nailbed with some of the nails cracked and curling towards the skin. In an interview at this time, Resident 7 stated they had asked staff to clip their toenails, but it was not done. Review of April 2025 Treatment Administration Record showed staff signed nail care was provided to Resident 7 on 04/01/2025, 04/08/2025, and 04/15/2025. In an interview on 04/21/2025 at 8:23 AM, Staff O (Licensed Practical Nurse) stated nail care was important because it helped decrease the risk of infections, made residents feel better, and lessened the risk of a nail to get snagged on something. In an observation at this time, Staff O confirmed Resident 7's toenails were too long, still curled over, and needed to be cut. Staff O asked Resident 7 if they had reported their nails needed to be clipped to a nurse, Resident 7 stated they had, but they still were not clipped yet. REFERENCE: WAC 388-97-1060 (2)(c).

Based on observation, interview, and record review the facility failed to ensure fall interventions were removed timely when assessed to be unbeneficial for 1 of 3 residents (Resident 50) reviewed for accident hazards and failed to ensure resident mattresses fit the bedframe for 1 of 5 residents (Resident 31) reviewed for positioning. These failures placed residents at risk for falls, injury, and discomfort. Findings included . <Falls> <Facility Policy> According to the facility's undated Falls policy, facility staff would assess each resident's risk for falls. Facility staff would evaluate and document falls that occurred in the facility, and identify and implement pertinent interventions. <Resident 50> According to a 04/07/2025 Admission Minimum Data Set (MDS - an assessment tool) Resident 50 had multiple medically complex diagnoses including cancer, heart failure, kidney disease, muscle weakness, and Parkinson's disease (a progressive neurological disorder that affects movement). This MDS showed Resident 50 had a fall since admission, in the last month prior to admission, and in the last 2-6 months prior to admission. Review of a 4/17/2025 fall Care Area Assessment (CAA) showed staff documented Resident 50 was a high-risk for falls due to an unsteady gait, reduced mobility, and acute illness, and had a history of recent and remote falls. Review of a 04/07/2025 progress note showed staff documented Resident 50 had a fall and interventions for floor mats would be initiated. According to a 04/07/2025 physician order, a floor mattress to both sides of the bed was ordered as a fall intervention for Resident 50. Review of a 04/08/2025 progress note showed staff reviewed the ordered interventions for floor mats put in place by staff after Resident 50's fall on 04/07/2025 and determined they were not an appropriate intervention and were to be discontinued. An intervention to offer toileting every 2-3 hours to prevent falling was initiated instead. Observations on 04/14/2025 at 12:07 PM and 04/15/2025 at 9:12 AM showed floor mats at both sides of Resident 50's bed. In an interview on 04/21/2025 at 11:54 AM, Staff B (Director of Nursing) stated it was their expectation once fall interventions were evaluated as not appropriate, they would be removed for safety. Staff B stated staff should have, but did not implement the changes and remove the floor mats for Resident 50. 42203 <Mattress/Bedframe fit> <Resident 31> According to the 02/13/2025 Admission MDS Resident 31 had medically complex diagnoses including a progressive neurological/movement disorder, and a wasting condition. The MDS showed Resident 31 had a history of falls prior to admission and moderate memory impairment. According to the 02/08/2025 Fall Risk Assessment Resident 31 was assessed to be at high risk for falls. The assessment showed Resident 31 had risk factors including a history of falls and diagnoses that created a risk for falls. According to the 02/13/2025 Falls CAA, Resident 31 had risk factors for falling including delirium, impaired cognition, the resident's progressive neurological/movement disorder, and a visual impairment. According to the 02/19/2025 skin breakdown care plan Resident 31 required a low air loss mattress (an inflated mattress that assists to offload pressure for residents at risk for skin breakdown). Observation on 04/18/2025 at 8:24 AM showed Resident 31 in their bed, lying on their back, with support on both sides with pillows. Resident 31's low air loss mattress was observed to extend wider than the bedframe by one inch on the resident's right side and by over four inches on the resident's left. On 04/18/2025 at 1:48 PM Staff B and Staff D (Maintenance Assistant) arrived at Resident 31's room to observe the bedframe and mattress. Staff B and Staff D observed the overhang of the mattress from the bedframe and determined it needed correcting. Staff D stated the bedframe required adjustment with extender bars that would allow the mattress to fit the bedframe appropriately. In an interview on 04/18/2025 at 1:54 PM Staff D stated the extender bars were necessary to prevent the mattress from moving. Staff D stated the mattress should be secured for safety. REFERENCE: WAC 388-97-1060 (3)(g).

Based on interview and record review, the facility failed to ensure 1 of 4 residents (Resident 27), reviewed for nutrition, received timely evaluation of weights, and implementation of effective interventions, to maintain adequate nutrition. This failure placed the residents at risk for ongoing weight loss and poor nutrition and potential harm. Findings included . <Facility Policy> According to the facility's revised March 2022 Weight Assessment and Intervention policy, residents' weights were to be monitored for undesirable or unintended weight loss. The policy showed any weight changes of five Percent (%) or more since the last weight assessment required nursing staff to immediately notify the dietitian in writing. <Resident 27> According to the 03/24/2025 Admission Minimum Data Set (MDS- an assessment tool) Resident 27 had diagnoses including congestive heart failure, dementia, gastric ulcer, and weakness to one side of the body. Resident 27 needed supervision or touching assistance with eating and it was important for them to have snacks. Review of the 03/20/2025 Malnutrition Care Plan (CP) showed staff were to obtain weights as ordered, and report changes to the physician and registered dietician. Review of physician's orders dated 03/19/2025 showed staff were to monitor Resident 27's weight daily and to notify the provider of more than two pounds (lbs) of weight gain or loss in one day or five lbs weight gain or loss compared to the weight in the last seven days. Review of April 2025 Medication Administration Record (MAR) showed Resident 27 weighed: 04/14/2025 - 111.3 lbs, 04/15/2025 - 109 lbs, 04/16/2025 - 108 lbs, 04/17/2025 - 108 lbs, 04/18/2025 - 109 lbs, 04/19/2025 - 101.2 lbs, 04/20/2025 - 100.8 lbs, and 04/21/2025 - 100.6 lbs. Weights taken between 4/16/2025 and 4/21/2025 represented a -6.85 % weight loss. Review of the 04/16/2025 nutritional risk assessment included a recommendation to add snacks daily due to resident's frequent activity and to continue to monitor for significant weight changes. Review of progress notes from 04/15/2025 through 04/21/2025 did not show documentation the provider was notified of the two lbs difference in weights per the physician's orders. Progress notes did not show written documentation was provided to the registered dietician immediately as stated in the facility's policy, about a greater than five % weight loss from 04/16/2025 through 04/20/2025. Progress notes showed snacks were implemented on 04/21/2025, five days after the nutritional risk assessment plan. In an interview on 04/18/2025 at 10:54 AM, Staff E (Resident Care Manager) reviewed the March 2025 physician orders and the April 2025 MAR that included orders the two lbs weight loss should have been called into the provider according to the physician orders. Staff E stated staff should have notified the provider of the two lbs weight loss and should check Resident 27's weight daily and review the previous day's weights to determine if there was a pattern. Staff E stated this was important as the doctor needed to review what caused the change in weight, whether it was food intake or medications/supplements. Staff E stated the provider could then determine what interventions were needed. In an interview on 04/21/2025 at 10:43 AM, Staff B (Director of Nursing) stated the weekend staff on 04/19/2025 and 04/20/2025 did not document notification of the weight loss to the provider. Staff B stated because they did not know the provider needed to be notified immediately. Staff B stated nurses should follow the providers orders but was unsure if the orders of weight loss needed to be reported, only weight gain. In an interview on 04/21/2025 at 12:43 PM, Staff A (Administrator) stated they expected staff to document weight loss and discuss the weight loss in the interdisciplinary team meeting for nutritional needs. Staff A stated they expected the provider would be notified of significant weight loss immediately. REFERENCE: WAC 388-97-1060(3)(h).

Based on observation, record review, and interview the facility failed to ensure residents were provided the artificial nutrition they were assessed to require for 1 of 1 residents (Resident 114) reviewed for tube feeding. The failure to ensure the full volume of artificial nutrition ordered was provided daily placed Resident 114 at risk for weight loss and other negative health outcomes. Findings included . <Facility Policy> According to the facility's November 2018 . Tube Feeding via Continuous Pump policy, when a resident required their nutrition be provided through a feeding tube, facility staff would document the amount and type of feeding provided. The policy showed the facility would document the average fluid intake. <Resident 114> According to the 04/11/2025 Nursing Admission Evaluation, Resident 114 admitted to the facility for treatment of conditions including for care after a stroke, for acute respiratory failure, and a swallowing difficulty. This evaluation showed Resident 114 received their dietary intake through a feeding tube. Record review showed a 04/11/2025 order for an artificial liquid nutrition formula to be provided at 80 Cubic Centimeters (CC) per Hour (HR) for 18 hours daily. The order gave a start time of 4:00 PM to continue through 10:00 AM for a total of 1440 CC of formula. The order included the amount of liquid nutrition to be provided each shift: 320 CC on day shift, 480 CC on evening shift, and 640 CC on night shift. Review of the April 2025 Medication Administration Record (MAR) showed on 04/12/2025 nurses documented they provided 333 CC of liquid nutrition on day shift rather than the 320 CC per the order, only 226 CC on evening shift instead of the 480 CC ordered, and 640 CC on night shift for a total 1199 CC for the day, rather than the 1440 CC ordered, 241 CC less than the order. The MAR did not include anywhere to document either the daily total provided (rather than the total per shift) or anywhere to document how much liquid nutrition remained at the end of the feeding. According to the April 2025 MAR on 04/13/2025 Resident 114 was provided only 375 CC of liquid nutrition on afternoon shift for a daily total of 1335 CC instead of the 1440 CC ordered, 105 CC less than ordered According to the April 2025 MAR on 04/14/2025 Resident 114 was provided only 320 CC of liquid nutrition on afternoon shift for a daily total of 1280 CC instead of the 1440 CC ordered, 160 CC less than ordered Observation on 04/14/2025 at 10:33 AM showed Resident 114 in bed with a pole next to the bed with a tube feeding pump attached. Hung from the pole were two bags, one containing water with 175 CC of water remaining. The second bag contained 400 CC of liquid nutrition and indicated a full bag contained 1500 CC. Neither bag was connected to the pump and the pump was not running. Observation on 04/17/2025 at 8:17 AM showed the liquid nutrition bag had 500 CC remaining. The pump setting corresponded to the ordered rate of 80 CC/HR, meaning when the feeding was due to stop at 10 AM (one-and-three-quarter hours later) there would be 360 CC left, rather than the 60 CC if Resident 114 received the ordered amount. Observation on 04/18/2025 at 9:26 AM showed Resident 114's feeding tube bag had 450 CC of the liquid nutrition remaining with 34 minutes of scheduled feeding remaining. The pump was set to 80 CC/HR meaning only another 46 CC would be provided before the feeding was scheduled to end. Observation on 04/18/2025 at 10:06 AM showed Staff N (Registered Nurse) gowning up to enter Resident 114's room. Staff N stated they were going to finish the tube feeding cycle for Resident 114. Staff N stated each day at 4 PM when the feeding started nurses hung a new 1500 CC bag and when the feeding ended at 10 AM the next day, any remainder was discarded. In an interview on 04/21/2025 at 10:10 AM, Staff E (Resident Care Manager) stated it was important for residents that required tube feeding to receive the nutrition they were ordered. Staff E stated Resident 114 required tube feeding because of swallowing difficulties after a stroke. Staff E stated Resident 114 was ordered 1440 CC of liquid nutrition daily. Staff E stated Resident 114 did receive some medications during their feeding (which required pausing the feeding and disconnecting the pump temporarily) but did not think this affected the amount of liquid nutrition the resident received. Staff E stated they were not sure if a daily total for Resident 114's liquid nutrition was monitored anywhere in the chart or if the amount of remaining liquid nutrition was documented somewhere. Staff E stated they would clarify if these totals were documented. No further information was provided. REFERENCE: WAC 388-97-1060(3)(f).

Based on interview and record review the facility failed to ensure medically-related social services were provided for 1 of 4 residents (Residents 29) reviewed for nutrition. The failure to involve facility social workers for residents demonstrating behaviors of rejection of care placed residents at risk for unmet health needs and other negative health outcomes. Findings included . <Resident 29> According to the 03/02/2025 Admission Minimum Data Set (MDS - an assessment tool) Resident 29 had intact memory. The MDS showed Resident 29 had diagnoses including respiratory failure and reduced mobility. The MDS showed Resident 29 was totally dependent on staff to transfer in and out of bed. The MDS showed Resident 29 admitted to the facility with a Stage 2 Pressure Ulcer (PU) and a Deep Tissue Injury (DTI). The MDS showed Resident 29 did not demonstrate behaviors of rejection of care. The MDS showed Resident 29 received a diuretic (urination causing) medication. Record review showed Resident 29 had 02/24/2025 physician's order to weigh the resident daily. Record review showed that on 18 occasions out of 41 occasions between 03/05/2025 and 04/14/2025, Resident 29 refused their daily weight. According to the 04/11/2025 Psychosocial - Refusal of Care . Care Plan (CP) Resident 29 had a goal to have no negative outcomes related to their refusal of needed treatments and cares. The CP included goals to determine Resident 29's experiences and preferences to eliminate/mitigate triggers to the extent possible, encourage active participation in care, and to inform Resident 29 of the risks and ramifications of continued noncompliance. The CP identified the Social Services staff among those responsible to implement these interventions. According to a 03/20/2025 Medication Administration progress note, Resident 29 refused a constipation treatment that day. According to a 03/24/2025 progress note Resident 29 refused their weekly skin assessment. The note showed staff approached Resident 29 multiple times and Resident 29 asked staff if they had anything better to do. According to a 03/28/2025 nurse's progress note, the nurse discussed refusals of care with Resident 29. This note showed the nurse asked Resident 29 to sign a Risks vs. Benefits form to indicate they understood the consequences of their rejection of care. Resident 29 refused to sign the form and stated they wanted their spouse to sign it. Record review showed Resident 29's spouse signed a Risks vs. Benefits form related to Resident 29's diuretic use and refusals of care on 03/29/2025. In an interview on 04/17/2025 at 1:35 PM Staff I (Social Services Director) stated assisting with behavioral health needs was among the responsibilities of the social services department. Staff I stated this included problem solving with residents with patterns of refusing cares and treatments. In an interview on 04/18/2025 at 10:35 AM Staff E (Resident Care Manager) stated when residents demonstrated refusals of care they tried to reason with the resident, talk to them and if it continues discuss risks and benefits. Staff E stated Resident 29 required daily weights due to their diuretic medication use. Staff E stated pain was a factor in Resident 29's refusals. Staff E stated they were unsure if the social services department was notified of Resident 29's refusals of care. In an interview on 04/18/2025 at 1:21 PM Staff J (Social Services Coordinator) stated they provided social services on Resident 29's unit. Staff J stated they heard Resident 29 did not want to get up occasionally. Staff J stated they were unaware Resident 29 frequently refused to be weighed. Staff J stated they wished they were informed of the refusals and stated I could have problem-solved . with Resident 29. REFERENCE: WAC 388-97-0960 (1).

Based on observation, interview, and record review the facility failed to ensure staff performed Cardiopulmonary Resuscitation (CPR- an emergency procedure consisting of chest compressions combined with giving breaths of air when the resident's heart stops and they stop breathing) to 1 of 3 residents (Resident 1) reviewed for unexpected death in the facility. The failure to ensure staff followed the facility's policy for CPR including staffs ability to accurately assess signs of irreversible death, immediately verify the Physician's Order (PO) for CPR status, immediately access the resident's POLST form (Physician Order for Life-Sustaining Treatment - a document the resident completes to declare their wishes for CPR or No CPR), initiate CPR, communicate effectively to the 911 operator, communicate effectively to the Emergency Medical Services (EMS) personnel, provide accurate residents records to EMS personnel placed 39 additional residents (Residents 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, & 39) who had current PO to receive CPR, at serious risk for adverse outcomes including death, and constituted an Immediate Jeopardy (IJ -noncompliance that has caused or is likely to cause, serious injury, harm, impairment, or death to a resident). On [DATE] at 6:26 PM, the facility was notified of an IJ in F678. The facility removed the immediacy on [DATE] after they audited the records of all residents, audited the resident POLST forms, educated staff on the facility's revised CPR policy and procedure, performed CPR drills, and implemented a plan of correction to sustain ongoing compliance. Findings included . <Facility Policy> The facility Emergency Procedure - CPR policy, dated ,d+[DATE], showed facility personnel completed training on the initiation of CPR for victims of cardiac arrest (heart stops beating, leading cause of death among adults). The policy directed staff: to initiate CPR if an individual was found unresponsive and not breathing normally; have a CPR team would be responsible to coordinate and direct other team members during the rescue efforts; to assess the unresponsive individual for abnormal or absence of breathing and begin CPR unless a DNR (Do Not Resuscitate) order specifically prohibited CPR; administer CPR if the individual's CPR/DNR status was unclear until status can be verified; CPR efforts by the CPR team continue until EMS personnel arrived. Review of the [DATE] face sheet showed Resident 1 admitted to the facility on [DATE] with a diagnosis of sepsis (a blood infection) and pneumonia (a lung infection) after a COVID-19 infection with respiratory failure. The [DATE] 3:54 PM nursing progress note showed Resident 1 was admitted for rehabilitation, was alert and oriented, had a normal heart rate, clear lung sounds, denied chest pain and shortness of breath. POs were reviewed by two nurses and the physician was informed of Resident 1's admission. Review of Resident 1's [DATE] PO showed POLST: Attempt Resuscitation/CPR. Medical Interventions: Full Treatment. Review of the POLST form signed by Resident 1 on [DATE] showed Resident 1 wanted CPR if they had no pulse and was not breathing and wanted full medical treatment with the primary goal to prolong life by all medically effective means. The POLST form was signed by the practitioner on [DATE] and scanned into the electronic medical record (EMR) on [DATE]. A [DATE] 11:25 PM nursing progress note showed at 9:55 PM Resident 1 was walking with a Certified Nursing Assistant (CNA) in the hallway, became weak and short of breath, and sat down on a bench. Staff brought Resident 1 back to their room in a wheelchair and started oxygen, Resident 1 was alert, pale, and talking, vital signs were taken, the oxygen level was 77% (normal ,d+[DATE]%), respirations were 28 breaths per minute (normal ,d+[DATE]), pulse was 136 beats per minute (normal ,d+[DATE] average 72), blood pressure (BP) did not register on machine (normal less than ,d+[DATE]), 911 was called at 10:00 PM. Review of the [DATE] voice transcript from the 911 call showed at 10:00 PM Staff C (Registered Nurse) provided Resident 1's name, facility address, room number, and identified that Resident 1 was becoming unconscious and CPR was in process. The transcript showed 10:01 PM Staff C stated Resident 1 was DNR. Review of the [DATE] audio recording from the 911 call showed Staff C told the operator that Resident 1 was short of breath, then did not answer the 911 operator's questions of: what was happening? was the patient unconscious? were they breathing? was anyone doing CPR? Staff C was talking to others in the background and then stated Resident 1 was a DNR. The operator asked if anyone was doing CPR and Staff C stated they still needed EMS to come to the facility. The 911 operator clarified Resident 1's name and stated EMS was dispatched. Review of the [DATE] Fire Department (FD) incident report showed the FD arrived at 10:10 PM with lights and sirens for an emergency response for advanced life support for Resident 1 in cardiac arrest. At 10:10 PM, the FD found Resident 1 sitting upright in a chair surrounded by staff, skin was cool, pale, clammy, eyes fixed, mouth gaping open, no pulse, not breathing, and incontinent of urine. FD assessment of Resident 1 was cardiac arrest prior to FD arrival. The report showed that staff told the FD they witnessed Resident 1's cardiac arrest, called 911, and staff claimed Resident 1 had a pulse and low BP when FD arrived. The report showed the patient was deceased at 10:10 PM with DNR paperwork provided by staff. The patient's name on the incident report was Resident 2's name. Resident 2 (Resident 1's roommate). Review of the [DATE] 11:25 PM nursing progress note showed facility staff was about ready to do CPR when the FD arrived, vital signs absent at time of FD arrival, FD decided not to initiate CPR, Resident 1 pronounced dead with no palpable pulse, no BP, no respirations, Resident Representative, Director of Nursing (DNS) and Physician were notified of Resident 1's death. In an interview on [DATE] at 3:13 PM, Staff C stated when they left the room to call 911 Resident 1 was unresponsive, but had a pulse, oxygen was on, and Resident 1 was sitting in the wheelchair. Staff C stated they instructed the CNAs in the room to get Resident 1 on the floor in case Resident 1 needed CPR, then Staff C left Resident 1 to call 911. Staff C stated when calling 911 they thought Resident 1 had a DNR. Staff C stated the physician order in the Electronic Medical Record (EMR) showed Resident 1 was a full code with CPR and full medical treatment. Staff C stated they could not find the POLST form in the binder at the nurse station and it should have be there. Staff C showed the investigator where the binder was located, opened the binder and found Resident 2's POLST form in the binder. Staff C stated, Resident 1's POLST was not in the binder on [DATE]. Staff C stated if a resident did not have a DNR the staff had to do CPR, and it could be stopped if a DNR was located. In an interview on [DATE] at 3:50 PM, Staff D (LPN, Licensed Practical Nurse) stated when the incident occurred on [DATE], they saw Staff C on the phone with 911, went to Resident 1's room, Resident 1 was sitting in a chair while two CNAs were rubbing Resident 1's chest over Resident 1's heart. Staff D went back to the nurse station, Staff C asked Staff D to get the crash cart. Staff C told Staff D that Resident 1 was not a full code, but Staff C was still looking for the CPR status. When Staff D delivered the crash cart to the room, they saw Resident 1 still sitting in the chair with two CNAs in the room. Staff D stated FD personnel arrived and laid Resident 1 on the floor to start CPR; Staff D left the room. Staff D stated the CNAs did not start CPR on Resident 1. In an interview on [DATE] at 3:58 PM, Staff B (Director of Nursing) stated when a resident was admitted to the facility, staff completed the POLST form with the resident, then the practitioner needed to sign the form, the form was placed in the doctor's file to be signed, then the POLST is scanned to the EMR and the original goes into a multi-resident binder at the nurse's station. The nurse entered the PO into the EMR and it showed on the resident's screen for quick access. Staff B stated when a resident required CPR, staff should follow the PO in the EMR and locate the POLST form in the multi-resident binder at the nurse's station. Staff B stated Resident 1's POLST form was in the physician file to be signed and was why the nurse could not find it. Staff B stated the CNA staff should have identified when Resident 1 stopped breathing and initiated CPR right away by placing the resident on the floor in a flat position to do CPR. Staff B stated if there is no POLST form then staff should start CPR. In an interview on [DATE] at 4:11 PM, Staff E (CNA, Certified Nursing Assistant) stated they were in the room with Resident 1 when Staff C placed the oxygen and checked vital signs. Staff E stated Staff C left the room to call 911 and told Staff E and Staff F (CNA) to get Resident 1 on the floor in case CPR was needed. Staff C stated Resident 1 was a bigger person and tough to move, the CNAs did not put Resident 1 on the floor because they did not want to risk breaking Resident 1's bones. Staff E stated Staff D arrived with the crash cart and FD was on their way. Staff E stated at that time they did not think Resident 1 had a pulse but did not check for a pulse. Staff E stated no one started CPR then FD arrived and placed Resident 1 on the floor but decided not to do CPR. In an interview on [DATE] at 4:50 PM Staff G (LPN) stated they were working on another floor and came to see what the emergency was about after Resident 1 had died . Staff G was told by Staff E and Staff F that Resident 1 was a DNR. Staff G went to the EMR and saw that Resident 1 was a full code, with CPR orders. Staff G asked Staff C about the code status and Staff C stated Resident 1 was a DNR. Staff G stated they looked in the multi-resident binder for the POLST form and observed Resident 2's POLST form with DNR status and no POLST form for Resident 1. Staff G stated Staff C looked in the EMR and stated Resident 1 was a full code with CPR. Staff G stated Staff C called the Director of Nursing and walked away. Review of a [DATE] written statement from Staff H (CNA) showed they were called to assist in Resident 1's room. When they entered, they saw Resident 1 sitting in a wheelchair with one CNA massaging the chest over the heart. Staff H stated they asked Staff C if the CNAs should get Resident 1 on the floor if the resident was a full code. Staff C left to check Resident 1's code status and came back and told them Resident 1 was a DNR then stepped out of the room to continue the phone call with 911. Staff C came back and stated Resident 1 was a full code and the three CNAs were getting ready to place Resident 1 on the floor when FD arrived. FD placed Resident 1 on the floor and dismissed the CNAs. The three CNAs left the room. Review of a [DATE] interview transcript completed by the Fire Chief of the responding FD unit showed the lead FD personnel stated in the initial dispatch Resident 1 was becoming unconscious, CPR was initiated, and the facility caller stated the patient was a DNR. Upon arrival FD found the patient unconscious, unresponsive and not breathing, in a seated position in a chair with staff supporting the patient upright. The FD lead stated the facility staff claimed the patient did have a pulse and low BP. When the FD personnel assessed Resident 1's carotid (neck) pulse for 10 seconds, there was no pulse. Resident 1 was moved to the floor to initiate CPR when the facility staff provided a POLST form marked DNR. Resident 1 was declared deceased , moved into their bed, and covered with a sheet. The patient information entered to the incident report was based on paperwork staff provided. The name on the incident report was Resident 2, not Resident 1. Observation on [DATE] at 3:13 PM with Staff C showed Resident 2's POLST form was in the binder at the nurse station. Resident 2's POLST form showed DNR and was signed by Resident 2 on [DATE]. Interview on [DATE] at 6:10 PM, Staff B (Director of Nursing) stated Resident 1's death was unexpected. Staff B stated the nurse should have followed the PO and started CPR. Staff B stated the nurse was not in the room with Resident 1 and the CNA staff did not identify when Resident 1 stopped breathing and did not have a pulse, which caused staff to not start CPR. Staff B stated Staff C should not have given Resident 2's POLST form, directing DNR to the FD personnel. Staff B stated the facility staff should have, but did not, identify when Resident 1 required CPR and did not follow the PO for full code and CPR. Refer to F609 - Reporting of Alleged Violations Refer to F610 - Investigate/Prevent/Correct Alleged Violation REFERENCE: WAC [DATE](1).

Based on interview and record review the facility failed to treat residents with dignity and respect and provide a dignified existence that promoted quality of life for 1 of 1 resident (Resident 2) reviewed for resident rights. The failure to have a process for staff to provide a comfortable environment for residents after the death of a roommate, placed residents at risk of feeling scared, unsafe, distressed, and have a diminished quality of life. Resident 2 was harmed, using the reasonable person concept, when their roommate (Resident 1) died and they were left in the same room with the deceased resident from 10:00 PM on [DATE] until 5:30 PM on [DATE], 19.5 hours. Resident 2 was placed in a situation to cause harm to their mental well-being, safety, and dignity when they were not separated from their dead roommate's body. Findings included . The [DATE] admission nursing assessment and [DATE] admission progress note showed Resident 2 admitted to the facility on [DATE], was cognitively intact, had some forgetfulness, was able to make their needs known, had adequate hearing, had adequate speech, was able to make themselves understood and able to understand others. The admission diagnoses for Resident 2 included depression and anxiety. In an interview on [DATE] at 5:30 PM, Staff C (Registered Nurse) stated there was an incident involving multiple staff and the Fire Department responders on [DATE] when Resident 1 died . Resident 1's body was kept in the room with Resident 2 until the mortuary came during the next evening shift ([DATE] @ 5:30 PM) to pick up the body. Staff C stated the night shift and the day shift did not move Resident 1 or Resident 2 to another room. Staff C stated they did not talk to Resident 2 about the death of their roommate on [DATE] or [DATE], because the body of Resident 1 was still in the room and Staff C did not want to scare Resident 2. Staff C stated it would be a natural reaction for any person to be scared when being around a dead person. Staff C stated they (Staff C) would not want to share a room with a dead body for 19.5 hours, but no one thought of moving either resident to another room. In an interview on [DATE] at 11:10 AM, Staff B (Director of Nursing) confirmed the body of Resident 1 was kept in the room with Resident 2 for over 19 hours which included overnight while Resident 2 slept and most of the waking hours of the following day. Staff B stated the nursing staff could have offered Resident 2 a different room or moved Resident 1's body to a different room, but the staff did not offer or move either resident. Staff B stated a reasonable person would be uncomfortable, and possibly scared, to be in a room with a dead body. Staff B stated they, themselves, would not want to stay in the room and would have moved to another room if their roommate died and the body remained in the room that long. Staff B stated because the body remained in the room, the environment of the room was not homelike, did not maintain the mental well-being, safety or dignity of Resident 2. Refer to F678 Cardiopulmonary Resuscitation (CPR) REFERENCE: WAC [DATE](,d+[DATE]).

Based on interview and record review the facility failed to ensure nursing staff and nursing aide staff had the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physician, mental and psychosocial well-being of each resident according to the facility assessment, resident-specific assessments and resident plans of care for 11 of 11 staff (Staff K, L, E, M, H - Certified Nursing Assistants and Staff C, N, G, D, O, P - Licensed Nurses) reviewed for competency. The failure to develop and implement a process to evaluate staff's competency and skills to perform job expectations placed residents at risk for accidents, injuries, infections, diminished quality of life, and diminished quality of care. Findings included . The 07/2024 Facility Assessment (FA) showed the facility provides the staff with training and educational opportunities to ensure they can provide the necessary level and type of care to support the facility resident population. The FA showed the competency of staff's skills were assessed by skills validation, testing and face-to-face encounters. The FA showed competency of staff would be assessed related to specific job duties and licensure/certification and would include Person-Centered Care, Activities of Daily Living, Disaster Planning and Procedures, Infection Control, Medication Administration, Measurements, Resident Assessments and Resident Examinations. In an interview and record review on 08/12/2024 at 10:55 AM, Staff M (Staff Development Nurse) provided the training records of Staff C, D, E, F, G, H, I, J, K, L, and M. Staff M reviewed the training records with the investigator. The training records did not have documentation to show the facility verified the nursing staff was competent to perform the specific job duties as expected and according to the licensure/certification of each staff person. Staff M stated there was not a system in place to verify nursing staff was competent to perform their jobs. In an interview on 08/12/2024 at 3:12 PM, Staff B (Director of Nursing) stated the facility did not have a system to verify nursing staff's competency to perform their job on hire or on an annual basis. When asked if competency of nursing staff was evaluated by the facility to ensure care is provided to residents according to professional standards, Staff B stated no, but it should be. REFERENCE: WAC 388-97-1080(1).

Based on interview and record review, the facility failed to ensure violations of alleged neglect, involving serious bodily injury, were reported immediately to the state survey agency in accordance with State law for 1 of 3 residents (Resident 1) who did not receive CPR when there was a Physician Order (PO) directing staff to perform Cardiopulmonary Resuscitation (CPR- an emergency procedure consisting of chest compressions combined with giving breaths of air when the resident's heart stops and they stop breathing). The facility's failure to identify and report alleged neglect after a catastrophic change in condition, that involved the death of Resident 1, placed 39 of 48 other residents who had POs to receive CPR, at serious risk of harm including death. Findings included . The facility policy Unusual Occurrence Reporting, dated ,d+[DATE] showed the facility reported unusual occurrences and other reportable events which affect the health, safety or welfare of residents as required by federal or state regulations. Review of the [DATE] nurse progress note showed Resident 1 admitted on [DATE] and died on [DATE] when their heart stopped beating and they stopped breathing. The progress note showed no CPR was started on Resident 1. Review of Resident 1's [DATE] PO showed POLST: Attempt Resuscitation/CPR. Medical Interventions: Full Treatment. In an interview on [DATE] at 6:10 PM, Staff B (Director of Nursing) stated Resident 1's death was unexpected. Staff B stated on [DATE] Resident 1 stopped breathing and did not have a pulse and staff neglected to follow the PO for full code and did not start CPR. Staff B stated the facility should have, but did not, report the incident to the state agency as required. Refer to F678 - Cardiopulmonary Resuscitation (CPR) Refer to F610 - Investigate/Prevent/Correct Alleged Violations REFERENCE: WAC [DATE](5)(a).