Every finding on record at Columbia Lutheran Home

Based on observation, interview, and record review, the facility failed to ensure food was handled appropriately in accordance with professional standards of food safety for 1 of 3 refrigerators (Kitchen Walk-in Refrigerator) and for 2 of 7 staff (Staff Q & Staff S), reviewed for food services. The failure to discard a food item past the best by date and perform hand hygiene, placed the residents at risk for foodborne illness (caused by the ingestion of contaminated food or beverages), cross contamination, and a diminished quality of life. Findings included. Review of the facility's policy titled, PQA [Product Quality Assurance]- Food Product Shelf Life Guidelines, revised on 01/28/2022, showed, Food manufacturer/supplier code dates, use by dates, use thru dates, or expires on dates should always be considered the first level of control. Review of the facility's undated policy titled, Hand Hygiene, showed, All staff will perform proper hand hygiene procedure to prevent the spread of infection to other personnel, residents, and the visitors. This applies to all staff working in all locations within the facility. The facility policy further indicated that hand hygiene is required between resident contacts and after handling contaminated objects. KITCHEN WALK-IN REFRIGERATORIn a joint observation and interview on 06/30/2026 at 8:32 AM with Staff L, Cook, showed a Sysco (brand name) Ultra-Premium Lemon Juice in the Kitchen Walk-in Refrigerator with a label date of 4/14 [04/14/2026] and a best before date of 2026 May 04 [05/04/2026]. Staff L stated 4/14 was the opened date, and that they were supposed to use the lemon juice by 05/04/2026. Staff L stated that the lemon juice should have been discarded and not stored in the refrigerator. In an interview on 07/08/2026 at 9:08 AM, Staff K, Dietary Manager, stated that they expected staff to follow the food item manufacturer's date for best use and discard them after the best before date. Staff K stated that the lemon juice found in the Kitchen Walk-in Refrigerator on 06/30/2026 should not have been stored in the refrigerator past the best before date (57 days after the best before date). Staff K further stated it was important to follow the date from the manufacturer to not serve expired food items to the residents. On 07/08/2026 at 9:41 AM, Staff A, Administrator, stated that the lemon juice found in the Kitchen Walk-in Refrigerator should have been discarded and that it was important because it was the recommendation from the manufacturer. STAFF QOn 06/30/2026 at 12:01 PM, Staff Q, Certified Nursing Assistant (CNA), was observed in the Birch dining room pushing Resident 53 in a wheelchair. Staff Q assisted Resident 53 to the table, locked their wheelchair brakes, applied a clothing protector, and set up their lunch meal by removing the food items from the tray. Staff Q then walked to the dining room's kitchen and served Resident 27's lunch tray without performing hand hygiene. Then, Staff Q grabbed Resident 80's lunch tray from the kitchen and set it up for them, during which the staff member was observed touching the inside of Resident 80's plates. Staff Q then returned to the kitchen to get a clothing protector for another resident. Staff Q did not perform hand hygiene after coming into contact with the residents or their personal equipment. In an interview on 06/30/2026 at 12:29 PM, Staff Q stated that they were expected to perform hand hygiene after serving each resident's tray. Staff Q stated that they did not perform hand hygiene after pushing Resident 53's wheelchair, locking the wheelchair brakes, applying a clothing protector, and setting up the meal. Staff Q further stated that hand hygiene should have been performed. STAFF SOn 06/30/2026 12:19 PM, Staff S, CNA, was observed removing a lunch tray from the cart, entering Resident 51's room, and placing the tray on their bedside table. Staff S adjusted the bedside table, lowered Resident 51's bed using the bed control, and applied clothing protector to the resident before leaving the room. Staff S did not wash their hands or perform hand hygiene after touching Resident 51's equipment. Then, Staff S walked to the Birch dining room and began pushing the meal cart down the hallway. In an interview on 06/30/2026 at 12:41 PM, Staff S was asked when hand hygiene should be performed during meal tray delivery. Staff S stated that they would perform hand hygiene anytime they touched residents' personal equipment. Staff S stated that they did not wash their hands after touching Resident 51's bedside table and bed control, and prior to pushing the meal tray cart. In an interview on 07/08/2026 at 10:11 AM, Staff C, Infection Preventionist, stated that hand hygiene should be performed before and after serving meals to residents, before and after providing resident care, and after coming into contact with a resident's personal equipment. In an interview on 07/08/2026 at 12:37 PM, Staff B, Director of Nursing, stated that hand hygiene should be performed both before and after meal tray delivery. Reference: (WAC) 388-97-1100 (3) .

Based on observation, interview, and record review, the facility failed to ensure residents who were trauma survivors and diagnosed with Post Traumatic Stress Disorder (PTSD - a mental health condition triggered by a terrifying event that was either experienced or witnessed) was adequately assessed and/or care planned for trauma-informed care and associated triggers in accordance with professional standards of practice for 3 of 3 residents (Residents 2, 7, & 56), reviewed for mood/behavior. These failures placed residents at risk for unidentified triggers, re-traumatization, and a decreased quality of life.Findings included . Review of the facility's undated policy titled, Trauma Informed Care, showed, It is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally-competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization. The policy showed the facility would collaborate with resident trauma survivors, and as appropriate other health care professionals to develop and implement individualized care plan interventions. The policy showed the facility would attempt to identify triggers which may re-traumatize residents with a history of trauma and be added to the resident's care plan. The policy further showed, In situations where a trauma survivor is reluctant to share their history, the facility will try to identify triggers which may re-traumatize the resident while respecting resident's rights and develop care plan interventions which minimize or eliminate the effect of the trigger on the resident. Review of the facility's undated policy titled, Behavioral Health Services, showed, The resident and family are included in the comprehensive assessment process along with the interdisciplinary team and outside sources, as appropriate. The care plan shall: a. Have interventions that are person-centered, evidence-based, culturally competent, trauma-informed, and in accordance with professional standards of practice. RESIDENT 2Review of Resident 2's admission record printed on 07/01/2026, showed they admitted to the facility on [DATE] with a diagnosis that included PTSD. Review of Resident 2's Trauma Informed Consent Care Violence in The Community, War, or Terrorism, care plan printed on 07/01/2026, did not show PTSD triggers, or trigger specific interventions. Review of Resident 2's February 2026 progress notes did not show Resident 2 was asked about their PTSD triggers or trigger specific interventions. In an interview on 07/07/2026 at 11:15 AM, when asked about PTSD triggers, Resident 2 stated that they had a hard time with silence and that they had a condition that I need to have consistent noise. Resident 2 further stated that if the facility provided any resources for PTSD, they would be interested depending on what was offered. In an interview on 07/07/2026 at 2:51 PM, Staff T, Certified Nursing Assistant (CNA), stated they would know if a resident had PTSD by looking in their care plan. In an interview and joint record review on 07/07/2026 at 3:13 PM, Staff U, Licensed Practical Nurse, stated residents with PTSD had different experiences, and that all of them did not respond the same way. Staff U stated that they would expect to identify a resident's triggers with PTSD and have interventions in place because everybody is different, and they would have to find the appropriate approach for the individual. A joint record review of Resident 2's care plan did not show specific triggers were identified. Staff U stated that they did not see any triggers. In an interview on 07/07/2026 at 3:39 PM with Staff N, Social Worker (SW), and Staff O, SW, Staff N stated that if a resident had PTSD they would try to provide trauma informed care for everyone, and would offer extra support like mental health. Staff O stated they would ask residents if they had any trauma or were abused in their life, had any triggers, would document that in a progress note, and include it in the residents' care plan. When asked if there was a trauma-informed care assessment, Staff O stated that they did not have a form, and that they just asked questions and had a conversation with the resident. Staff O further stated that they expected a resident with PTSD to have an individualized care plan with specific trauma triggers and interventions to address those. In a joint record review and interview on 07/07/2026 at 4:06 PM, with Staff O and Staff N showed Resident 2 had a care plan for trauma informed care. Staff N stated that they were not aware of specific triggers or interventions for Resident 2. Staff O stated they did not see any triggers in Resident 2's care plan. In a follow-up interview on 07/08/2026 at 2:36 PM, Staff O stated that Resident 2 had PTSD from the war and that they did not like to talk about it. Staff O stated that there was no documentation in Resident 2's Electronic Health Records (EHR) showing if staff attempted to identify Resident 2's PTSD triggers and whether the resident denied having them. On 07/08/2026 at 3:31 PM, Staff B, Director of Nursing, stated they would expect social services staff to connect a veteran resident with mental health services. Staff B stated that if staff knew the residents' triggers and interventions that would help, they should be in the residents' care plan. Staff B stated they expected staff to try and obtain residents' PTSD triggers through resident/family interviews and/or their medical records. RESIDENT 7Review of Resident 7's medical diagnosis list printed on 07/02/2026, showed Resident 7 had a PTSD diagnosis. Review of the comprehensive care plan printed on 06/30/2026, did not show documentation that addressed Resident 7's history of trauma and/or triggers. In an interview on 07/06/2026 at 1:32 PM, Resident 7 stated that they had PTSD and I still get triggered. Resident 7 stated that some triggers for them included, someone coming up behind them and tapping them, it startles me, also if they [staff] knock loudly, it startles me, I've [I have] asked them [staff] not to. Another thing is getting in my bubble [personal space], makes me feel uncomfortable. When asked if Resident 7 was included in developing a care plan that addressed their triggers or interventions that may help them, Resident 7 stated, I've told [Staff N], but I don't [do not] think it's [it is] getting addressed. In an interview and joint record review on 07/07/2026 at 11:15 AM, Staff AA, CNA, stated that they knew how to care for a resident with PTSD by looking for triggers and interventions in the care plan. Staff AA stated that they were not aware of any residents with a PTSD diagnosis. A joint record review of Resident 7's comprehensive care plan showed that Resident 7 had PTSD, and it did not show any specific triggers or interventions. Staff AA stated that there was nothing really [specific] for Resident 7's PTSD. In an interview and joint record review on 07/08/2026 at 3:10 PM, Staff BB, Registered Nurse, stated that they were unsure if any current residents had PTSD. Staff BB stated that they did not know if Resident 7 had any triggers. A joint record review of Resident 7's comprehensive care plan did not show any specific triggers or interventions that addressed Resident 7's PTSD. Staff BB stated, it doesn't [does not] say anything specific about triggers. In an interview and joint record review on 07/07/2026 at 3:38 PM, Staff O stated that they asked residents if they had any history of abuse, neglect or trauma. Staff O stated that if there was trauma they would put in a care plan that included triggers and specific interventions. Staff N stated that they would identify a resident with PTSD from the doctor here or from hospital notes. Staff N and Staff O stated that they did not have a trauma-informed care assessment for residents. Staff N stated that Resident 7 had a PTSD diagnosis. A joint record review of Resident 7's comprehensive care plan did not show any specific triggers or interventions that addressed Resident 7's PTSD. Staff N stated, there should be triggers and interventions specific to [Resident 7] in the care plan. In an interview and joint record review on 07/08/2026 at 4:09 PM, Staff B stated, we don't [do not] do an assessment for PTSD and that social services does an interview with residents. Staff B stated that if the interview showed triggers, then that should be put in a care plan. Staff B stated that they expected everyone to have individualized care plans. A joint record review of Resident 7's comprehensive care plan did not show any specific triggers or interventions that addressed Resident 7's PTSD. Staff B stated, I don't see any triggers. I'm [I am] going to put them in now and I'm going to talk to [Resident 7] first. RESIDENT 56Review of the admission record printed on 07/07/2026 showed Resident 56 was admitted to the facility on [DATE] with diagnosis that included chronic (something that continues over an extended period) PTSD. Review of the quarterly Minimum Data Set (an assessment tool) dated 05/04/2026 showed that Resident 56 was exhibiting several behavioral symptoms and had a diagnosis of PTSD. Review of Resident 56's EHR, under the assessment tab showed no trauma informed care assessment completed or the resident's trauma triggers were identified. An observation on 07/01/2026 at 9:19 AM, showed Resident 56 was crying while seated in their wheelchair in the hallway. In an interview and joint record review on 07/08/2026 at 9:42 AM with Staff N and Staff O, Staff N stated that Resident 56's behaviors were related to dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and sundowning (a state of confusion that occurs in the late afternoon and lasts into the night), and that the facility was unable to complete an assessment. When questioned regarding trauma informed care assessment, or whether the resident's representative was asked about past trauma, Staff N and Staff O stated that the facility did not have a specific trauma informed care assessment form. A joint record review of the resident's EHR showed that no assessment had been conducted to identify the resident's trauma history, triggers, or cultural preferences. In an interview on 07/08/2026 at 12:23 PM, Staff B stated that residents with a history or diagnosis of PTSD would undergo a trauma assessment so that any identified triggers would be addressed in their care plan. Reference WAC 388-97-1060 (1)(3)(e) .

Based on interview and record review, the facility failed to initiate non-pharmacological interventions for pain management prior to administering as needed (PRN) pain medication for 3 of 6 residents (Residents 3, 14 & 39), reviewed for pain management. This failure placed the residents at risk for unnecessary medications and incomplete pain control. Findings included. Review of the facility's undated policy titled, Pain Management, showed that the facility would ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. The policy also showed that non-pharmacological interventions would include environmental comfort measures, physical modalities, cold compress, massage, repositioning, exercises, music, relaxation, activities, spiritual, comfort support. Further review of the policy showed that the facility staff would reassess resident's pain management at established intervals for effectiveness and or adverse consequences such as tolerance, physical dependence, increase sensitivity to pain, constipation [having a difficult time passing stool], nausea, vomiting, dry mouth, sleepiness, dizziness, and/or confusion, depression [persistent feeling of sadness and loss of interest] itching and sweating. RESIDENT 3Review of the quarterly Minimum Data Set (MDS – an assessment tool) assessment dated [DATE] showed that Resident 3 was admitted to the facility on [DATE] with diagnoses that included surgical amputation (removal of a limb or part of a limb) below the left knee, meralgia paresthetica (nerve compression causing tingling, burning, numbness, or pain) of lower limb, and osteoarthritis (a condition in which the protective cushioning at the ends of the bones wears down, causing the bones to rub against each other) of left knee. Review of the narcotic (opioid- controlled pain medication) care plan printed on 07/01/2026 showed Resident 3 had a goal for, Will be free of any adverse side effects from pain medication and an intervention that read, Monitor for altered mental status, anxiety [intense and excessive feelings of worry, nervousness, or fear], constipation, depression, dizziness, lack of appetite, nausea, vomiting, pruritus [itchiness], respiratory distress, sedation, urinary retention [inability to urinate]. Observe for adverse reactions with every interaction with the resident. Review of an order summary report printed on 07/01/2026 showed Resident 3 had the following orders:- Oxycodone [opioid – controlled/strong pain medication] tablet as needed for pain - NON-MED [non-pharmacological] INTERVENTIONS MUST BE OFFERED PRIOR TO GIVING PRN MEDS. Document interventions used on MAR & progress note:1. Deep breathing relaxation techniques 2. Going to Activity of choice 3. Offer beverage or favorite snack 4. Quiet music 5. Warm blanket. 6. Other - Describe in progress note. every 1 hours as needed. Review of the January 2026 Medication Administration Record (MAR) showed Resident 3 received PRN Oxycodone without documented evidence that non-pharmacological interventions were attempted on 01/30/2026. Further review of the January 2026 MAR did not show Resident 3 was monitored for adverse side effects to their PRN oxycodone use. Review of the February 2026 MAR showed Resident 3 received PRN Oxycodone without documented evidence that non-pharmacological interventions were attempted on the following dates:- 02/01/2026, 02/02/2026, 02/03/2026, 02/05/2026, 02/06/2026, 02/11/2026, 02/12/2026, 02/16/2026, 02/18/2026, 02/19/2026, 02/21/2026, 02/22/2026, 02/26/2026, and on 02/28/2026.Further review of the February 2026 MAR did not show Resident 3 was monitored for adverse side effects to their PRN oxycodone use. Review of the March 2026 MAR showed Resident 3 received PRN Oxycodone without documented evidence that non-pharmacological interventions were attempted on the following dates:- 03/03/2026, 03/04/2026, 03/08/2026, 03/09/2026, 03/13/2026, 03/14/2026, 03/17/2026, 03/19/2026, 03/21/2026, 03/23/2026, 03/24/2026, 03/25/2026, and on 03/28/2026. Further review of the March 2026 MAR did not show Resident 3 was monitored for adverse side effects to their PRN oxycodone use. Review of the April 2026 MAR showed Resident 3 received PRN Oxycodone without documented evidence that non-pharmacological interventions were attempted on the following dates:- 04/02/2026, 04/03/2026, 04/05/2026, 04/06/2026, 04/14/2026, 04/16/2026, 04/20/2026, 04/24/2026, 04/26/2026, 04/28/2026, and on 04/29/2026. Further review of the April 2026 MAR did not show Resident 3 was monitored for adverse side effects to their PRN oxycodone use. Review of the May 2026 MAR showed Resident 3 received PRN Oxycodone without documented evidence that non-pharmacological interventions were attempted on the following dates:- 05/03/2026, 05/07/2026, 05/09/2026, 05/10/2026, 05/11/2026, 05/13/2026, 05/15/2026, 05/16/2026, 05/17/2026, 05/18/2026, 05/19/2026, 05/20/2026, 05/21/2026, 05/22/2026, 05/23/2026, 05/25/2026, 05/26/2026, 05/28/2026, 05/29/2026, 05/30/2026, and on 05/31/2026.Further review of the May 2026 MAR did not show Resident 3 was monitored for adverse side effects to their PRN oxycodone use. Review of the June 2026 MAR showed Resident 3 received PRN Oxycodone without documented evidence that non-pharmacological interventions were attempted on the following dates:- 06/01/2026, 06/04/2026, 06/05/2026, 06/07/2026, 06/08/2026, 06/09/2026, 06/10/2026, 06/11/2026, 06/12/2026, 06/14/2026, 06/15/2026, 06/17/2026, 06/18/2026, 06/19/2026, 06/20/2026, 06/22/2026, 06/23/2026, 06/24/2026, 06/25/2026, 06/26/2026, 06/28/2026, and on 06/30/2026.Further review of the June 2026 MAR did not show Resident 3 was monitored for adverse side effects to their PRN oxycodone use. Review of the July 2026 MAR from 07/01/2026 through 07/07/2026 showed Resident 3 received PRN Oxycodone without documented evidence that non-pharmacological interventions were attempted on the following dates:- 07/01/2026, 07/02/2026, 07/03/2026, 07/04/2026, and on 07/07/2026.Further review of the July 2026 MAR did not show Resident 3 was monitored for adverse side effects to their PRN oxycodone use. In an interview on 07/08/2026 at 11:05 AM, Staff G, Registered Nurse, stated they would provide residents with non-pharmacological interventions such as warm blanket, coffee, positioning or other interventions prior to providing them with PRN opioid medications such as oxycodone, and then document it in the residents' MAR. Staff G further stated that they would monitor residents for adverse side effects to oxycodone use and document it in the residents' MAR. In an interview and joint record review on 07/08/2026 at 11:56 AM, Staff D, Resident Care Manager (RCM), stated they expected staff to provide residents with non-pharmacological interventions prior to providing residents with their PRN pain medications. Staff D stated they expected staff to monitor residents for adverse side effects to PRN opioid medications and document it in residents' chart. A joint record review of January 2026 MAR through July 2026 MAR showed that Resident 3 received PRN Oxycodone without documented evidence that non-pharmacological interventions were attempted on the above dates and/or that Resident 3 was monitored for adverse side effects to their oxycodone use. A joint record review of the narcotic care plan showed Resident 3 would be monitored for adverse side effects to narcotic/opioid medication use. Staff D stated that Resident 3 should have been provided with non-pharmacological interventions prior to administration of their PRN oxycodone. Staff D further stated that Resident 3 should have been monitored for adverse side effects to their oxycodone use and documented in their MAR. RESIDENT 14Review of the admission MDS assessment dated [DATE] showed Resident 14 was admitted to the facility on [DATE] and was cognitively intact. Further review of the MDS showed the resident had diagnoses that included closed fracture (broken bone) of left tibia (shin bone) and pain. Review of a pain care plan printed on 07/01/2026 showed Resident 14 had an intervention for, Monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations [feeling something that is not actually there or present], dysphoria [feeling very unhappy or dissatisfied], nausea, vomiting, dizziness and falls. Review of an order summary report printed on 07/01/2026 showed that Resident 14 had the following orders:- Oxycodone tablet as needed for pain- NON-MED INTERVENTIONS MUST BE OFFERED PRIOR TO GIVING PRN MEDS. Document interventions used on MAR &progress note:1. Deep breathing relaxation techniques 2. Going to Activity of choice 3. Offer beverage or favorite snack 4. Quiet music 5. Warm blanket. 6. Other - Describe in progress note. Review of the May 2026 MAR showed Resident 14 received PRN Oxycodone without documented evidence that non-pharmacological interventions were attempted on 05/30/2026. Further review of May 2026 MAR did not show Resident 14 was monitored for adverse side effects to their PRN oxycodone use. Review of the June 2026 MAR showed Resident 14 received PRN Oxycodone without documented evidence that non-pharmacological interventions were attempted on the following dates:- 06/01/2026, 06/04/2026, 06/05/2026, 06/06/2026, 06/07/2026, 06/08/2026, 06/09/2026, 06/10/2026, 06/11/2026, 06/12/2026, 06/13/2026, 06/14/2026, 06/15/2026, 06/16/2026, 06/17/2026, 06/18/2026, 06/19/2026, 06/20/2026, 06/21/2026, 06/22/2026, 06/23/2026, 06/24/2026, 06/25/2026, 06/26/2026, 06/27/2026, 06/28/2026, and on 06/30/2026.Further review of the June 2026 MAR did not show Resident 14 was monitored for adverse side effects to their PRN oxycodone use. Review of the July 2026 MAR showed Resident 14 received PRN Oxycodone without documented evidence that non-pharmacological interventions were attempted on the following dates:- 07/01/2026, 07/02/2026, 07/03/2026, 07/04/2026, 07/05/2026, 07/06/2026, and on 07/07/2026.Further review of the July 2026 MAR did not show Resident 14 was monitored for adverse side effects to their PRN oxycodone use. A joint record review and interview on 07/08/2026 at 1:06 PM with Staff D showed the May 2026 MAR through July 2026 MAR indicated that Resident 14 received PRN Oxycodone without documented evidence that non-pharmacological interventions were attempted on the above dates and/or that Resident 14 was not monitored for adverse side effects to their oxycodone use. A joint record review of the pain care plan showed Resident 14 would be monitored for adverse side effects to pain medication. Staff D stated that Resident 14 should have been provided with non-pharmacological interventions prior to administration of their PRN oxycodone. Staff D further stated that Resident 14 should have been monitored for adverse side effects to their oxycodone use and documented in their MAR. On 07/08/2026 at 5:12 PM, Staff B, Director of Nursing, stated they expected staff to provide non-pharmacological interventions to residents prior to administering their PRN opioid medications and to document in the residents' MAR. Staff B stated they expected residents to be monitored for adverse side effects to opioid use and that staff documented in the residents' charts. Staff B stated that staff should have provided Residents 3 and 4 with non-pharmacological interventions prior to administration of their PRN oxycodone, monitored for adverse side effects to their PRN oxycodone use, and documented in their medical records. RESIDENT 39Review of Resident 39's admission record printed on 07/01/2026, showed they admitted to the facility on [DATE]. Review of Resident 39's physician orders showed an order with a start date of 01/10/2026 for Buprenorphine Transdermal Patch (prescription opioid used to treat severe, long-term pain that requires continuous medication via patch to be applied to the skin and has not responded to other options) weekly 5 (five) micrograms (unit of measurement) per hour. Further review of the order showed one patch was to be applied transdermally one time a day every Saturday for pain and removed per schedule. Review of the comprehensive care plan printed on 07/01/2026, showed Resident 39 had a pain care plan with an intervention to Administer analgesia [analgesics-painkillers] as per orders. Give 1/2 [half] hour before therapy or uncomfortable care. Review of the January 2026 MAR showed a weekly order for Buprenorphine with a start date of 01/10/2026. The MAR further showed the medication was not administered as scheduled on 01/10/2026, 01/17/2026, and on 01/24/2026. Review of the January 2026 progress notes showed the following:-An eMAR [electronic Medication Administration Record] note for Buprenorphine dated 01/10/2026, showed faxed. -An eMAR note for Buprenorphine dated 01/17/2026, showed on order.-An eMAR note for Buprenorphine dated 01/24/2026, showed refaxed.Further review of the progress notes did not show a follow-up was done on the status of the medication or whether the physician or resident representative were notified of the reason the Resident 39 did not receive the medication. Review of the May 2026 MAR showed a weekly order for Buprenorphine. The MAR further showed the medication was not administered as scheduled on 05/09/2026 and on 05/23/2026 (marked as refused). Review of the May 2026 progress notes showed the following:-An eMAR note for Buprenorphine dated 05/09/2026, showed faxed. The note did not show a follow-up was done on the status of the medication or whether the physician or resident representative were notified of the reason Resident 39 did not receive the medication.-An eMAR note for Buprenorphine dated 05/23/2026, did not show why Resident 39 refused the medication, if staff reapproached the resident, or if the physician and representative were notified. Review of the July 2026 MAR showed a weekly order for Buprenorphine. The MAR further showed the medication was not administered as scheduled on 07/04/2026. Review of the July 2026 progress notes showed the following:-An eMAR note for Buprenorphine dated 07/04/2026, showed 7/4/26 [07/04/2026] Not given still on order. Further review of the progress notes did not show a follow-up was done on the status of the medication or whether the physician or resident representative were notified of the reason Resident 39 did not receive the medication. In a phone interview on 07/07/2026 at 2:13 PM, Staff I, Pharmacist, stated the pharmacy supplied Buprenorphine to the facility on [DATE] and sent two patches. Staff I stated they sent two patches on 05/10/2026 and refilled again on 05/19/2026. Staff I stated the pharmacy sent out four patches on 07/06/2026. Staff I stated that if the resident did not receive their pain patch as scheduled, they could assume their pain was not well controlled. Staff I further stated that after roughly three days the resident could potentially experience pain without the patch. On 07/08/2026 at 10:15 AM, Staff J, Licensed Practical Nurse, stated that if a controlled substance pain medication was out of stock, they would check their facility emergency kit first or call the pharmacy to get the medication delivered, and assess the resident's pain. Staff J stated that a resident could experience withdrawal symptoms or pain if they did not receive their medication as ordered. Staff J stated that they would notify the physician to see if an alternative medication could be ordered and notify the resident and/or their representative. Staff J further stated that if a resident refused medication, they would try to reapproach the resident again several times and would notify the physician and family. In an interview and joint record review on 07/08/2026 at 10:48 AM, Staff E, RCM, stated that if a controlled substance pain medication was out of stock, they would call pharmacy right away to get the medication delivered as soon as possible. Staff E stated that they would place the resident on alert charting for missing medication, monitor their pain, notify the physician and family, and document. Staff E stated that they did not know what on order meant and could assume it meant the nurse called the pharmacy and ordered the medication. Staff E stated they would expect staff to keep following up with the pharmacy. A joint record review of the January 2026 MAR showed that Buprenorphine was not administered to Resident 39 as scheduled on 01/10/2026, 01/17/2026, and on 01/24/2026. A joint record review of the January 2026 progress notes did not show a follow-up was done on the status of the medication or whether the physician or resident representative were notified on the reason Resident 39did not receive the medication. Staff E stated that Resident 39 did not receive the medication for three Saturdays (as scheduled) and did not see follow-up documentation as to why and who was notified. A joint record review of May 2026 MAR showed Buprenorphine was not administered as scheduled on 05/09/2026 and on 05/23/2026 (marked as refused). A joint record review of May 2026 progress notes did not show a follow-up was done on the status of the medication or why Resident 39 refused the medication, if staff reapproached the resident, or if the physician and representative were notified. Staff E stated they did not see documentation of a follow-up with the pharmacy or why Resident 39 had refused their medication and who was notified. A joint record review of July 2026 MAR showed Buprenorphine was not administered as scheduled on 07/04/2026. A joint record review of the July 2026 progress notes did not show a follow-up was done on the status of the medication or whether the physician or resident representative were notified of the reason Resident 39 did not receive the medication. Staff E stated it looks like Resident 39 did not get their pain medication on 07/04/2026 and did not see documentation that the physician or family were notified. On 07/08/2026 at 2:16 PM, Staff B stated they expected nursing staff to follow the resident's care plan when administering pain medication. Staff B stated that if staff could not administer medication either because it was not in stock or if the residents refused, they would expect staff to document it. Staff B stated that they would expect staff to follow up with the pharmacy on the delivery of the medication, put it on their 24-hour report, and let the RCM and physician know. Staff B further stated it was important to follow up with pharmacy to make sure [Resident 39's] pain is controlled. Reference: (WAC) 388-97-1060 (1)

Based on observation, interview, and record review, the facility failed to appropriately store drugs and/or biologicals for 1 of 2 medication carts ([NAME] Cart) and for 1 of 1 resident (Resident 53), reviewed for medication storage. This failure placed the residents at risk for receiving compromised and/or ineffective medications and unauthorized access to medication. Findings included. [NAME] CARTReview of the facility's undated policy titled, Insulin [medication that maintains normal levels of blood sugar] Pen, showed, Insulin pens must be clearly labeled with the resident name, physician name, date dispensed, type of insulin, amount to be given, frequency, and expiration date. In addition, it showed, Insulin pens should be disposed of after 28 days [from date opened] or according to manufacturer's recommendation. Observation on 07/07/2026 at 9:12 AM with Staff J, Licensed Practical Nurse (LPN), showed one insulin lispro (fast-acting insulin) pen was opened and dated 05/20/2026. In an interview on 07/07/2026 at 9:16 AM, Staff J stated that once an insulin pen was opened it was good for a month. Staff J stated that they wanted to confirm with the pharmacy. In a follow-up interview at 10:53 AM, Staff J stated that they talked to the pharmacist and the insulin lispro should be replaced twenty-eight days after opening. Staff J further stated that they disposed of the insulin lispro that had an opened date of 05/20/2026. In an interview on 07/07/2026 at 2:25 PM, Staff I, Pharmacist, stated that insulin lispro was good for twenty-eight days after it was opened. In an interview on 07/08/2026 at 4:09 PM, Staff B, Director of Nursing, stated that they expected the insulin lispro to be disposed of 28 days after opening unless the manufacturer stated something different. RESIDENT 53Review of the facility's undated policy titled, Medication Storage, showed, All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. Observations on 06/30/2026 at 8:15 AM and at 10:00 AM showed a Nystatin powder (prescription medicine used to treat yeast infections on the skin) bottle sitting on Resident 53's bedside table. In an interview on 07/08/2026 at 8:22 AM, Staff R, LPN, stated that medications must always be stored securely inside the medication cart. Staff R further stated that medications should never be left at a resident's bedside unless there was a specific physician order. In an interview on 07/08/2026 at 12:47 PM, Staff B stated that their expectation was that medications should not be left at a resident's bedside. Reference: (WAC) 388-97-1300 (2) .

Based on observation, interview, and record review, the facility failed to ensure Enhanced Barrier Precautions (EBP-precaution to protect residents from multidrug-resistant organisms [a germ that is resistant to medications that treat infections]) practices were followed by 1 of 7 staff (Staff M), reviewed for infection control practices. Additionally, the facility failed to ensure respiratory equipment was stored properly for 1 of 1 resident (Resident 32). These failures placed the residents, visitors, and staff at an increased risk for infection, related complications and a diminished quality of life. Findings included. Review of the facility's undated policy titled, Enhanced Barrier Precautions, showed An order for enhanced barrier precautions will be obtained for resident with.indwelling medical devices [such as a urinary catheter (a semi-flexible tube inserted into the bladder to drain urine)]. It showed that PPE [Personal Protective Equipment-gloves, gown] for enhanced barrier precautions is only necessary when performing high-contact care activities. Additionally, it showed that high-contact resident care activities included changing linens. STAFF MReview of an undated Centers for Disease Control and Prevention signage titled, Enhanced Barrier Precautions, showed, Staff must wear gloves and a gown for high-contact resident care activities that included changing linens. Review of Resident 80's physician orders printed on 07/02/2026, showed that Resident 80 had an indwelling urinary catheter. Observation on 07/02/2026 at 10:21 AM, showed Staff M, Certified Nursing Assistant, was changing the Resident 80's linens and was not wearing a gown. In an interview and joint observation on 07/02/2026 at 10:30 AM, Staff M stated that Resident 80 had a urinary catheter and was on EBP. Staff M stated that they would wear appropriate PPE when performing high-contact resident care activities. A joint observation of the signage in Resident 80's room showed that changing linens was an example of high-contact resident care. Staff M stated that they were not wearing a gown when they changed Resident 80's linens. In an interview on 07/08/2026 at 12:40 PM, Staff C, Infection Preventionist, stated that EBP was used for any resident who had wounds, indwelling tubes, and urinary catheters. Staff C stated they expected staff to where PPE (gown and gloves) whenever doing high-contact resident care. Staff C stated that changing lines was considered high-contact resident care and they would expect staff to use a gown and gloves for a resident on EBP. Staff C further stated that they expected Staff M to wear a gown when changing Resident 80's linens. In an interview on 07/08/2026 at 12:45 PM, Staff B, Director of Nursing, stated that if a resident was on EBP, they expected staff to wear a gown and gloves when changing linens. RESIDENT 32Review of the facility's undated policy titled, Oxygen Administration, showed, Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Review of the order summary report active as of 07/08/2026 showed that Resident 32 had an order for oxygen 2 (two) L/min (liters per minute – unit measurement) via nasal cannula (a flexible plastic tube that delivers extra oxygen right into nose). Observation on 06/30/2026 at 8:20 AM, showed Resident 32 was not in their room. Further observation of the resident's room showed that their oxygen humidifier (an attachment for oxygen machine that adds moisture to the air a patient breathes) bottle connected to the concentrator and nasal cannula, was sitting directly on the floor. Observation on 06/30/2026 at 9:57 AM, showed that Resident 32 was in bed wearing an oxygen nasal cannula at a flow rate of two liters per minute. Further observation showed that the oxygen humidifier bottle was connected to the concentrator and the nasal cannula was sitting directly on the floor. In an interview on 07/08/2026 at 8:22 AM, Staff R, Licensed Practical Nurse, stated that oxygen tubing and associated equipment should be stored properly, the humidifier bottle should be secured in the designated humidifier holder on the concentrator and should not be placed on the floor. In an interview on 07/08/2026 at 9:07 AM, Staff C stated that the oxygen humidifier bottle should not be placed on the floor. In an interview on 07/08/2026 at 12:23 PM, Staff B stated that they expected that oxygen tubbing and equipment should be stored properly and should not touch the floor. Reference: (WAC) 388-97-1320 (1) .

Based on observation, interview and record review, the facility failed to ensure residents received care and services in accordance with professional standards of practice for 2 of 2 residents (Residents 6 & 5), reviewed for quality of care. The failure to obtain weights consistently per physician order, monitor edema (swelling), and appropriately document skin assessments placed the residents at risk for unmet care needs, worsening medical conditions, and related complications. Findings included . Review of the facility's undated policy titled, Weight Monitoring, showed, Based on residents' comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident clinical condition demonstrates that this is not possible or resident preference indicate otherwise. RESIDENT 6Review of the order summary report active as of 07/08/2026 showed that Resident 6 had an order for Furosemide (water pill) for congestive heart failure (when a heart muscle does not pump blood as well as it should to be), Triamterene & Hydrochlorothiazide (water pill) for edema, and to be weighed weekly. Review of the April 2026 Medication Administration Record (MAR) showed that Resident 6's weight was not obtained on 04/10/2026 and was blank. Review of the May 2026 MAR showed that Resident 6's weights were not obtained and documented as NA [Not applicable] on 05/08/2026 and 05/29/2026. Further review of the MAR showed Resident 6's weight was not obtained on 05/22/2026 and was blank. Review of the June 2026 MAR showed that Resident 6's weight was not obtained and documented as NA on 06/19/2026. Review of Resident 6's progress notes between 04/01/2026 and 06/30/2026 showed no documentation of weight refusals, nor any evidence that the physician was notified of the refusal of care. Review of Resident 6's Electronic Health Record showed there was no order or care plan in place to monitor edema. In an interview and joint observation on 07/07/2026 at 10:34 AM, Staff R, Licensed Practical Nurse (LPN), stated that residents with edema required a specific monitoring order. Staff R stated that Resident 6 was taking Triamterene & Hydrochlorothiazide for edema, and that there was no order to monitor edema in the resident's orders. A joint observation showed no visible edema in Resident 6's lower extremities. Staff R stated that because the resident was free of edema, they did not think the medication the resident was taking for edema was necessary and that their physician would be notified. Staff R further stated that any resident refusal of care would be documented in the resident's medical record. In an interview and joint record review on 07/07/2026 at 11:12 AM, Staff E, Resident Care Manager, stated that if a resident had edema, a specific monitoring order should be in place. A joint record review of the order summary report as of 07/07/2026 showed no active order to monitor Resident 6's edema. Additionally, a joint review of the care plan printed on 07/03/2026 showed no care plan for edema management. Staff E stated that there was no order to monitor edema or a care plan to manage it. In an interview on 07/08/2026 at 12:41 PM, Staff B, Director of Nursing, stated that staff were expected to follow physician orders regarding weekly weights and edema monitoring. RESIDENT 5Review of the facility's undated policy titled, Skin Assessment, showed, A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, and weekly thereafter. Further review of the policy showed that documentation of the skin assessment would include documenting observations, type of wound, description of the wound, and documentation if the resident refused assessment and why. Review of Resident 5's June 2026 Treatment Administration Record (TAR), showed an order for Weekly skin check by LN [Licensed Nurse], started on 05/24/2026. It showed that LNs should document a minus sign (-) for no NEW skin problem and a plus sign (+) for a skin problem and then to document in progress note. The TAR further showed (+ [skin problem]) were documented on 06/07/2026 and on 06/14/2026. Review of the progress note on 06/07/2026, showed that the LN documented skin rashy as the documentation for marking (+) on the TAR. Further review of Resident 5's progress notes from 05/20/2026 through 07/02/2026 showed no documentation to indicate what skin problem Resident 5 had on the skin assessment done on 06/14/2026. Review of a wound consult note dated 06/19/2026, showed that Resident 5 was referred for a skin and wound care consultation. It further showed that Resident 5 was found to have a Stage 3 pressure ulcer (a deep, crater-like wound that penetrates all skin layers) to their coccyx (tailbone). In an interview and joint record review on 07/08/2026 at 9:40 AM, Staff J, LPN, stated that nurses would do skin checks for residents on their shower day and nurse aides will let us know if they see anything during care. Staff J stated that they would document in the TAR and if they marked a (+), then they would chart in a progress note. A joint record review of Resident 5's June 2026 TAR showed (+) was documented on 06/14/2026. A joint record review of Resident 5's progress notes from 05/20/2026 through 07/02/2026, showed no documentation to explain/indicate what skin problem Resident 5 had on the skin assessment done on 06/14/2026. Staff J stated, what was the issue [on 06/14/2026]? I don't [do not] know. In an interview on 07/08/2026 at 10:05 AM, Staff E stated that nurses are supposed to check [residents' skin] every week on shower day. Staff E stated that if a new problem was found during the skin checks, we document it in the progress notes. A joint record review of Resident 5's progress notes from 05/20/2026 through 07/02/2026, showed no documentation explaining/indicating what new skin problem Resident 5 had on the skin assessment done on 06/14/2026. Staff E stated, I don't know. I don't see anything. When asked if it was a new skin issue on 06/14/2026, Staff E stated, I'm [I am] not sure, they didn't document, so I don't know. When asked why Resident 5 was seen by the wound consultant on 06/19/2026, Staff E stated that Resident 5 was found to have a Stage 3 pressure ulcer. In an interview on 07/08/2026 at 11:35 AM, Staff W, LPN/Treatment Nurse, stated that on 06/07/2026, Resident 5 had a rash and that on 06/14/2026, nobody documented why it was marked (+) in the TAR. In an interview and joint record review on 07/08/2026 at 11:59 AM, Staff B stated they expected there to be documentation in the progress notes when a (+) was marked on a resident's TAR. A joint record review of Resident 5's progress notes from 05/20/2026 through 07/02/2026, showed no documentation to indicate what skin problem Resident 5 had on the skin assessment done on 06/14/2026. Staff B stated, I don't [do not] see any documentation and yes it should be documented. Staff B further stated that their expectation for skin checks was not met. Reference: (WAC) 388-97-1060 (1)(3)(b).

Based on record review and interview, the facility failed to ensure pharmacy services were provided to meet the needs of 1 of 5 residents (Resident 3), reviewed for medication administration. The failure to administer and/or document medication administration in accordance with professional standards of practice placed the resident at risk for negative outcomes and a diminished quality of life.Findings included .Review of the facility's undated policy titled, Medication Administration, showed, Medications are administered by licensed nurses. as ordered by the physician and in accordance with professional standards of practice. Administer medication as ordered in accordance with manufacturer specification. Sign MAR [Medication Administration Record] after [medications were] administered. Report and document any adverse side effects or refusals.Review of the admission record showed Resident 3 was admitted to the facility on [DATE] with diagnoses that included hypertensive heart disease (condition in which long-term high blood pressure causes damage to the heart), diabetes mellitus type 2 (chronic condition characterized by insulin [hormone that regulates blood sugar in the blood] resistance and high blood sugar levels), post-traumatic stress disorder (PTSD - a mental health condition triggered by a terrifying event that was either experienced or witnessed), cellulitis (skin infection caused by bacteria), gastro-esophageal reflux disease (stomach acid flows back into the esophagus [muscular tube that carries food from the mouth to the stomach] causing heartburn and regurgitation), and pain.Review of the February 2026 MAR did not show documentation that Resident 3's medications were given, the MAR was blank for the following:- Rivaroxaban (for blood clots) two times a day - on 02/08/2026 at 8:00 AM, on 02/21/2026 at 8:00 AM, and on 02/25/2026 at 8:00 AM- Farxiga (lowers blood sugar) one time a day - on 02/25/2026 at 8:00 AM- Metformin (lowers blood sugar) two times a day - on 02/08/2026 at 8:00 AM and on 02/25/2026 at 8:00 AM- Aspirin (reduces pain and fever) one time a day - on 02/08/2026 at 8:00 AM- Fluoxetine (treats depression [persistent feeling of sadness and loss of interest]) one time a day - on 02/08/2026 at 8:00 AM- Cefuroxime Axetil (treats bacterial infection) two times a day - on 02/08/2026 at 8:00 AM- Diclofenac (reduces pain) topical gel three times a day - on 02/26/2026 at 8:00 AM and at 12:00 PM; and on 02/27/2026 at 8:00 AM and at 12:00 PM- Pregabalin (treats nerve pain) three times a day - on 02/08/2026 at 8:00 AM and at 12:00 PM - Insulin Aspart (fast-acting insulin) solution - per sliding scale [as needed based on the measurement of the blood sugar] four times a day - on 02/08/2026 at 7:30 AM and at 11:30 AM, on 02/25/2026 at 7:30 AM and 11:30 AM, and on 02/26/2026 at 11:30 AM Review of the March 2026 MAR did not show documentation that Resident 3's medications were given, the MAR was blank for the following:- Rivaroxaban - on 03/14/2026 at 8:00 AM, on 03/20/2026 at 8:00 AM, on 03/22/2026 at 8:00 AM, on 03/23/2026 at 8:00 AM, and on 03/28/2026 at 8:00 AM- Farxiga - on 03/14/2026 at 8:00 AM and on 03/20/2026 at 8:00 AM- Metformin - on 03/14/2026 at 8:00 AM and on 03/20/2026 at 8:00 AM- Diclofenac - on 03/02/2026 at 8:00 AM and at 12:00 PM- Insulin Aspart - on 03/03/2026 at 11:30 AM, on 03/11/2026 at 11:30 AM, on 03/12/2026 at 11:30 AM, on 03/14/2026 at 7:30 AM and at 11:30 AM, on 03/15/2026 at 11:30 AM, on 03/20/2026 at 7:30 AM and at 11:30 AM, and on 03/21/2026 at 11:30 AMReview of the April 2026 MAR did not show documentation that Resident 3's medications were given, the MAR was blank for the following:- Rivaroxaban - on 04/05/2026, on 04/09/2026, and on 04/10/2026, all for 8:00 AM- Farxiga - on 04/10/2026 at 8:00 AM- Insulin Aspart - on 04/10/2026 at 7:30 AM and 11:30 AM, and on 04/13/2026 at 8:00 PM- Metformin - on 04/10/2026 at 8:00 AM- Insulin Glargine (long-acting insulin) one time a day - on 04/13/2026 at 8:00 PM- Aspirin - on 04/10/2026 at 8:00 AM- Fluoxetine - on 04/10/2026 at 8:00 AM - Nicotine transdermal patch (a patch applied to the skin that can help people quit smoking) - on 04/10/2026 at 8:00 AM- Omeprazole (reduces stomach acid) one time a day - on 04/10/2026 at 7:00 AM- Triamterene - Hydrochlorothiazide (water pill) one time a day - on 04/10/2026 at 8:00 AM- Vitamin D3 (supplement) - on 04/10/2026 at 8:00 AM- Pregabalin - on 04/10/2026 at 8:00 AM and at 12:00 PM - Diclofenac - on 04/10/2026 at 8:00 AM and at 12:00 PMOn 07/08/2026 at 11:05 AM, Staff G, Registered Nurse, stated that to provide residents with their medications, they would first check the residents' MAR to confirm the orders, take medications from the medication cart, and then check one more time before giving the medications to the residents. Staff G stated they would document in the residents' MAR after the residents took their medication or if they refused them.In an interview and joint record review on 07/08/2026 at 11:56 AM, Staff D, Resident Care Manager, stated they expected staff to administer residents' medications as prescribed and to be documented in their MAR whether the medications were administered or refused. A joint record review of the February 2026 MAR, March 2026 MAR, and April 2026 MAR did not show documentation that Resident 3's medications were given on the above dates and times. Staff D stated that Resident 3's MARs were blank for the reviewed dates and times. Staff D stated they expected staff documented in Resident 3's MARs whether the medications were given or not. Staff D further stated that if it was not documented, it was not done.In an interview and joint record review on 07/08/2026 at 5:15 PM, Staff B, Director of Nursing, stated they expected residents were administered their medications as ordered. A joint record review of the February 2026 MAR, March 2026 MAR, and April 2026 MAR showed Resident 3's MARs were blank for the medications on the above reviewed dates and times. Staff B stated Resident 3's MARs were blank, not documented, not done. Staff B further stated they expected staff to document medication administration and/or refusals in Resident 3's MARs and that holes in the MAR should have not been left.Reference: (WAC) 388-97-1300 (1)(b)(ii)(3)(a).

Based on observation, interview, and record review, the facility failed to obtain registry verification to ensure staff met competency evaluation requirements before allowing to serve as a nurse aide for 1 of 5 staff (Staff M), reviewed for nursing aide registry. This failure placed the residents at risk for abuse and unmet care needs.Findings included .Review of the facility's policy titled, Background Investigations, dated February 2022, showed, OBRA [Omnibus Budget Reconciliation Act - state-operated data base that tracks nursing assistants who meet federal requirements to work in skilled nursing facilities] Registry Inquiries are conducted on all NACs [Nursing Assistant Certified or CNAs] at least one week prior to date of hire and renewed every two years as required. Further review of the policy showed, the human resources department will contact the OBRA registry to verify that the applicant is eligible to be employed as a certified nurse aid in a skilled facility. OBRA renewal will be conducted every two years.Review of the undated employee records showed Staff M, CNA, was hired by the facility on 02/27/2024 as a Nursing Assistant Registered (NAR) and became a CNA on 07/09/2024. Further review of the employee's records did not include documentation from the nurse aide registry.Review of Staff M's time sheet from April 2025 to July 2026 showed Staff M had been actively working as a CNA and their last worked date was 07/06/2026.On 07/02/2026 at 10:21 AM, Staff M was observed providing care to a resident in room [ROOM NUMBER].On 07/07/2026 at 9:58 AM, Staff A, Administrator, stated that Staff M was a NAR when first hired [on 02/27/2024] and did not flag for OBRA registry review when Staff M became a CNA [on 07/09/2024]. Staff A stated that Staff M was removed from their working schedule on 07/06/2026 when the facility became aware that Staff M did not have an OBRA registry verification completed. Staff A further stated that Staff M should not have been working without an OBRA registry verification.Reference: (WAC) 388-97-1660 (3)(c).

Based on observation, interview, and record review, the facility failed to provide care and services in a manner that promotes dignity for 1 of 1 resident (Resident 80), reviewed for dignity. The facility failed to ensure resident on urinary catheter (a semi-flexible tube inserted into the bladder to drain urine) was provided with privacy and failed to transport the resident in a forward-facing position, placing the resident at risk for decreased self-worth, feelings of embarrassment, and a diminished quality of life.Findings included .Review of the facility's undated policy titled, Promoting/Maintaining Resident Dignity, showed, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances residents quality of life by recognizing each residents individuality.Review of the annual Minimum Data Set (an assessment tool) dated 04/10/2026 showed Resident 80 had intact cognition. The assessment further showed that Resident 80 had urinary catheter.Observation on 07/02/2026 at 10:09 AM, showed Staff P, Certified Nursing Assistant, was transporting Resident 80 in a shower chair down in the first-floor hallway toward the shower room. Resident 80's Foley catheter bag was hanging uncovered from the side of the chair, leaving the urine clearly visible to other residents and staff present in the hallway. Observation on 07/02/2026 at 10:25 AM, showed Resident 80 was observed being assisted out of the shower room by Staff P. The resident was seated in a shower chair while Staff P pulled the resident's shower chair backward behind them to their room. Resident 80's Foley catheter was partially covered by a bedsheet, leaving the tubbing and drainage bag visible in the hallway.In an interview on 07/02/2026 at 10:46 AM, Staff P stated that Resident 80's catheter did not have a privacy cover during the transport in the hallway. Staff P stated that the catheter collection bag was changed recently, did not have a privacy cover, and it should not have been visible in the hallway. When asked regarding why Staff P pulled the resident on shower chair backward through the hallway rather than pushing forward, Staff P stated that it was difficult to push Resident 80 forward on the shower chair. During an interview on 07/02/2026 at 10:56 AM, Resident 80 expressed a preference to have their urinary drainage bag covered. When asked about being transported backward to their room on a shower chair, Resident 80 stated that the facility's shower chair wheels were not working properly.In an interview on 07/07/2026 at 10:50 AM, Staff E, Resident Care Manager, stated that catheter collection bags must be covered in a privacy cover whenever a resident was transported through the hallway. Staff E further stated that staff were expected to push wheelchairs and transport chairs forward rather than pulling them backwards.In an interview on 07/08/2026 at 12:31 PM, Staff B, Director of Nursing, stated that the facility's expectation was for catheter collection bags to be covered in a privacy bag whenever residents were transported through the hallways. Staff B further stated that staff should push residents forward rather than pulling them backwards, ensuring residents could see where they were going.Reference: (WAC) 388-97-0180 (2).

Based on observation, interview, and record review, the facility failed to ensure physical restraints (any manual method, physical or mechanical device, equipment, or material attached or adjacent to the resident's body that cannot be removed and restricts freedom of movement) were implemented solely when required resident-specific medical symptoms were identified, a physician's order for the specific type of restraint was obtained, and the least restrictive measures were utilized first to treat the medical symptoms for 2 of 2 residents (Residents 46 & 54), reviewed for physical restraints. This failure placed the residents at risk for loss of freedom of movement, adverse psychological effects, independence, and self-direction.Findings included .Review of the facility's undated policy titled, Resident Alarms, showed, It is the policy of this facility to utilize resident alarms in limited circumstances, in accordance with resident's needs, goals, and preferences, so the resident will be able to attain or maintain his or her highest practicable level of physical mental and psychological well-being. The facility's policy defines an alarm as, Physical or electronic device that monitors resident movement and alerts to the staff by either audible or inaudible means when movement is detected. The facility's policy showed, The facility shall establish and utilize a systemic approach for the safe and appropriate use of resident alarms, including effort to identify risks; Evaluate and analyze risk; implement interventions to reduce risk; And monitor for effectiveness of the interventions and modifying interventions when necessary. Medical symptoms shall be identified and documented in the medical record the information may come from the residence medical history, physical exam, or individual observation. When alarms are in use or under consideration, risk of adverse consequences related to their alarm shall be identified. Resident directed approach shall be implemented in accordance with the residents needs goals and preferences. Alarms shall be initiated only to address specific medical symptoms or unique risk, when the benefit what the alarm outweighs the risk associated its use. Supervision and other resident-specific intervention shall be implemented and documented prior to the use of the alarm. The policy further showed that if the medical symptoms or risk warranting the use of the alarms are no longer present, the alarm will be discontinued.According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.20.1, dated in October 2025, showed, Any manual method or physical or mechanical device, material, or equipment that meets the definition of a physical restraint must have: physician documentation of a medical symptom that supports the use of the restraint, a physician's order for the type of restraint and parameter of use, and a care plan and a process in place for systematic and gradual restraint reduction (and/or elimination, if possible), as appropriate. The RAI further showed that the identification of medical symptoms should assist the facility in determining if the specific medical symptom can be improved or addressed by using other, less restrictive interventions. The facility should perform all due diligence and document this process to ensure that they have exhausted alternative treatments and less restrictive measures before a physical restraint is employed to treat the medical symptom. Review of the facility's undated consent titled, Safety Device Assessment and Consent, showed, Safety Devices are initiated only after less restrictive measures have been demonstrated to be insufficient. The least restrictive device would then be implemented. The consent further showed that reduced independence and loss of dignity were listed among the potential risks of the bed/chair alarms.RESIDENT 46Review of the admission record printed on 07/08/2026 showed Resident 46 was admitted to the facility on [DATE].Review of Resident 46's Safety Device Assessment and Consent form, signed by the resident on 12/05/2024, showed bed and chair alarm consent was obtained upon admission alongside other standard admission paperwork. The consent showed the use of a bed and chair alarm for fall risk, alongside a high-low bed as a standard of care intervention. However, the form's section titled, The least restrictive interventions that have been attempted are: was left blank. There was no documentation to verify that the facility attempted or considered less restrictive measures prior to implementing the bed and chair alarms.Review of the annual MDS dated [DATE] showed Resident 46 had moderately impaired cognition. The assessment further showed that Resident 46 did not have behavioral symptoms or history of falls.During the Resident Council meeting on 07/02/2026 at 2:05 PM, when residents were asked if they were treated with respect and dignity, Resident 46 stated that they were not, alleging that the facility implemented bed and chair alarms based just on their age.In an observation and interview on 07/06/2026 at 9:41 AM, Resident 46 was sleeping in their room in a wheelchair, with their head resting on a pillow placed on their nightstand. The resident's wheelchair alarm was active. When interviewed regarding consent for the alarms, Resident 46 stated, I'm 86 and they put it on your chair whether you want it or not. The resident stated they could not recall if they consented to the bed and chair alarms, or if the associated risks and benefits were discussed. Furthermore, Resident 46 stated that they do not attempt self-transfers and consistently wait for nursing assistants to assist them. When asked about the use of alarms, Resident 46 stated they were used to it.In an observation and interview on 07/07/2026 at 4:07 PM, showed Resident 46 was sleeping in their wheelchair with their head resting on a pillow placed on their nightstand. When asked about their bed and chair alarms, the resident stated, I do not like it, I'm old and I'm used to it. Resident 46 further stated they were afraid to move independently because they knew that if they moved, the alarm would go off.Review of the order summary report printed on 07/07/2026 showed Resident 46 had an order for high and low bed as safety devices with order start date of 12/05/2025. Further review of the order summary showed there was no bed or chair alarm order for Resident 46.Review of the nursing progress notes dated 04/08/2026, 04/11/2026, 04/12/2026, and 04/15/2026 showed Resident 46 was alert and oriented X 3 - 4 [a person's mental status, awareness, and brain function, it means the person is awake, conscious, and can correctly answer questions about their identity, location, time, and current situation].Review of the physician progress notes dated 02/12/2026 and 03/30/2026 showed that Resident 46 had unspecified mild dementia (a memory loss thinking problems with unknown underlying cause) without behavioral disturbance, psychotic disturbance (severe mental break from reality), mood disturbance (persistent and intense emotional states), and anxiety (feeling of fear, nervousness, or worry about what might happen next).Review of Resident 46's care plan printed on 07/07/2026 showed bed and chair alarms were placed as an intervention for fall risk. Further review of Resident 46's care plan showed no comprehensive care plan was initiated for the bed and chair alarms that indicated defined clinical goals for the devices, a specified duration for their use, and criteria for ongoing evaluation or reduction.In an interview and joint record review on 07/07/2026 at 10:55 AM, Staff E, Resident Care Manager, stated that an assessment, physician order, consent, and a care plan were required prior to implement bed and chair alarms. When asked why these alarms were utilized for Resident 46, Staff E stated that they did not have the resident's fall history and did not think the resident required the alarms. Staff E further stated that the facility typically implemented bed and chair alarms for residents exhibiting confusion, to address fall risks, and to prevent falls. However, Staff E was unable to provide record that showed what less restrictive measures, if any, were attempted for Resident 46 prior to implementing the alarms. A joint record review of the care plan printed on 07/07/2026 showed that there was no comprehensive care plan initiated for Resident 46's alarms. Staff E provided no further information.In an interview on 07/07/2026 at 2:52 PM, Staff B, Director of Nursing, stated that Resident 46 had dementia, cognitive impairment, and a moderate risk for falls. Staff B stated that Resident 46 was admitted in December 2024 and had not experienced a fall since admission. Staff B stated that the facility implemented bed and chair alarms upon admission if a resident had history of falls. When asked about the less restrictive measures attempted for Resident 46 prior to implementing the alarms, Staff B was unable to provide documentation, stating the devices were applied upon admission. Staff B stated that bed and chair alarms were not considered restrictive devices because they were not physically attached to the residents and did not prevent mobility; therefore, a restrictive device care plan was not required.RESIDENT 54Review of the admission record printed on 07/08/2026 showed Resident 54 was admitted to the facility on [DATE].Review of the quarterly MDS dated [DATE] showed Resident 54 had moderately impaired cognition. The assessment further showed that Resident 54 did not have behavioral symptoms or history of fall.Review of the facility's fall investigation dated 02/20/2026 showed Resident 54 experienced a witnessed fall. The investigation indicated Resident 54 lost balance while pivoting during a transfer with one staff member, resulting in the resident being assisted to the floor. Further review of the investigation showed that Resident 54's care plan was updated to require one-to-two-person assistance or the use of sit-to-stand mechanical lift for all transfers until the resident was cleared by therapy.Review of the facility's fall investigation dated 03/20/2026 showed Resident 54 was found sitting on the floor next to their bed. The investigation indicated that Resident 54 was alert and oriented and had been attempting to reach a call light that had fallen off their bed. Further review of the investigation showed that bed and chair alarms were implemented to be active at all times to prevent future falls or injuries.Review of Resident 54's Safety Device Assessment and Consent form, signed by the resident on 03/20/2024, showed the use of a bed and chair alarm to prevent fall/injury. However, the form's section titled, The least restrictive interventions that have been attempted are: was left blank. There was no documentation to verify that the facility attempted or considered less restrictive measures prior to implementing the bed and chair alarms.Review of Resident 54's care plan printed on 06/30/2026 showed bed and chair alarms were placed as an intervention, To prevent fall/injury, related to recent fall without calling for assistance. Further review of the resident's care plan showed no comprehensive care plan was initiated for the bed and chair alarms that indicated specific clinical goals for the devices, a specified duration for their use, and criteria for ongoing evaluation or reduction.In an observation on 06/30/2026 at 8:29 AM and at 2:45 PM, showed Resident 54 was sitting in their wheelchair and their wheelchair alarm was on.In an observation on 06/30/2026 at 8:37 AM, Resident 54 was assisted to a standing position by a staff member, which triggered the resident's wheelchair loud alarm. Resident 54 was heard stating, I hate that.During an observation and interview on 07/01/2026 at 2:31 PM, Resident 54 was observed in bed with their bed alarm on. When interviewed regarding the bed alarm and whether it restricted their movement, Resident 54 stated the sound bothered them and restricted their movement, adding, I am used to it.In an observation on 07/06/2026 at 9:25 AM, Resident 54 was in bed with their bed at its lowest position and the be alarm was on.In an interview on 07/07/2026 at 10:22 AM, Staff P, Certified Nursing Assistant, stated that Resident 54 had bed and chair alarms and they had never observed the resident to self-transfer, noting that the resident consistently waited for staff assistance.In an interview and joint record review on 07/07/2026 at 10:45 AM, Staff E stated that Resident 54 was placed on bed and chair alarms due to confusion and a history of falls. When asked regarding what less restrictive measures were attempted prior to implementing the alarms, Staff E stated they did not have that information because Resident 54 had recently moved to the unit. Staff E further stated that while the facility completed quarterly assessments, there were no specific criteria utilized to determine whether to continue or discontinue the alarms. A joint record review of the care plan printed on 06/30/2026 showed that no comprehensive care plan had been initiated for Resident 54's bed and chair alarms. Staff E provided no further information.In an interview on 07/07/2026 at 2:33 PM, Staff B stated that Resident 54's bed and chair alarms were placed due to dementia, stroke [when blood flow to an area of brain is cut off], obesity [excessive amount of body fat], and Resident 54 had experienced two falls since admission. Staff B stated that the first fall was witnessed, resulting in staff lowering Resident 54 to the ground, and the second fall occurred while the resident was attempting to reach for their call light. When asked if the facility had attempted any less restrictive measures prior to implementing the alarms, Staff B was unable to provide records demonstrating that less restrictive interventions were tried. Staff B stated that bed and chair alarms were not considered restrictive devices.Reference: (WAC) 388-97-0620 (1)(4)(c).

Based on observation, interview, and record review, the facility failed to accurately assess 2 of 4 residents (Residents 46 & 53), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure resident assessments were completed accurately on the MDS regarding restraints (devices or methods that limit a resident's freedom of movement), and dental status placed the residents at risk for unidentified and/or unmet care needs, and a diminished quality of life.Findings included.According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.20.1, dated in October 2025, showed, .an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian and/or other legally authorized representative, or significant other as appropriate or acceptable. It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT [Interdisciplinary Team] completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment.Review of the facility's undated policy titled, MDS 3.0 Completion, showed, Residents are assessed, using a comprehensive assessment process, in order to identify care and to care needs and to develop an interdisciplinary care plan.According to federal regulation, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI specified by the State.RESIDENT 46Review of the Safety Device Assessment and Consent form, signed by Resident 46 on 12/05/2024, showed bed and chair alarms consent was obtained.Review of the Safety Devices assessment dated [DATE] showed Resident 46 had bed and chair alarms.Review of the quarterly MDS dated [DATE] showed Resident 46 had not used bed and chair alarms.Observations on 07/06/2026 at 9:41 AM and 07/07/2026 at 4:07 PM showed Resident 46 had bed and chair alarms in place.Review Resident 46's care plan printed on 07/07/2026 showed bed and chair alarms were implemented as interventions for fall risk.In an interview and joint record review on 07/08/2026 at 11:04 AM with Staff V, MDS Coordinator and Staff F, MDS Nurse, Staff V stated that the facility followed the RAI manual for MDS completion. Staff V stated that if a resident had a bed and chair alarms, it would be coded on the MDS assessment. A joint record review of the care plan printed on 07/07/2026 showed Resident 46 had chair/bed alarms. A joint record review of the resident's safety devices assessment dated [DATE] showed that the resident had bed/chair alarms. A joint record review of Resident 46's quarterly MDS dated [DATE] showed the bed/chair alarms were not coded on the MDS. Staff F stated, It looks like we missed it, and that the MDS would be modified.RESIDENT 53Review of Resident 53's significant change MDS dated [DATE] showed Section L0200D (obvious or likely cavity or broken natural teeth) was not marked.Observation on 07/01/2026 at 9:28 AM, showed Resident 53 had visible broken tooth in their lower left jaw.Review of the denture consultation dated 02/25/2026 showed that Resident 53 had a broken tooth.In an interview and joint record review on 07/08/2026 at 11:15 AM, Staff F stated that they assessed the resident's dental status and review dental consult notes to complete the MDS's oral/dental status section. A joint record review of the denture consultation dated 02/25/2026 showed that Resident 53 had broken teeth. A joint record review of the significant change MDS dated [DATE] showed section L0200D was not marked. Staff F stated that they have already modified the MDS due to inaccuracies. In an interview on 07/08/2026 at 12:41 PM, Staff B, Director of Nursing, stated that staff were expected to follow the RAI manual and ensure MDS assessments were completed accurately.Reference: (WAC) 388-97-1000(1)(b).

Based on interview and record review, the facility failed to ensure the Preadmission Screen and Resident Review (PASRR) Level II (refers to the evaluation process conducted after a Level I screening indicates a possible serious mental illness or intellectual disability to ensure that individuals receive appropriate care and support based on their specific needs and conditions) was obtained for 1 of 5 residents (Resident 59), reviewed for PASRR coordination. This failure placed residents at risk of not receiving the necessary behavioral health services and a diminished quality of life.Findings included.Review of the quarterly Minimum Data Set (MDS-an assessment tool) assessment, dated 06/17/2026, showed Resident 59 had diagnoses that included bipolar disorder (a mental health condition causing extreme shifts in mood, energy, activity levels, and concentration) and Post Traumatic Stress Disorder (PTSD - a mental health condition triggered by a terrifying event that was either experienced or witnessed).Review of a document titled, PASRR Notice of Determination, dated 04/09/2026, showed Resident 59 had a mental health diagnosis, met the requirements for nursing facility level of care due to current mental health needs, and that Resident 59 may benefit from specialized behavioral health services. Further review of the document showed, The full PASRR [Level II] report will be sent to the nursing facility where you are staying and will become part of your medical record within 30 days.Review of the Electronic Health Record (miscellaneous/documents tab) printed on 07/02/2026 did not show Resident 59's Level II PASRR full report.In an interview and joint record review on 07/08/2026 at 2:22 PM, Staff N, Social Worker, stated that the PASRR Notice of Determination would generally have an evaluation (Level II full report) attached to it. A joint record review of the PASRR Notice of Determination dated 04/09/2026 showed Resident 59 met requirements for nursing facility level of care and may benefit from specialized services. A joint record review of the miscellaneous/documents tab did not show Resident 59 had a Level II PASRR report. Staff N stated, I don't [do not] see one [Level II PASRR full report]. When asked if Resident 59 may benefit from specialized services, Staff N stated, yes. When asked if there was any follow-up after the 30 days as mentioned in the Notice of Determination, Staff N looked in the residents' notes and in email correspondence with the state PASRR office. Staff N stated, I don't see anything and stated that they expected there to have been a follow-up about Resident 59's Level II PASRR full report.In an interview on 07/08/2026 at 6:18 PM, Staff B, Director of Nursing, stated that they would expect PASSR [State PASRR office] to send the report.Reference: (WAC) 388-97-1975(8)(10).

Based on interview and record review, the facility failed to monitor a resident's weight and follow up timely on dietician recommendations for 1 of 3 residents (Resident 5), reviewed for nutrition. These failures placed the resident at risk for unrecognized weight loss, nutrition-related complications, and a diminished quality of life. Findings included.Review of the facility's undated policy titled, Weight Monitoring, showed, A weight monitoring schedule will be developed upon admission for all residents. Further review showed that newly admitted residents' weights would be monitored weekly for at least 4 [four] weeks and that most residents are on a weekly weight schedule.Review of Resident 5's physician orders dated 05/20/2026 showed they were re-admitted to the facility on [DATE] and showed an order to weigh resident weekly on Sunday day shift.Review of Resident 5's Weights and Vitals Summary, printed on 07/06/2026, showed the last weight obtained for Resident 5 was on 05/24/2026.Review of Resident 5's June 2026 Medication Administration Record (MAR), showed that Resident 5 refused to have their weight done on 06/07/2026, 06/21/2026 and 06/28/2026. It further showed that on 06/14/2026, the MAR was marked for other/see nurse notes and no weight was obtained.Review of the progress note on 06/14/2026 showed no documentation as to explain why Resident 5's weight was not obtained.Review of Resident 5's July 2026 MAR, showed that on 07/05/2026, the MAR was marked for other/see nurse notes and no weight was obtained.Review of the progress note on 07/05/2026 showed no documentation to explain why Resident 5's weight was not obtained.Review of the dietician note dated 07/02/2026 showed, resident needs additional calories and protein d/t [due to] underweight status and for healing of pressure ulcer [bed sore]. Further review showed, RD [Registered Dietician] talked to [the] nurse and informed her that she was going to add Glucerna [drinkable meal supplement] shake to orders. An additional dietician note on the same day showed, RD requested current wt [weight] for resident-last wt was done on 5/24 [05/24/2026].Review of Resident 5's nutrition care plan printed on 07/02/2026 showed the interventions to monitor weight weekly as ordered and provide oral nutritional supplements as ordered.In an interview on 07/07/2026 at 8:40 AM, Staff X, Certified Nursing Assistant, stated that nurses would let them know if a weight needs to be done. When asked if a resident refused to get weighed, Staff X stated they would offer an alternative, talk to a nurse.In a phone interview and joint record review on 07/07/2026 at 10:34 AM, Staff Y, Registered Dietician, stated, I have a recommendation form I use to communicate with staff. A joint record review of Resident 5's Weights and Vitals Summary showed the last weight obtained for Resident 5 was on 05/24/2026. Staff Y stated, I've [I have] asked for an updated weight. When asked how often Resident 5 was supposed to be weighed, Staff Y stated I believe monthly. She didn't [did not] have one [a weight] in June [2026]. Staff Y further stated that on 07/02/2026, I said I was going to add Glucerna shake to her orders. I talked to a nurse. I would expect them to add that. A joint record review of the July 2026 MAR showed no order for Glucerna. Staff Y stated, I will follow up with them tomorrow.In an interview and joint record review on 07/08/2026 at 8:19 AM, Staff J, Licensed Practical Nurse, stated that resident weights were checked weekly on shower days. Staff J stated that if a resident refused, we try again. I will come back a few times. Then tell the manager [if still refusing] and mostly at the end of the day or shift, I usually get it [residents' weight]. Staff J stated that the dietician communicated recommendations by giving a list of who needs a reweigh, they will give us a paper [recommendation form] if there's [there is] a change. A joint record review of the physician orders showed that Resident 5 had an order for weekly weights. Another joint record review of the Weights and Vitals Summary showed the last weight obtained for Resident 5 was on 05/24/2026. Staff J stated that Resident 5 was not cooperative and a challenge to weigh. Another joint record review of the dietician note dated 07/02/2026 showed, RD talked to nurse and informed her that she was going to add Glucerna shake to orders. An additional dietician note on the same day showed RD requested current wt for resident-last wt was done on 5/24. Staff J stated that Staff Y mentioned verbally to me, I thought she put it in [Glucerna order]. Staff J stated if the dietician asked to reweigh a resident they expected it to be done on that day.In an interview and joint record review on 07/08/2026 at 8:35 AM, Staff E, Resident Care Manager, stated that Resident 5 had an order for weekly weights and that if they refused, they expected it to be documented. Staff E stated that Resident 5 re-admitted on [DATE]. A joint record review of the Weights and Vitals Summary showed the last weight obtained for Resident 5 was on 05/24/2026. Review of Resident 5's July 2026 MAR, showed that on 07/05/2026, the MAR was marked for other/see nurse notes and no weight was obtained. A joint record review of the progress notes for 07/05/2026 showed no documentation of why a weight was not obtained. Staff E stated that there was no progress note. A joint record review of the dietician note dated 07/02/2026 showed, RD talked to nurse and informed her that she was going to add Glucerna shake to orders. An additional dietician note on the same day showed RD requested current wt for resident-last wt was done on 5/24 [05/24/2026]. Staff E stated that the dietician requested a weight for Resident 5 and it has not been done yet. It should be done. She needs to get weighed. Staff E looked at Resident 5's physician orders and stated, I don't [do not] see the order. Staff E stated, the nurses and me were responsible for putting in the orders from the dietician and they would follow up.In an interview on 07/08/2026 at 4:09 PM, Staff B, Director of Nursing, stated that they expected staff to follow orders for obtaining weights for residents and if residents refused I want them [staff] to document that they refuse. Staff B stated that they expected staff to follow dietician recommendations for the most part. Staff B looked through their emails for Staff Y's recommendations to add Glucerna and stated, I don't [do not] have her recommendations. Staff B further stated, we try to get the reweighs done pretty soon after the dietician requested.Reference: (WAC) 388-97-1060 (3)(h).

Based on observation, interview, and record review, the facility failed to provide adequate supervision for 1 of 3 residents (Resident 59), reviewed for accident/hazards. The failure to ensure aspiration precautions (safety measures designed to prevent food, liquids, or saliva from entering the airway and lungs) were implemented, placed the resident at risk for accidents, injury, and other negative outcomes.Findings included.Review of the facility's undated policy titled, Accidents and Supervision, showed, The resident environment will remain as free of accident hazards as is possible and this includes, identifying hazards and risks, evaluating and analyzing hazards and risks, implementing interventions to reduce hazards and risks and monitoring for effectiveness and modifying interventions when necessary.Review of the speech therapy Evaluation and Plan of Treatment, dated 06/22/2026, showed that Resident 59 had a diagnosis of dysphagia (difficulty swallowing). It showed that Resident 59 had been referred for speech therapy evaluation due to a report of choking via RCM [Resident Care Manager]. It showed under the section titled Diet Assessment/Recommendations that it was recommended for Resident 59 to be on aspiration precautions. It further showed under the section Assessment Summary that Aspiration precautions [signage] posted.Review of the comprehensive care plan printed on 06/30/2026, showed no documentation that Resident 59 was on aspiration precautions.Observation on 06/30/2026 at 8:48 AM, showed a sign above Resident 59's bed which indicated, Aspiration Precautions and Do Not leave food/drink. It showed that Resident 59 needed 1:1 [one to one] help at meals with cues/reminders. Additional observation showed Resident 59 with a breakfast meal tray on their bedside table and was eating their breakfast without staff supervision.In an interview, joint record review, and joint observation on 06/30/2026 at 8:53 AM, Staff R, Licensed Practical Nurse, stated Resident 59 was on aspiration precautions, Staff R stated, I'm [I am] not sure. A joint record review of Resident 59's comprehensive care plan showed no documentation that Resident 59 was on aspiration precautions. A joint observation showed a sign above Resident 59's bed which indicated, Aspiration Precautions and Do Not leave food/drink. It showed that Resident 59 needed 1:1 help at meals with cues/reminders. Staff R stated, I'm not sure about that, I need to ask the RCM. Further observation showed Resident 59 eating eggs and drinking coffee and an Ensure [drinkable meal supplement] bottle without staff supervision. Staff R stated that yes food had been left and that Resident 59 always eats by himself.A joint observation and interview on 06/30/2026 at 9:12 AM with Staff E, RCM, showed a sign above Resident 59's bed which showed, Aspiration Precautions and Do Not leave food/drink. It showed that Resident 59 needed 1:1 help at meals with cues/reminders. Staff E stated that Resident 59 was not on aspiration precautions and took the sign off the wall.In an interview on 07/02/2026, Staff Z, Speech Language Pathologist, stated that they communicated their recommendations for aspiration precautions by notifying the physician and RCMs, and then placing an aspiration precautions sign in the resident's room. Staff Z stated they expected staff to follow the sign. Staff Z stated that Resident 59 was assessed on 06/22/2026 and that they were on aspiration precautions and they had put the aspiration precautions signage above Resident 59's bed. Staff Z stated that Resident 59 continued to be on aspiration precautions and had not been reassessed to be taken off aspiration precautions.In an interview and joint record review on 07/02/2026 at 4:17 PM, Staff E stated that if a resident was on aspiration precautions, it should be on the nurse's MAR [Medication Administration Record] and care plan and if they [speech therapy] say a resident needs to be on aspiration precautions they let us know. A joint record review of the speech therapy note dated 06/22/2026, showed that it was recommended by speech therapy for Resident 59 to be on aspiration precautions. Staff E stated, I think I care planned that for him [Resident 59]. A joint record review of Resident 59's comprehensive care plan showed no care plan or intervention for aspiration precautions. Staff E stated, I don't see anything. Staff E put in an order for aspiration precautions for Resident 59 and stated, I will put in a care plan now for aspiration precautions.In an interview and joint record review on 07/08/2025 at 4:09 PM, Staff B, Director of Nursing, stated that if a resident was on aspiration precautions they expected speech therapy to give their recommendations to the RCMs and the RCMs would update the care plan. A joint record review of the speech therapy note dated 06/22/2026, showed it was recommended for Resident 59 to be on aspiration precautions. It further showed under the section Assessment Summary that Aspiration precautions [signage] posted. Staff B stated that's not what she should do. This isn't how it should be communicated. Staff B further stated that based on this note, we don't [do not] know what speech therapy wanted for aspiration precautions.Reference: (WAC) 388-97-1060(3)(g).

Based on observation, interview, and record review, the facility failed to ensure a pressure ulcer/injury (bed sore) was identified timely, documented, and provided interventions consistent with professional standards for 1 of 1 resident (Resident 5), reviewed for pressure ulcer/injury. This failure placed the resident at risk for unmet skin care needs, worsening pressure wound, and a diminished quality of life. Findings included.Review of the facility's undated policy titled, Skin and Wound Care, showed, It is the policy and practice of this facility that a resident who enters this facility without pressure ulcers does not develop pressure injuries unless the individual's clinical condition demonstrates that they were unavoidable.Review of the facility's undated policy titled, Skin Assessment, showed, A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, and weekly thereafter. Review of the policy showed that documentation of the skin assessment would include documenting observations, type of wound, description of the wound, and documentation if the resident refused assessment and why. Further review of the policy showed that documentation for all abnormal skin integrity conditions would be documented in the Treatment Administration Record (TAR) and then staff would enter a progress note in the chart and begin Alert charting.Review of facility's document titled, Admit/Readmit Screener, dated 05/20/2026, showed that under the section titled, Skin Integrity, showed Yeasty [itchy red rash] rashes on buttocks/perineum [area of the body at the bottom of the pelvis]/groin.Review of the quarterly Minimum Data Set (an assessment tool) dated 06/05/2026, showed that Resident 5 had no pressure ulcers.Review of Resident 5's skin care plan, printed on 07/02/2026, showed the intervention for the LN [Licensed Nurse] to perform skin assessment every week, document on TAR. Further review showed the intervention to Assess/monitor/document record wound progress. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress.Review of Resident 5's June 2026 TAR, showed an order for Weekly skin check by LN, started on 05/24/2026. It showed that LNs should document a minus sign (-) for no NEW skin problem and a plus sign (+) for a skin problem and then to document in progress note. The TAR further showed a (+ [skin problem]) were documented on 06/07/2026 and on 06/14/2026.Review of the progress note on 06/07/2026, showed that the LN documented skin rashy, as the documentation for marking (+) on the TAR. Further review of Resident 5's progress notes from 05/20/2026 through 07/02/2026, showed no documentation of the skin assessment done on 06/14/2026, where a (+) was marked on the TAR.Review of a wound consult note dated 06/19/2026, showed that Resident 5 was referred for skin and wound care consultation. It further showed that Resident 5 was found to have a Stage 3 pressure ulcer (a deep, crater-like wound that penetrates all skin layers) to their coccyx (tailbone).Observation on 07/06/2026 at 8:51 AM, showed Resident 5 lying on their back in bed on an air mattress (specialized mattress used to prevent and heal pressure ulcers).In an interview on 07/07/2026 at 8:40 AM, Staff X, Certified Nursing Assistant, stated that they let the nurse know if they noticed any skin changes on a resident.In an interview and joint record review on 07/08/2026 at 9:40 AM, Staff J, Licensed Practical Nurse, stated that nurses do skin checks for residents on their shower day and nurse aides will let us know if they see anything during care. Staff J stated that they would document in the TAR and if they marked a (+), then they would chart in a progress note. A joint record review of Resident 5's June 2026 TAR showed (+) was documented on 06/14/2026. A joint record review of Resident 5's progress notes from 05/20/2026 through 07/02/2026, showed no documentation of the skin assessment done on 06/14/2026, where a (+) was marked on the TAR. Staff J stated, what was the issue [on 06/14/2026]? I don't [do not] know. Another joint record review of the wound consult note dated 06/19/2026 showed that Resident 5 was found to have a Stage 3 pressure ulcer. Staff J stated that Resident 5 had a Stage 3 pressure ulcer. When asked if there was any documentation between the note on 06/07/2026 where a rash was noticed and the wound consult note on 06/19/2026, Staff J stated, I don't [do not] see any.In an interview on 07/08/2026 at 10:05 AM, Staff E, Resident Care Manager, stated that nurses are supposed to check [residents' skin] every week on shower day. Staff E stated that if a new problem was found during the skin checks, we document it in the progress notes. A joint record review of Resident 5's June 2026 TAR showed an order for Weekly skin check by LN, started on 05/24/2026. It showed that LNs should document a minus sign (-) for no NEW skin problem and a plus sign (+) for a skin problem and then document in progress note. A joint record review of the progress note on 06/07/2026, showed that the LN documented skin rashy, as the documentation for marking (+) on the TAR. Further review of Resident 5's progress notes from 05/20/2026 through 07/02/2026, showed no documentation of the skin assessment done on 06/14/2026, where a (+) was marked on the TAR. Staff E stated, I don't know. I don't see anything. When asked if it was a new skin issue on 06/14/2026, Staff E stated, I'm [I am] not sure, they didn't document, so I don't know. When asked why Resident 5 was seen by the wound consultant on 06/19/2026, Staff E stated that Resident 5 had been evaluated for a wound that was found to be a Stage 3 pressure ulcer. When asked when the Stage 3 pressure ulcer was discovered Staff E stated I don't know when it got found. [Staff W, LPN/Treatment Nurse] should know.In an interview on 07/08/2026 at 11:35 AM, Staff W stated that on 06/07/2026 Resident 5 had a rash, and that on 06/14/2026, nobody documented why it was marked (+) in the TAR. Staff W stated that Resident 5 had a Stage 3 pressure ulcer that was discovered on 06/19/2026.In a follow-up interview on 07/08/2026 at 11:48 AM, Staff E stated that that there was no documentation about why Resident 5 had been referred to the wound consultant on 06/19/2026.In an interview and joint record review on 07/08/2026 at 11:59 AM, Staff B, Director of Nursing, stated that Resident 5 was readmitted on [DATE] and that they did not have a pressure ulcer at that time. Staff B stated that they expected there to be documentation in the progress notes for the (+) marked on 06/14/2026. A joint record review of Resident 5's progress notes from 05/20/2026 through 07/02/2026, showed no documentation of the skin assessment done on 06/14/2026, where a (+) was marked on the TAR. Staff B stated, I don't [do not] see any documentation and yes it should be documented.Reference: (WAC) 388-97-1060 (3)(b).

Based on interview and record review, the facility failed to ensure personal hygiene was consistently provided to 1 of 3 residents (Resident 24), reviewed for activities of daily living (ADL). This failure placed the resident at risk for poor hygiene, unmet care needs, and a diminished quality of life.Findings included .Review of the facility's undated policy titled, Activities of Daily Living (ADLs), showed, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate. Care services will be provided for. bathing, dressing, grooming. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.Review of the facility's undated policy titled, Promoting/Maintaining Resident Dignity, showed, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Groom and dress residents according to resident preference.Review of an admission Minimum Data Set (MDS - an assessment tool) dated 04/10/2026 showed Resident 24 was admitted to the facility on [DATE] and was cognitively intact. Further review of the MDS showed Resident 24 required partial to moderate assistance with personal hygiene including shaving.Review of the progress notes from 04/06/2026 to 07/08/2026 did not show that Resident 24 preferred to have facial hair and/or that they refused to be shaved.Review of the ADL care plan showed Resident 24 required one person assist with showers/bathing and with personal hygiene. Further review of the care plan did not show that Resident 24 had history of refusing to be shaved or that they preferred to have facial hair.Review of the resistive-to-care care plan did not show that Resident 24 had history of refusing to be shaved or that they preferred to have facial hair.Observation on 06/30/2026 at 2:46 PM showed Resident 24 had long facial hair on their chin, above their upper lip, approximately half an inch long. Resident 24 stated that they preferred their facial hair to be shaved off. Resident 24 stated that their facial hair was shaved when they first admitted to the facility. Resident 24 stated, What woman do you think likes to have a beard? I don't [do not]. Resident 24 further stated, I can't [cannot] do it on my own, I don't [do not] have a razor or shaving cream, they used to help me with that. I used to get shaved when I first came here, but then they stopped. Resident 24 stated that staff had not offered to shave their facial hair off or I would not have a beard by now.On 07/02/2026 at 12:34 PM, Resident 24 was observed with long facial hair on their chin, above their upper lip.On 07/06/2026 at 12:16 PM, Resident 24 was observed having long facial hair on their chin, above their upper lip. Resident 24 stated they had a bed bath last Friday [07/03/2026] and that they were not offered to shave.In an interview and joint observation on 07/08/2026 at 11:19 AM, Staff H, Certified Nursing Assistant, stated they would offer female residents with facial hair to be shaved on scheduled shower days or assist them with shaving during bed baths. Staff H stated that Resident 24 required one person assist with shaving. A joint observation showed Resident 24 had long facial hair approximately half an inch on their chin and above their upper lip. Resident 24 stated, I would love to have my face shaved; it itches like crazy; I have not been shaved in a long time, last bath was Friday [07/03/2026]. Resident 24 stated that staff did not offer to shave them on their bath day. Staff H stated, [Resident 24] has long facial hair, and that if they were assigned to Resident 24 they would have offered Resident 24 to shave their facial hair.In an interview and joint observation on 07/08/2026 at 11:27 AM, Staff G, Registered Nurse, stated they expected staff to shave female residents' facial hair on shower days. A joint observation showed Resident 24 had long facial hair approximately half an inch on their chin, above their upper lip. Staff G stated that Resident 24 should have been offered to shave their facial hair.In an interview and joint record review on 07/08/2026 at 11:37 AM, Staff D, Resident Care Manager, stated they expected staff to assist female residents to shave their facial hair on their shower days and/or when requested. A joint record review of the comprehensive ADL care plan, the refusal-of-care care plan, and the progress notes from 04/06/2026 to 07/08/2026 did not show that Resident 24 was offered to shave their facial hair. Staff D stated that Resident 24 required staff assistance with ADLs and would require one person assist with shaving. Staff D further stated that Resident 24 should have been offered to shave their facial hair.In an interview on 07/08/2026 at 5:05 PM, Staff B, Director of Nursing, stated that they expected staff to assist Resident 24 with shaving their facial hair on their shower days and that refusals should be documented.Reference: (WAC) 388-97-1060 (2)(c).

Based on interview and record review, the facility failed to notify a resident and their representative of a discharge in writing for 1 of 3 residents (Resident 1), reviewed for discharge process. This failure placed the resident and their representative at risk for not having an opportunity to make an informed decision about the discharge and about their rights to appeal the discharge.Findings included.Review of a face sheet showed Resident 1 admitted to the facility on [DATE] with diagnoses that included dementia (a condition when a person's brain slowly stops working the way it used to) with agitation and anxiety disorders (when worry becomes so strong and frequent that it gets in the way of daily life). Further review showed Resident 1 had a listed representative.Review of Resident 1's progress note, dated 12/25/2025 at 10:54 PM, showed Resident 1 was transferred to the hospital for medical evaluation.Review of Resident 1's document titled, Notice of Transfer or Discharge, dated 12/25/2025, showed Resident 1 was transferred to a hospital and that [Resident 1] refused to sign. Further review did not show documentation of the notice was mailed to Resident 1's representative.Review of Resident 1's nursing progress note, dated 12/26/2025, showed Staff B, Resident Care Manager (RCM), contacted Resident 1 by phone and received verbal confirmation of his preference not to return to the facility from the hospital.Review of Electronic Health Records (EHR) did not show documentation of Resident 1, and their representative was provided with a written notification for his discharge on [DATE].In an interview on 02/04/2026 at 11:14 AM, Resident 1's representative stated that they were Resident 1's legal decision maker. When asked how the facility notified them of Resident 1's discharge on [DATE], Resident 1's representative stated, They [Facility] only notified me that he was transferred to the hospital, and that If the hospital sent him back, they should have accepted him.In an interview and joint record review on 02/06/2026 at 12:40 PM, Staff D, Medical Records, stated that Resident 1 had a representative and that his representative signed the facility admission paperwork on 12/13/2025. Staff D stated, [Resident 1] said he couldn't [could not sign] and asked for [Resident 1's representative] to sign. A joint record review of Resident 1's EHR did not show documentation of Resident 1, and their representative was provided with a written notification for his discharge on [DATE]. When asked if there were records not included in Resident's EHR, Staff D stated, At the moment, everything is scanned [included in Resident 1's EHR].In an interview and joint record review on 02/06/2026 at 12:50 PM, Staff C, RCM, stated that the facility's process for notification of transfers and discharges included providing a written notice to the resident and their representative. Staff C stated that Resident 1 was transferred to the hospital on [DATE] and that Resident 1 was discharged when he verbally declined to be returned to the facility on [DATE]. Staff C further stated that Resident 1 had a representative. A joint record review of Resident 1's notice of transfer and discharge, dated 12/25/2025, showed a section titled, Appeal Rights. Further joint record review did not show documentation of the notice was mailed to Resident 1's representative. When asked if Resident 1's representative was notified of the transfer and discharge in writing, Staff C stated, I don't [do not] see it, it would show when it was mailed [to Resident 1's representative].In an interview and joint record review on 02/06/2025 at 1:10 PM, Staff B stated that notices were provided to the resident upon transfer or discharge. A joint record review of Resident 1's progress note dated 12/26/2025 showed Staff B received verbal confirmation from Resident 1 of his preference not returning to the facility. Staff B stated that they did not contact Resident 1's representative to notify them of Resident 1's discharge on [DATE]. When asked if Resident 1's representative received written notification of the discharge and appeal rights, Staff B stated, No, it does not show it was mailed. Staff B stated that the facility's process for discharge notifications was not followed.In an interview on 02/06/2026 at 1:32 PM, Staff A, Director of Nursing, stated that they expected written notifications of resident transfers and discharges would be provided to the resident and their representative.Reference: (WAC) 388-97-0120 (2) (a-c).

Based on observation, interview, and record review, the facility failed to ensure foods were stored and handled appropriately in accordance with professional standards of food safety for 2 of 2 kitchen refrigerators (Kitchen Reach-In refrigerator and Kitchen Walk In refrigerator), 1 of 1 kitchen dry storage room, 2 of 7 unit refrigerators ([NAME] dining room pantry white refrigerator and [NAME] pantry silver refrigerator), 1 of 3 dining rooms ([NAME] dining room), and 2 of 4 halls (Dogwood and [NAME]), reviewed for food services. The failure to date and discard food items past the use by/expire date, cover food items during meal tray delivery, and use appropriate food handling when assisting residents placed the residents at risk for food borne illness (caused by the ingestion of contaminated food or beverages), cross contamination, and a diminished quality of life. Findings included . Review of the facility's policy titled, Food Safety Product Labeling and Dating Guidelines, revised on [DATE] showed, Once a product does have a documented use by date, the FDA [Food and Drug Administration] Food Code and Sodexo Policy requires the product to be consumed or discarded by that date. Review of the facility's policy titled, Food Safety Policies and Standards, revised on [DATE] showed, Manufacture's expiration dates must be adhered to. Further review showed, Employees may not contact exposed ready to eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. Review of the facility's undated policy titled, Room Service Policy, showed, Staff will transport patient food and beverage in covered carts or cover individual food and beverage items. EXPIRED FOOD ITEMS IN THE KITCHEN'S REACH-IN REFRIGERATOR In an interview and joint observation on [DATE] at 8:05 AM, Staff D, Food Service Manager, stated they expected dietary staff to label and date open food items. Staff D further stated they expected dietary staff to check food items for use by date and to discard items passed the use by date. Joint observation with Staff D showed one gallon of fat free milk with used by date of [DATE] in the kitchen reach-in refrigerator. Staff D stated that the fat free milk should have been discarded. In an interview on [DATE] at 2:30 PM, Staff A, Administrator, stated they expected food items in the kitchen refrigerators to not be expired or passed the use by date. Staff A further stated that the dietary staff should have discarded expired or passed the use by date items. SPOILED FOOD ITEMS IN THE KITCHEN'S WALK-IN REFRIGERATOR In an interview and joint observation [DATE] at 8:10 AM, Staff D stated they expected dietary staff to check for any rotten or mold food items and to discard if found. Joint observation with Staff D showed reddish-purple grapes with white fuzzy substance in the kitchen walk-in refrigerator. Staff D stated that the white fuzzy substance on the grapes was mold and that it should have been discarded. In an interview on [DATE] at 2:30 PM, Staff A stated they expected the dietary staff to check the food items in the kitchen refrigerators and discard if there was mold. FOOD LABELING IN THE KITCHEN DRY STORAGE ROOM In an interview and joint observation on [DATE] at 8:13 AM, Staff D stated they expected food items to be labeled and dated. Joint observation with Staff D showed two unopened and unlabeled bags of cereal in the kitchen dry storage room. Staff D stated the two unopened and unlabeled bags looked like Cheerios [brand of cereal]. Staff D stated the bags of cereal should have been labeled/dated. In an interview on [DATE] at 2:30 PM, Staff A stated they expected the dietary staff to label and date the food items in the dry storage room. EXPIRED FOOD ITEMS IN THE [NAME] DINING ROOM PANTRY REFRIGERATORS In an interview and joint observation on [DATE] at 2:20 PM, Staff Q, Registered Dietitian, stated they expected food items in the refrigerator to be labeled and dated. Joint observation with Staff Q showed two unopened yogurts with an expiration date of [DATE] in the white refrigerator and one carton of Med Plus 2.0 (nutritional supplement) vanilla flavored with an expiration date of [DATE] in the silver refrigerator in the [NAME] dining room pantry. Staff Q stated they expected staff to check items and discard them if expired. In an interview on [DATE] at 9:00 AM, Staff D stated they expected both dietary and nursing staff to have discarded expired items on the unit refrigerators. Staff D stated Dietary staff will maintain and throw away expired or use by date items or if resident/family brings items we will follow policy of three days then throw away. Nursing will assist as well. We check daily. Ultimately it's us [dietary staff] who are responsible. In an interview on [DATE] at 2:30 PM, Staff A stated they expected the dietary staff to check and discard expired food items in the unit refrigerators. FOOD HANDLING IN THE [NAME] DINING ROOM Observation on [DATE] at 11:57 AM showed Staff X, Nursing Assistant Certified (NAC), was assisting Resident 21 with her lunch tray. Staff X peeled the banana and then moved the unpeeled banana with their bare hands to another part of the plate. In an interview on [DATE] at 12:49 PM, Staff X stated they would take off the cover and cut their food if they need help. Staff X further stated they would use a knife or gloves to peel food and cut it. In an interview on [DATE] at 11:25 AM, Staff I, Licensed Practical Nurse, stated nursing staff would have to wear gloves if peeling bananas or use dining utensils. Staff I further stated that nursing staff would not touch an unpeeled banana with their hands. In an interview on [DATE] at 11:35 AM, Staff E, Unit Manager, stated they would expect nursing staff to use the utensils on the tray for cutting food and to use gloves to peel bananas. Staff E further stated nursing staff should not touch the banana or food with their bare hands. In an interview on [DATE] at 1:00 PM, Staff B, Director of Nursing, stated they would expect the nursing staff to not touch food items with their bare hands when they assist residents with their food tray. UNCOVERED FOOD ITEMS DURING MEAL TRAY DELIVERY [NAME] DINING ROOM Observations on [DATE] at 12:20 PM showed three unknown staff carried three uncovered cheesecakes on the meal trays out of the [NAME] dining room into the hall. In an interview on [DATE] at 12:49 PM, Staff X stated the food was usually covered by the kitchen whom they get the trays from. In an interview on [DATE] at 12:56 PM, Staff L, Dietary Aide, stated the cheesecake was not covered at first until they got some plastic wrap brought up to them. Staff L further stated the cheesecake should have been covered. In an interview on [DATE] at 11:25 AM, Staff I stated the trays being delivered in hall to resident rooms should have items covered. In an interview on [DATE] at 11:40 AM, Staff D stated anytime food was going down the hall it should be covered. Staff D further stated, We don't go down the hall with uncovered food. In an interview on [DATE] at 2:30 PM, Staff A stated they would expect food items to be covered when traveling in the halls to resident rooms. 45146 DOGWOOD HALLWAY TRAY Observation on [DATE] at 12:16 PM, showed Staff DD, NAC, was carrying an uncovered cheesecake on a meal tray from Dogwood Hall dining room to room [ROOM NUMBER]. At 12:23 PM, Staff DD was observed carrying another meal tray with uncovered cheesecake from the dining room to room [ROOM NUMBER]. Observation on [DATE] at 12:18 PM, showed Staff T, Infection Control Nurse, was carrying an uncovered cheesecake on a meal tray from Dogwood Hall dining room, entered room [ROOM NUMBER] and placed it on Resident 3's bedside table. Further observation showed Staff T was carrying another uncovered cheesecake on a meal tray from the dining room down the hallway to the second floor nurse station and entered room [ROOM NUMBER]. In an interview on [DATE] at 12:24 PM, Staff DD stated that the cheesecake on the meal tray was not covered when they were delivered. In an interview on [DATE] at 12:28 PM, Staff T stated that the cheesecake on the meal tray was not covered when it was delivered to room [ROOM NUMBER] and stated they would make sure all food items were covered. Observations on [DATE] at 12:39 PM, at 12:55 PM, and at 2:01 PM, showed Resident 3 was sleeping and did not eat their lunch. Observations showed their lunch tray with uncovered cheesecake was sitting on their bedside table. In an interview on [DATE] at 8:46 AM, Staff D stated that meal trays should be placed in a covered meal cart and delivered to rooms. Staff D stated that when a single tray delivered from the dining room to a residents' room, they expected all food items on the tray to be covered. 47680 [NAME] HALLWAY TRAY Observation on [DATE] at 12:19 PM, showed Staff J, NAC, left the [NAME] dining room with a meal tray and walked down the hallway and delivered the meal tray to room [ROOM NUMBER]-B with the cheesecake uncovered. Staff Z, Nursing Assistant Registered, walked down the hallway with a meal tray and delivered it to room [ROOM NUMBER]-D with the cheesecake uncovered. At 12:23 PM, Staff Z took another meal tray from the [NAME] dining room and delivered it to room [ROOM NUMBER]-D with the cheesecake uncovered. In an interview on [DATE] at 12:44 PM, Staff J stated their process was to take the meal tray from the dining room and deliver it to the residents' room. When asked if the food was covered, Staff J stated, It's always covered, but not sure what happened today and that they were not sure if the dietary aide did not have any supplies. In an interview on [DATE] at 12:52 PM, Staff L was asked about the uncovered cheesecake, Staff L stated that they were not covered because they were out of plastic wrap and that their supervisor had brought some in. Staff L further stated that the first few trays that were delivered to resident rooms had uncovered cheesecake and when the plastic wrap was brought up to them, they started to cover the cheesecake. In an interview on [DATE] at 1:30 PM, Staff D stated that they expected food items on the meal tray to be placed in a covered cart and delivered room by room. Staff D stated that they expected that anything that went down the hallway was covered. In an interview on [DATE] at 10:25 AM, Staff A stated that they expected meal trays to be delivered down the hallway in a covered cart or the food on the tray to be individually covered. Reference: (WAC) [DATE] (3)

Based on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR- an assessment used to identify people referred to nursing facilities with Serious Mental Illness (SMI), intellectual disabilities (ID); or related conditions are not inappropriately placed in nursing homes for long term care) forms were accurate and/or sent out timely for a Level II PASARR referral for 5 of 7 residents (Residents 2, 22, 34, 63 & 39), reviewed for PASARRs. This failure placed the resident at risk for not receiving the care and services appropriate for their needs. Findings included . Review of the facility's undated policy titled, PASRR Program Policy, showed, This facility coordinates assessments with the preadmission screening and resident review (PASRR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. All applicants to this facility will be screened by Social Services for serious mental disorders or intellectual disabilities and related conditions in accordance with the State Medicaid rules for screening .Social Services shall be responsible for keeping track of each resident's PASRR screening status and referring to the appropriate authority. RESIDENT 2 Resident 2 admitted to the facility on [DATE] with diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), Post-Traumatic Stress Disorder (PTSD - a mental health condition that's caused by an extremely stressful or terrifying event either being part of it or witnessing it), and psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions). Review of the quarterly Minimum Data Set (MDS - an assessment tool) dated 12/19/2024, showed Resident 2 had active diagnoses of depression, psychotic disorder and PTSD. Review of Resident 2's Level I PASARR dated 07/03/2024, showed diagnosis of personality disorder (long-term patterns of behavior and inner experiences that differ significantly from what is expected) was marked. Resident 2's Level 1 PASARR did not reflect Resident 2's diagnoses of mood disorder, PTSD and psychotic disorder. Further review of the PASARR showed Level II evaluation referral was required for SMI. Review of the Electronic Health Record (EHR) showed no documentation that Resident 2's PASARR Level I was corrected to include the correct diagnoses of the resident. Review of the social service note dated 01/14/2025 showed that Resident 2's PASARR Level II referral was sent (six months after Level II evaluation referral was required). In an interview and joint record review on 03/18/2025 at 1:43 PM, Staff G, Social Services, stated that when a resident admitted from the hospital, they would review PASARR for accuracy and make corrections as needed. Staff G further stated that if Level II evaluation was required, they would send the referral. A joint record review of Resident 2's Level I PASARR dated 07/03/2024, showed mood disorder, PTSD and psychotic disorder were not documented on the PASARR. Staff G stated that Resident 2's PASARR Level I, Could be more accurate. When asked why Resident 2's PASARR referral was not sent in July 2024, Staff G stated that they found Resident 2's PASARR Level I during a PASARR audit. On 03/20/2025 at 8:59 AM, Staff B, Director of Nursing/Director of Social Services, stated that they would expect Social Services review and correct PASARR forms. Staff B further stated they expected Resident 2's PASARR to be accurate, and Level II referral was made timely. 47680 RESIDENT 22 Review of the face sheet printed on 03/17/2025 showed that Resident 22 admitted to the facility on [DATE] with diagnoses that included schizophrenia (serious mental health condition that affect how they think, feel and behave), anxiety (intense and excessive feelings of worry, nervousness, or fear) and other recurrent depressive disorders. Review of Resident 22's Level 1 PASARR dated 11/08/2024, showed that Section IA (SMI) was marked for schizophrenia. It did not show that it was marked for anxiety and recurrent depressive disorder. Further review showed that Section IV (4- Service Needs and Assessor Data) was marked for No level II evaluation indicated. RESIDENT 34 Review of the face sheet printed on 03/18/2025 showed that Resident 34 admitted to the facility on [DATE] with diagnoses that included major depressive disorder and PTSD. Review of Resident 34's Level I PASARR dated 09/09/2024, showed that Section IA was marked for depressive disorder. It did not show that it was marked for PTSD. Further review showed that Section IV was marked for No level II evaluation indicated. In an interview and joint record review on 03/18/2025 at 11:16 AM, Staff H, Social Services, stated that they reviewed Level I PASARRs on admission for accuracy and if the Level I PASARRs were not accurate, they would fill out a new Level I PASARR and send it to the PASSAR evaluator for review if needed. Joint record review of Resident 22's diagnosis list showed a diagnosis for anxiety and other recurrent depressive disorders. Review of Resident 22's Level I PASARR dated 11/08/2024 showed that anxiety and depressive disorder were not marked in Section IA. When asked if it was accurate, Staff H stated, I guess not. Further review of Resident 22's Level I PASARR showed in Section IV, it was marked for No level II evaluation indicated. When asked if it was accurate, Staff H stated, it can be and that Resident 22 was very stable. Staff H stated they were trained to only mark No level II evaluation required when making changes to Level I PASARR on admission in the most recent training they had. Joint record review for Resident 34's diagnosis list showed that they had a diagnosis of PTSD. Joint record review of Resident 34's Level I PASARR dated 09/09/2024, showed that PTSD was not marked on Section IA. When asked if it was accurate, Staff H stated, Not totally accurate. When asked if Section IV was accurate, Staff H stated that based on when Resident 34 was admitted to the facility, their Level I PASARR was accurate because Resident 34 was very functional. Staff H further stated from their understanding, even if a resident had an SMI diagnosis, they do not mark level II evaluation indicated if the resident's condition was stable and that they were able to manage it. In an interview and joint record review on 03/20/2025 at 12:11 PM, Staff B stated that they expected PASARRs to be completed accurately when completed by their staff and when they are completed by the hospital. Staff B stated that if PASARRs were inaccurate, I expect them [staff] to make it accurate, do a correction and to send it in as soon as they are aware. Joint record review of Resident 22's Level I PASARR dated 11/08/2024, showed that Section IA was not marked for anxiety and recurrent depressive disorder and Section IV was marked for No level II evaluation indicated. Staff B stated that they would have expected Resident 22's Level I PASARR to be accurate. Joint record review of Resident 34's Level I PASARR dated 09/09/2024, showed Section IA was not marked for PTSD and Section IV was marked for No level II evaluation indicated. Staff B further stated that they would have expected Resident 34's Level I PASARR to be completed accurately. 52331 RESIDENT 63 Review of the face sheet printed on 03/18/2025 showed that Resident 63 admitted to the facility on [DATE] with diagnoses that included PTSD. Review of the Level I PASARR dated 12/11/2024 completed by the hospital, showed Section IA was marked No for SMI indicators. Further review showed Section IV was marked No Level II evaluation indicated. Review of another Level I PASARR dated 12/11/2024 completed by Staff G, showed Section IA was marked Yes for SMI indicators and the box for anxiety disorder (mental health condition with excessive worry and feeling of fear) was marked and written PTSD inside the box. Further review showed Section IV was marked No Level II evaluation indicated. A joint record review and interview on 03/18/2025 at 12:00 PM with Staff G, showed Resident 63's Level I PASARR completed by Staff G dated 12/11/2024 was marked Yes for SMI indicators and no Level II referral required. Staff G stated, Based on this form, I should send out PASARR Level II. A joint record review and interview on 03/20/2025 at 12:39 PM, Staff B, stated We should send out Level II PASARR for Resident 63. 51090 RESIDENT 39 Resident 39 admitted to the facility on [DATE] with a diagnosis of mood disorder. Review of Resident 39's Level I PASARR completed by the hospital, dated 02/20/2025, showed Section IA was marked No, which indicated that Resident 39 did not have SMI identified. It further showed that Section IV was not completed. In an interview on 03/18/2025 at 10:55 AM, Staff G stated that they were responsible for ensuring Level I PASARR forms were reviewed for accuracy when residents admitted to the facility. Staff G stated that during their review of Level I PASARRs, they would make a referral for Level II PASARR evaluation If the resident will be [at the facility] longer than 30 days. A joint record review and interview on 03/18/2025 at 11:06 AM, showed Resident 39's Level I PASARR completed by Staff G dated 02/20/2025, showed that Section IA was marked Yes, to indicate Resident 39 had a SMI identified. It further showed that Section IV was marked No Level II evaluation indicated, which showed Resident 39 did not show indicators of SMI. When asked if Section IV was accurately completed, Staff G stated, I can't choose any other box, and that they believed it was completed accurately. A joint record review and interview on 03/20/2025 at 1:31 PM with Staff B, showed Resident 39's Level I PASARR completed by Staff G dated 02/20/2025, showed that Section IA was marked Yes, and Section IV was marked No Level II evaluation indicated. Staff B stated that they expected PASARR evaluations to be completed accurately. Staff B further stated that Resident 39's Level 1 PASARR dated 02/20/2025 should have been marked Level II evaluation referral required for SMI, in Section IV. Reference: (WAC) 388-97-1915 (2)

Based on observation, interview, and record review, the facility failed to develop a comprehensive system for ensuring residents and representatives could anonymously report their concerns for 2 of 2 facility floors (First Floor & Second Floor), reviewed for grievances. This failure placed residents and representatives at risk for unresolved concerns, unmet care needs, and a diminished quality of life. Findings included . Review of the facility's undated policy titled, Grievance and Concerns, showed, At admission, the Admissions department designee informs the Resident/Resident's Authorized Representative about their right to voice grievances orally, in writing, and anonymously regarding the care and treatment/lack of treatment, lost/misplaced personal items, behavior of staff and of the other residents, and other concerns during their stay. Review of the facility's undated document titled, Resident Handbook, did not show documentation of a system to file grievances anonymously. Review of the facility's undated form titled, Grievance/Concern Form, did not show documentation of a system to file grievances anonymously. FIRST FLOOR In an interview and joint observation on 03/20/2025 at 9:07 AM Staff E, Unit Manager, stated that they oriented residents to the facility's grievance form upon admission to the facility. Staff E further stated that grievances can be filed in writing by submitting a completed grievance form to a staff member. When asked how grievances could be filed anonymously, Staff E stated that there is a box at the front desk. Joint observation of the first-floor front desk area did not show a box that was accessible to persons submitting a completed grievance form. Staff E stated that completed grievance forms would be collected by staff and filed in the social worker's mailbox, located in a locked office on the first floor. Staff E stated that the process for collection of completed grievance forms was not anonymous. SECOND FLOOR In an interview on 03/20/2025 at 9:18 AM, Staff H, Social Services, stated they were the appointed grievance officer. When asked how completed grievance forms were collected, Staff H stated that completed grievance forms would be collected by staff and filed in the social worker's mailbox, located in a locked office on the second floor. Staff H further stated that they did not recall the facility having a box to drop [grievances] into and that We don't have an anonymous process. Another joint record review and interview on 03/20/2025 at 9:50 AM with Staff E, showed the facility's undated document titled, Resident Handbook, did not show documentation of a system to file grievances anonymously. Staff E stated that the information provided in the Resident Handbook did not include information on how to file a grievance anonymously. Staff E further stated, I don't see it. In an interview on 03/20/2025 at 1:59 PM, Staff A, Administrator, stated We don't have an anonymous box identified as a grievance collection site. Staff A stated they expected residents/representatives would have access to a system to file a grievance anonymously. Staff A further stated, There will be a process to have grievances collected anonymously. Reference: (WAC) 388-97-0460 (1)

Based on observation, interview, and record review, the facility failed to comprehensively assess the increased risk for skin breakdown, failed to follow care plans, and implement timely interventions necessary to prevent the development of pressure ulcers for 3 of 5 residents (54, 68, & 82), reviewed for pressure ulcers. These failed practices caused harm to Resident 54 and Resident 68 and diminished the quality of life. Resident 54 developed a facility acquired pressure ulcers with partial and full thickness skin loss and pain. Resident 68 pressure ulcer caused pain, loss of quality sleep, limited his ability to ambulate and move around the facility. Findings included . The National Pressure Ulcer Advisory Panel (NPUAP) Pressure Injury (Ulcer) definition and stages include: A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable [DIAGNOSES REDACTED] of intact skin. Intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED], which may appear differently in darkly pigmented skin. Presence of blanchable [DIAGNOSES REDACTED] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, and intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). RESIDENT 54 Resident 54 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. In a review of the most recent Minimum Data Set (MDS) assessment dated [DATE], showed the resident had impaired cognition, and needed 1-2 staff person assistance with bed mobility, transfers, dressing and personal hygiene. In a review of the facility's admission assessment, it showed the resident was admitted to the facility with no skin/pressure injury. The resident was identified to be at high risk for developing a pressure injury and skin breakdown. Review of the resident skin assessment and progress notes dated 05/08/18, 2 months after admit, showed, Noted intact fluid filled blisters to right inner heel measured 2.0x3.0 centimeter (cm). The left plantar foot has intact fluid blister measuring 2.7x2.7cm. The progress notes showed the resident's Nurse Practitioner (ARNP), was notified and had examined the resident. The note showed that the ARNP diagnosed the cause as being r/t (related to) [MEDICAL CONDITION] ([MEDICAL CONDITION].) The progress notes also indicated that the ARNP ordered the resident to see a wound care specialist. The facility received an order for [REDACTED]. In a review of the Wound Care note dated 05/22/18, Staff L, Wound Care Specialist/ARNP documented the resident's right heel had an open blister, and left heel had an intact blood filled blister. The right heel was described as related to [MEDICAL CONDITION], with red granulation tissues (new tissues formed), moderate amount of slough, [MEDICATION NAME] and necrotic tissues (dead tissues). Primary Etiology: Pressure. There was no documention from Staff L that included measurements, or a clear assessment and description for the left heel. Review of the Wound Care note dated 05/29/18, showed the resident's right heel was identified as a stage 2 pressure ulcer. There was no measurements, clear assessment or description for the left heel. In a review of the resident original skin care plan dated 11/13/15, and with revisions on 05/10/18 and 05/29/18, showed the resident had impaired skin integrity related to left foot and right heel. Interventions included, repositioning the resident every 2 hours, use pillows and cushions to bony prominence areas, and a Low air loss mattress (initiated on 05/29/18). The facility care planned the resident for vascular ulcers and not pressure ulcers despite the [DIAGNOSES REDACTED]. Review of the facility's task documentation for the month of (MONTH) (YEAR) related to the care plan interventions, showed there was no documentation charted that the interventions were being done. The documentation areas were blank. During an observation on 05/29/18 at 1:55 PM, the resident was observed lying in bed. The resident had 2 different types of pressure relieving boots. Despite, the placement of the boots, the resident heels were in direct contact with the foot board and the bed mattress. In an interview on 05/29/18 at approximately 2:00 PM, Staff C, Registered Nurse (RN)/Resident Care Manager (RCM), stated, the resident had bilateral heel blisters, and a wound care nurse was following the resident. Staff C further stated, the blisters developed due to the resident's heels having direct contact and pressure. During an observation and interview on 05/30/18 at 8:26 AM with Staff H, Licensed Practical Nurse/Wound Nurse, showed the resident had two skin breakdowns on her heels. Staff H stated, It is a vascular wound. Staff H also stated, she would describe the left heel wound as a vascular wound, with 80% slough and 20% granulation tissue. Staff H further stated, the facility was not describing the wounds as pressure ulcers, because the the resident had a [DIAGNOSES REDACTED]. Staff H acknowleged, Yes, those were pressure ulcers that were unstageable, with slough (dead tissue), you cannot see the wound bed and cannot stage it. However, they use the definition given by the ARNP and the wound specialist, which were conflicting. While Staff H inspected and palpated the resident's left heel. The resident jerked and attempted to kick and pull her legs away from Staff H. The resident was grimacing throughout the observation. The resident was asked if she was in pain and the resident nodded, and stated, Yes. Review of the resident pain care plan dated 03/20/14 (revised on 12/29/16), showed no documented evidence that the resident's skin breakdown, and pain risks/concerns were identified, updated or addressed by the facility. The resident's current physician orders [REDACTED]. During an observation and interview with Staff C, RCM, on 05/31/18 at 7:50 AM, Staff C reiterated that the skin breakdown started because the resident's heels were touching and rubbing each other. The resident was observed lying in bed. The boots were on, but the resident's heels were in direct contact with the bed. The resident reported pain and was grimacing during the observation. During a record review and interview on the same day at 8:01 AM, Staff C stated the resident was not referred or seen by Physical Therapy related to the pressure ulcers or concerns with positioning. According to Staff C, there was no documentation in the clinical record that the Registered Dietitian, (RD), or Interdisciplinary team (IDT), had specific notes or documentation addressing the resident skin breakdown. Staff C stated, There is no IDT note because it was initially identified as [MEDICAL CONDITION]. During a meeting and record review the same day at 9:07 AM, with Staff H, Wound Nurse, Staff B, Staff Development Coordinator (SDC)/RN, and Staff A, Director of Nursing (DNS)/RN. Staff A stated, the resident was at high risk for developing pressure ulcers. Staff A was asked why the resident's clinical record showed conflicting diagnoses, and or staging/descriptions of the resident pressure ulcers. Staff A stated, that the facility could have done better in identifying the type, accurately staging and documenting the pressure ulcers for Resident 54. Staff A also confirmed, there was no supporting documentation the facility had implemented interventions to prevent the development of pressure ulcers, including therapy, RD or that IDT had addressed the resident's pressure ulcers. During the same meeting, Staff H stated, that based on the current clinical presentation of the pressure ulcers, which had started as fluid filled blisters over a bony prominence area, had worsened and deteriorated. During a follow up meeting the same day at 10:21 AM, with Staff B, SDC, Staff A, DNS, and Staff K, ARNP. Staff K stated, she had inspected and assessed Resident 54's skin breakdown and had diagnosed it with [MEDICAL CONDITION]. When asked clarifying questions, such as the location, cause of the wound, or if the resident had any laboratory tests to diagnose the resident with [MEDICAL CONDITION], Staff K was not able to provide an answer. During the meeting, Staff A requested an order from Staff K for an Ankle-Brachial Index (ABI), (a test and confirm blood flow to the lower extremities and [DIAGNOSES REDACTED]. During an interview and record review on 05/31/18 at 10:37 AM, Staff J, RD stated, she had been notified initially that the resident had [MEDICAL CONDITION] ulcers and not pressure ulcers. Staff J stated, it was confusing for her because she had not heard a [DIAGNOSES REDACTED]. According to Staff J, she put a note having knowledge that the resident had [MEDICAL CONDITION] ulcers. When asked, if the nutritional needs for a [MEDICAL CONDITION] ulcer will be different from a pressure ulcer, Staff J stated, Yes. During a joint observation and interview with Staff I, RN, on 06/01/18 at 4:53 AM, the resident was observed in bed, awake and grimacing. Staff I assessed the resident heels. Despite of the placement of the boots, the resident heels were in direct contact with the bed. The resident reported pain to Staff I and to the surveyor during the observation. Staff I stated he was not sure which type of boot to apply between the right and left heel because it was not clear on the care plan. Review of the ABI study result dated 06/01/18, showed the resident had a reading of 1.84 (normal value 0.90 and above) to both right and left lower extremities, indicative of a normal result and a good blood flow/supply to the lower extremities. In an interview with Staff L, Wound Care Specialist/ARNP at 8:16 AM, confirmed that the resident had pressure ulcers to both heels and the wounds had deteriorated. The right heel was initially a stage II pressure ulcer and now Unstageable. The left heel was initially a stage II pressure ulcer, now a deep tissue injury. According to Staff L, her documentation could be improved to meet the national standards, and NPUAP guidelines to accurately define and describe a pressure ulcer. The resident was at high risk for developing pressure ulcer, but the facility failed to implement and use timely interventions to prevent the development of a facility acquired pressure ulcer. RESIDENT 68 The resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was initially admitted under Hospice care, but Hospice services was discontinued three months later, on 02/11/18. In a review of the resident's most recent MDS assessment dated [DATE], showed the resident required staff assistance with bed mobility, transfers and toilet use. The MDS also documented the resident did not ambulate/walk inside or outside his room. The resident was identified to have an unstageable pressure ulcer on admit. Review of the admission skin assessment showed the resident had soft heels, the left heel had eschar, with dark edges. The facility identified the resident to be at high risk for developing a pressure ulcer. Review of the skin integrity care plan dated 11/03/17 (revised seven months later, on 05/30/18), showed the resident had the presence of lateral heel eschar. Interventions included: float heels when in bed with pillow bridging, low air loss mattress in bed, check the resident skin every shift, and treat resident pain prior to treatment, turning and to ensure the resident's comfort. Review of the facility's task documentation for the month of (MONTH) (YEAR) related to the care plan interventions, showed there was no documentation charted that the interventions were being done. The documentation areas were blank. Review of the resident's clinical record showed, weekly wound care flow sheets, and nursing progress notes from admission to 05/31/18. Documentation showed the facility had documented the resident to have left heel Necrotic/Eschar. There was no clear evidence or documentation, on what type of wound/skin breakdown the resident had. The facility had care planned the resident for Eschar and not a pressure ulcer despite the [DIAGNOSES REDACTED]. During the initial tour of the facility on 05/29/18 at 11:00 AM, the resident was observed to be lying flat in bed, his heels were not floated and he was on a regular mattress. During an observation and interview with the resident on 05/31/18 at 10:16 AM, the resident stated his heels, specifically his left one was bothering him. The resident said See here (pointing to his L heel), this has gotten worse 2-3 weeks now, it was because of me walking on it and using it. The resident reported daily pain, that affected his ability to sleep and ability to walk. In the same interview and observation the resident reported no one had offered to float his heels, or turn him while he was in bed. The resident's heels were not floated. During a record review and interview on the same day at 2:00 PM with Staff H, Wound Nurse, and Staff A, DNS. Staff H stated, the resident had a pressure ulcer on admission but the facility was calling it eschar instead of a pressure ulcer. During a joint observation and interview with Staff A, DNS, at 2:05 PM, the resident was observed lying in bed. The resident stated, the sore on his left heel was worse, added it was because of his slippers that they did not have enough support and cushion causing pressure to his foot and heel. The resident further stated, he had his slippers for a while now and the facility was aware of his heel problem. The resident reported, no one had turned or floated his heels since his admission. The resident continued to report his discomfort and pressure pain to his left heel. The resident's heels were not floated, and he was on a regular mattress. During a record review and interview with Staff C, RCM, at 2:14 PM, stated, the resident was not on a specific pain regimen to address the left heel pressure ulcer. The resident's current Physician orders [REDACTED]. During an observation and interview with the resident on 06/01/18 at 4:51 AM, the resident was observed lying flat in bed and awake. The resident heels were not floated, and he was pushing the foot of the bed with direct pressure contact. When asked, if his heels were bothering him, the resident stated, yes. During a joint observation with Staff H, Wound Nurse, and Staff A, DNS, at 7:37 AM, the resident's left heel was observed to have an wound that was unable to be assessed and had moderate discharge noted to the old dressing. The resident was observed to have guarding and jerking when being touched by the wound nurse. The resident stated his heels bothered him and stated it hurt when he walked. During a record review and interview at approximately 1:00 PM, Staff A stated, the resident was not seen or referred to the Physician, Wound Care Specialist and/or Physical Therapy related to his pressure ulcer, concerns with his foot or improper footwear. Further review of the resident's clinical record showed there was no evidence, or documentation the IDT, a physician or specialist had re-assessed or reevaluated the effectiveness of current interventions to promote healing, ease the pain/discomfort, and accurately assess and monitor the resident's response to the treatment or intervention. The resident plan of care was not developed in accordance to the resident needs and risk factors present. The clinical records showed no documentation that the facility had provided the timely necessary care, services, or interventions to minimize the risk and promote wound healing. RESIDENT 82 Resident 82 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. In a review of the most recent quarterly MDS assessment, dated 04/25/18 revealed the resident was not cognitively intact. The MDS also revealed there were no current pressure ulcers but Resident 82 was at risk. In addition, the resident needed extensive assistance with all of her activities of daily living including bed mobility which required two person assistance. A review of past MDS assessments dating back to (MONTH) of (YEAR) showed that the resident never had a pressure ulcer or Deep Tissue Injury. Documentation in a progress note dated 5/3/18, indicated Suspected DTI to right ankle, right Achilles, right heel, right big toes and left anterior ankle. The note indicated the Primary ARNP was verbally notified and treatment was initiated as ordered. A review of her Kardex (a document used by the nursing assistants with instruction on providing care) for skin showed there were no interventions for skin. A review of the Care Plan for Skin integrity related to dry fragile skin initiated on 3/13/15 and reviewed on 5/4/18 to include the new DTI, showed the goal was for the Intact skin will remain intact. The interventions did now show specific interventions to prevent pressure related injuries even though the MDS indicated she was at high risk for developing skin injuries. A Review of care plan revealed impaired skin integrity with a goal for the pressure ulcer to show signs of healing dated 05/19/18. A review of the progress noted dated 05/04/18 revealed a suspected DTI with care to include cream. In a quarterly review progress note dated 05/06/18, revealed a DTI on the right ankle with wounds on ankle, Achilles, and big toe. DTI was marked on the left anterior ankle. Progress notes dated 05/20/19 revealed eschar on lower extremities. In an interview on 05/30/18 at 8:40 AM, the daughter of resident 82 said she gets sores on her heels. There was one recently that was brought to my attention. DTI was noted on 05/30/18 in the progress notes. In an interview and observation on 06/01/18 at 10:13 AM Staff R provided care to Resident 82 heel. The wound was observed on the right foot of the resident. The big toe had an unopened purple sore. The right heel has a large wound with eschar and drainage on the bandage. The wound was not completely covered in eschar. The wound had drained through the bandage that was applied to the heel. A review of the record revealed the wound was marked as DTI on the care plan and progress notes. In an interview on 06/01/18 at 10:15 AM Staff X stated we call the wound a DTI. Staff X stated that a DTI was part of a pressure sore. It has not been staged yet. The facility did not protect the resident skin or provide enough interventions to prevent skin injuries. Reference (WAC) 388-97-1060 (3)(b)

Based on interview and record review the facility failed to ensure 2 of 6 residents (#109 and #144) were free of significant medication errors. Failure to administer infectious disease antibiotics resulted in harm for Resident #109 as evidenced by the resident's required re-hospitalization . The facility failed to follow physician prescribed orders for Resident #144, which placed the resident at risk for experiencing potential adverse side effects to the medication. Findings include: RESIDENT #109 Resident #109 was admitted to the facility in February 2017 with [DIAGNOSES REDACTED]. In an interview on 04/25/17 at 2:19 PM, the resident's significant other stated, There was a problem with (the resident) getting a medication, there was a missed medication from the infectious disease doctor to continue the IV antibiotics, it was missed then the resident had to be re-hospitalized . Review of an infectious disease (ID) physician consultation report dated 02/22/17, revealed the resident was on appropriate antibiotics since 12/08/2016 but with highly abnormal scan in January 2017, would not feel comfortable stopping ertapenem/fluconazole (IV antibiotics) at this time . continue ertapenem/fluconazole will try to obtain MRI (magnetic resonance imaging) within next 1-2 wk (week). Review of the resident's Medication Administration Record [REDACTED]. Review of the resident's re-hospitalization history and physical revealed the resident was readmitted to the hospital on [DATE] after the resident's family noted the resident had been in bed all day, a glazed look on his face and less responsive than normal along with a new tremor to the resident's hands that had not been present prior. Further review of the history and physical revealed the resident presented: Currently alert with deficits mostly indicating impaired cognition, .and hand tremor. DDX (differential diagnosis) broad, including infection (UTI vs intraabdominal vs recurrent spinal abscess as it seems he was supposed to continue IV ertapenem/fluconazole (antibiotics) until ID (infectious disease) follow up and repeat MRI) CAUTI (catheter associated urinary tract infection) not septic .on February 2017 culture. Catheter has not been changed since then. Lumbar [MEDICATION NAME] Abscesses .as it seems he was supposed to continue IV ertapenem/fluconazole (antibiotics) until ID follow up .although it seems this fell through. Review of the resident's hospital discharge summary dated 03/13/17 revealed: (Resident #109) was placed on antibiotics for unclear initial source [MEDICAL CONDITION] (generalized serious infection) (Resident #109's) toxic metabolic [MEDICAL CONDITION] (medical condition resulting from serious, generalized infection) improved somewhat, he did not fully recover his prior baseline and will likely need more time to fully clear. By problem: Acute toxic metabolic [MEDICAL CONDITION], improving slowly .continue ertapenem 1 gm q 24h (every 24 hours) and fluconazole 400mg PO q day (by mouth every day) for infection (IV antibiotics) UNTIL DISCONTINUED BY VA INFECTIOUS DISEASES #CAUTI with proteus mirabilis - will be covered by ertapenem (IV antibiotics) for spinal infection above #Lumbar [MEDICATION NAME] Abscesses, persistent phlegmon per MRI read on 3/10/17 In an interview on 05/01/17 at 8:58 AM Staff B, Licensed Nurse (LN), stated there was a medication error report on the missed antibiotic. Review of the facility's Medication Discrepancy Log report dated 03/06/17 revealed: Event Description - returned from f/u infectious disease to continue 2 ABOs (antibiotics) ertapenum and fluconazole. Order was not specific, said continue ertapenem and fluconazole, and not carried out. Resident continued on fluconazole per original order until 2/21, ertapenum ended on 2/21. Sig. Y/N - no F/U Action - LN inserviced on transcribing orders from appts/consults and to seek clarification if orders are not specific. Reviewed with ARNP who signed off on recommendation and will ensure that either she will assist to clarify or will write specific orders based on recommendation. In an interview on 05/01/17 at 10:58 AM, Staff Q, ARNP, was asked what effects the missed antibiotics had on the resident, Staff Q stated, It sent him back to the hospital. In a phone interview on 05/10/17 at 12:45 PM, Staff HH, Infectious Disease Internal Medicine Physician stated, The ordered antibiotics were prematurely stopped and there is evidence to suggest the resident's infection got worse. RESIDENT 144 Review of Resident 144's physician orders [REDACTED]. - [MEDICATION NAME] 1 mg as needed every 6 hours for anxiety/agitation - Lisinopirl 10 mg every day for high blood pressure. The medication was to be held if the systolic blood pressure was > (greater than) 100 or the heart rate was < (less than) 60. Review of the MAR from March 29th through April 26th revealed the resident's systolic blood pressure was consistently above 100 and on two occasions the resident's heart rate was below 60. The LN administered the lisinopirl even though the directive was to hold the medication. Review of the April MAR indicated [REDACTED]. The LN administered the [MEDICATION NAME] within four hours and not the prescribed 6 hours. Review of the facility's medication error reporting log revealed these errors were not identified by the facility. In an interview on 04/28/17 at 9:20 AM, the Director of Nursing Services stated the medication errors will be investigated immediately. Reference (WAC) 388-97-1060 (3)(k)(iii)

Based on observation, interview, and record review, the facility failed to ensure supervision was provided to one of two sample residents (Resident #1) who received a hot beverage prior to lunch service. Resident #1 obtained a second degree burn (blisters and diffuse redness) to her thigh which required daily dressing treatments. Failure to provide staff supervision of residents drinking hot beverages in one of four dining rooms, placed residents at risk for unnecessary burns and/or accidents. Findings include: Interview with the Director of Nurses (DON) on 10/25/11 at 3:00 p.m. found the facility's expectation for staff when serving hot beverages, was to provide supervision to the residents. The DON provided a written policy, "Standards and General Information: Safety Protocol for Hot Food/Liquids," dated 06/10/04, which explained staff would initiate the "STIR" policy (Stir-Test-If a safe temperature...begin offering to the resident-Re-evaluate the resident's response throughout the meal...). The policy documented, "DO NOT PLACE HOT/STEAMING ITEMS WITHIN REACH OF A CONFUSED RESIDENT...and LN's (licensed nurses) are to supervise..." RESIDENT #1 Resident #1 was recently admitted to the facility for long term care related to Alzheimer's Disease, an eye condition, and degenerative joint disease among others. The comprehensive initial assessment dated [DATE] documented the resident had long and short term memory problems; required cueing for recall; wore glasses for vision; required staff to setup meals and required supervision/oversight for eating/drinking. The assessment also documented the resident required extensive assistance of one staff member for dressing, toileting, personal hygiene (combing hair, brushing teeth, washing face and hands), and bathing; was able to self propel a wheelchair; and did not have oral/dental/swallowing problems. On 10/25/11 at 11:15 a.m., the resident's treatment record was reviewed. According to the record, the treatment nurse documented on 10/19/11 the resident's left upper and inner thigh had "open/intact blisters"...measuring seven centimeters (cm) by three cm. On 10/19/11 the resident's physician ordered a daily application of medicated cream (Silvadene) to be applied to the resident's wound and covered daily with a non-adherent dressing. On 10/25/11 at 11:30 a.m., the resident was asked what happened to her thigh. She said, "I don't remember any more..." The resident denied pain to the blistered area. When the resident was asked specific questions, she repeated the questions word for word asked of her, but was unable to inform the surveyor about herself, where she ate, if she had family, nor any information about the burn. It was determined the resident was non-interviewable. The medication nurse, Staff A, was interviewed on 10/25/11 at 11:32 a.m. about the burn. She said the aide, Staff B, told her about the resident's reddened skin immediately after the aide discovered it after lunch on 10/19/11. Staff A said, "(the named resident) was drinking coffee...saw spills on floor...I got order for treatment...everybody was inserviced not to serve anything unless supervised (by staff)..." On 10/25/11 at 1:05 p.m., the resident's treatment nurse, Staff C, was observed providing wound care to the resident's left thigh. Staff C stated the resident had been pre-medicated with a pain reliever, Tylenol, 30 minutes before the dressing change to ensure the resident was comfortable during the treatment. There was a slight yellow drainage noted on the non-adhearing dressing when it was removed from the wound. The nurse cleaned the wound with normal saline; applied the medicated cream and placed a non-adherent dressing on the wound. The resident showed no signs of discomfort during the treatment. According to the "Wound/Skin Monitor" sheet dated 10/24/11, the resident's "diffused reddened area" (burn) had lessened in width for one area from 3.0 cm recorded on 10/19/11 to 1.0 cm on 10/24/11. The wound had increased in length from 7 cm on 10/19/11 to 9 cm on 10/24/11. The "blister ruptured open area (wound)" was measured on 10/24/11 and documented as 0.5 cm long by 9 cm wide by 0.1 cm deep. Review of the facility's incident log and investigation of the resident's skin injury dated 10/19/11, found the facility determined the resident's "diffuse-reddened area with open area and (1) intact blister to L (left) inner thigh" was "preventable." The investigation revealed staff provided a hot beverage (coffee) to the resident before lunch on 10/19/11 and left the resident in the dining room for 10 minutes unsupervised to independently drink coffee. The investigation also documented the resident had recent increased "confusion and anxious behavior..." and was found to have a urinary tract infection on 10/19/11. The investigation documented the NA did not realize the resident had spilled coffee to her lap/clothing when coffee was found on the floor near the resident on 10/19/11. The investigation found staff quesioned the resident about the coffee spill when discovered, but the resident stated she did not know what happened. The investigation documented the resident was unable to say what happened when asked upon discovery. The nurses' aide (NA) reported she "did not see the spill to the residents clothing and the resident did not show any s/s (signs and symptoms) of distress." The resident's burn was discovered after dining service and during provision of personal care by the NA. The NA reported the burn to Staff A, a nurse. On 10/25/11 at 1:20 p.m., the Director of Nurses (DON) verified there was no supervision provided to this resident after she was given coffee to drink independently. At 2:45 p.m. the DON reported she immediately trained staff when she was aware of the resident's injury. She said her training included, "...if (staff ) serves any hot beverages and foods (to residents), staff must stay with the resident (to supervise). She also explained, "anyone (residents) drinking, anyone (residents) confused must be supervised (by staff) and attended to...for (resident) safety..." Failure to provide supervised dining had the potential to cause unnecessary injury to residents.

Based on observation, interview and record review the facility failed to ensure that care plan interventions were consistently implemented for 1 of 5 residents (# 41) who had experienced accidents and/or injuries. Failure to implement interventions planned to reduce the risk of injury for Resident #41 resulted in a laceration that required sutures. Findings include: Resident # 41 was admitted to the facility in August 2005 with multiple [DIAGNOSES REDACTED]. The resident used a HTR tilt and recline wheel chair that was propelled by staff from one location in the facility to another. Review of the accident injury log found that on 4/7/2010 at 6:00 a.m., the resident was found with an injured foot. The facility investigation described the injury as bruising to the great and second toes on the right, and noted the injury site was " showing disfiguration " and was " painful to touch. " The LN documented the physician was notified of the change in condition and an order for [REDACTED]. The x rays revealed a fracture of the lateral aspect of the base of the great toe (proximal phalanx). treatment for [REDACTED]. Review of the facility investigation indicated the injury was of unknown origin. In addition, that the fracture was likely a " self inflicted " injury or it was " possible " it was a " spontaneous " injury. After the injury, the care plan was revised and new interventions were implemented to minimize the risk of injury were implemented. The interventions identified included placing " blue boots " on the residents feet at all times. Although the intervention to wear the blue boots at all times was implemented after the injury to the left foot on 4/7/2010, a second injury affecting the left foot was found on 7/12/2010. On 7/12/2010 at 7:15 p.m., an additional injury to the left foot was found. The Licensed Nurse (LN) described finding blood on the floor and a laceration between the great and second toe on the left foot. The LN also documented because the site was bleeding she was not able to measure the laceration. The LN wrapped the resident ' s foot with a bandage, contacted the physician, and coordinated the resident transfer to the emergency room . The resident returned to the facility after treatment in the emergency room for the laceration that required sutures. On 7/20/2010 during observations, the resident was wearing a blue splint on the left foot and a soft cushion boot on the right foot. The splint extended several inches beyond the resident ' s toes, and the soft cushion boot exposed only the tip of the great toe on the right foot. Additional padding was observed on the leg/foot rest, a pillow was positioned under the resident legs, and this kept her legs from direct contact with the leg support. On 7/21/2010, at 1:30 pm, LN # H was observed changing the dressing on the laceration. The LN measured the laceration, and found it was 7 centimeters long and reported that it had five sutures. The laceration stretched from the top of the foot, ran between the two toes, and ended on the bottom of the foot just below the two toes. On 7/22/10 at 8:30 a.m. LN # C was interviewed about the investigation of the injury. She verified according to the care plan, Resident # 41 should have been wearing the blue boots. After reviewing the investigation, the LN agreed the documentation did not identify if the boots were in place. At 3:00 p.m., LN # C reported she had re-interviewed the staff members who were present at the time the injury was found. She stated she had discovered the boots to protect the feet were not in place for approximately four hours, prior to the discovery of the injury. Not ensuring the care plan to place the boots to protect the resident feet resulted in a laceration that required sutures.