Every finding on record at Corwin Center At Emerald Heights

Based on observation, interview, and record review, the facility failed to ensure food items were handled appropriately in accordance with professional standards of food safety for 1 of 1 kitchen (Main Kitchen), reviewed for food services. The failure to date and label food items placed the residents at risk for foodborne illness (caused by the ingestion of contaminated food or beverages) and a diminished quality of life. Findings included .Review of the facility's policy titled, Food Services: Food Storage and Safe Handling, revised in July 2026, showed: The Facility shall monitor all dry storage pantries, refrigerators, and freezers for safe food handling practices.i. All items will be labeled and dated.ii. All food items will be stored in a covered container or other appropriate receptacle.iii. Opened items in fridges will be thrown away after three (3) days, unless longer holding times are specified by the Food Services: Food Storage Use by Guideline. Any food items that remain open after specified guidelines will be disposed.iv. Staff will dispose of any food items that do not meet the above criteria.A joint observation and interview on 07/29/2026 at 10:47 AM with Staff E, Corporate Chef/Director of Food and Beverage, showed the following opened spices and seasoning mix without open and/or use by dates:-two opened Tandoori Masala-one opened Gumbo File Powder-one opened Juniper Berries-one opened Smoked Chipotle-one opened Ground Sumac-one opened Everything Bagel blend (seasoning mix)Staff E stated that the above spices should have been dated on the day they were received. Staff E stated that they could still use the spices by just looking at them but the qualities might have deteriorated. Staff E further stated that it would have been better if the spices and seasoning mix had a received date, an open date, and a use by date.In an interview on 07/30/2026 at 9:43 AM, Staff A, Administrator, stated that they expected the kitchen staff to be aware of when those spices were expiring, and that all spices should be labeled with both the date it was opened and the use by date.Reference: (WAC) 388-97-1100 (3).

Based on observation, interview, and record review, the facility failed to ensure medication administration was documented in accordance with professional standards of practice for 5 of 5 residents (Residents 20, 52, 57, 50 & 39), reviewed for medication administration. The failure to administer and/or document medication administration in accordance with professional standards of practice placed the residents at risk for negative outcomes and a diminished quality of life.Findings included.Review of the facility's policy titled, Administering Medications, revised on 04/17/2026 showed, Medications shall be administered in a safe and timely manner, and as prescribed. The individual administering the medication must initial, or sign off, on the resident's MAR [Medication Administration Record] on the appropriate line after giving each medication.RESIDENT 20Observation on 07/28/2026 at 9:04 AM showed Staff H, Registered Nurse, prepared and signed off medications in the MAR prior to administering them to Resident 20. Staff H clicked OK [okay] on the MAR after pouring each medication into a medication cup, the medication orders in the MAR turned green, which indicated that the MAR was signed off before Staff H administered the medications to Resident 20.RESIDENT 52Observation on 07/28/2026 at 9:19 AM showed Staff H prepared and signed off medications in the MAR prior to administering them to Resident 52. Staff H clicked OK on the MAR after pouring each medication into a medication cup, the medication orders in the MAR turned green, which indicated that the MAR was signed off before Staff H administered the medications to Resident 52.RESIDENT 57Observation on 07/28/2026 at 9:26 AM showed Staff H prepared and signed off medications in the MAR prior to administering them to Resident 57. Staff H clicked OK on the MAR after pouring each medication into a medication cup, the medication orders in the MAR turned green, which indicated that the MAR was signed off before Staff H administered the medications to Resident 57.In an interview on 07/28/2026 at 9:46 AM, Staff H stated that prior to administering medications, they would check the residents' medication orders one by one, that medications were available in the medication cart, would prepare the medications as prescribed, then would administer the medications to the residents. When asked about documentation of medication administration, Staff H stated that they clicked okay after preparing each medication turning the MAR green indicating that the medication was administered. When asked if they signed off the MAR before residents took their medications, Staff H stated, Yes. When asked what they would do if residents refused their medications, Staff H stated that they would unsign the MAR and would document the refusal.RESIDENT 50Observation on 07/28/2026 at 10:00 AM showed Staff F, Licensed Practical Nurse, prepared and signed off medications in the MAR prior to administering them to Resident 50. Staff F clicked OK on the MAR after pouring each medication into a medication cup, the medication orders in the MAR turned green, which indicated that the MAR was signed off before Staff F administered the medications to Resident 50.RESIDENT 39Observation on 07/28/2026 at 10:08 AM showed Staff F prepared and signed off medications in the MAR prior to administering them to Resident 39. Staff F clicked OK on the MAR after pouring each medication into a medication cup, the medication orders in the MAR turned green, which indicated that the MAR was signed off before Staff F administered the medications to Resident 39.In an interview on 07/28/2026 at 10:30 AM, Staff F stated that their process for medication administration was to check for medication orders, check that medications were available, then they would administer medications to the residents. Staff F stated that they signed off the MAR by clicking okay when preparing the medications before administering them to the residents. When asked what they would do if residents refused their medications, Staff F stated that they would unsign the MAR and would document the refusal.In an interview on 07/30/2026 at 12:17 PM, Staff C, Interim Director of Nursing Services, stated they expected medications to be administered as ordered and per the MAR. Staff C stated they expected staff to document on the MAR after medications were administered to the residents. Staff C further stated that Staff H and Staff F should not have signed off on the MAR prior to administering medications to Residents 20, 52, 57, 50 and 39.Reference: (WAC) 388-97-1300 (1)(b)(i)(ii).

Based on interview and record review, the facility failed to ensure the COVID-19 (a highly transmissible infectious virus that causes respiratory illness and in severe cases can cause difficulty breathing and could result in impairment or death) vaccine was offered to 1 of 5 residents (Resident 17), reviewed for immunizations. The failure to educate and offer the COVID-19 vaccine placed the resident at risk for contracting the COVID-19 virus and related complications.Findings included.Review of the facility's policy titled, [Facility] COVID-19 Vaccination Policy and Procedure, revised in April 2026, showed, It is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complications from COVID-19. by educating and offering our residents the COVID-19 vaccine.Review of the Centers for Disease Control and Prevention (CDC) online document titled, Staying Up to Date with COVID-19 Vaccines, dated 11/19/2025, recommended a 2025-2026 COVID-19 vaccine for people ages 6 [six] months and older. It further showed that getting the 2025-2026 COVID-19 vaccine is especially important if you.are living in a long-term care facility.Review of the admission record printed on 07/24/2026 showed that Resident 17 was admitted to the facility on [DATE].Review of Resident 17's Electronic Health Record (EHR) showed the last documented COVID-19 vaccine for Resident 17 was administered on 05/15/2025. It further showed no documentation that Resident 17 was offered the most recent COVID-19 (2025-2026 COVID-19) vaccine.In an interview on 07/28/2026 at 1:34 PM, Staff C, Infection Preventionist/Interim Director of Nursing Services, stated that they offered the COVID-19 vaccine to residents on admission and if it's [it has] been greater than six months after they had received a COVID-19 vaccine. Staff C further stated that the 2025-2026 COVID-19 vaccine was the most recent available COVID-19 vaccine.In a follow-up interview and joint record review on 07/30/2026 at 10:02 AM, Staff C stated that they followed the CDC recommendations for providing the COVID-19 vaccine to residents. A joint record review of Resident 17's EHR showed the last documented COVID-19 vaccine for Resident 17 was administered on 05/15/2025. It further showed no documentation that Resident 17 was offered the most recent COVID-19 (2025-2026 COVID-19) vaccine. Staff C stated that Resident 17 should have been offered the 2025-2026 COVID-19 vaccine.Reference: (WAC) 388-97-1620 (2)(b)(i)(ii).

Based on interview and record review, the facility failed to ensure the influenza vaccine (used to prevent influenza [an infection of the nose, throat, and lungs]) was offered to 1 of 5 residents (Resident 17), reviewed for immunizations. This failure placed the resident at risk of acquiring, transmitting, and/or experiencing potentially avoidable complications from influenza disease.Findings included.Review of the facility's policy titled, Influenza, Prevention and Control of Seasonal, revised in November 2025, showed, Unless contraindicated, all residents and staff will be offered the [influenza] vaccine.Review of the admission record printed on 07/24/2026 showed Resident 17 was admitted to the facility on [DATE].Review of Resident 17's Electronic Health Record (EHR) showed no documentation that Resident 17 was offered the influenza vaccine during the 2025-2026 influenza season.In an interview and joint record review on 07/28/2026 at 1:34 PM, Staff C, Infection Preventionist/Interim Director of Nursing Services, stated that influenza vaccinations were offered at admission and during flu [influenza] season. A joint record review of Resident 17's EHR showed no documentation that Resident 17 was offered the influenza vaccine during the 2025-2026 influenza season. Staff C further stated that Resident 17 was not offered the influenza vaccine during the 2025-2026 influenza season.Reference: (WAC) 388-97-1340 (1)(2).

Based on observation, interview, and record review, the facility failed to ensure medications were secured for 1 of 3 medication carts (Willow Cart), reviewed for medication storage. This failure placed residents at risk for receiving compromised and/or ineffective medications and unauthorized access to medication.Findings included.Review of the facility's policy titled, Medication Storage and Labeling, reviewed in June 2026, showed, It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security . a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.Review of the facility's policy titled, Administering Medications, revised on 04/17/2026 showed, During administration of medications, the medication cart is kept closed and locked when out of sight of the medication Nurse. Observation on 07/28/2026 at 1:55 PM showed the [NAME] medication cart was unlocked and unattended.A joint observation and interview on 07/28/2026 at 1:59 PM with Staff I, Licensed Practical Nurse, showed the [NAME] medication cart was unlocked. Staff I stated that the medication cart was not supposed to be left unlocked, it should have been locked.In an interview on 07/30/2026 at 12:17 PM, Staff C, Interim Director of Nursing Services, stated they expected medications carts to be secured and locked. Staff C further stated that the [NAME] medication cart should have been locked.Reference: (WAC) 388-97-1300 (2).

Based on interview and record review, the facility failed to ensure a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS - an assessment tool) was completed for 1 of 4 residents (Resident 5), reviewed for comprehensive assessment after a significant change. This failure placed a resident at risk for delayed care planning, unmet care needs, and a diminished quality of life.Findings included .Review of 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 October 2025, showed that a SCSA is required to be performed when a terminally ill resident enrolls in a hospice (compassionate care provided to individuals who are in the final stages of a terminal illness) program or changes hospice providers and remains a resident at the nursing home. The Assessment Reference Date (ARD) must be within 14 days from the effective date of the hospice election. The RAI manual further showed that the assessment should be completed no later than 14 days after the determination was made (determination date plus 14 calendar days).Review of the facility's policy titled, Minimal Data Set [MDS], revised on 06/30/2026, showed, According to federal regulations, 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 . Significant Change in Status Assessment (SCSA) - a comprehensive assessment completed within 14 days of the identification of a status change that meets the requirements outlined in the RAI manual. It further showed A SCSA is required when a resident enrolls in a hospice program or changes hospice providers and remains in the facility.Review of the admission record printed on 07/29/2026 showed Resident 5 was readmitted to the facility on [DATE].Review of the Hospice Notification form dated 03/03/2026 showed that Resident 5 was admitted to hospice services on 03/03/2026.Review of Resident 5's SCSA MDS dated [DATE] showed it was completed on 03/27/2026, 24 days after hospice election (10 days late).In an interview on 07/28/2026 at 9:29 AM, Staff D, Resident Care Manager, stated that Resident 5 had been in hospice care since 03/03/2026.In an interview on 07/30/2026 at 2:48 PM, Staff G, MDS Nurse, stated they followed the RAI Manual to complete MDS assessments. A joint record review of Resident 5's SCSA MDS dated [DATE] showed it was completed on 03/27/2026. A joint record review of the hospice notification form showed that Resident 5 was admitted to hospice services on 03/03/2026. Staff G stated that Resident 5's SCSA MDS was completed late, and it should have been completed on 03/17/2026.In an interview on 07/30/2026 at 2:50 PM, Staff C, Interim Director of Nursing Services, stated that it was their expectation that Resident 5's SCSA MDS be completed timely and accurately.Reference: (WAC) 388-97-1000 (3)(b).

Based on interview and record review, the facility failed to ensure admission Minimum Data Set (MDS - an assessment tool) was completed within 14 days of admission for 1 of 5 residents (Resident 41), reviewed for comprehensive assessments. This failure placed residents at risk for delayed and/or unmet care needs, and a diminished quality of life.Findings included.Review of the 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 October 2025, showed that the admission assessment must be completed by the end of day 14, counting the date of admission to the nursing home as day one.Review of the facility's policy titled, Minimum Data Set (MDS), dated 06/30/2026, showed, According to federal regulations, 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 . admission Assessment - completed within 14 days of admission counting the day of admission as day #1[number one].Review of an admission MDS dated [DATE] showed Resident 41 was admitted to the facility on [DATE]. The MDS further showed that it was completed on 11/17/2025 (four days late).In an interview and joint record review on 07/30/2026 at 11:47 AM, Staff G, MDS Nurse, stated they followed the RAI manual for completion of MDS assessments. Staff G stated admission MDS would be completed by day 14, including the admission date. A joint record review of the admission MDS dated [DATE] showed Resident 41 was admitted to the facility on [DATE] and that it was completed on 11/17/2025. Staff G stated that Resident 41's MDS was completed late.In an interview on 07/30/2026 at 12:11 PM, Staff B, Director of Nursing Services, stated they expected MDS were completed following the RAI manual for dates of completion according to admit date s or ARD [Assessment Reference Date] dates. Staff B further stated that Resident 41's MDS should have been completed timely.Reference: (WAC) 388-97-1000 (1)(b)(3)(a).

Based on interview and record review, the facility failed to develop care plans for 2 of 5 residents (Residents 5 & 7), reviewed for comprehensive care plans. The failure to develop care plans for diuretic (medications that help move extra fluid out of the body) use placed the residents at risk for unmet care needs and a diminished quality of life. Findings included .Review of the facility's policy titled, Comprehensive Care Plan, revised in January 2026, showed, It is the policy of the [facility name] to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.Review of the facility's policy titled, High Risk Medications, revised in January 2026, showed, This facility recognizes that some medications are associated with greater risks of adverse consequences than other medications. These high-risk medications can include .diuretics and any other medication that can bear a heightened risk. The policy further showed, The residents' care plan shall alert staff to monitor for adverse consequences of any high-risk medications given. The resident's care plan shall include interventions to minimize risk of adverse consequences.RESIDENT 5Review of the admission record printed on 07/29/2026 showed Resident 5 was readmitted to the facility on [DATE].Review of Resident 5's comprehensive care plan printed on 07/28/2026 showed no care plan for diuretic medication use.Review of Resident 5's physician's orders dated 03/03/2026 showed an order for a diuretic medication.Review of a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS-an assessment tool) dated 03/13/2026 showed that Resident 5 was on diuretic medication.RESIDENT 7Review of the admission record printed on 07/28/2026 showed Resident 7 was readmitted to the facility on [DATE].Review of Resident 7's comprehensive care plan printed on 07/28/2026 showed no care plan for diuretic medication use.In an interview on 07/28/2026 at 9:23 AM, Staff F, Licensed Practical Nurse, stated that Resident 5 and Resident 7 were on diuretic medications.In an interview on 07/28/2026 at 9:29 AM, Staff D, Resident Care Manager, stated that Resident 5 and Resident 7 were on diuretic medications. Staff D stated that they would expect a care plan for diuretic medication use when residents were not in hospice care. Staff D further stated that Resident 5 and Resident 7 were on hospice care and that they did not need a care plan for diuretic use since the goal is comfort.In an interview on 07/30/2026 at 1:34 PM, Staff C, Interim Director of Nursing Services, stated that they would expect a care plan for diuretic medication use and that Resident 5 and Resident 7 should have had care plans for their diuretic medication use.References: (WAC) 388-97-1020(1), (2)(a)(b) .

Based on interview and record review, the facility failed to ensure the facility assessment (document describing resident population and needs to determine staff and other resources necessary to competently care for residents) was updated to accurately determine and identify the resources needed for the facility's resident care needs. This failure placed the residents at risk for unmet care needs.Findings included .Review of the facility's policy titled, Facility Assessment, dated 04/30/2026, showed, This facility conducts and documents a facility-wide assessment to determine what resources are necessary to care for our residents competently during both day-to-day operations (including nights and weekends) and emergencies. b. The facility's resources, including but not limited to. v. Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies. Additionally, the facility will consider specific staffing needs for each shift (e.g., day, evening, night, weekend shifts) and for each resident unit in the facility based on changes to resident population.Review of the facility assessment dated [DATE] showed the assessment did not address or include the following:- Resources necessary to care for residents including nights and weekends.- Contracts, memorandums of understanding ([NAME]), or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies.- Consider specific staffing needs for each resident unit in the facility and adjust as necessary based on changes to its resident population.- Consider specific staffing needs for each shift, such as day, evening, night, and adjust as necessary based on any changes to its resident population.In an interview on 07/30/2026 at 2:23 PM, Staff A, Administrator, stated that the facility assessment did not show that the facility assessed and evaluated the resources necessary to care for residents including nights and weekends. Staff A stated that the facility assessment did not indicate the facility had contracts, MOUs, or other agreements with third parties such as hospice (compassionate care provided to individuals who are in the final stages of a terminal illness). Staff A stated that it was not documented in the facility assessment that the facility considered specific staffing needs for each resident unit for each shift (day, evening, night). Staff A further stated that if the [facility assessment] policy mentioned them, they should have been included in the facility assessment.Reference: (WAC) 388-97-1620 (2)(b)(i)(ii).

Based on observation, interview, and record review, the facility failed to discard expired sanitizing solution test strips for 2 of 2 kitchens (Fire Side Grill Kitchen and Main Kitchen) and failed to ensure food items were stored and handled appropriately in accordance with professional standards of food safety for 1 of 1 dry storage room (Main Kitchen Dry Storage Room) and for 1 of 1 resident refrigerator (Resident Use Only Refrigerator), reviewed for food services. In addition, the facility failed to cover food items during meal tray delivery. These failures placed the residents at risk for foodborne illness (caused by the ingestion of contaminated food or beverages) and a diminished quality of life. Findings included . Review of the facility's policy titled, Food Services: Food Storage and Safe Handling, revised in [DATE], showed the facility would provide safe and sanitary storage, preparations, distribution, serving, and disposal of food in accordance with professional standards for food service safety. Review of the facility's policy titled, Use and Storage of Food Brought in by Family or Visitors, revised in [DATE], showed that all the food items that were already prepared by the family or visitor brought in would be labeled with content and would be dated. The policy further showed that food items not consumed within three days, would be discarded by facility staff. EXPIRED SANITIZING SOLUTION TEST STRIPS A joint observation and interview on [DATE] at 8:13 AM with Staff N, Executive Chef, showed they used the [NAME] (brand name) test strips to check the sanitizing solution ppm (parts per million-unit of measurement). Further observation showed that the [NAME] test strips had an expiration date of [DATE]. Staff N then got another bottle of [NAME] test strips that had an expiration date of [DATE]. Staff N stated, I need to order new bottle of test strips, I cannot find one that [was] not expired, but it [[NAME] test strips] still works. MAIN KITCHEN DRY STORAGE ROOM In an interview and joint observation on [DATE] at 9:04 AM, Staff N stated they expected staff to follow the use by date from manufacturer to discard the food items. Joint observation with Staff N showed five unopened bottles of coconut aminos (salty, savory seasoning sauce made from the fermented sap of coconut palm and sea salt) with used by date of [DATE], four unopened bottles of Balsamic vinegar with used by date of [DATE], and two unopened bottles of Sriracha hot honey with used by date of [DATE]. Staff N stated that the expired food items should have been discarded. RESIDENTS USE ONLY REFRIGERATOR In a joint observation and interview on [DATE] at 12:32 PM with Staff C, Infection Preventionist, showed a half loaf of bread in a clear plastic bag with use by date of [DATE] for Resident 258, and a small container of soup dated [DATE] for Resident 27. Staff C stated that the facility kept food items brought in by family for three days and food items then would be discarded by facility staff. Staff C further stated that Resident 258's half loaf of bread and Resident 27's soup should have been thrown away. In an interview on [DATE] at 3:38 PM, Staff O, Director of Food and Beverage/Executive Chef, stated that staff should not have used expired test strips and that they expected expired food items to be discarded even if they were unopened. In an interview on [DATE] at 12:36 PM, Staff A, Administrator, stated they expected staff to follow the food policy. Staff A further stated that they expected staff to discard expired test strips and food items. 46912 UNCOVERED FOOD ITEMS Review of the facility's policy titled, The Dining Experience, dated 2017, showed that In the event of a hall tray, all food items and beverages shall be wrapped individually when leaving the dining area. In the event food needs to be transported from the main kitchen to the Skilled kitchen all food items shall be wrapped until they reach their destinations. Observation on [DATE] at 11:56 AM, showed unidentified staff carrying uncovered mandarin oranges [canned] from the meal cart down the hallway to the dining room. At 12:00 PM, Staff U, Nursing Assistant Certified (NAC), carried uncovered cake from the meal cart to room [ROOM NUMBER]. At 12:03 PM, Staff U carried uncovered cake from the meal cart to room [ROOM NUMBER] and Staff P, NAC, carried uncovered mandarin oranges from the meal cart to room [ROOM NUMBER]. Additional observation at 12:07 PM showed unidentified staff were carrying uncovered mandarin oranges and cake to room [ROOM NUMBER]. In an interview and joint observation on [DATE] at 12:21 PM, Staff P stated that normally they [food items] were covered in clear wrap. Joint observation showed that the mandarin oranges were not covered. Staff P stated that food items should be covered when being transported through the hallways. In an interview on [DATE] at 3:39 PM, Staff O stated that they expected anything [food items] travelling outside the kitchen has to be covered all the way to the resident's rooms. Staff O stated that cake and mandarin oranges, should be covered when being transported to resident rooms. In an interview on [DATE] at 3:48 PM, Staff A stated they expected staff to follow the food policy for covering food items. Reference: (WAC) [DATE] (3)

Based on observation, interview, and record review, the facility failed to appropriately use Personal Protective Equipment (PPE-use of face mask, gown, and gloves) for 1 of 4 staff (Staff T) and failed to perform hand hygiene during meal tray pass for 3 of 8 residents (Residents 52, 39 & 257), reviewed for infection control. In addition, the facility failed to handle a urinary catheter (a semi-flexible tube inserted into the bladder to drain urine) bag appropriately for 1 of 1 resident (Resident 23), reviewed for urinary catheter care. These failures placed the residents, staff, and visitors at an increased risk of infection and related complications. Findings included . Review of the facility's undated policy titled, Transmission-Based (Isolation) Precautions, showed that Transmission-based precautions .refer to actions (precautions) implemented in addition to standard precautions that are based upon the means of transmission .in order to prevent or control infections. It showed that Droplet Precautions is Intended to prevent transmission of pathogens spread through .respiratory droplets that are generated by a resident who is coughing, sneezing, or talking. It further showed that the recommendations for PPE for Droplet Precautions included, [NAME] [put on] a mask upon entry into the patient room. Review of the facility's policy titled, Infection Prevention and Control Program, revised in 2025, showed, Standard Precautions: All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. PPE USE Observation on 04/16/2025 at 8:52 AM, showed Staff T, Nursing Assistant Certified (NAC), wearing a N95 (a device designed to protect the wearer against particles and help prevent the spread of germs) mask and helping the resident in room [ROOM NUMBER]D (Droplet Precautions room). Staff T left the room and did not take off their soiled mask and did not put on a new one. Further observation showed a PPE cart outside the room. Additional observation on 04/16/2025 at 12:08 PM, showed Staff T came out room [ROOM NUMBER]W (Droplet Precautions room) and did not change their soiled N95 mask. Staff T then went into room [ROOM NUMBER] wearing the same N95 mask. Staff T then went into room [ROOM NUMBER]D (Droplet Precautions room). Staff T did not change masks between resident rooms. Further observation showed a PPE cart outside the room. In an interview on 04/16/2025 at 2:15 PM, Staff T stated that we wear masks when we go in [to Droplet Precautions rooms] and then take off everything and put on a new mask. Staff T further stated that their process was to take off their old [soiled] mask in the resident's room, sanitize their hands and put a new mask on inside the room. In an interview on 04/22/2025 at 10:24 AM, Staff C, Infection Preventionist, stated that they expected staff to wear PPE when going into a Droplet Precautions room, provide care, take off PPE inside of the room, perform hand hygiene and put on a new mask. When asked where staff should put on their new mask, Staff C stated, outside the room. In an interview on 04/23/2025 at 12:12 PM, Staff B, Director of Nursing, stated that for staff taking care of a resident on Droplet Precautions, they expected staff to wear PPE when entering the room, provide care, take off PPE and perform hand hygiene. Staff B further stated that they expected staff to change their soiled masks after leaving the Droplet Precautions room. 52331 HAND HYGIENE RESIDENT 52 Observation on 04/18/2025 at 8:16 AM, showed Staff P, NAC, delivered Resident 52's meal tray to their bedside table, moved the bedside table closer to Resident 52, and moved their walker away. Staff P did not perform hand hygiene in between tasks and/or after leaving Resident 52's room. RESIDENT 39 Observation on 04/18/2025 at 8:18 AM showed Staff P delivered Resident 39's meal tray to their room without performing hand hygiene. Staff P placed Resident 39's meal tray on their bedside table and moved the bedside table in front of Resident 39. Staff P did not perform hand hygiene in between tasks and/or after leaving Resident 39's room. RESIDENT 257 Observation on 04/18/2025 at 8:20 AM, showed Staff P delivered Resident 257's meal tray to their room without performing hand hygiene. Staff P moved the bedside table closer to Resident 257 and moved their walker away. In an interview on 04/18/2025 at 8:36 AM, Staff P stated that they should have done hand hygiene before entering and after leaving the rooms of Residents 52, 39 and 257. In an interview on 04/22/2025 at 11:29 AM, Staff D, Resident Care Manager, stated that Staff P should have performed hand hygiene after they touched anything in the residents' rooms and/or after leaving the resident's room. In an interview on 04/22/2025 at 12:57 PM, Staff C stated they expected all staff to do hand hygiene before entering and after leaving the residents' room. In an interview on 04/23/2025 at 4:19 PM, Staff B stated that they expected staff to perform hand hygiene before entering and after leaving the residents' room. INDWELLING URINARY CATHETER RESIDENT 23 Resident 23 admitted to the facility on [DATE] with diagnoses that included urinary retention (inability to completely empty the bladder [body organ that collects urine]), benign prostatic hyperplasia (an enlargement of the prostate gland [male reproductive gland]). Multiple observations on 04/16/2025 at 10:51 AM, at 1:22 PM, and at 2:04 PM, showed Resident 23's indwelling urinary catheter drainage bag was hanging under their bed and touching the floor. A joint observation and interview on 04/16/2025 at 2:13 PM, Staff Q, Registered Nurse, showed Resident 23's catheter drainage bag hanging from the right side of bed and touching the floor. Staff Q stated that Resident 23's drainage bag should not have touched the floor. In an interview on 04/22/2025 at 11:29 AM, Staff D stated that Resident 23's drainage bag should not have touched the floor, and that there should have been a barrier between the floor and the drainage bag. In an interview on 04/22/2025 at 12:57 PM, Staff C stated that they expected the resident's drainage bag should not have touched the floor. In an interview on 04/23/2025 at 4:19 PM, Staff B stated that the indwelling urinary catheter drainage bag should not be on the floor. Reference: (WAC) 388-97-1320 (1)(a)(c)(2)(c)

Based on observation, interview, and record review, the facility failed to ensure resident records were complete and accurate for 4 of 6 residents (Residents 42, 36, 53 & 3), reviewed for resident records. The failure to accurately write medications orders, fill out resident forms properly, and complete/check routine bed positioning device placed the residents at risk for unmet care needs, inaccurate monitoring, potential for injury, and a diminished quality of life. Findings included . Review of the facility's policy titled, High Risk Medications, revised in 2025, showed that the facility recognized that some medications were associated with greater risks of adverse consequences than other medications and that high-risk medications included medications that treat diabetes-high levels of sugar in the blood). The policy further showed that the facility would obtain and document specific parameters for administration or withholding certain high-risk medications such as insulin (medication/hormone that regulates the body's blood sugar level) as per the physician's or practitioner's orders. Review of the facility's policy titled, Medication Orders, revised in 2025, showed that the elements of medications orders were .date and time the order is written . resident's full name .name of medication . dosage-strength of medication is included . time or frequency of administration . duration or stop date if applicable . route of administration . Type/Formulation (if applicable) . hour of administration (if applicable) . diagnosis or indication for use. RESIDENT 42 Review of Resident 42's physician orders printed on 04/17/2025 showed an order dated 06/27/2024 for Multiple Vitamin-Minerals (multivitamin with minerals- a supplement) to give one tablet by mouth every day. The multivitamin order further showed to monitor for BEHAVIOR: Combative: 1) Approach in a calm manner, 2) Discourage behavior, 3) Offer food/drink, 4) Offer choices, S) Assess for pain or discomfort, hot or cold, 6) provide guidelines for behavior, 7) Reproach in a short time, 8) Remove from the situation. Review of the April 2025 Medication Administration Record (MAR) showed Resident 42 was administered their multivitamin every day from 04/01/2025 to 04/23/2025 with exception of 04/21/2025. In an interview and joint record review on 04/23/2025 at 10:57 AM, Staff H, Registered Nurse, stated that medication orders had the resident's name, the name of the medication, dose, route, frequency, and reason why the medication was given. A joint record review showed Resident 42's April 2025 MAR had an order for multivitamin with minerals with instructions to monitor for combative behavior within the body of the order. Staff H stated that Resident 42's multivitamin order was started on 06/27/2024. Staff D further stated that Resident 42 was not monitored for behaviors and that the behavior order should not have been part of Resident 42's multivitamin order, it was entered by mistake, it should not be there. A joint record review and interview on 04/23/2025 at 2:14 PM with Staff D, Resident Care Manager, showed Resident 42's April 2025 MAR had an order of multivitamin that included orders to monitor for combative behaviors and interventions listed within the body of the order. Staff D stated that the order for monitoring combative behaviors should not have been part of Resident 42's multivitamin order. A joint record review and interview on 04/23/2025 at 3:24 PM with Staff B, Director of Nursing Services, showed Resident 42's April 2025 MAR had an order for monitoring combative behavior within the body of their multivitamin order. Staff B stated that the order for monitoring behaviors should not have been part of Resident 42's multivitamin order and that Resident 42, did not have any behaviors to monitor for. RESIDENT 36 Review of Resident 36's April 2025 MAR printed on 04/17/2025, showed orders for insulin glargine (type of insulin) to administer 20 units (unit of measurement) subcutaneously (under the skin) every morning at 7:00 AM. Further review of the insulin order did not show parameters for when to hold the medication and/or when to notify the provider [medical doctor or physician assistant). In an interview and joint record review on 04/23/2025 at 2:39 PM, Staff D stated they expected to see parameters for residents receiving insulin for when to hold the medication and/or to notify the provider. A joint record review of the April 2025 MAR showed Resident 36 had orders for insulin glargine without parameters. Staff D stated that Resident 36's insulin glargine order did not have parameters to hold the medication and/or to notify the provider if the blood sugar showed certain numbers [too low and too high blood sugar levels]. Staff D further stated that Resident 36's insulin order for glargine should have had parameters. In an interview and joint record review on 04/23/2025 at 3:19 PM, Staff B stated that Resident 36's order for insulin glargine should have had parameters for when to hold the medication and/or notifying the provider. 52331 RESIDENT 53 Review of the facility's policy titled, Preadmission Screening and Resident Review (PASRR or PASARR- an assessment used to identify residents 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), revised in October 2017, showed, Social Services or Designee shall review all Level I screening forms for accuracy. If at any time the Facility finds that the previous Level I screening was incomplete, erroneous, or no longer accurate, the facility shall immediately complete a new screening using Level I form. Review of the face sheet printed on 04/17/2025 showed Resident 53 admitted to the facility on [DATE] with diagnosis that included depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Review of Resident 53's Level I PASARR dated 02/17/2025, did not show depression was documented in Section IA (SMI). A joint record review on 04/23/2025 at 11:33 AM with Staff I, Social Services Associate, showed Resident 53's face sheet listed a diagnosis of depression. A joint record review of Resident 53's Level I PASARR dated 02/17/2025 showed that depression was not marked in Section IA. Staff I stated that Resident 53 had a diagnosis of depression. When asked if Resident 53's Level II PASARR was accurate, Staff I stated that it was not and that they should have updated Section IA to include the diagnosis of depression. In an interview on 04/23/2025 at 4:19 PM, Staff B stated that they expected all the information on PASARR forms to be completed accurately. In an interview on 04/23/2025 at 5:15 PM, Staff A, Administrator, stated that they expected Social Services would follow the PASARR policy and complete the form accurately. 52133 RESIDENT 3 Review of the facility's policy titled, Proper Use of Positioning Devices, revised in January 2014, showed Positioning Devices can be considered a restraint when they are used to limit the resident's freedom of movement (prevent the resident from leaving his/her bed) . Positioning Devices are only permissible if they are used to treat a resident's medical symptoms or to assist the resident with mobility and transfer . An assessment will be made to determine [whether] the resident will benefit from the use of a positioning device and that the resident can physically and safely use one. Multiple observations on 04/16/2025 at 9:21 AM, on 04/17/2025 at 9:21 AM, and on 04/18/2025 at 2:30 PM showed Resident 3's left side bed positioning device was loose and able to wiggle when moved from side to side. Review of Resident 3's facility room rounds form, dated 04/18/2025 did not show bed positioning devices were listed and/or that it was regularly inspected. In an interview and joint record review on 04/23/2025 at 1:23 PM, Staff A stated that staff (managers doing room rounds) would check for bed positioning devices and document on the facility room rounds form sections under, Is the room in good repair? and/or Furniture in good repair. Staff A stated, the bed positioning devices are attached to the bed, so when they check the bed those are included in the bed. The bed is considered furniture. A joint record review of the room rounds form for Resident 3 dated 04/18/2025 showed check marks were documented under sections, Is the room in good repair? and Furniture in good repair. Staff A stated check marks documented on room rounds form meant that there were no issues found. Staff A stated that they were made aware of Resident 3's left bed positioning device was loose and wiggly that day [04/18/2025] when the work order was made. Staff A further stated that they expected the managers to check the bed positioning devices as a bed is furniture. So, they will check the positioning devices with the bed and if there are any issues with them to notify [Staff A] and make a work order. When asked if Resident 3's room rounds form was accurately documented that bed positioning devices were monitored, Staff A stated that the bed positioning devices were checked under the sections for room in good repair and furniture in good repair. Reference: (WAC) 388-97-1720 (1)(a)(ii)

Based on observation, interview, and record review, the facility failed to ensure medications were properly stored for (Resident 2) and failed to dispose of expired medical supplies for 1 of 1 medication room (Cedar Hallway Medication Room), reviewed for medication storage and labeling. These failures placed the residents at risk of medication errors, receiving compromised medical supplies, possible infections, and adverse consequences. Findings included . Review of the facility's policy titled, Storage of Medications, revised in August 2012, showed that the facility would store all drugs (medications) and biologicals (medical supplies) in a safe, secure, and orderly manner. The policy further showed, the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. RESIDENT 2 Resident 2 admitted to the facility on [DATE] with diagnosis that included Alzheimer's disease (a progressive brain disorder that affects memory, thinking, and behavioral skills). Observation on 04/16/2025 at 12:29 PM, showed Resident 2 in their wheelchair self-propelling themselves through the hallway and picked up something off the ground. Further observation showed that it was a pill, and that Resident 2 handed it to Staff U, Nursing Assistant Certified. In an interview on 04/16/2025 at 12:38 PM, Staff U stated that Resident 12 had handed them a tiny pill and I took it to my supervisor. In an interview on 04/23/2025 at 9:00 AM, Staff G, Licensed Practical Nurse, stated that medications should be stored in the medication cart, and they would not expect there to be loose pills. When asked about medications found on the ground, Staff G stated that there should be no loose pills on the ground or the cart. In an interview on 04/23/2025 at 12:12 PM, Staff B, Director of Nursing Services, stated they expected medications to be stored securely, in bubble packs or containers. Staff B further stated that there should be no loose pills in the medication cart or on the ground. 52133 MEDICATION STORAGE ROOM In a joint observation and interview on 04/21/2025 at 3:00 PM with Staff D, Resident Care Manager, showed that the Medication storage room had the following expired medical supplies: - One box of 100 syringes of Medline (brand name) 3 milliliters (ml- unit of capacity) 25-gauge (G- unit of thickness) x 1 inch (in- unit of length) safety syringes with an expiration date of 08/16/2024. - Three boxes of 40 syringes totaling to 120 syringes of BD (brand name) 60 ml syringe Luer-lock (style of syringe tip) tip with an expiration date of 04/30/2024. Staff D stated, the night shift nurses checked the medication room daily and conducted random audits from nursing and the pharmacy. Staff D stated that expired medications and supplies would then be discarded if found. Staff D further stated that the Medline syringes and BD syringes were expired and should have been discarded. In an interview on 04/23/2025 at 4:19 PM, Staff B stated that they would expect staff to not use expired supplies and discard expired supplies if found. Reference: (WAC) 388-97-1300(2)

Based on interview and record review, the facility failed to accurately assess 3 of 19 residents (Residents 24, 48 & 10), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate assessments regarding weights and constipation (passing fewer than three stools a week or having a difficult time passing stool) 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 1.19.1, dated October 2024, 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. The MDS manual further showed to mark/code medications given to the resident by any route. The Observation Period (also known as the Look-back period) is the time-period over which the resident's condition or status is captured by the MDS and ends at 11:59 PM on the day of the Assessment Reference Date (ARD or assessment period). RESIDENT 24 Review of a quarterly MDS dated [DATE] showed Resident 24's admitted to the facility on [DATE]. Further review of the MDS showed a weight of 168 pounds (lbs. - unit of mass/weight measurement) was entered in Section K (Swallowing/Nutritional Status) under K0200B (resident's weight). Review of the weight record printed on 04/17/2025 showed that Resident 24 weighed 165.8 lbs. on 01/17/2025. In an interview and joint record review on 04/22/2025 at 2:17 PM with Staff F, Registered Dietician, stated they follow the RAI manual for completion of MDSs. Staff F stated they used the most current resident's weight during the look back period to code for it in Section K. A joint record review of Resident 24's quarterly MDS dated [DATE] showed a weight of 168 lbs. A joint record review of Resident 24's weight record showed a weight of 165.8 lbs. on 01/17/2025. Staff F stated that the most current weight of 165.8 [rounded to 166] lbs. on 01/17/2025 should have been entered in Resident 24's MDS and that the MDS was coded inaccurately. In an interview on 04/23/2025 at 3:10 PM, Staff B, Director of Nursing Services, stated they expected MDSs to be completed fully, on time, submitted on time, and be accurate. Staff B further stated they expected Resident 24's MDS to be accurate. 52331 RESIDENT 10 Review of Resident 10's quarterly MDS dated [DATE] showed 123 lbs. was entered in Section K0200B. Review of the February 2025 weight record printed on 04/21/2025, showed Resident 10's weight was 122 lbs. on 02/03/2025. A joint record review and interview on 04/22/2025 at 1:06 PM with Staff E, MDS Coordinator, showed Resident 10's quarterly MDS dated [DATE] was coded 123 lbs. in Section K0200B. A joint record review of February 2025 weight record showed Resident 10's weight was 122 lbs. on 02/03/2025. Staff E stated that Staff F was responsible for Section K0200B and that Resident 10's MDS was inaccurate. In an interview on 04/22/2025 at 2:16 PM, Staff F stated Resident 10's MDS dated [DATE] was inaccurate and that the weight of 122 lbs. should have been entered in Resident 10's quarterly MDS. In an interview on 04/23/2025 at 4:19 PM, Staff B stated they expected MDSs to be completed accurately. 46912 RESIDENT 48 Review of the RAI Version 3.0 manual, dated October 2024, showed that constipation was defined as If the resident has two or fewer bowel movements during the 7-day look-back period. Review of the significant change in status MDS assessment dated [DATE], did not show constipation was marked for Resident 48 in Section H (Bladder and Bowel) under H0600 (constipation). Review of the undated daily charting [bowel functions] from 03/29/2025 through 04/04/2025 showed Resident 48 had two bowel movements in the 7-day look-back period. In an interview and joint record review on 04/22/2025 at 1:06 PM, Staff E stated their process for coding for constipation was to look at bowel records and only code for hard stools. A joint record review of the RAI manual showed that constipation was defined as, If the resident has two or fewer bowel movements during the 7-day look-back period. And a joint record review of the daily charting from 03/29/2025 through 04/04/2025, showed Resident 48 had two bowel movements in the 7-day look-back period. Staff E stated, it should have been coded for constipation, and it was not. In an interview on 04/23/2025 at 12:12 PM, Staff B stated they expected the MDS assessment to be completed accurately. Reference: (WAC) 388-97-1000 (1)(b)

Based on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR- an assessment used to identify residents 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 3 of 6 residents (Residents 10, 53 & 32), reviewed for PASARRs. This failure placed the residents at risk for not receiving the care and services appropriate for their needs. Findings included . Review of the facility's policy titled, Preadmission Screening and Resident Review, revised in October 2017, showed, Social Services or Designee shall review all Level I screening forms for accuracy. If at any time the Facility finds that the previous Level I screening was incomplete, erroneous, or no longer accurate, the facility shall immediately complete a new screening using Level I form. If the corrected Level I screening identifies a possible serious mental illness or intellectual disability or related condition, Social Services or designee shall notify Developmental Disability Administration (DDA) and/or the mental health PASRR evaluator so that a Level II evaluation can be conducted. RESIDENT 10 Review of the face sheet printed on 04/17/2025 showed Resident 10 admitted to the facility on [DATE] with diagnoses that included major depressive disorder (depression - a mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety disorder (intense and excessive feelings of worry, nervousness, or fear). Review of Resident 10's Level I PASARR dated 04/29/2024, showed Section IA (SMI) was marked for mood disorder depression and anxiety disorder. Further review showed that Section IV (4- Service Needs and Assessor Data) was marked for No level II evaluation indicated. RESIDENT 53 Review of the face sheet printed on 04/17/2025 showed Resident 53 admitted to the facility on [DATE] with diagnosis that included depression. Review of Resident 53's Level I PASARR dated 02/17/2025, showed Section IA (SMI) was marked for no SMI. Further review showed that Section IV was marked for No level II evaluation indicated. In an interview and joint record review on 04/23/2025 at 11:33 AM, Staff I, Social Services Associate, stated they reviewed Level I PASARRs for accuracy, and that if any diagnoses listed in the SMI section of the PASARR were marked, PASARRs needed to be sent to the PASARR office for a Level II evaluation. A joint record review of Resident 10's Level I PASARR dated 04/29/2024 showed that Section IA was marked for depression and anxiety disorder. Further review of Resident 10's Level I PASARR showed in Section IV, it was marked for No level II evaluation indicated. When asked if it was accurate, Staff I stated it was not accurate and that they should have sent a Level II referral to the PASARR coordinator for Resident 10. A joint record review of Resident 53's face sheet printed on 04/17/2025 showed a diagnosis for depression. Review of Resident 53's Level I PASARR dated 02/17/2025 showed that depression was not marked in Section IA, and No level II evaluation indicated. Staff I stated Resident 53's Level I PASARR was not accurate, depression should have been marked, and they should have sent a Level II referral to the PASARR coordinator. In an interview on 04/23/2025 at 4:19 PM, Staff B, Director of Nursing Services, stated that they expected PASARR forms to be completed accurately and that Level II PASARR referral would be sent to the PASARR coordinator if residents had a SMI diagnosis. In an interview on 04/23/2025 at 5:15 PM, Staff A, Administrator, stated that they expected Social Services would follow the PASARR policy and send out Level II PASARR referrals if required. 47218 RESIDENT 32 Review of the face sheet printed on 04/17/2025 showed Resident 32 had a diagnosis of anxiety. Review of Resident 32's Level I PASARR dated 03/19/2025 showed anxiety was marked in Section IA. Further review of the Level I PASARR showed that referral for Level II evaluation was not marked. A joint record review and interview on 04/23/2025 at 11:33 AM with Staff I, showed that Resident 32's PASARR dated 03/19/2025 had anxiety marked in the SMI section and no referral for Level II was marked. Staff I stated that Resident 32 had diagnosis of anxiety and that their PASARR should have been marked for Level II evaluation referral. Staff I further stated that Resident 32's Level I PASARR should have been sent to the PASARR coordinator for a Level II evaluation. In an interview on 04/23/2025 at 4:06 PM, Staff A, Administrator, stated they expected staff to follow the facility's PASARR policy. Reference: (WAC) 388-97-1975(1)

Based on interview and record review, the facility failed to ensure resident-centered care and treatment were provided in accordance with professional standards of practice when facility staff failed to do skin care evaluations for 1 of 4 residents (Resident 12), reviewed for skin conditions. This failure placed the resident at risk for unmet care needs and a diminished quality of care. Findings included . Review of the facility's undated policy titled, Skin Observation, showed, Early recognition of skin break down is key to the overall management and resolving of the skin issue. It is imperative and stressed that skin assessments be completed as scheduled. It further showed that The Licensed Nurse is expected to perform a full body skin audit weekly per facility protocol. Review of the facility's undated policy titled, Comprehensive Care Plan, showed, The comprehensive care plan will describe, at a minimum .the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Review of Resident 12's Skin Conditions care plan, revised on 11/13/2024, showed that Resident 12 has fragile skin, prone to bruising and/or skin tears. It further showed the intervention for weekly skin checks, document results. Review of the March 2025 Treatment Administration Record (TAR) showed Resident 12 had an order for Weekly skin check that started on 01/26/2023. It further showed on 03/29/2025 that a skin check was not done because Resident 12 was sleeping. Review of the April 2025 TAR showed Resident 12 had an order for Weekly skin check that started on 01/26/2023. It further showed on 04/12/2025 that a skin check was not done because Resident 12 was sleeping. In an interview and joint record review on 04/18/2025 at 10:15 AM, Staff V, Registered Nurse, stated that they follow the care plan when caring for residents. Joint record review of Resident 12's Skin Conditions care plan, showed to perform weekly skin checks. Further joint record review of Resident 12's March 2025 and April 2025 TARs showed no documentation that skin checks were performed on 03/29/2025 and on 04/12/2025. Staff V stated that there should have been weekly skin checks. In an interview and joint record review on 04/18/2025 at 11:32 AM, Staff D, Resident Care Manager, stated that every resident was on weekly skin checks. A joint record review of the March 2025 and April 2025 TARs showed Resident 12 had no documentation that skin checks were performed on 03/29/2025 and 04/12/2025. Staff D stated that the nurse stated that the resident was sleeping and that the nurse needs education. They need to be choosing the appropriate options. Staff D stated that the expectation was that skin checks should be done weekly. In a follow up interview on 04/23/2025 at 11:04 AM, Staff D stated that they expected the care plan to be followed as guidance. In an interview and joint record review on 04/23/2025 at 12:12 PM, Staff B, Director of Nursing, stated that they expected care plans to be followed and if it says to do weekly skin checks, I expect weekly skin checks. A joint record review of the March 2025 and April 2025 TARs showed Resident 12 had no documentation that skin checks were performed on 03/29/2025 and 04/12/2025. Staff B stated it had been documented that the resident was sleeping and they [the nurse] should have come and tried again or should have told the next shift. Reference: (WAC) 388-97-1060 (1)(3)(b)

Based on observation, interview and record review, the facility failed to monitor significant weight loss for 1 of 2 residents (Resident 53), reviewed for nutrition/hydration. This failure placed the residents at risks for nutrition-related complications, and a diminished quality of life. Findings included . Review of the facility's policy titled, Weight Loss/Gain, Unintentional, revised in February 2024, showed, The Registered Dietitian [RD] will be notified of any weight change equal to or greater than 4% over 1 month or 8% over 6 [six] months. The policy further showed, the resident's attending provider [medical doctor or physician assistant], family/DPOA [Durable Power of Attorney] as well as any other appropriate clinicians will be notified with unanticipated significant weight changes. Resident 53 was admitted to the facility on [DATE] with diagnosis that included dementia (a progressive condition that affects the brain). Review of nutrition care plan dated 02/17/2025, showed Resident 53 was at risk for altered nutritional status and/or weight loss. The nutrition care plan further showed that staff would offer a nutritional supplement if Resident 53 ate less than 50% of a meal. Review of the nutrition care plan dated 02/19/2025 showed that Resident 53 was at Risk for inadequate nutritional intake related to poor appetite, often about 25% of meals, with a goal of no unplanned and unpreventable weight loss, through the next quarterly review. The care plan interventions showed that the RD would monitor weights, oral intake and would initiate trial oral nutrition supplements as needed. Review of the nursing progress note dated 02/25/2025, showed Staff F, RD, documented that Resident 53 was seen/reviewed for nutrition and new onset of poor oral intake. The progress notes further showed Resident 53 weighed 133.3 pounds (lbs. - unit of mass/weight measurement). Staff F noted nutrition interventions/recommendations to add Boost (brand name) High Protein supplement 120 milliliters (ml - unit of volume measurement), assistance at mealtimes and encourage oral intake, and weighed weekly as able. The progress notes further showed the nutritional goal was for oral intake to meet or exceed 50% of meals, to not have unintentional/unpreventable weight loss, and that Staff F would monitor monthly or as needed. Review of the admission Minimum Data Set (an assessment tool) dated 02/24/2025, showed Resident 53 required partial/moderate assistance with eating and had a weight of 133 lbs. Review of Resident 53's weight report printed on 04/17/2025, showed the following: -On 02/18/2025 - 133.4 lbs. -On 03/24/2025 - 118.8 lbs. -On 04/14/2025 -115.8 lbs. Resident 53 had a significant weight loss of 12.93 % from 02/18/2025 to 04/14/2025, in less than two months. During multiple observations on 04/17/2025 at 9:05 AM, on 04/18/2025 at 9:17 AM, and on 04/22/2025 at 12:54 PM, Resident 53's food tray had less than 25% of meal consumed. In an interview and joint record review on 04/22/2025 at 2:46 PM, Staff H, Registered Nurse, stated they checked the weight tracker in Matrix (the program for electronic health record) for weight loss. Staff H further stated that they would reweigh to make sure the weight was accurate, checked if the resident was eating, and then would notify the provider, Staff F, and/or speech therapy [or Speech Language Pathologist-experts in communication and treats various swallowing problems]. Staff H stated then they would make a progress note. A joint record review of the weight record showed Resident 53 had a significant weight loss on 03/24/2025 and 04/14/2025 with no documentation that the provider, Staff F, and/or SLP were notified. In an interview and joint record review on 04/22/2025 at 2:55 PM, Staff F stated that they assessed all residents upon admit, quarterly, monthly for high-risk residents, and as needed. Staff F further stated the facility would notify them of residents' weight loss either in person, by email, or during the monthly nutrition at risk meeting. Staff F stated they would communicate with the provider either in person or by email if there was significant weight loss. A joint record review of the weight records and progress notes showed that Resident 53 had a significant weight loss on 03/24/2025 and 04/14/2025 and there was no documentation that the provider and/or Staff F were notified. Staff F stated they were not notified and were unaware of Resident 53's weight loss and that they missed Resident 53's weight loss on 03/24/2025. In an interview and joint record review on 04/24/2025 at 3:16 PM, Staff D, Resident Care Manager, stated that if a resident had a significant weight loss, the nursing staff would reweigh and weigh again the next day to ensure accuracy of weight. Staff D stated that if the weight was accurate, they would notify the provider and Staff F of the weight loss. A joint record review showed that Resident 53 had significant weight loss on 03/24/2025 and 04/14/2025 with no documentation that the provider or Staff F were notified. Staff D stated there should be communication to Staff F and the provider if there was weight loss. In an interview on 04/24/2025 at 4:19 PM, Staff B, Director of Nursing Services, stated they expected the nursing staff to notify the provider and Staff F if weight loss was discovered. Reference: (WAC) 388-97-1060(3)(h)

Based on interview and record review, the facility failed to ensure adequate monitoring of adverse side effects and parameters (when to notify the provider or hold the medication) for insulin (medication/hormone that regulates blood sugar levels) were conducted for 1 of 5 residents (Resident 36), reviewed for unnecessary medications. This failure placed the resident at risk for unmet care needs, related complications, and a diminished quality of life. Findings included . Review of the facility's policy titled, High Risk Medications, revised in 2025, showed that the facility recognized that some medications were associated with greater risks of adverse consequences than other medications and that high-risk medications included medications that treat diabetes (high levels of sugar in the blood). The policy further showed that the facility would obtain and document specific parameters for administration or withholding certain high-risk medications such as insulin as per the physician's or practitioner's orders. MONITORING FOR ADVERSE SIDE EFFECTS Review of Resident 36's April 2025 Medication Administration Record (MAR) printed on 04/17/2025, showed orders for insulin Glargine (brand name insulin) to administer 20 units (unit of measurement) subcutaneously (under the skin) once a day at 7:00 AM and another order for Humalog (brand name insulin) to administer 10 units subcutaneously twice a day at 11:00 AM and 5:00 PM. Further review of the MAR did not show Resident 36 was being monitored for hypoglycemia (blood sugar level is lower than the standard range) and/or hyperglycemia (blood sugar level is higher than the standard range). Review of the April 2025 Treatment Administration Record (TAR) printed on 04/17/2025, did not show Resident 36 was being monitored for hypoglycemia and/or hyperglycemia. Review of Resident 36's care plan dated 12/24/2024 showed interventions to Monitor for sx [symptoms] of hypoglycemia: Rapid onset- Skin pale, cold, clammy, sweaty, confusion, anxious [state of worry, unease, or nervousness] or nervous behavior, personality changes, weak fine tremors, hunger, headaches, dizziness, vision changes, shallow breathing, rapid strong pulse, seizures [abnormal electrical activity in the brain]/coma [prolonged loss of consciousness], low blood sugar, staggering gait. Treat per orders and notify MD [medical doctor or provider] for continued care after stabilization . Monitor for s/sx [signs/symptoms] of hyperglycemia slow onset - Skin hot, dry, face flushed, fruity odor to breath, dehydration [when there is not enough fluid in the body], weak rapid pulse, deep labored breathing, drowsiness, lethargy, nausea, vomiting, thirst, irritable, polyuria [urinating more than normal], low blood pressure, high blood sugar. Treat per orders and notify MD for continued care after stabilization. In an interview and joint record review on 04/23/2025 at 11:11 AM, Staff G, Licensed Practical Nurse, stated that residents who got medications for diabetes or insulin should have had an order for monitoring for hypoglycemia and hyperglycemia that would show up in the MAR or TAR for the nurses to document. A joint record review of Resident 36's April 2025 MAR and TAR did not show an order for monitoring signs and symptoms of hypoglycemia and hyperglycemia. Staff G stated that they did not see an order in Resident 36's MAR and TAR to monitor hyperglycemia and hypoglycemia, and that there should have been. In another interview on 04/23/2025 at 11:20 AM, Staff G stated that Resident 36 had a care plan that indicated monitoring for signs and symptoms of hypoglycemia and hyperglycemia. When asked staff if there was adequate ongoing documentation to show that Resident 36's was being monitored for hypoglycemia and hyperglycemia, Staff G stated, No, there is none. In an interview and joint record review on 04/23/2025 at 2:32 PM, Staff D, Resident Care Manager, stated they expected residents receiving insulin to be monitored for hypoglycemia and hyperglycemia. A joint record review of April 2025 MAR and TAR did not show Resident 36 was being monitored for insulin use. Staff D stated they did not see Resident 36 was monitored for hyperglycemia/hypoglycemia and that they should have been. PARAMETERS FOR INSULIN USE Review of Resident 36's April 2025 MAR printed on 04/17/2025, showed orders for insulin Glargine to administer 20 units subcutaneously every morning at 7:00 AM. Further review of the insulin order did not show parameters for when to hold the medication and/or to notify the provider. In an interview and joint record review on 04/23/2025 at 2:39 PM, Staff D stated they expected to see parameters for residents receiving insulin for when to hold the medication and/or to notify the provider. A joint record review showed Resident 36's April 2025 MAR had orders for insulin Glargine without parameters. Staff D stated that Resident 36's insulin Glargine order did not have parameters to hold it and/or to notify the provider if the blood sugar showed certain numbers [too low and too high blood sugar levels]. Staff D further stated that Resident 36's insulin order for Glargine should have had parameters for when to hold it and/or notify the provider. In an interview on 04/23/2025 at 3:19 PM, Staff B, Director of Nursing Services, stated they expected residents who were getting insulin to be monitored for signs and symptoms of hypoglycemia and hyperglycemia. Staff B stated Resident 36's orders to monitor signs and symptoms for hypoglycemia and hyperglycemia and should have started it when Resident 36 readmitted to the facility on [DATE], Staff B further stated they should have had parameters for insulin use. Reference: (WAC) 388-97-1060 (3)(k)(i)(4)

Based on interview and record review, the facility failed to ensure adequate monitoring was in place for psychotropic (mind altering) medications for 1 of 5 residents (Resident 18), reviewed for unnecessary medications. This failure placed the resident at risk for unnecessary medications, adverse side effects, and a diminished quality of life. Findings included . Review of the facility's policy titled, Psychotropic Medication Use, revised in 2025, showed, with the use of psychotropics, each resident will be monitored for medication effectiveness and side effects/adverse consequences. Resident 18 was admitted to the facility on [DATE] with multiple diagnoses that included dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) with psychosis (mental disorder caused by abnormal thinking and perception) and anxiety (intense and excessive feelings of worry, nervousness, or fear). Review of Resident 18's April 2025 Medication Administration Record (MAR) showed an order for Seroquel (an antipsychotic-medication that treats psychosis) 25miligrams (mg- a unit of measurement) by mouth three times a day for dementia with psychosis that started on 12/05/2024 and was administered to Resident 18 from 04/01/2025 through 04/18/2025 three times a day. Further review of the MAR did not show documentation that Resident 18 was being monitored for adverse side effects of the antipsychotic medication. Review of Resident 18's April 2025 MAR showed orders for Lorazepam (medication for anxiety) 0.5 mg by mouth every day that started on 04/10/2025 and was administered to Resident 18 from 04/10/2025 through 04/18/2025 and was discontinued on 04/18/2025. The MAR further showed a new order for Lorazepam 0.5 mg by mouth every six hours for anxiety that started on 04/18/2025 and was administered to Resident 18 from 04/19/2025 through 04/21/2025. Further review of the MAR did not show documentation that Resident 18 was being monitored for adverse side effects of the antianxiety medication. Review of Resident 18's April 2025 Treatment Administration Record (TAR) showed no documentation that Resident 18 was being monitored for adverse side effects for antipsychotic and/or antianxiety medications. In an interview and joint record review on 04/22/2025 at 2:30 PM, Staff H, Registered Nurse, stated that when psychotropic medications were given to the residents they would monitor for adverse side effects and would document on the MAR, TAR, or in the nursing progress note. Joint record review of the April 2025 MAR/TAR, and progress notes did not show Resident 18 was being adequately monitored for adverse side effects for their antipsychotic and/or antianxiety medications. In an interview and joint record review on 04/23/2025 at 2:14 PM, Staff D, Resident Care Manager, stated that they expected staff to monitor the residents on psychotropic medications for adverse side effects and to document on the resident's MAR or TAR. Joint record review of April 2025 MAR and TAR did not show Resident 18 was being adequately monitored for adverse side effects for their antipsychotic and/or antianxiety medications. Staff D further stated that there should have been documentation for monitoring Resident 18's adverse side effects for their antipsychotic and/or antianxiety medications. In an interview on 04/23/2025 at 4:19 PM, Staff B, Direct of Nursing Services, stated they would expect the nurses to monitor for adverse side effects when a resident was receiving antipsychotic or antianxiety medications. Reference: (WAC) 388-97-1060 (3)(k)(i)(4) .

Based on interview and record review, the facility failed to ensure a resident received education regarding the potential risks and benefits when offering influenza vaccine (used to prevent influenza [an infection of the nose, throat, and lungs]) for 1 of 5 residents (Resident 10), reviewed for immunizations. This failure placed the resident and/or their representative at risk of not being fully informed of the risks and benefits before making decisions about their influenza immunization. Findings included . Review of the facility's policy titled, IC [Infection Control]-Influenza Vaccine, revised in January 2023, showed that Prior to the vaccination [influenza vaccine], the resident (or resident's legal representative) or employee will be provided information and education regarding the benefits and potential side effects of the influenza vaccine. It further showed, Provision of such education shall be documented in the resident's .medical record, as applicable. Review of a nursing progress note dated 11/04/2024, showed Resident [Resident 10] received her flu [Influenza] shot per resident's direction on 11/04/2024. Review of Resident 10's clinical record (electronic health record and paper record) showed no documentation that Resident 10 and/or their representative was provided risks and benefits of the influenza vaccine. In an interview on 04/22/2024 at 10:24 AM, Staff C, Infection Preventionist, stated that they provided risks and benefits for vaccinations prior to giving vaccinations to residents. Staff C stated that we have a VIS [Vaccine Information Statement] that we give them. When asked if Resident 10 was provided risks and benefits for their influenza vaccination given on 11/04/2024, Staff C stated I can't find it. It must have been lost. In an interview on 04/23/2024 at 12:12 PM, Staff B, Director of Nursing, stated that they expected the influenza vaccine to be offered to all residents, annually during flu season. Staff B further stated that they expected risks and benefits to be provided to residents prior to receiving the influenza vaccine and it should be documented either on paper or in a note. Reference: (WAC) 388-97-1340 (2)

Based on observation, interview, and record review, the facility failed to provide adequate supervision for 1 of 1 resident (Resident 1), and failed to accurately assess, identify and/or monitor residents at risk of elopement for 5 of 6 residents (Residents 1, 5, 2, 3 & 4), reviewed for accident hazards. Resident 1 experienced harm when they exited the facility unsupervised, was subsequently found by a bystander outside the facility lying on the ground and sustained a significant injury requiring a hospital admission. This failed practice placed the residents at risk for elopement, falls, and injury. Findings included . Review of the facility's policy titled, Elopement and Wandering, Risk of, revised in February 2020, showed, It is the policy of the [Facility name] to ensure that residents who exhibit wandering behavior and/or are at risk of elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. The policy showed, The facility is equipped with door locks/alarms to help avoid elopements. It showed, The facility shall establish and utilize a systemic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. The policy further showed residents would be assessed for risk of elopement and unsafe wandering upon admission, quarterly, as needed, and adequate supervision will be provided to help prevent accidents or elopements. Review of the facility's policy titled, Incidents and Accidents- [Facility name], reviewed on 04/08/2025, showed, It is the policy of this facility for staff to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident. The policy further showed, The purpose of incident reporting can include: Assuring that appropriate and immediate interventions are implemented and corrective actions are taken to prevent recurrences and improve the management of resident care. Review of the facility's policy titled, Elopement/Missing Person, revised in February 2016, showed, Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the License Nurse, Social worker, Assistant DON [or DNS-Director of Nursing] and or Director of Nursing. The policy further showed, When a departing individual returns to the facility, the Director of Nursing Services or designee shall: . n. Ensure Elopement Book is current. ELOPEMENT THAT RESULTED IN A FRACTURE RESIDENT 1 Review of Resident 1's undated face sheet showed they admitted to the facility on [DATE] with diagnoses that included the following: -adjustment disorder with depressed mood (characterized by feelings of sadness, hopelessness, and a lack of enjoyment), -primary insomnia (sleep disorder characterized by difficulty falling asleep, staying asleep, or experiencing poor sleep quality), -depression (serious mood disorder of persistent sadness that affects how you feel, think, and behave), -unspecified moderate dementia (memory loss) with mood disturbance (significant cognitive impairment impacting ability to perform basic daily activities with changes in emotional state), -repeated falls, -anxiety disorder (feelings of excessive worry, fear, and other physical and behavioral symptoms that interfere with daily life) and -unsteadiness on feet. Review of Resident 1's Elopement Risk Evaluation dated 12/23/2024, showed the resident scored a 10 indicating that they were at risk of elopement. The elopement risk evaluation form further showed the CLINICAL AREA [#] 7. Diseases (dementia, any type of mental illness), were blank (if the resident had 2 or more present diagnoses an additional 4 points would have been added to the score). Review of Resident 1's Falls Risk Evaluation dated 12/23/2024, showed the resident scored a 13 indicating that they were a high risk for falls. An additional Falls Risk Evaluation dated 03/05/2024, showed the resident scored a 13 indicating that they were at a high risk for falls. Review of Resident 1's comprehensive care plan printed on 04/07/2025 (at 12:09 PM) showed no [at risk for] elopement care plan. Review of Resident 1's falls care plan printed on 04/07/2025 (at 12:09 PM) showed Resident 1 was at risk for falls due to history of falls, generalized weakness, and dementia with poor safety awareness and impulsiveness. Review of Resident 1's nursing progress note event dated 03/30/2025, showed Resident was awake and alert throughout shift. She was wheeling around the unit and was found by NAC [Nursing Assistant Certified] near mailboxes outside of [the] [Facility Name] Hallways. Resident was redirected to her room and told to remain on unit for her safety. Note made to further discuss wanderguard [a system in which a resident at risk for elopement/wanderer wears a bracelet, sensors that monitor doors, and alarm in real time] with RCM [Resident Care Manager] as resident has a [sic] Hx [history] of exploring. Review of Resident 1's nursing progress note event dated 03/31/2025, showed Resident awake the entire [sic] [NOC-night] shift, was up in wheelchair, self-propelling constantly in the unit due to [sic] complaint of insomnia, no exit seeking noted [signed at 7:43 AM by Staff J, Registered Nurse (RN)]. Review of Resident 1's nursing progress note event dated 03/31/2025, showed Resident was wandering unit in WC [wheelchair] throughout entire [evening] shift. Continuously had to be redirected away from doors and taken out of rooms of other residents. Wanderguard for her safety to be further discussed with RCM and DPOA [Durable Power of Attorney] [signed on 04/01/2025 at 1:04 AM by Staff D, RN]. Review of Resident 1's nursing progress note event dated 04/01/2025, showed at 10:40 PM, a [unknown] staff member had requested an Uber ride. The note showed, The Uber driver informed the security guard [about a resident [Resident 1] on the ground], who subsequently called 911. It showed that a staff member informed the nurse that Resident 1 had fallen outside of the facility. The note further showed that staff found Resident 1 on the curbside concrete, having tipped over in a wheelchair with the right side rail removed. Right arm and wrist bleeding were observed. The [City] Fire Department Medic was already present to transport the individual [resident] to the emergency room for further evaluation. Review of Resident 1's Hospital emergency room note dated 04/01/2025 (at 11:29 PM) showed, a Bystander found patient [the resident] down outside the facility and called 911. Patient is confused, oriented to self only and states she was out driving tonight. Staff came out once aid car arrived and identified the patient as their resident. Review of Resident 1's Hospital Discharge Summary dated 04/07/2025 showed Resident 1's discharge diagnosis included an unwitnessed ground-level fall, right elbow fracture (broken bone), and moderate dementia. It further showed Resident 1 was found to have an elbow laceration [cut] with an olecranon [bony tip of the elbow] fracture, as well as volume depletion [reduction in fluid or dehydration] with mildly elevated CK [Creatine Kinase-may indicate recent muscle trauma or strenuous exercise]. Observation and interview on 04/07/2025 at 2:24 PM, showed Resident 1 was lying in bed with a bandage around their right arm/elbow area and a wanderguard to their left wrist. Resident 1 stated they fell and broke an elbow. Observation on 04/08/2025 at 2:20 PM, showed an unknown [therapy] staff was working with Resident 1. Resident 1 stated, I think I want to travel a little bit further and see what's going on at the big house. Staff advised resident to stay in their room as they were on precautions. Observation on 04/11/2025 at 1:52 PM, showed Resident 1 was self-propelling in their wheelchair down the hallway. On 04/07/2025 at 12:25 PM, Staff G, NAC, stated that Resident 1 was able to propel themselves in their wheelchair and that Resident 1 did a lot of things on her own, and would refuse assistance from staff at times. On 04/07/2025 at 1:09 PM, Staff E, Licensed Practical Nurse (LPN), stated Resident 1 had somehow got outside, and fell from their wheelchair and had a fracture. Staff E stated that Resident 1 wandered and self-propelled themselves in their wheelchair but had not witnessed them exit seeking. In an interview and joint record review on 04/07/2025 at 3:15 PM, Staff A, DNS, stated residents were assessed for risk of elopement upon admission using their Elopement Risk Evaluation. Staff A stated that if a resident was at risk for elopement, they would expect the resident to be identified in their Elopement/Wander Risk Book and in their care plan. Joint record review of Resident 1's Elopement Risk Evaluation dated 12/23/2024, showed Resident 1 scored a 10, Staff A stated that according to their assessment Resident 1 was at risk for elopement and the intervention that was put in place was diversion-distraction. Staff A stated that Resident 1 was able to propel themselves in their wheelchair. Staff A stated that on 03/31/2025 Resident 1 exited the Center/facility into a common and safe area that was not considered a part of their Center. Staff A stated that there was access to exit doors where Resident 1 had been found, and that they would say the area was safe but, the fact that it does have exit doors is a concern. Staff A further stated that they were not personally informed that Resident 1 had left the Center on 03/31/2025, or that they possibly needed a wanderguard. Staff A stated that on 04/01/2025, Resident 1 had a fall and was on neuro checks. Staff A stated that later that day at 10:40 PM, a staff member had called for an Uber ride, and that when they arrived the Uber driver informed them that someone had fallen and that they informed the guardhouse. Staff A stated that the staff member went back into the facility to let the nurse know that Resident 1 had fallen off the sidewalk out of their wheelchair and landed on their right side. A joint observation and interview on 04/07/2025 at 3:48 PM, Staff A showed a metal door at the end of Cedar Hallway that was not locked/alarmed. Staff A stated that Resident 1 took this route to go outside of the facility when they eloped on 04/01/2025. Staff A stated that this door was alarmed with residents who used a wanderguard. In another interview on 04/07/2025 at 3:57 PM, Staff A stated that when Resident 1 eloped and fell on [DATE], it was an avoidable accident. When asked if Resident 1 obtained any harm from the elopement incident on 04/01/2025, Staff A stated, she fell and broke her arm. Staff A stated that Staff D could have verbally informed management when Resident 1 had left the Center on 03/31/2025 and was found near the mailboxes and they could have put another intervention in place. Staff A stated that they had not reviewed the progress notes for Resident 1, and that their expectation was for progress notes to be reviewed daily in their clinical meeting. Staff A stated that they could have increased supervision, highly considered to have a wanderguard, or done 15 or 30 minute checks, and did not need consent for these frequent checks. Staff A further stated they would have expected these frequent checks to be in place following Resident 1 exiting the Center on 03/31/2025. On 04/07/2025 at 4:13 PM, Staff D stated that they worked with Resident 1 on evening shift on 03/30/2025 and 03/31/2025. Staff D stated that on 03/30/2025, Resident 1 was just wheeling around, and that on 03/31/2025 Resident 1 was found near the mailboxes outside of the Center by staff and she was brought back. Staff D stated that Resident 1 should not have been left unsupervised as she was at risk for elopement. Staff D stated that further down the hall near the mailboxes where Resident 1 was found, there was the main entrance with access to exit doors. Staff D stated that they stopped Resident 1 on multiple occasions as they opened doors and redirected them in the Center. Staff D stated that it was very clear that Resident 1 was going to all the doors. Staff D stated that it was getting to a point to where she was going to exit the facility, and that it became much more apparent, more than likely it was going to happen. Staff D stated that they documented Resident 1's behavior and what had occurred on 03/31/2025 in the progress notes and reported it during shift report with other staff. Staff D stated that they talked with Staff C, RCM, LPN, who told them to report it to Staff B, Charge Nurse. Staff D further stated that they sent Staff B an email informing them about Resident 1's attempts to exit seek and consideration for a wanderguard. Review of an email notification dated 04/01/2025 (1:16 AM) showed, Staff D sent an email to Staff B, Staff D stated, I wanted to bring up the potential of getting [Resident 1] a Wanderguard. She has been wandering the unit, entering peoples' rooms, and found by an NAC out by the mailboxes near the concierge. She constantly needs redirection away from the doors throughout the shift and can be difficult to persuade/not always listening when asked to return. I caught her twice today trying to open the Cedar entrance door and once trying to go through the 2 main doors that lead toward the kitchen/laundry exit from Cedar. She agreed to sit in her WC at the entrance just holding the door open, but it took much more convincing to get her to completely leave it alone. In a joint record review and interview on 04/08/2025 at 3:14 PM with Staff K, IT Technician, showed a Delivery Report for Staff D's email sent to Staff B on 04/01/2025 at 1:15 AM. The report further showed, The message was successfully delivered. Staff K stated, What I can tell from this is that the email was successfully delivered on 04/01/2025 at 1:15 AM. If it was placed into a folder that the recipient normally doesn't check like a junk folder, then it could be missed, but in the system it shouldn't have been placed in a different folder because it was sent internally [within the same system]. On 04/07/2025 at 4:51 PM, Staff B stated that they had been made aware by Resident 1's Representative that Resident 1 had got out the front and had gone to the hospital. Staff B stated that Resident 1 was unsupervised and found outside of the facility (on 04/01/2025). When asked if Resident 1 had obtained any harm from this incident, Staff B stated, she fractured her elbow. Staff B stated that Resident 1 should not have been left alone or unsupervised outside of the facility. Staff B stated that it was their expectation to review notes as regularly as possible, but did not take documentation in the progress notes as notification. Staff B stated that they did not review the progress notes documented by Staff D until after Resident 1's elopement on 04/01/2025. Staff B stated they did not receive an email from Staff D informing them of Resident 1's attempt to exit or consider for a wanderguard. Staff B further stated, I do think it [elopement incident that occurred on 04/01/2025] was avoidable. On 04/08/2025 at 2:02 PM, Staff C, stated that on the other side of the metal door on Cedar Hallway, it was considered independent living, but sometimes residents of the Center would dine or visit there. Staff C stated that if a resident was at risk for elopement or a high fall risk they should not be left unsupervised and should be accompanied outside of those doors. Staff C stated that they review progress notes with the Charge Nurse, DON, MDS [Minimum Data Set-an assessment tool] Coordinator, and sometimes the Administrator. Staff C stated, I think something happened that we didn't meet, and that this [review of progress notes for Resident 1's [wandering/exit-seeking] behavior on 03/30/2025 to 03/31/2025] didn't get discussed in detail, or we would have caught that. Staff C stated that they were doing something and were interrupted on 03/31/2025 when Staff D came in to report Resident 1's behavior. Staff C stated that they did not have a good recollection of the conversation, but they did know they, passed her [Staff D] off to the appropriate care manager. In a follow up interview and joint record review on 04/08/2025 at 3:13 PM with Staff B, stated they expected elopement assessments to be completed and accurate. Joint record review of Resident 1's face sheet printed on 12/23/2024 showed diagnoses that included adjustment disorder with depressed mood, depression, unspecified moderate dementia with mood disturbance and anxiety disorder. Joint record review of Resident 1's Elopement Risk Evaluation dated 12/23/2024, showed clinical area 7. was blank. Staff B stated that the intent was to go back [to complete the evaluation] once all of the diagnoses were entered, but that the appropriate box should have been checked based on the hospital discharge summary. Staff B further stated that Resident 1's elopement score would have increased to 14 based on their diagnoses. Joint record review of Resident 1's Falls Risk Evaluation dated 12/23/2024, showed Resident 1 was a high fall risk. Staff B further stated Resident 1 who was a high fall risk should not have been outside of the Center unsupervised. In a phone interview on 04/11/2025 at 1:56 PM, Staff F, NAC, stated that on 04/01/2025 they finished their evening shift around 10:40 PM, and ordered an Uber ride. Staff F stated that the Uber driver informed them that they had notified the security that there was a lady on the ground, and that they thought they needed help. Staff F stated that they saw Resident 1 laying on the ground with their wheelchair laying sideways and bleeding from her elbow. Staff F stated they quickly went inside the facility to inform the nurse and by the time they went back outside 911 had already arrived. Staff F further stated Resident 1 was always looking for an exit and that most of the time they were in their wheelchair going around the facility. Staff F stated that the metal door at the end of Cedar Hallway did not alarm, unless the resident had a wanderguard and that Resident 1 did not have a wanderguard at the time. Staff F further stated Resident 1 should not have been unsupervised outside of the Center. In a joint record review and interview on 04/11/2025 at 3:55 PM, with Staff A, showed Resident 1's Elopement Risk Evaluation dated 12/23/2024. Staff A stated, she would have at least scored a 4 for question 7, and that it would have increased Resident 1's elopement score to a 14. In another interview and joint record review on 04/11/2025 at 4:10 PM, Staff A stated that Resident 1's fall risk score was a 13 indicating that they were a high fall risk. Staff A stated that Resident 1 had a history of falls. Staff A stated that Resident 1 was at risk of elopement and a high fall risk and should not have been unsupervised when they eloped on 04/01/2025. Staff A further stated that the facility staff was not searching for Resident 1 or were aware that the resident was missing on 04/01/2025, until it was reported by the Uber driver to staff and was found aways from the facility Center. Staff A stated that staff outside of the Center were not responsible for Resident 1's safety and that they did not have access to their medical information, and that Resident 1 was the Center staff's responsibility. ACCURATE ASSESSMENTS AND IDENTIFICATION OF ELOPEMENT RISKS RESIDENT 5 Review of Resident 5's undated face sheet showed they admitted to the facility on [DATE] with diagnoses that included unspecified moderate dementia with agitation, depression, and anxiety disorder. Review of Resident 5's Elopement Risk Evaluation dated 12/12/2024, showed the resident scored a 12 indicating that they were at risk of elopement. The evaluation further showed that under clinical area, 7. Diseases, 2 was marked [indicating 1 diagnosis was present]. On 04/11/2025 at 2:41 PM, Staff H, NAC, stated Resident 5 was not at risk for elopement. Staff H further stated that Resident 5 had dementia and was able to propel themselves in their wheelchair. In an interview and joint record review on 04/11/2025 at 3:13 PM, Staff I, RN, stated that Resident 5's elopement score was a 12 meaning that they were at risk for elopement. Joint record review of Resident 5's face sheet showed diagnoses that included unspecified moderate dementia with agitation, depression, and anxiety disorder. Joint record review of the Elopement Risk Evaluation dated 12/12/2024 showed that under clinical area, 7. Diseases, 2 was marked [indicating 1 diagnosis was present]. Staff I stated a 2 or more present [diagnosis] should have been checked instead, increasing Resident 5's elopement score to a 14. In a joint record review and interview on 04/11/2025 at 3:56 PM, with Staff A, showed Resident 5's Elopement Risk Evaluation dated 12/12/2024, elopement score of 12. Staff A stated Resident 5's elopement score should have been 14. RESIDENT 2 Review of Resident 2's undated face sheet showed they admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease (progressive brain disorder that primarily affects memory, thinking, and behavior), anxiety disorder, and unspecified severe dementia with psychotic [a state where an individual loses touch with reality] disturbance. Review of Resident 2's Elopement Risk Evaluation dated 12/19/2024, showed the resident scored a 16 indicating that they were at risk of elopement. The evaluation further showed 7. Diseases, 2 was marked [indicating 1 diagnosis was present]. In a joint record review and interview on 04/11/2025 at 2:57 PM with Staff I, showed Resident 2's Elopement Risk Evaluation dated 12/19/2024 showed a score of 16, and an intervention for Wanderguard Bracelet Door Alarm. Staff I stated Resident 2 was at risk for elopement and they thought Resident 2 did not have a wanderguard. Staff I further stated it was important to know that Resident 2 did have a wanderguard, and did not remember documenting in the electronic treatment administration record if they had one. Staff I stated that Resident 2's Elopement Risk Evaluation dated 12/19/2024 was incorrect as Resident 2 had more than one diagnosis for dementia or mental illness present. Staff I stated that 2 or more [diagnosis] present, should have been checked instead of increasing Resident 2's elopement score. In a joint record review and interview on 04/11/2025 at 4:00 PM with Staff A, showed Resident 2's Elopement Risk Evaluation dated 12/19/2024, revealed the resident scored a 16 indicating that they were at risk of elopement. The evaluation further showed 7. Diseases, 2 was marked [indicating 1 diagnosis was present]. Staff A stated that it should have been a 2 or more present and that a new Elopement Risk Evaluation had been completed, and Resident 2 had an updated score of 22. In a follow-up interview and joint record review on 04/11/2025 at 3:50 PM, Staff A stated their expectation was for the Elopement Risk Evaluations to be complete and accurate. Staff A stated their expectation was for these assessments to be completed upon admission, quarterly, or with any changes. Joint record review of the Elopement/Wander Risk Book Index Page 1 and 2 dated 04/02/2025, showed Resident 1, 2, and 5 were not identified as being at risk of wandering/elopement. Staff A stated that social services were responsible for the Elopement/Wander Risk Book and expected residents that were at risk for elopement or had a known history of wandering be identified in the book. Staff A stated they did not know the reason why Residents 1, 2, and 5 were not in the book, but did know that they were on a list they sent to social services yesterday (04/10/2025) to update and would have expected these residents to already have been in the book. MONITORING RESIDENTS AT RISK FOR ELOPEMENT Review of the facility's policy titled, [Facility name] Resident Alarms, reviewed 04/2025, showed When alarms are utilized, additional monitoring shall be provided, including but not limited to: i. Verifying alarms are used in accordance with the resident's care plan. ii. Verifying alarms are working properly . Review of Resident 2's physician orders printed on 04/11/2025 showed no monitoring for elopement risk intervention. On 04/11/2025 at 2:16 PM, Staff H stated they were employed full time and had worked on the Aspen Unit of the facility. When asked which residents were at risk for elopement on their unit, Staff H stated Resident 2, 3 and 4. Staff H stated that Resident 2 had dementia, wandered around, and did not have a wanderguard. Joint observation and interview on 04/11/2025 at 2:37 PM with Staff H, showed Resident 2 did have a wanderguard to the back of their wheelchair. Staff H stated they were unaware that Resident 2 had a wanderguard and was something staff should be aware of. In an interview on 04/11/2025 at 2:57 PM, Staff I stated the process for wanderguard was to have a consent and have orders to check placement and function. Staff I stated this was important because staff could hear the wanderguard alarms if functioning properly and stop or prevent the resident from leaving or getting injured stating because most of the time when they escape they can get injured. Staff I stated that they were not sure if Resident 2 was at risk of elopement or had a wanderguard. In an interview on 04/11/2025 at 4:00 PM, Staff A stated that there were no [physician] orders to check for Resident 2's wanderguard placement and function prior to 04/11/2025, and that there should have been. RESIDENT 3 Resident 3 admitted to the facility on [DATE]. Review of Resident 3's Elopement Risk Evaluation dated 09/19/2024, showed the resident scored a 20 indicating that they were at risk of elopement. The evaluation further showed an intervention for Diversion-Distraction and Wanderguard Bracelet Door Alarm, were checked off. Review of Resident 3's physician orders printed on 04/11/2025, showed no monitoring for elopement risk intervention prior to 04/10/2025 [the resident was identified as at risk for elopement based on the 09/19/2024 elopement risk evaluation]. In a joint record review and interview on 04/11/2025 at 4:09 PM with Staff A, Resident 3 had physician orders to check for placement and function for wanderguard. Staff A stated that the wanderguard orders were initiated on 04/10/2025 and that they should have been in place prior to that as the resident was at risk for elopement since 09/19/2024. RESIDENT 4 Resident 4 admitted to the facility on [DATE]. Review of Resident 4's Elopement Risk Evaluation dated 12/26/2024, showed the resident scored a 14 indicating that they were at risk of elopement. The evaluation further showed an intervention for Wanderguard Bracelet Door Alarm, was checked off. Review of Resident 4's physician orders printed on 04/11/2025 showed no monitoring for elopement risk intervention prior to 04/10/2025 [the resident was identified as at risk for elopement based on the 12/26/2024 elopement risk evaluation]. In an interview on 04/11/2025 at 2:19 PM, Staff H stated Resident 4 had a wanderguard on their wheelchair and that they always [everyday] attempted to open doors or tried to use the elevator by themselves. In an interview and joint record review on 04/11/2025 at 2:50 PM, Staff I stated that Resident 4 was at risk of elopement. Staff I stated that Resident 4 tried to go to the elevator, or to door or window at the end of the Aspen hallway. Staff I stated Resident 4 had a wanderguard. Joint record review of Resident 4's physician orders showed an order to check placement and function of the wanderguard dated 04/11/2025. Staff I stated Resident 4 should have had orders when the wanderguard was first initiated. In an interview and joint record review on 04/11/2025 at 3:50 PM, Staff A stated that their expectation was for orders to check placement and function of wanderguard to be in place, to ensure that they were functioning. Joint record review of Resident 4's physician orders showed physician orders to check for placement and function of Resident 4's wanderguard. Staff A stated that they were initiated on 04/10/2025 and that it should have been in place prior as Resident 4 had a wanderguard since 12/26/2024. Reference: (WAC) 388-97-1060 (3)(g)

Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistance with hot water for 1 of 3 residents (Resident 2), reviewed for accident hazards. This failure caused harm to Resident 2 who sustained a partial thickness burn (second degree burn, involving the epidermis/part of the dermis [layers of the skin] that forms blisters [small pocket of body fluid], are red and painful) and pain after hot water spilled on Resident 2's left upper arm, left forearm, left abdomen, and left flank (side of the body between ribs and hip). Findings included . Review of the facility's policy titled, Hot Liquid Safety, revised in October 2023, showed all Residents are assessed for their ability to handle containers and consume hot liquids. Residents with difficulties will receive appropriate supervision and use of assistive device to consume hot liquids. Interventions will be individualized and noted on the resident's plan of care. Interventions include but are not limited to: a) Wide based cup b) Cups with lids and handles c) Limit Styrofoam cups to residents with difficulties d) Aprons e) Disallow hot liquids while lying in bed. The policy also showed that staff shall respond immediately to spills or other accidents with hot liquid to minimize the risk for burns. Review of the facility's policy titled, Activities of Daily Living (ADL), Supporting, revised in March 2018, showed that appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care. Resident 2 was readmitted to the facility on [DATE], with diagnoses that included [left] hemiplegia (paralysis that affects only one side of body), dementia (memory loss), and muscle weakness. Review of Resident 2's ADL function care plan initiated on 07/31/2023, showed Resident 2 needed assistance to complete quality care and to complete routine/desired daily ADLs due to cerebral hemorrhage (brain bleed) with flaccid (weak) left hemiplegia, and impaired cognition. The care plan directed staff to assist with ADL's as needed, to have necessary items in place, to provide verbal cues as needed, and to allow Resident 2 to complete tasks in efficient time, safe and quality manner. Review of the quarterly Minimum Data Set assessment dated [DATE], showed Resident 2 was cognitively intact and had functional limitation on one side of their upper and lower extremity. The assessment also showed that Resident 2 required setup assistance with eating and drinking. Review of the interdisciplinary note dated 12/05/2023 at 12:16 AM, documented that Resident 2 spilled hot water on their body while trying to open their thermos bottle. The note also showed that blisters were noted on Resident 2's left forearm, left flank covering ribs and small portion of their back. Review of the emergency room hospital record dated 12/05/2023, showed Resident 2 sustained superficial partial thickness burn and blistering of skin noted on their left upper arm, left forearm, left abdomen, and left flank. On 12/07/2023 at 9:28 AM, observation showed Resident 2 was sitting in their wheelchair with wound dressing on their left forearm burn area. Observation showed Resident 2 had weakness on their left side of their body. When asked about their burn incident, Resident 2 stated that on 12/04/2023 during evening time, they requested hot water from the facility staff and asked staff to leave the lid of the thermos loose so that they could open it easily. Resident 2 stated the thermos lid was tightly closed and they could not open it easily. When they tried to open it, they spilled the hot water on them. Resident 2 also said that at that time they were in bed, they pressed their call-light for assistance, they did not get immediate assistance and it took the staff for more than 5 minutes to respond to the call. Resident 2 stated they had pain due to the burns. Review of the electronic health record showed no documentation to show that Resident 2's was evaluated for safety for potential injury from hot liquid or to use a thermos bottle at bed side. Review of Resident 2's care plan printed on 12/07/2023, showed no care plan was initiated for safety of potential injury from hot liquids or to use a thermos bottle at bed side. On 12/07/2023 at 10:43 AM, Staff G, Nursing Assistant Certified, stated that they would supervise residents when they consume hot water and would not leave hot water at the resident's bedside. On 12/15/2023 at 10:34 AM, joint record review with Staff C, Resident Care Manager, showed there was no assessment completed for Resident 2 for safety concerns and potential for injury from hot liquids or a care plan to use thermos at bed side. On 12/15/2023 at 11:09 AM, Staff B, Director of Nursing, stated that they would expect staff to check the temperature of hot beverages prior to giving it to the resident. Staff B also stated that speech therapist assessed Resident 2 as independent with eating. However, the facility was unable to provide any record that showed the resident was assessed for safety when they were using hot water while in bed or care plan for use of thermos bottle at bed side. On 12/15/2023 at 11:30 AM, Staff A, Administrator, stated that they would expect the facility staff to follow the facility's hot liquid safety policy. Reference: (WAC) 38-97-1060 (3)(g)

Based on interview and record review, the facility failed to ensure a resident received adequate supervision to prevent accidents for one of four (#1) sample residents. Failure to ensure Resident #1 was supervised by staff while in the bathroom as per the plan of care resulted in the resident falling and sustained a substantial injury, broken teeth, which was actual harm. Findings included . Resident #1 was readmitted to the facility, on 01/10/2020, after the surgical repair of a [MEDICAL CONDITION]. The Admission Minimum Data Set assessment, dated 01/17/2020, showed the resident needed extensive assistance with Activities of Daily Living such as transfers, walking, and toileting, and identified that the resident had a history of [REDACTED]. The care plan, dated 01/10/2020, showed a fall prevention plan which included a low bed with one side of the bed against the wall, a tilt-in-space wheelchair (which reclined), and a floor mat on the open side of the bed. In addition, alarms were placed in the bed, wheelchair, and the floor mat, to alert staff if the resident attempted to stand and/or walk. Record review showed that Resident #1 had a non-injury fall in the bathroom on 01/19/2020. The facility investigation of the fall on 01/19/2020 showed that staff had assisted the resident to the toilet, and then left the resident alone in the bathroom. The resident then had an unwitnessed fall in the bathroom. The investigation showed that the resident's care plan and care directive was reviewed and updated to reflect that the resident was not to be left alone in the bathroom, and that staff were educated on the new intervention. On 01/29/2020, Resident #1 had another fall after being left unattended on the toilet. The facility investigation summary showed that a nursing assistant had left the resident in the bathroom to answer a call light. The nursing assistant heard the resident call out, went back to the resident's bathroom and found the resident on the floor in a seated position. The resident had blood on her lips. The facility contacted 911 and the resident was transferred to the emergency room . The emergency room discharge instructions showed the resident had sustained dental trauma (broken teeth). The facility investigation conclusion showed that the resident had a fall with injury related to failure of staff to stay with the resident while in the BR(bathroom). Review of a statement from the nursing assistant, dated 01/29/2020 and typed by the facility administrator regarding the resident's 01/29/2020 fall, showed that the nursing assistant had left Resident#1 in the bathroom so as to answer a call light. The statement showed that the nursing assistant did know that the resident should not have been left alone. During an interview on 02/21/2020 at 5 PM, the Administrator stated that the caregiver who had left the resident alone and unsupervised in the bathroom on 01/29/2020 had been aware of the care plan intervention to not leave the resident alone in the bathroom, and had acknowledged they had not followed the care plan. During an interview on 03/20/2020 at 1:30 PM, the Director of Nursing Services stated that the caregiver made an executive decision not to follow the care plan. The facility investigation of the fall showed the care plan directive that staff were not to leave the resident alone in the bathroom had not been followed. The facility caregiver did not provide the necessary supervision as care planned which resulted in the resident sustaining dental trauma (broken teeth). WAC 388-97-1060 (3)(g)

Based on observation, interview, and record review, the facility failed to provide adequate supervision and follow the resident directed plan of care for one of three residents (Resident 1) reviewed for avoidable accidents and falls. These failures caused harm to Resident 1 who sustained a substantial injury (fracture) from an avoidable accident (fall). Findings included . A review of the facility policy titled, Falls, Assessment, and Documentation dated (MONTH) (YEAR) showed Falls are defined as unintentional decrease in elevation for any reason. and Falls are a leading cause of morbidity (disease) and mortality (death) among the elderly in nursing homes. The policy directed the facility staff to: New fall interventions will be placed depending on the situation surrounding the fall. Resident 1 was a long term care resident of the facility. The resident [DIAGNOSES REDACTED]. A review of the resident's most recent quarterly Minimum Data Set (MDS) assessment, dated 12/03/18, showed the resident had intact cognition and needed two-person extensive assistance with bed mobility and transfers. The MDS also showed the resident's balance was unsteady when moving from seated to standing positions, during transfers between the bed and the chair or wheelchair, and the resident was only able to stabilize her balance with staff assistance. A review of the resident's Self-care deficit care plan, dated 08/26/18, showed the resident had self-care deficit related to fatigue, pain, anxiety, decreased visual and motor ability, muscle weakness, and inability to put clothing on lower or upper body. The care plan directed the facility staff to assist the resident with one person staff assistance with activities of daily living (ADL), place and have necessary items in place, and offer supervision and verbal cues. A review of the resident's ADL care plan, dated 08/26/18, showed the resident had impaired physical mobility, Stage 4 sacral pressure injury, [MEDICAL CONDITION] (disease of peripheral nerves causing numbness or weakness), arthritis, fatigue, pain, and decreased muscle strength, and compromised ability to transfer to and from various surfaces. A review of the resident's fall care plan, dated 08/26/18, showed the resident was at risk for falls and injury related to impaired mobility, fatigue, side effects of current medications, loss of muscle strength and decreased sensation to bilateral lower extremities. The care plan directed the facility staff to: A. Consult with therapy regarding current functional status and follow all recommendations and the restorative programs. B. Monitor, anticipate and intervene for potential factors of falls. C. Anticipate the resident needs. D. Keep personal items within the resident's reach. A review of the facility's incident reporting log from 05/01/18 to 05/15/19 showed the resident had a fall on 04/26/19 and sustained a significant injury (fracture). Review of the facility incident investigation report, dated 04/26/19, showed, NAC (nursing assistant certified) had assisted Resident 1 to the EOB (edge of bed) with her feet planted firmly on the floor. Resident leaned forward to grab an item and NAC was able to intervene and assist her. He asked her to ask for help if she needed anything and turned to the closet to get out a blouse for her to wear. As he turned, he saw her fall to her knees and was able to stop her from pitching further forward onto the floor, thus preventing further injury. Review of the x-ray result and hospital record dated 04/27/19 showed the resident had suffered a left ankle fracture with mild soft tissue swelling following the fall incident. During an interview and record review on 05/23/19 at 10:17 AM with Staff E, Licensed Practical Nurse/Resident Care Manager (LPN/RCM), Staff J, LPN/RCM, Staff J stated that she was very familiar with the resident and the fall that happened on 04/26/19. According to Staff J, the resident was sitting at the edge of the bed when Staff L, Nursing Assistant (NA), turned away from the resident to get something (resident's clothing) from the closet. Staff J also stated that the resident may have been trying to reach for something before the accident happened. On 05/23/19 at 10:24 AM, the Director of Nursing (DNS) joined the interview and stated that the NAC (Staff L) had turned away with his back towards the resident and that this information was written on the witness statement and incident report summary. The DNS also stated that the resident needed one person assistance with ADLs, including bed mobility and transfers, and was care-planned to have stand-by assistance and supervision when sitting at the edge of the bed. According to the DNS, the resident was sitting on an air-mattress and this could potentially affect the resident's balance when sitting at the edge of the bed. During a phone interview on 05/23/19 at 10:43 AM with Staff L, NA, stated that on the day of the resident's fall, he had been in the process of dressing the resident and the resident was sitting at the edge of the bed prior to the fall. Staff L stated that he turned around to get the resident's clothes from the closet and after that, I heard a noise and I heard her (Resident 1) too. She (Resident 1) said Oh my God (and) when I turned around, she was already on her knees. Staff L also stated that Resident 1 would have not fallen If I was standing there . I should have kept her within my reach and line of sight and not turned my back. According to Staff L, he should have prepared everything he needed to help dress the resident and give whatever the resident was looking or reaching for before turning his back. Staff L stated that the resident's plan of care at the time of incident showed Resident 1 needed help and assistance with bed mobility and transfer and that the residident's balance was not stable and required supervision and cuing. Staff L stated, Supervision means the resident should be within my line of sight. Staff L further stated that the resident was on an air-mattress which was more slippery than the regular mattress, The air mattress will alternate the air and could affect the resident's balance when sitting. During an interview on 05/23/19 at 12:35 PM with the resident and the resident's husband, the resident stated she could recall exactly what happened on the day she fell and broke her ankle. The resident stated she was being assisted by Staff L, NA. The resident stated that what happened was that he (Staff L) turned his back on me to get my clothes and adjust my wheelchair, He turned his back and got my clothes. It happened so quickly. The resident stated that her bed had an air mattress at the time of the incident and for whatever reason I slid and fell out of bed . The air mattress was slippery. I remember having a sheet as well at the time, so I slid and took it with me to the floor. The resident stated that she knew she fractured something because of the pain and swelling on her ankle, It was bad .my leg was swollen. It was painful. The resident pointed to where Staff L was when he turned and walked away from her to adjust her wheelchair and get her clothes from her closet (approximately 6 feet away from the bed). The resident stated that Staff L was not within arm's length (reach of her). The resident further stated that the fracture had caused pain, discomfort, and limited her mobility. Review of the (MONTH) 2019 Medication Administration Record [REDACTED]. On 04/28/19, the resident had reported and documented pain of 10/10 that resulted to the resident being transferred to the emergency room for further treatment and evaluation. During a joint interview and record review on 05/23/19 at 1:54 PM with Staff K, Rehabilitation/Therapy Director, Staff K provided and reviewed all therapy notes for Resident 1 from 05/01/18 to 05/15/19. Staff K stated, Based on the therapy notes and plan of care, the resident required stand by assistance and supervision from staff if and when sitting at the edge of the bed. Staff K further stated that stand by assistance meant the staff should be providing direct supervision to the resident, and not leave the resident unattended and unsupervised. Reference: (WAC) 388-97-1060 (3)(g)

Based on observation, interview and record review the facility failed to ensure 1 of 2 residents (Resident #1) reviewed for hospice care from a sample of 4 hospice residents and census of 57 residents received necessary care related to urinary elimination assessment and intervention at the end of life by two nursing staff (B and C) over two shifts. This resulted in the resident being found with severe discomfort due to over distended bladder relieved by urinary catheterization (tube inserted into the bladder) and resulted in possible unrelieved pain at end of life. Findings include: Corwin Center is a skilled nursing facility located in Redmond Washington. Observation 07/13/15 at 2:00 p.m. found a variety of residents with care needs living at the facility. Record review found Resident #1 was admitted to the facility 06/19/15 with a terminal condition, enrolled in Hospice care. Resident #1's care plans provided staff direction for anticipated concerns: - Hospice Rapid Deterioration Plan directed nurses to keep resident comfortable at all times - Hospice Care Plan identified Follow Hospice care directives. - Risk for Bowel/Bladder Incontinence care plan Note urine characteristics: color, clarity, odor, amount, consistency, frequency and if blood is present - Risk for/Actual Pain care plan directed Observe for nonverbal s/s of pain: grimacing, moaning, increased VS (vital signs like pulse, temperature and blood pressure), guarding (protecting) areas of body, diaphoresis (sweating), dilated pupils. Progress notes documented after admission, Resident #1 experienced a rapid decline in condition related to his terminal condition. Resident#1 was given Oxygen at 2 liters/minute and pain medication as prescribed. Progress notes written by Staff A (day shift nurse) dated 06/22/16 at 2:30 p.m. documented Resident #1 became embarrassed due to incontinence (involuntary elimination of urine) and had increased pain. Notes documented new orders: [MEDICATION NAME] 0.25 mg orally every 4 hours routinely and insert Foley catheter for comfort. A written order signed by the Hospice nurse dated 6/22/15 at 2:00 p.m. directed Please initiate from MD (medical doctor) signed hospice POC (plan of care) orders: Insert urinary catheter to drainage - prefer 16 fr (french) catheter. Indications were: patient comfort. Medication orders were to give 5 mg [MEDICATION NAME] Solution every 4 hours and continue [MEDICATION NAME] Solution 5mg every 4 hours as needed for moderate to severe pain or shortness of breath. Progress notes written by Staff B (Evening shift nurse) dated 06/22/15 at 9:40 p.m. documented: Resident #1's Oxygen was increased to 3 liters/minute in response to increased breathing rate and a drop in Oxygen saturation. Family was able to give spoonfuls of nectar thick liquid. Resident #1 was turned every 2 hours and Unable to insert catheter. There was no documented assessment or evaluation of urine output or follow up regarding inability to insert the urinary catheter. One dose as needed [MEDICATION NAME] 10 mg given at 9:30 p.m. for moaning. Progress notes written by Staff C (Night shift nurse) dated 06/23/15 at 8:00 a.m. documented Resident slept quietly through the night. No moaning, restlessness noted. Routine [MEDICATION NAME] given at midnight and 0400. No signs of difficulty breathing noted. There was no documented assessment or evaluation of urine output or comment regarding the urinary catheter. No as needed [MEDICATION NAME] was given. Progress notes and a separate statement written by Staff A documented on 06/23/15 at 08:00 a.m. Resident #1 was in acute distress with an over distended bladder. Staff A documented she received change-of-shift report from Staff C who told her Resident #1 was fine. On entering Resident #1's room he was heard moaning, saw crying and appeared to be in distress. Resident #1 was observed grabbing at his groin. Staff A noted abdominal distention and facial grimacing when she touched the pubic area. Resident #1's temperature was 102 degrees. Staff A documented she catheterized Resident #1, draining 880 cubic centimeters (cc) of mixed urine and blood from Resident #1's bladder. According to the National Institutes of Health, a normal bladder can contain 1 1/2 to 2 cups of urine (360-500 cc). http://www.niddk.nih.gov/health-information/health-topics/Anatomy/urinary-tract-how-it-works/Pages/anatomy.aspx Staff A documented after the procedure, Resident #1 appeared comfortable, smiled and fell asleep. In written statements, Staff B and C said they thought Resident #1 could wait until morning to have the catheter inserted. Neither Staff B or C documented efforts to clarify the order for urinary catheterization, or further attempts to catheterize the resident or assessment of Resident #1's bladder. Neither nurse used the facility bladder scanner (sonogram used to evaluate the amount of urine in a bladder) to evaluate Resident #1's bladder. Facility incident report documented mis-communication, lack of communication or lack of nursing response to communication: - Staff B said Staff A told her Resident #1 could wait until morning to have the catheter inserted. Staff B passed this information on to Staff C. Both nurses followed this verbal communication instead of clarifying the order or assessing the resident's elimination status. - Staff A, Staff B and Staff I attempted to pass the catheter at the start of evening shift on 6/22/15 but were not successful. Staff A & B agreed that Staff J (working on the assisted living unit) could try. Staff J said he was called once but was busy and was not called again. I did not hear from them again so I assumed they got it in. - Staff D (Evening Nursing Assistant) told Staff B Resident #1 had no urine output. He wasn't wet all shift, I told (Staff B) many times. Staff B did not respond to the report of no urine output. - Staff E (Night Shift Nursing Assistant) documented she turned and changed Resident #1 twice during the night shift but the resident was dry except for a 1 1/2 inch wet spot. Staff E documented Resident #1 yelled a lot but denied pain when asked. Staff E documented she did not report the dry briefs or Resident #1 yelling out. On interview 07/13/15 at 4:50 p.m. Staff A stated at the end of her day shift on 06/22/15 she gave report about Resident #1's need for a urinary catheter. Staff A confirmed she tried to insert the catheter after Staff B said she was unable to do so. Staff A stated she told Staff B to give the resident a break as it may be easier to insert the catheter later. On interview 07/22/15 at 2:40 p.m. the Hospice nurse stated: Goals of care are emotional and physical comfort from the patient's point of view. Resident #1 had requested the catheter. Physical palpation will tell you something about the bladder. If in doubt, pass the catheter. If staff was unable to insert the catheter, they should call Hospice. The Hospice nurse could have come to the facility to insert the catheter or the resident could have been sent to the Hospice center for care. The Hospice nurse confirmed no one from the facility called to report difficulty inserting the urinary catheter. On interview 07/23/15 at 1:00 p.m. Staff F (day shift nursing assistant) stated she checked and turned Resident #1 at 6:30 a.m. on 06/23/15. Staff F said she saw the the resident was moaning in pain, very sweaty, and had a temperature. Staff F stated she specifically told Staff C about Resident #1's condition. According to Staff F, Staff C said Oh, O.K. On interview 07/13/15 at 5:45 p.m. the administrator and director of nursing services (DNS) confirmed Staff B and C did not meet minimum standards for care.