Every finding on record at Cottesmore of Life Care

Based on observation, interview, and record review, the facility failed to ensure residents' with fluid restrictions had fluid intake monitoring to avoid fluid overload for 3 of 3 sampled residents (Residents 94, 100, and 111) when reviewed for nutrition. This failure placed residents at risk of fluid overload, avoidable discomfort, and a diminished quality of life. Findings included .Resident 94 Review of the electronic health record (EHR) showed Resident 94 admitted to the facility on [DATE] with diagnoses to include heart failure, right ankle pain and dysphagia (difficulty swallowing). Resident 94 was able to make needs known. Observation on 02/23/2026 at 11:51 AM and 02/24/2026 at 10:06 AM showed Resident 94 lying in bed with a water pitcher within reach on the bedside table. Review of a provider's order, dated 02/19/2026, showed Resident 94 had a fluid restriction of 2000 milliliters per 24 hours to be split between nursing and dietary. Review of Resident 94's Medication Administration Record (MAR) from 02/19/2026 through 02/24/2026 did not show totals of all fluids provided by both dietary and nursing on each shift to ensure Resident 94's provider ordered fluid restriction had been followed. During an interview on 02/24/2026 at 12:20 PM, Staff M, Certified Nursing Assistant (CNA), stated they were assigned to Resident 94 and provided them with a full pitcher of water. Staff M stated they were unaware Resident 94 was on a fluid restriction. Resident 100 Review of the EHR showed Resident 100 admitted to the facility on [DATE] with diagnoses to include heart failure, kidney disease and edema (swelling caused by fluid). Resident 100 was able to make needs known. Observation on 02/24/2026 at 1:00 PM showed Resident 100 had a full water pitcher on their bedside table. Review of a provider's order, dated 01/27/2026, showed Resident 100 had a fluid restriction of 2000 milliliters per 24 hours to be split between nursing and dietary. Review of Resident 100's MAR from 02/01/2026 through 02/24/2026 did not show totals of all fluids provided by both dietary and nursing on each shift to ensure Resident 100's provider ordered fluid restriction had been followed. During an interview on 02/25/2026 at 1:36 PM, Resident 100 stated they were unaware they were on a fluid restriction. Resident 100 stated they were receiving a full water pitcher at bedside until yesterday evening. During an interview on 02/26/2026 at 9:57 AM, Staff H, Resident Care Manager, stated residents on fluid restrictions should not have a water pitcher at bedside. Staff H stated the expectation was that staff were educated on fluid restrictions and the provider's order was followed to document the total amount consumed from nursing and dietary. During an interview on 02/26/2026 at 11:59 AM, Staff B, Director of Nursing Services (DNS), stated the MAR did not show totals of fluid that were provided, to include all of nursing, dietary, and fluid independently consumed in a 24-hour period. Staff B stated the lack of fluid restriction monitoring and documentation did not meet their expectations. Resident 111 Review of the EHR showed Resident 111 admitted to the facility on [DATE] with diagnoses to include end stage renal disease (ESRD, the final, permanent stage of kidney failure where function drops below 10–15%), dependance on renal dialysis (the life-sustaining requirement for regular, long-term, or permanent artificial filtration of blood due to ESRD), and diabetes (too much sugar in the blood). Resident 111 was able to make needs known. Review of provider's orders showed a fluid restriction of 1200 milliliters (ml) in 24 hours, dated 02/17/2026, with the kitchen providing 720 ml (breakfast 240 ml, lunch 240 ml, and dinner 240 ml) and nursing staff providing 480 ml (day 180 ml, evening 180 ml, and night 120 ml). Review of the MAR for February 2026 showed monitoring of Resident 111's fluid provided by nursing staff but did not show tracking of fluid provided by the kitchen or daily totaling of all fluids consumed. Observation of Resident 111's door showed a blue cup sign. During an interview on 02/25/2026 at 1:44 PM, Staff R, CNA, stated there was signage to indicate a resident was on a fluid restriction, to include a hummingbird (nectar thick liquid) and bee (honey thick liquid) signs. Staff R stated those were the only fluid restriction signs. Staff R stated they were unsure what the blue cup sign on Resident 111's door indicated. During a follow-up interview on 02/25/2026 at 1:49 PM, Staff R, CNA, stated they asked the nurse and the blue cup sign indicated Resident 111 was on a fluid restriction. During an interview on 02/25/2026 at 1:52 PM, Staff S, CNA, stated they were aware of a resident's fluid restriction because it was in the care plan and a blue cup sign would be placed on their door. Staff S stated there were no residents on a fluid restriction in their area (which included Resident 111's room). Staff S, after viewing Resident 111's blue cup sign, stated they were previously unaware of Resident 111's fluid restriction. During an interview on 02/25/2026 at 1:56 PM, Staff T, Registered Nurse, stated they were aware of fluid restrictions because it would be in the care plan and a blue cup would be placed on their door. Staff T stated if a resident had a fluid restriction nursing staff should record all fluid intake in the MAR and it should be totaled daily to ensure a resident had not exceeded their fluid intake. Staff T stated Resident 111's MAR did not include totaling of fluids consumed. Reference WAC 388-97-1060(3)(i)

Based on interview and record review, the facility failed to implement Abuse Prohibition policies and procedures including but not limited to identification, investigation, protection and reporting for 1 of 3 sampled residents (Resident 1) when reviewed for abuse. These failures placed residents at risk for unidentified abuse, neglect, and/or injury. Findings included .The facility Abuse, Neglect and Exploitation policies, revised October 2022, showed It is the policy of the facility that all allegations of abuse, neglect.are promptly and thoroughly investigated. Complaints and grievances will be investigated as outlined. The facility will ensure all residents are protected from physical and psychosocial harm during and after the investigation.In response to the allegations the facility will ensure that alleged violations are reported within 24 hours to the Administrator and other officials in accordance with State law through established procedures. Review of the electronic health record (EHR) showed Resident 1 readmitted to the facility on [DATE] with diagnoses to include chronic kidney disease, anxiety and Parkinson's disease (movement disorder of the nervous system). Resident 1 was able to make needs known. Review of the Resident Council meeting minutes dated 11/28/2025 showed a complaint that Resident 1 informed staff they needed a brief change. Staff stated they would inform another Certified Nursing Assistant (CNA). Resident 1 was not attended to in a timely fashion. Review of a grievance form dated 11/28/2025 showed, Night shift slamming doors and disruptive and night shift staff are not managing their scheduled time effectively in regard to brief changes. The grievance was signed by Staff L, Activities Director. Review of the facility's Documentation of Follow-Up showed all night shift nursing assistants were provided in-service education related to Leaving residents who do not have the ability to make their needs known without a brief change for multiple hours. Review of the provided documentation did not show evidence of an interview with Residents 1 to determine if there was an outcome to the residents and if neglect had occurred or evidence of interviews with residents or staff. During an interview on 02/25/2026 at 3:51 PM, Resident 1 stated they informed a CNA at 10 PM that they had a bowel movement (BM) and required a brief change. The CNA turned off the call light and stated they would inform the CNA assigned to Resident 1. The assigned CNA responded approximately 3 hours later at 1 AM. During an interview on 02/26/2026 at 8:45 AM, Staff L, Activity Director, stated after writing the grievance they believed the incident was an allegation of neglect and reported the incident to Staff A, Administrator, who was also the Abuse Coordinator. Staff L stated, A resident sitting in their BM for 3 hours seems like neglect to me. As a mandated reporter I was informed to report those concerns to Staff A. During an interview on 02/26/2026 at 11:50 AM, Staff K, CNA, stated if a resident reported not having a brief change for several hours after requesting it they would assist the resident and then report it to the nurse for staff neglecting to provide care to the resident. During an interview on 02/26/2026 at 11:52 AM, Staff H, Resident Care Manager, stated when a resident reported they did not receive timely care, the staff member should notify management and complete grievance due to the allegation of neglect. Staff H stated three hours was an unacceptable amount of time to wait. During an interview on 02/25/2026 at 12:54 PM, Staff A, Administrator, stated they interviewed Resident 1 and staff were provided education as a resolution to the concern. During an interview on 02/26/2026 at 12:03 PM, Staff B, Director of Nursing Services, stated they were unaware of the situation until yesterday. Staff B stated an investigation to include interviews, a skin assessment, social services evaluation and determining if there was an allegation of neglect should have been completed. Staff B stated the lack of investigation did not meet their expectations. Reference WAC 388-97-0640(6)(a)(b)

Based on interview and record review, the facility failed to ensure the minimum data set assessment (MDS) accurately reflected the status for 2 of 19 sampled residents (Residents 11 and 8) when reviewed for accuracy of assessments. Failure to accurately reflect Resident 11's hospice status and Resident 8's pressure ulcer/skin injury status placed the residents at risk for unmet care, inaccurate medical record data, and a diminished quality of life.Findings included. Resident 11Review of the electronic health record (EHR) showed Resident 11 readmitted to the facility on [DATE] with diagnoses of dementia (a decline in mental abilities, severe enough to interfere with daily life), chronic obstructive pulmonary disease (restricted airflow making it difficult to breathe), and anxiety disorder. Resident 11 usually was able to make needs known. Review of the EHR showed Resident 11 had an active focused care plan for terminal prognosis, (a medical assessment that an incurable, irreversible, or progressive disease is expected to end in death, often within six months or less) initiated on 10/07/2025, showed Resident 11 received hospice services (end of life care and services) with interventions being implemented. Review showed hospice care services were being provided and documented per the active provider's order for hospice. Review of the quarterly MDS dated [DATE] showed it was coded No for hospice services. During an interview on 02/26/2026 at 12:47 PM, Staff D, MDS Coordinator (MDSC), stated Resident 11 was receiving hospice services and the 01/08/2026 quarterly MDS was coded No, and should have been coded, Yes. Staff D stated the MDS needed to be modified. During an interview on 02/26/2026 at 12:51 PM, Staff B, Director of Nursing Services (DNS), stated Resident 11's quarterly MDS dated [DATE] was inaccurately coded for hospice and did not meet their expectations. Resident 8 Review of the EHR showed Resident 8 admitted to the facility on [DATE] with diagnoses of dementia, stage 4 pressure ulcer (the most severe form of skin and tissue damage caused by long-term pressure), and anemia (lack of healthy red blood cells reducing oxygen supply to the body). Resident 8 was unable to communicate needs. Review of the quarterly modification MDS dated [DATE] showed Resident 8 had a stage 4 pressure ulcer (PU). Review of the EHR showed Resident 8 had an active provider's order dated 06/30/2025 to provide daily treatment to a stage 4 PU to the left lower back area. Review showed the treatment was provided per the provider's order. Review of the quarterly MDS dated [DATE] showed Resident 8 had a stage 3 PU (wound that exposed fatty tissue, not as deep as a stage 4) and not a stated 4 PU. During an interview on 02/26/2026 at 1:14 PM, Staff E, MDSC, stated Resident 8 had a stage 4 PU; however, the quarterly MDS dated [DATE] was coded for a stage 3 PU and should have been coded for a stage 4 PU. Staff E stated the MDS needed to be modified. During an interview on 02/26/2026 at 1:35 PM, Staff B, DNS, stated Resident 8's quarterly MDS dated [DATE] was inaccurately coded for a stage 4 PU and this did not meet their expectations. Reference WAC 388-97 -1000 (1)(b)(4)(a)

Based on interview and record review, the facility failed to provide nonpharmacological interventions (NPI) prior to the use of as needed pain medications for 1 of 6 sampled residents (Resident 7) when reviewed for pain management. This failure placed the residents at risk of receiving unneeded medications and a diminished quality of life. Findings included .Review of the electronic health record (EHR) showed Resident 7 readmitted on [DATE] with diagnoses to include left foot pain, diabetes (too much sugar in the blood) and peripheral vascular disease (condition that restricts blood flow). Resident 7 was able to make needs known. Review of Resident 7's medication list showed a provider's order dated 01/27/2026 for oxycodone (a narcotic opioid pain medication) every four hours as needed (PRN) for pain.Review of Resident 7's February 2026 MAR showed oxycodone administered 20 out of 28 days. There was no documentation NPI was offered/provided prior to the administration of the oxycodone. During an interview on 02/26/2026 at 10:03 AM, Staff C, Resident Care Manager, stated nursing staff should have offered ice and repositioning prior to administering the as needed pain medication. Staff C stated the expectation was to document Resident 7's pain level and the interventions attempted and make sure the appropriate PRN medication was given for the pain level. During an interview on 02/26/2026 at 11:58 AM, Staff B, Director of Nursing Services, stated the expectation was when an order for a PRN pain medication was entered into the EHR staff should have also indicated an area on the MAR to document that a NPI was offered and if it met the resident's needs. Reference WAC 388-97-1060(1), -1620(2)(b)(i)(ii)

Based on observation, interview, and record review the facility failed to consistently maintain the medication refrigerator temperature log in 1 of 3 medication rooms (Transitional Care Unit/TCU), to ensure resident's were assessed to self-administer medications for 1 of 1 sampled residents (Resident 6), and 2 of 6 medication/treatments carts (TCU treatment and TCU medication carts) , when reviewed for medication storage. These failures placed the residents at risk of receiving compromised or ineffective medications, drug diversion, and potential loss of medications/treatments. Findings included .Medication Refrigerator Observation on 02/25/2026 at 10:44 AM with Staff C, Resident Care Manager (RCM), of the medication room refrigerator located in the Transitional Care Unit (TCU) medication room showed various liquid medications. Medications included a vial of a medication solution used to detect tuberculosis (TB, a serious illness that mainly affects the lungs), a box of an Arexvy vial kit (vaccine used to prevent lower respiratory tract disease), and a box of influenza vaccine (used to protect against the influenza virus during flu season) with six single-dose, prefilled syringes. The freezer had several ice packs that were frozen solid. Attached to the refrigerator door was the February 2026 Medication Refrigerator/Freezer Temperature Log. Review of the February 2026 Medication Refrigerator/Freezer Temperature Log from 02/01/2026 – 02/25/2026 showed refrigerator parameters were between 36 – 46 Fahrenheit (F, temperature scale) and the freezer parameters were between -4 - 14 F. The log showed multiple missing documented temperatures, temperatures documented outside of parameters for both the refrigerator and freezer, and multiple times the temperatures were documented one time a day. The section of the form that showed Notes/Corrections Made, had documentation that was illegible/writing not readable which was documented on 02/04/2026, 02/19/2026, and 02/24/2026; however, there were multiple times there was no documentation for temperatures out of parameters in that section of the form. During an interview on 02/25/2026 at 10:44 AM, Staff C, RCM, stated the February 2026 medication refrigerator/freezer temperature log in the TCU medication room had missing temperatures and temperatures logged outside of temperature parameters. Staff C stated the temperatures were not consistently being documented twice a day and should have been because there were vaccines being stored in the refrigerator. During an interview on 02/25/2026 at 11:53 AM, after reviewing the TCU medication room's February 2026 Medication Refrigerator/Freezer Temperature Log, Staff B, Director of Nursing Services (DNS), stated there were gaps/holes in the documentation and temperatures were not consistently being monitored twice a day as required. Staff B stated there were temperatures logged outside of parameters as low as 30 F for the refrigerator and below -4 for the freezer. Staff B stated the writing noted in the notes/corrections made, section of the form was hard to read and unclear what was documented. Staff B stated this did not meet their expectations. Medication at Bedside Review of the electronic health record showed Resident 6 admitted to the facility on [DATE] with diagnoses to include epilepsy (a disorder marked by sudden recurrent episodes of loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain), diabetes (too much sugar in the blood), and kidney disease. Resident 6 was able to make needs known. Observation on 02/23/2026 at 10:32 AM showed Resident 6 in bed with two pill cups with medications on the bedside table with no facility staff present. Observation showed Resident 6 consumed both pill cups' medication during an interview. Review of a Medication Self-Administration Review assessment, dated 11/20/2025, showed Resident 6 was assessed to be able to self-administer medicated eye drops, but not any pill medications. Review of the care plan, initiated 07/08/2024, showed Resident 6 was assessed to be able to self-administer medicated eye drops, but not any pill medications. During an interview on 02/27/2026 at 9:23 AM, Staff Q, Registered Nurse, stated residents were allowed to self-administer medications if they were assessed to be competent and kept them in a locked box. Staff Q stated Resident 6 was not assessed to be able to self-administer any medications. During an interview on 02/27/2026 at 10:51 AM, Staff B, DNS, stated residents should be assessed prior to self-administering medications and medications should not be left at bedside without this assessment. Staff B stated Resident 6's medications at bedside did not meet expectations. Medication Storage Observation on 02/23/2026 at 12:20 PM showed a treatment cart on Transition Care Unit (TCU) unlocked and no staff were around. During an interview on 02/23/2026 at 12:21 PM, Staff P, Licensed Practical Nurse, stated the treatment cart should have been locked. Observation on 02/25/2026 at 10:31 AM showed a medication cart on TCU left unlocked with no staff round. During an interview on 02/25/2026 at 10:33 AM, Staff O, Staff Development Coordinator, stated the cart should have been locked. During an interview on 02/25/2026 at 1:03 PM, Staff B, Director of Nursing Services, stated the treatment and medication carts should be locked at all times when not attended by licensed nurses, and having the treatment and medication cart unlocked on TCU unit did not meet expectations. Reference WAC 388-97-1300(2), -2340

Based on observation, interview, and record review, the facility failed to provide food in accordance with preferences for 1 of 1 sampled resident (Resident 94) when reviewed for preferences. This failure placed residents at risk for reduced nutritional intake and a diminished quality of life. Findings included.Review of the electronic health record (EHR) showed Resident 94 admitted on [DATE] with diagnoses to include congestive heart failure, right ankle pain and dysphagia (difficulty swallowing). Resident 94 was able to make needs known. During an interview on 02/23/2026 at 1:04 PM, Resident 94 stated they had spoken to the dietician and discussed receiving smaller portion size. Resident 94 stated they were still getting large meal portions and at times felt overwhelmed with the amount of food. Observation on 02/24/2026 at 8:42 AM showed Resident 94's meal tray card had Regular Texture, heart health, no salt packet, fluid restriction 1500 ml. There were no preferences listed. Review of a Registered Dietician progress note dated 01/23/2026 showed Add small portions to meals per resident request. Review of Resident 94's EHR showed a 01/21/2026 provider's order for Heart healthy (cardiac) diet, regular texture, thin consistency, no salt packets, small portions with meals. During an interview on 02/24/2026 at 12:42 PM, Staff F, Dietary Manager, stated they must have missed transferring information to the resident's meal card related to the portion sizes. Reference WAC 388-97-1140(6)

Based on observation and interview, the facility failed to post the location of the survey results and place the binder in identifiable location. This failure prevented residents, family members and visitors from exercising their right to review past survey results and the facility's plans of correction to evaluate the quality of care provided by the facility. Findings included .During an interview with Resident Council on 02/25/2026 at 3:45 PM, Residents 1, 10, and 16 stated they were not aware of the location of the state survey inspections. Observation on 02/25/2026 at 4:15 PM showed the state inspection binder was located at the front reception desk, lying on its side. The desk height was higher than a tabletop, which made it difficult for an individual in a wheelchair to view the title located on the top of the binder. There was no signage posted that identified that the binder was there. During an interview on 02/25/2026 at 4:15 PM, Staff G, Receptionist, stated there was no signage posted showing where the survey binder could be located. During an interview on 02/25/2026 at 4:18 PM, Staff A, Administrator (ADM), stated the facility previously had a sign posted but it was taken down during a remodel. Staff A stated the lack of signage did not meet expectations. Reference WAC 388-97-0480

Based on observation, interview and record review, the facility failed to ensure an environment that is free from accident hazards by not following their fall protocol, which included bed height placement, fall assessment, and call light within reach for 7 of 12 residents (Residents 2, 4, 5, 6, 7, 8, and 10) reviewed for falls. This failure placed residents at risk of increased falls, significant injury with fall, and a diminished quality of life.Findings included.Review of a facility policy titled Fall Management, dated 03/11/2025, showed a fall risk assessment would be completed upon admission, readmission, quarterly, change in condition, and with any fall, utilizing the fall risk evaluation form. Review of the policy showed a referral to the Lippincott procedures fall management for long term care to assist with fall prevention and management interventions. Review of the Lippincott Nursing Procedures, 8th edition, showed standards of practice for fall prevention in long term care were:-keep the bed in its lowest position so the patient could easily reach the floor when getting out of bed. This position would also reduce the distance to the floor in case the patient would fall.-keep the call light positioned so it would be within the patient's reach at all times.-Respond promptly to the patient's call light to help limit the number of times the patient would get out of bed without help. RESIDENT 1Resident 1 admitted to the facility on [DATE] with diagnoses that included subdural and subarachnoid hemorrhage (a bleed in the brain), history of falling, muscle weakness, difficulty in walking, and restlessness and agitation. The discharge minimum data set (MDS), an assessment tool, dated 01/30/2025, showed Resident 1 was dependent on staff for care.During an interview on 01/05/2026 at 03:15 PM, Collateral Contact (CC) A, family member, said Resident 1 had a fall at an assisted living facility before going to the hospital. CC A said Resident 1 had been on fall precautions while at the hospital. CC A said Resident 1 was discharged from the hospital and admitted to the facility on [DATE]. CC A said Resident 1 fell while at the facility and hit their head only a few hours after arriving there and had to return to the hospital. CC A said Resident 1 could not recover from the fall, was placed on hospice, and sent to a different facility where they eventually passed away. Review of the progress notes, dated 01/30/2025, showed Resident 1 arrived at the facility at approximately 01:00 PM on 01/30/2025 for admission. Review showed upon arrival, Resident 1 was confused.Review of the Fall Risk Evaluation dated 01/30/2025, showed Resident 1 had a fall risk score of 20, indicating a high risk for a fall.Review of a risk management document dated 01/30/2025 at 08:30 PM, showed Resident 1 had a fall from bed. Review showed Resident 1 was observed on the floor next to their bed lying sideways on the ground with their head against the wall and their legs tangled in the bed sheets. Review showed Resident 1 was having a seizure (sudden surge of electrical activity in the brain, leading to changes in awareness, movement, or sensation) after the fall. Record review showed Resident 1 was sent to the hospital for evaluation and treatment at 09:00 PM. Review showed Resident 1 had their bed in low position, bare feet, and was agitated and confused.Review of the care plan dated 01/30/2025 showed Resident 1 was at risk for falls with interventions of bed in lowest position, falling star protocol, transfer with mechanical lift, provide appropriate footwear, and physical therapy to evaluate and treat.Review of the hospital history and physical, dated 01/30/2025 at 09:42 PM showed Resident 1 was admitted to the hospital with seizure like activity and altered mental state.Observations and interview of Resident 1 were not able to be conducted due to the resident not being present.RESIDENT 4Resident 4 admitted to the facility on [DATE] with diagnoses that included altered mental status, muscle weakness, repeated falls, and spinal stenosis (narrowing of the spinal canal). The 5-day Medicare MDS dated [DATE], showed Resident 4 was moderately cognitively impaired and dependent on staff for care.Review of a progress note dated 12/29/2025 at 10:13 AM showed Resident 4 rolled out of bed. Review showed Resident 4 received a skin tear from the fall.Review of a progress note dated 01/01/2026 at 07:41 AM showed Resident 4 was found lying on the mat next to their bed on the left side at 05:15 AM. Review showed Resident 4 had fecal matter on their face and on the floor. Review of a risk management document dated 01/01/2026 at 0515 showed Resident 4 was given a room move to be closer to the nurses station for increased monitoring due to their falls.Review of the care plan showed interventions placed on admission on [DATE] were call light within reach, complete fall risk assessment and orient to room.Review of the progress notes dated 12/25/2025 at 06:07 PM showed Resident 4 was able to use their call light appropriately.Review of the care plan showed interventions placed on 12/31/2025 were bilateral mobility rails and floor mats to left side of their bed.Review of the fall risk evaluation, dated 01/04/2026, showed Resident 4 had a fall risk score of 20, indicating a high risk for falls. Observation on 01/09/2026 at 11:22 AM showed Resident 4 sitting in a wheelchair next to the bed in their room. Observation showed the bed against the wall on the right side of the bed, showed the call light hanging down the wall and behind the bed and not within Resident 4's reach. Observation showed a star on the door next to Resident 4's name, indicating they were on the falling star protocol.Attempts to interview Resident 4 were unsuccessful. RESIDENT 6Resident 6 admitted to the facility on [DATE] with diagnoses that included cognitive impairment, muscle weakness, repeated falls, and unsteadiness on feet. The quarterly MDS, dated [DATE], showed Resident 6 was mildly cognitively impaired.Review of progress notes dated 10/28/2025 at 09:52 PM showed Resident 6 was observed on the floor crawling back into bed. Review showed Resident 6 was attempting to use their urinal independently.Review of progress notes dated 11/19/2025 at 07:07 PM showed Resident 6 was observed on the floor, sitting on their buttocks in their room. Review showed Resident 6 was trying to exercise independently and attempted to stand up. Review showed Resident 6 was re-educated to wait for staff to assist with their needs.Review of progress notes dated 11/24/2025 at 08:18 PM showed Resident 6 was observed sitting on the floor in their room. Review showed Resident 6 was encouraged to use common areas for better sight for staff.Review of progress notes dated 12/31/2025 at 07:21 PM showed Resident 6 had a fall in the dining room. Review showed Resident 6 was eating dinner and slid out of their chair. Review showed a provider order was placed to therapy to evaluate safety and positioning while in their wheelchair.Review of the fall risk evaluation dated 01/03/2026, showed Resident 6 had a fall risk score of 24, indicating a high risk for falls. Review of the care plan dated 11/04/2025 showed Resident 6 was to have their call light and have a reacher (a device used to increase the range of a person's reach and grasp) within reach. Observation on 01/08/2025 at 12:46 PM showed Resident 6 sitting in a wheelchair next to their bed, the bed was against the wall on the right side, the call light hanging down the wall, behind the bed and not within reach, and no reacher within reach. Observation showed a star on the door next to Resident 6's name, indicating they were on the falling star protocol.Observation on 01/09/2025 at 11:20 AM showed Resident 6 sitting in a wheelchair next to their bed, the bed was against the wall on the right side, the call light hanging down the wall, behind the bed and not within reach, and no reacher within reach. Observation showed a star on the door next to Resident 6's name, indicating they were on the falling star protocol.During an interview on 01/09/2026 at 11:20 PM, Resident 6 said they could not reach their call light and did not know where their reacher was. RESIDENT 7Resident 7 admitted to the facility on [DATE] with diagnoses that included adult failure to thrive (loss of weight, appetite, and interest in activities), muscle weakness, repeated falls, and low back pain. The quarterly MDS dated [DATE], showed Resident 7 had moderate cognitive impairment. Review of the progress notes dated 10/03/2025 at 02:37 PM showed Resident 7 had an assisted fall with no injuries.Review of the fall risk evaluation dated 10/03/2026 showed Resident 7 had a fall risk score of 14, indicating a high risk for falls. Observation on 01/08/2026 at 01:40 PM showed Resident 7 in bed. Observation showed the bed was in a high position (waist level).During an interview on 01/09/2026 at 11:57 AM, Resident 7 said they have a fear of falling while in bed. Resident 7 said the staff often leave the bed too high after providing care. Resident 7 said they prefer the bed be at a lower level. RESIDENT 2Resident 2 admitted to the facility on [DATE] with diagnoses that included vascular dementia (a loss of cognitive functioning), adult failure to thrive, muscle weakness, difficulty in walking, and a history of falling. The quarterly MDS, dated [DATE], showed Resident 2 was severely cognitively impaired.Review of the fall risk evaluation dated 11/11/2025 showed Resident 2 had a fall risk score of 16, indicating a high risk for a fall. During an observation on 01/08/2026 at 01:44 PM, showed Resident 2 in bed. Observation showed Resident 2's bed in a high position (waist level). Observation on 01/09/2026 at 11:07 AM showed Resident 2 in bed. Observation showed Resident 2's bed in a high position (waist level). Attempts to interview Resident 2 were not successful due to cognition. RESIDENT 5Resident 5 admitted to the facility on [DATE] with diagnoses that included muscle weakness, difficulty in walking, and chronic pain. The quarterly MDS dated [DATE], showed Resident 5 was cognitively intact.Review of the fall risk evaluation dated 12/06/2025, showed Resident 5 had a fall risk score of 16, indicating a high risk for falls. Observation on 01/08/2026 at 01:39 PM showed Resident 5 in bed. Observation showed the bed was in a high position (waist level). Observation on 01/09/2026 at 11:11 AM showed Resident 5 in bed. Observation showed the bed was in a high position (waist level).During an interview on 01/09/2026 at 11:12 AM, Resident 5 said the staff had left their bed at that height when they left the room after providing care. RESIDENT 8Resident 8 admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis (weakness and paralysis on one side of the body), muscle weakness, repeated falls, and unsteadiness on feet. The quarterly MDS, dated [DATE], showed Resident 8 was cognitively intact. Review of the fall risk evaluation, dated 11/20/2025, showed Resident 8 had a fall risk score of 16, indicating a high risk for falls. Observation on 01/08/2026 at 01:45 PM, showed Resident 8 in their bed. Observation showed the bed was in a high position (waist level). Resident 8 did not wish to participate in an interview. RESIDENT 10Resident 10 admitted to the facility on [DATE] with diagnoses that included vascular dementia, epilepsy (reoccurring seizures), and muscle weakness. The quarterly MDS dated [DATE], showed Resident 10 was severely cognitively impaired. Review of the fall risk evaluation dated 10/14/2022 showed Resident 10 had a fall risk score of 12, indicating a high risk of falls. Review of the Electronic Health Record (EHR) showed this fall risk evaluation as the most recent fall assessment. (Review showed the fall risk evaluation was not completed quarterly per policy.)Observation on 01/09/2026 at 11:08 AM showed Resident 10 in bed. Observation showed the bed in high position (waist level).Attempts to interview Resident 10 were unsuccessful.During an interview on 01/09/2026 at 12:38 PM, Staff B, Certified Nursing Assistant (CNA) said, if a resident was a high risk for falls, the nurse would let the aide know. Staff B said there would be a star on the door indicating high fall risk. Staff B said the bed would be put in the lowest position, they would keep the door open, and complete frequent checks. Staff B said if a resident was a high fall risk, their bed should not be in a high position, it should be in a low position. During an interview on 01/09/2026 at 12:45 PM, Staff C, CNA said, if a resident was a high fall risk their bed would be put in a low position, they would check on them often, and leave the door open. Staff C said if a resident was a high risk for falls, their bed should not have been high and it should be low for safety.During an interview on 01/09/2026 at 01:12 PM, Staff D, Licensed Practical Nurse (LPN) said, each resident would have a fall risk assessment completed to assess for fall risk. Staff D said if a resident was a fall risk, the interventions would be in the care plan and on the Kardex. Staff D said if a resident was a fall risk, the bed should be low and not at a high level. During an interview on 01/09/2026 at 02:30 PM, Staff E, Resident Care Manager/Registered Nurse (RCM/RN) said, if a resident was identified as being a fall risk, they would be put on the falling star program where they would place a card with a star outside of the door, letting everyone know they were a fall risk. Staff E said more frequent observations would be done. Staff E said the information would be on the Kardex and they would notify nurses and aides. Staff E said the interdisciplinary team would make a decision about placing residents on the falling star program and what interventions would have been put in place. Staff E said not all residents with a high fall risk score were added to the falling star program or have a star on their door. Staff E said if a resident was a high fall risk, their bed should not be in a high position if they are in their bed. Staff E said the call light should be within reach for all residents.During an interview on 01/09/2026 at 02:57 PM, Staff A, Director of Nursing/Registered Nurse (DNS/RN) said not all residents at high risk for falls were put on the falling star program. Staff A said if they were not on the falling star program, but were a high risk for falls, management would communicate interventions in the care plan and Kardex. Staff A said it is their expectation that the bed would not be elevated high at waist level for a resident that was a fall risk. Staff A said it is standard of practice for all beds to be at sitting level or lower. Staff A said it is their expectation that call lights be within reach of all residents, including a fall risk. Reference WAC 388-97-1060(3)(g).

Based on interview and record review, the facility failed to ensure residents were administered their ordered anticoagulation (blood thinner-to reduce the risk of the formation of blood clots) medication for 3 of 15 sampled residents (Resident 1, 2, and 3) reviewed for significant medication errors. Resident 3 experienced harm when they did not receive anticoagulation medication as ordered for 17 days due to a medication reconciliation error and had a decline in condition that included signs and symptoms of a stroke (a medical condition that occurs when blood flow to the brain is interrupted or reduced, leading to brain tissue damage) that required transport to the emergency room (ER) for evaluation and treatment. This failure placed residents who were prescribed anticoagulant medications at risk for medical complications, injury and a decreased quality of life. Findings included .Review of the facility policy titled Coumadin (warfarin sodium) Therapy, reviewed 09/16/2024, states 2. The coumadin order should specify the following:A. Name of medicationB. Strength of medicationC. DosageD. Frequency of medicationE. Route of administrationF. Duration of therapyG. Diagnosis or indication for useH. Coagulation test (PT and INR are recomme3nded to be drawn at least monthly) <Resident 3> Review of Resident 3's admission Minimum Data Set (MDS, a required assessment tool), dated 06/27/2025, showed Resident 3 originally admitted on [DATE] with multiple diagnosis which included atrial fibrillation (a common heart rhythm disorder where the upper chambers of the heart beat irregularly and rapidly), hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (a stroke with weakness of one side of the body). The MDS documented Resident 3 was severely cognitively impaired. A review of the August 2025 electronic medication administration record (eMAR) documented Resident 3 was ordered Rivaroxaban (an anticoagulant). The eMAR documented Resident 3 did not receive 17 doses of Rivaroxaban between the dates of 07/12/2025-07/28/2025. The missed doses occurred on: 07/12/2025 07/13/2025 07/14/2025 07/15/2025 07/16/2025 07/17/2025 07/18/2025 07/19/2025 07/20/2025 07/21/2025 07/22/2025 07/23/2025 07/24/2025 07/25/2025 07/26/2025 07/27/2025 07/28/2025 The electronic health record (EHR) for Resident 3, documented on 06/25/2025, a provider ordered Rivaroxaban oral tablet 20 milligrams (MG) give one tablet by mouth one time a day for atrial fibrillation with a start date of 06/25/2025. This order was discontinued on 07/11/2025 at 8:56 PM with no corresponding progress note indicating the reasoning. A progress note, dated 07/28/2025 at 08:45 AM, documented At approx. 8:30 AM, resident was being toileted by CNA [certified nursing assistant]. He was fine getting on to toilet but when she went to take him off toilet, his left side went limp, he developed L [left side] sided facial droop, slurred speech and L arm and leg appear flaccid. 911 was called immediately and he was taken to [hospital] at approx. 08:45 AM. Wife notified and will meet him in ER. Review of hospital records, dated 07/28/2025, showed Resident 3 was admitted to the hospital with an ischemic stroke, left sided weakness. Resident 3's stroke scale went from an eight to a 12 while in the hospital for two days. On 08/14/2025 at 1:47 PM, Staff C, Resident Care Manager (RCM)/Licensed Practical Nurse (LPN), said she was in Resident 3's orders to change his Entresto (heart medication) order from a pill form to a liquid form. Staff C said, the Rivaroxaban order was accidentally discontinued on 07/11/2025 while she was changing the Entresto order to liquid form. Staff C said, she was not sure what happened. Staff C said this resident should have continued getting the Rivaroxaban daily. When asked how many days Resident 3 did not receive Rivaroxaban. Staff C said, Resident 3 did not receive the medication for 17 days (07/11/2025-07/28/2025) with Resident 3 discharging to the ER on [DATE] for a change in condition. On 8/18/2025 at 4:03 PM a form titled, Performance Improvement Action Plan (PIP), Process: Anticoagulant care was submitted by the Director of Nursing Services to The Department. The PIP describes: International Normalized Ratio (INR-a blood test to assess the clotting ability of the blood) records with anticoagulant orders will be reviewed daily in clinicalResident Care Mangers will enter all anticoagulant orders and must be signed off with a 2nd nurse signature validating accuracy of ordersAnticoagulant education initiated with nursing staff <Resident 1>Review of Resident 1's annual MDS, dated [DATE], showed Resident 1 originally admitted on [DATE] with multiple diagnosis which included atrial fibrillation, presence of prosthetic heart valve (an artificial replacement for a damaged or diseased heart valve used to restore proper blood flow through the heart), and history of other venous thrombosis and embolism (thrombosis refers to the formation of a blood clot inside a blood vessel and an embolism occurs when a blood clot travels through the bloodstream and blocks a blood vessel causing a blockage). The MDS documented Resident 1 was cognitively intact. A review of the August 2025 electronic medication administration record (eMAR) documented Resident 1 was ordered Warfarin (an anticoagulant). The eMAR documented Resident 1 did not receive five doses of Warfarin between the dates of 08/13/2025-08/17/2025. The missed doses occurred on: 08/13/2025 08/14/2025 08/15/2025 08/16/2025 08/17/2025 The Warfarin flow sheet (an ongoing working form) for Resident 1 documented an order was received on 08/12/2025 that read Warfarin Sodium Oral tablet give 4.5 MG every evening with a stop date of 08/17/2025. The EHR for Resident 1 documented on 08/12/2025 the transcribed order for Warfarin Sodium Oral tablet give 4.5 MG by mouth one time only for warfarin related to chronic combined systolic and diastolic heart failure (the heart chambers have difficulty both pumping blood effectively and relaxing and filling with blood properly) until 08/17/2025 23:59. This Warfarin order was placed with an inaccurate time code for administration, one time only versus daily.On 08/18/2025 at 3:07 PM, when asked about the Warfarin flow sheet and the missed doses of coumadin for Resident 1, Staff B, RCM/Registered Nurse (RN), was able to show where the flow sheet was updated correctly. Staff B said, the Warfarin order for Resident 1was put in with the correct start date and end date but as a one-time only order instead of daily. Staff B said, the Warfarin order was put into the computer incorrectly. Staff B said, Resident 1 should have received Warfarin on the dates of 08/13/2025, 08/14/2025, 08/15/2025, 08/16/2025, and 08/17/2026. Staff B said, the Warfarin flow sheet documented an order was received on 08/12/2025 for Warfarin 4.5 MG by mouth daily until 08/17/2025. Staff B said, the Licensed Nurse (LN) unfortunately entered the order incorrectly into the eMAR. Staff B said, the Warfarin order was put in with the correct dosage, start date, and stop date but instead of daily it was put in as one time only. The start date was 08/12/2025 and the stop date was 08/17/2025 so when the LN signed the eMAR as administered on 08/12/2025 the order completed itself. Staff B said, Resident 1 did not receive Warfarin on 08/13/2025, 08/14/2025. 08/15/2025, 08/16/2025, or 08/17/2025 and Resident 1 should have. Staff B said, for order reconciliation the RCMs should be looking at the orders written for accuracy daily. <Resident 2>Review of Resident 2's admission MDS dated [DATE], showed Resident 2 admitted on [DATE] with multiple diagnosis which included atrial fibrillation. The MDS documented Resident 2 was moderately cognitively impaired. A review of the August 2025 eMAR documented Resident 2 was ordered Warfarin. The eMAR documented Resident 2 did not receive one dose of Warfarin on 08/07/2025. The Warfarin flow sheet for Resident 2 documented an order was received on 08/04/2025 that read Warfarin Sodium Oral tablet give 2.5 MG every Thursday starting on 08/07/2025 with no stop date indicated. This order was discontinued on 08/07/2025 (Thursday) at 11:59 AM prior to the dose to be administered at 5:00 PM. The EHR for Resident 2 documented on 08/04/2025 provider ordered Warfarin Sodium Oral tablet give 2.5 MG by mouth every Thursday for atrial fibrillation to start on 08/07/2025 which the computer placed as the first dose to be given on the following Thursday. On 08/18/2025 at 3:40 PM, Staff C, RCM/LPN, was asked why Resident 2 did not receive their Warfarin on 08/07/2025 and 08/08/2025. Staff C said, Resident 2 had orders for Warfarin 5mg one time a day on Monday, Tuesday, Wednesday, Friday, Saturday, and Sunday with a start date of 08/04/2025 which was discontinued on 08/07/2025 and an order dated 08/04/2025 to start on 08/07/2025 (Thursday) for Warfarin 2.5 MG one time a day every Thursday at 1700. This order was discontinued on 08/07/2025 at 11:39 AM. Staff C said, it looks like Warfarin was held on 08/08/2025. Staff C said, Resident 2 should have received the Warfarin on 08/07/2025.On 08/18/2025 at 4:03 PM, Staff A, Director of Nursing Services (DNS)/RN said, Resident 3 had an order for Rivaroxaban that was discontinued in error. Staff A said, the Rivaroxaban order should not have been discontinued, and Resident 3 should have continued to receive it daily. Staff A said, Staff B had reported to Staff A the discrepancy in the Warfarin order for Resident 1 and immediately did an audit for all anticoagulants to ensure accuracy. Staff A said, the Warfarin order for Resident 1 was placed incorrectly into the eMAR resulting in the resident missing five doses of Warfarin on the dates of 08/13/2025, 08/14/2025, 08/15/2025, 08/16/2025, and 08/17/2025. Staff A said, the Warfarin order for Resident 2 was discontinued prior to the dose that was to be administered on 08/07/2025 preventing the resident from getting the dose for that day. Staff A said she was not aware of a policy for order reconciliation.Reference: WAC 388-97-1060(3)(k)(iii).

Based on observation, interview, and record review, the facility failed to prepare and store food in a sanitary manner in the main kitchen and 3 of 3 resident refrigerators (West, East, and Transitional Care Unit) when reviewed for kitchen. This failure placed residents at risk of consuming expired or spoiled food, foodborne illness, avoidable discomfort, and a diminished quality of life. Findings included . Observation on [DATE] at 9:10 AM to 9:26 AM of the kitchen showed the following: 1) Two freestanding refrigerators with temperature logs missing 5 of 13 temperatures. 2) One freestanding refrigerator with opened and undated whipped frosting. 3) Three plates of cooked and plated breakfast meal plates on the shelf above the steamtable without temperature controls. 4) Walk-in refrigerator/freezer combo temperature log missing 3 of 13 temperatures. 5) Freezer with frozen vegetable medley in a metal container with no labeling, pan of stuffing with a ,d+[DATE] date, open bag of vegetable medley left open with no date, and a bag of chicken patties left open with no date. 6) Dry storage with box of rice left open with no labeling and four bags of powdered gravy opened without labeling. Observation on [DATE] at 11:33 AM to 1:07 PM of the kitchen showed the following: 1) Staff Y, Dietary Aide, performed hand hygiene, placed barehand on a rolling garbage can to pull it from beneath a counter, threw away the paper towel, and then returned to work. 2) Staff Z and Staff AA, Dietary Aides, with loose hair uncovered by hairnet working in the kitchen. Observation on [DATE] at 1:22 PM showed the Transitional Care Unit (TCU) resident refrigerator contained three hardboiled eggs unshelled without a date and one small plastic container with a shelled hardboiled egg without date. Observation on [DATE] at 1:27 PM showed the East Hall resident refrigerator contained an opened can of soda without labeling and a carton of oat milk with the date written over the use by date. Observation on [DATE] at 1:27 PM showed the East Hall resident refrigerator contained a bottle of chipotle spread with a use by date of [DATE], a bottle of jalapeno sauce with a use by date of [DATE], six bottles of vitamin water with use by dates of [DATE], and one bottle of vitamin water with a use by date of [DATE]. Observation showed the temperature log informed staff that the refrigerator temperature should be between 36- and 46-degrees Fahrenheit. During an interview on [DATE] at 3:11 PM, Staff BB, Food Service Director, stated food in the kitchen refrigerator should be dated with a use by date once opened and the observations of unlabeled items did not meet expectation. Staff BB stated food should not be prepared and left above the steamtable without temperature control. Staff BB stated all hair should be covered by hairnets when working in the kitchen and staff should use the foot operated garbage cans when performing had hygiene. Staff BB stated Staff Y should not have touched the garbage can when performing hand hygiene and Staff Z and AA should have had their hair completely covered. Staff BB stated the temperature log on the [NAME] Hall did not meet expectation because it was for monitoring vaccine refrigerators. Staff BB stated the food storage in the [NAME], East and TCU resident refrigerators did not meet expectation because of unlabeled or expired items. During an interview on [DATE] at 10:29 AM, Staff C, Regional [NAME] President, stated food in the refrigerators should be labeled and sealed once opened. Staff C stated food that was not served should be thrown away or kept on temperature controls. Staff C stated hairnets should cover all staff hair when in the kitchen and staff should not touch the garbage can when performing hand hygiene. Staff C stated the facility's resident refrigerators did not meet expectation. Reference WAC [DATE] (3), -2980

Based on interview and record review, the facility failed to provide written notification of the reason for transfer to the hospital to the Office of State Long-Term Care Ombudsman (SLTCO, an advocacy group for residents in a nursing home) and/or to the resident/resident representative of discharges for 4 of 4 sampled residents (Residents 32, 54, 95, and 26) reviewed for hospitalization and/or discharge. These failures placed residents at risk for being inappropriately discharged , lack of access to an advocate who could inform them of their options and rights, and to ensure that the SLTCO and resident/ resident representative was aware of facility practices and activities related to transfers and discharges. Findings included . Resident 32 Review of the electronic health record (EHR) showed Resident 32 readmitted to the facility on [DATE] with diagnoses that included heart failure, kidney failure, and diabetes (too much sugar in the blood). Resident 32 was able to make needs known. Review of Resident 32's EHR showed a hospitalization on [DATE], readmission to the facility on [DATE], hospitalization on [DATE], and readmission to the facility on [DATE]. The EHR did not show documentation that transfer notices were provided for either discharge to the SLTCO. During an interview on 01/09/2025 at 2:48 PM, Staff B, Director of Nursing Services (DNS) stated social services should notify the SLTCO of transfer/discharges. During an interview on 01/10/2025 at 2:17 PM, Staff F, Social Services Director (SSD), stated the SLTCO was not notified of Resident 32's transfer/discharge to the hospital on 06/13/2024 or on 11/02/2024 and should have been. 46148 Resident 54 Review of the EHR showed Resident 54 admitted to the facility on [DATE] with diagnoses including congestive heart failure (when the heart fails to pump blood effectively) and kidney disease. Review of the EHR showed Resident 54 was discharged to the hospital on 06/06/2024. The EHR did not show documentation the resident or their representative was notified in writing of the reason for transfer. THe EHR did not show documentation the SLTCO office was notified of the transfer. During an interview on 01/09/2025 at 10:55 AM, Staff E, Registered Nurse (RN), stated they did not use a transfer form, We just call the residents power of attorney (POA). During an interview on 01/09/2025 at 1:19 PM, Staff F, SSD, stated, We did not send any ombudsman notification for [Resident 54's] transfer to the hospital on 06/06/2024. 49926 Resident 95 Review of EHR showed Resident 95 admitted to the facility on [DATE] with diagnoses that included postprocedural hemorrhage of a digestive system organ or structure following a digestive system procedure (bleeding after procedure), cancer of pancreas and altered mental status. Review of Resident 95's discharge minimum data set assessment (MDS), an assessment tool, dated 10/26/2024, showed an unplanned discharge with return anticipated. Review of the EHR showed no documentation about SLTCO notification. Review of the EHR showed no documentation about nursing home transfer or discharge notice. During an interview on 01/10/2025 at 12:00 PM, Staff F, SSD, stated the social service department was to complete SLTCO notification, but it was not done in the past months. Resident 26 Review of EHR showed Resident 26 admitted to the facility on [DATE] with diagnoses that included cellulitis (infection) of right lower limb, anxiety and atrial fibrillation (an irregular heart rate that causes poor blood flow). Review of Resident 26's discharge MDS, dated [DATE], showed an unplanned discharge with return anticipated. Review of the EHR showed no documentation about nursing home transfer or discharge notice. During an interview on 01/10/2025 at 12:00 PM, Staff F, SSD, stated the nursing department would provide transfer and discharge notice when a resident was sent to the hospital. Staff F was not able to locate documentation regarding transfer/discharge notices for Residents 95 and 26. During an interview on 01/13/2025 at 10:45 AM, Staff B, Director of Nursing Services, stated the nursing department was responsible for the transfer/discharge notices and not having this documentation in the records was not an acceptable practice. Reference WAC 388-91-0120(2)(a-d)

Based on interview and record review, the facility failed to provide a bed-hold notice in writing at the time of transfer/discharge to the hospital and/or to provide/complete bed-hold notices within 24 hours of transfer/discharge to the hospital for 3 of 4 sample residents (Residents 32, 26, and 95) reviewed for hospitalization /discharge. This failure placed the residents at risk for a lack of knowledge regarding the right to a bed-hold while they were hospitalized . Findings included . Resident 32 Review of the electronic health record (EHR) showed Resident 32 readmitted to the facility on [DATE] with diagnoses that included heart failure, kidney failure, and diabetes (too much sugar in the blood). Resident 32 was able to make needs known. Review of Resident 32's EHR showed a hospitalization on [DATE] with readmission to the facility on [DATE] and a hospitalization on [DATE] with readmission to the facility on [DATE]. The EHR did not show documentation the resident and/or the resident's responsible party was offered a bed hold for either transfer/discharge to the hospital. During an interview on 01/09/2025 at 2:48 PM, Staff B, Director of Nursing Services (DNS), stated the Director of Admission should offer bed holds and follow up as needed. Staff B stated bed holds for Resident 32's transfer/discharges to the hospital were not done and should have been. 49926 Resident 95 Review of the EHR showed Resident 95 admitted to the facility on [DATE] with diagnoses that included postprocedural hemorrhage of a digestive system organ or structure following a digestive system procedure (bleeding after procedure), cancer of pancreas and altered mental status. Review of Resident 95 discharge minimum data set assessment (MDS), an assessment tool, dated 10/26/2024, showed an unplanned discharge with return anticipated. Review of the EHR did not show documentation of a bed hold. Resident 26 Review of the EHR showed Resident 26 admitted to the facility on [DATE] with diagnoses that included cellulitis (infection) of right lower limb, anxiety and atrial fibrillation (an irregular heart rate that causes poor blood flow). Review of Resident 26's discharge MDS, dated [DATE], showed an unplanned discharge with return anticipated. Review of the EHR did not show documentation of a bed hold. During an interview on 01/10/2025 at 12:00 PM, Staff F, Social Service Director, stated the nursing department was responsible for bed hold documentation when a resident was sent to the hospital. Staff F was not able to provide any documentation about bed holds for Residents 95 and 26. During an interview on 01/13/2025 at 10:45 AM, Staff B, DNS, stated the nursing department was responsible for providing and documenting bed holds, and not having this documentation in the records was not an acceptable practice. Reference WAC 388-91-0120(4)

Based on interview and record review, the facility failed to ensure Pre-Admission Screening and Resident Review (PASARR) assessments were accurately completed for 3 of 6 sampled residents (Residents 29, 49 and 40) reviewed for PASARRs and unnecessary medications. This failure placed the residents at risk for unidentified mental health care needs. Findings included . Review of a document titled, Pre-admission Screening and Resident Review (PASARR), dated 09/26/2024, showed the facility would ensure that potential admissions were to be screened for possible mental disorders or intellectual disabilities and related conditions. A positive Level I screen necessitated an in-depth evaluation of the individual by the state designated authority, known as PASARR Level II, which must be conducted prior to admission to a nursing facility. Resident 29 Review of Resident 29's admission minimum data set assessment (MDS, a required assessment), dated 07/29/2024, showed the resident admitted on [DATE] with multiple health conditions including bipolar disorder, (a mental illness that causes extreme shifts in mood, energy activity levels and concentration), depression, and post-traumatic stress disorder (PTSD, an anxiety disorder that develops in reaction to physical injury or severe mental or emotional distress). The resident was able to make their needs known. Review of Resident 29's electronic health record (EHR) showed a Level I PASARR, dated 07/24/2024, was completed by a social work staff at a local medical care facility. The PASARR form had documentation that was marked No Level II evaluation indicated at this time due to exempted hospital discharge: Level II must be completed if scheduled discharge does not occur. During an interview on 01/09/2025 at 8:40 AM, Staff F, Social Service Director (SSD), stated the PASARR was now incorrect since Resident 29 did not discharge within the designated 30 days from the facility. Staff F, SSD, stated the PASARR for Resident 29 would need to be corrected. During an interview on 01/09/2025 at 8:49 AM, Staff C, Regional [NAME] President, stated it was their expectation that the SSD corrected or redid the Level I PASARR to ensure the resident received the Level II PASARR evaluation by the state evaluator. 40817 Resident 49 Review of the EHR showed Resident 49 admitted to the facility on [DATE] with diagnoses of hemiplegia (inability to move one side of the body), dementia (a general term for a group of brain conditions that cause a decline in mental abilities), and depression. Resident 49 was not able to make needs known. Review of the PASARR Level I, dated 12/15/2023, showed Resident 49 required a PASARR Level II. During an interview on 01/09/2025 at 10:59 AM, Staff F, SSD, stated any resident with a mental health diagnosis should be referred for a PASARR Level II. Staff F stated Resident 49 had a mental health diagnosis and the PASARR Level I dated 12/14/2023 showed a PASARR Level II was required. During an interview on 01/10/2025 at 10:49 AM, Staff F stated Resident 49's PASARR Level I was not transmitted to the PASARR coordinator, and this did not meet expectation. During an interview on 01/13/2025 at 10:27 AM, Staff C, Regional [NAME] President, stated PASARR Level I should be transmitted timely and Resident 49's lack of PASARR Level II did not meet expectation. 46148 Resident 40 Review of the EHR showed Resident 40 admitted to the facility on [DATE] with diagnoses to include dementia and traumatic subarachnoid hemorrhage (a bleed in the brain). Review of Resident 40's EHR showed a PASARR Level I with a completion date of 11/18/2024. The recommendation was for the resident to be referred for a PASARR Level II evaluation which was required for a change of condition. Review of the EHR did not show PASARR Level II documentation. During an interview on 01/09/2025 at 10:32 AM, Staff F, SSD, stated they had not referred Resident 40 for a PASARR Level II. During an interview on 01/09/2025 at 1:44 PM, Staff B, DNS, stated it was their expectation that the SSD complete any PASARR Level II referrals and Resident 40 should have been referred. Reference WAC 399-97-1915 (1)(2)(a-c)

Based on observation, interview, and record review, the facility failed to ensure care plans were reviewed and revised after each quarterly assessment for 3 of 4 sampled residents (Residents 32, 50, and 22) when reviewed for care planning. This failure placed residents at risk of not receiving required care, avoidable decrease in health status, and a diminished quality of life. Findings included . Resident 32 Review of the electronic health record (EHR) showed Resident 32 admitted to the facility on [DATE] with diagnoses that included heart failure, kidney failure, and diabetes (too much sugar in the blood). Resident 32 was able to make needs known. Review of Resident 32's modified annual minimum data set assessment (MDS, a required assessment), dated 12/11/2024, showed the resident received dialysis (treatment to filter wastes and water from the blood) and received a mechanically altered and therapeutic diet (a meal plan that is designed to treat a medical condition or symptom). During an interview and observation on 01/08/2025 at 8:46 AM, Resident 32 stated they did not think they were on a special diet and did not think they were on a fluid restriction (a diet that limits the amount of fluids consumed each day); however, there was a sign posted on the wall above the resident's bed that showed, No Water Pitcher at bedside Fluid Restriction. Review of the provider order, dated 01/03/2023, showed Resident 32 was prescribed an 1800 milliliter (ml) fluid restriction. Nursing to provide 240 ml on day shift, 240 ml on evening shift, and 240 ml on night shift. Fluids from the kitchen for meals: Breakfast 360 ml, lunch 360 ml, dinner 360 ml related to end stage renal disease (kidney failure). During a follow-up interview on 01/08/2025 at 8:54 AM, Resident 32 stated they went to dialysis three days a week and that that the dialysis access site was located on their left arm, and they had no access site on their chest. Review of Resident 32's dialysis focused care plan, initiated on 02/22/2024, showed an intervention dated 07/24/2024 for the resident to be on enhanced barrier precautions (EBP, an approach of targeted gown and glove use during high contact resident care activities) due to a peripherally inserted central catheter (PICC, an inserted flexible tube used to administer intravenous fluids and drugs) site on the chest. During an interview on 01/09/2025 at 9:35 AM, Staff L, Registered Nurse (RN), stated Resident 32 did not have a PICC site on their chest and was not on EBP. During an interview on 01/09/2025 at 2:03 PM Staff M, RN/Unit Care Coordinator (RN/UCC), stated Resident 32's care plan did not meet expectations due to Resident 32 did not have a PICC site to the chest and the care plan needed to be revised. During an interview on 01/09/2025 at 3:46 PM, Staff B, Director of Nursing Services (DNS), stated Resident 32's care plan showed that they were on EBP due to a PICC site on their chest; however, the PICC was no longer there. Staff B stated that the care plan should have been revised. Review of Resident 32's nutrition focused care plan, revised on 01/08/2025, showed an intervention dated 03/29/2024 for fluid restriction of 1800 milliliters per day. This care plan did not show how much fluid would be provided during each meal or how much fluid could be provided each shift in between meals. During an interview on 01/09/2025 at 1:38 PM, Staff L, RN, stated residents on fluid restrictions should be care planned and should include how much fluid was provided by the kitchen for each meal and how much fluid was to be provided by nursing for each shift according to the provider order. During an interview on 01/09/2025 at 3:57 PM, Staff B, DNS, stated Resident 32's care plan for fluid restrictions did not meet expectations due to it needed to be more detailed of the breakdown of fluids to be provided as in the provider order and that did not happen for Resident 32. Staff B stated Resident 32's care plan needed to be revised. Review of the EHR showed Resident 32 had not been invited to a care conference after they admitted to the facility. During an interview on 01/10/2025 at 10:46 AM, Staff F, Social Services Director (SSD), stated Resident 32 had not had a care conference after admitting to the facility. Resident 50 During an interview on 01/07/2025 at 11:35 AM, Resident 50 stated they did not recall attending a care conference. Review of Care Plan Conference Record showed Resident 50's most recent care conference was held on 07/26/2024 and an invitation for a care conference had been mailed to Resident' 50's power of attorney on 12/30/2024. Review of the EHR showed Resident 50 had a quarterly MDS on 10/24/2024. During an interview on 01/10/2025 at 10:47 AM, Staff F, SSD, stated Resident 50 should have had a care conference after the 10/24/2024 quarterly assessment. Resident 22 During an interview on 01/07/2025 at 12:39 PM, Resident 22 stated it had been several months since their last care conference. Review of Care Plan Conference Record showed Resident 22's most recent care conference was held on 09/12/2024. Review of the EHR showed Resident 22 had a quarterly MDS on 12/10/2024. During an interview on 01/10/2025 at 10:47 AM, Staff F, SSD, stated Resident 22 should have had a care conference in December 2024 and was on the schedule to have a care conference in February 2025. During an interview on 01/08/2025 at 2:10 PM, Staff F, SSD, stated the facility was having difficulty maintaining the care conference schedule and some residents may not have had a quarterly care conference. Staff F stated residents should have care conferences when admitting to the facility, quarterly after the MDS assessment, and as need/requested. During an interview on 01/13/2025 at 10:22 AM, Staff C, Regional [NAME] President, stated care conferences should occur within the first 21 days after admitting to the facility, quarterly, and with change of condition. Staff C stated Resident 32's lack of care conference since admitting to the facility did not meet expectation. Staff C stated Residents 50 and 22 should have had care conferences after their comprehensive assessments. Reference WAC 388-97-1020(2)(c)(d)

Based on observation, interview, and record review, the facility failed to ensure there was a system to provide care and services consistent with standards of quality of care for 2 of 3 sampled residents (Residents 57 and 71) when reviewed for edema/heart failure, for 4 of 8 sampled residents (Residents 7, 40, 57 and 78) when reviewed for bowel management, for 1 of 1 sampled residents (Resident 40) when reviewed for hospice service, and for 1 of 3 sampled residents (Resident 32) when reviewed for hospitalization . The failure to develop and implement person-centered edema/heart failure care plans (CPs) that included notifying the provider of changes in condition, routine monitoring of weights and fluid status, implementing bowel program orders when required, including the hospice plan of care and to provide speech evaluation upon return from hospital per provider orders, placed the residents at risk for unmet needs, medical complications, constipation, and a diminished quality of life. Findings included . <EDEMA/HEART FAILURE> Review of an email dated 01/14/2025 showed Staff B, Director of Nursing Services (DNS), stated they did not have protocol for congestive heart failure (CHF, a chronic condition that occurs when the heart can't pump enough blood to meet the body's needs) or edema (swelling of a body part) management and these are physician/provider driven and resident specific. Review of the American Heart Association (Vol.8, No.3) Heart Failure Management in Skilled Nursing Facilities, published 04/08/2015, recommended for residents at risk for decompensation/exacerbation (decline in condition/a sudden worsening of a chronic illness or medical condition), residents should adhere to daily weight monitoring (same time of day-preferably first thing in the morning after the first toileting) and fluid volume evaluations. A weight gain of three to five pounds over three to five days should alert licensed staff to perform an advanced assessment of volume status, vital signs, and respiratory status; then promptly notify the physician with the findings. Routine daily symptom monitoring should occur for any degree of edema, abnormal lung sounds, cough (especially when lying down), jugular vein distention (JVD, a bulging of major veins in the neck and a key symptom of heart failure), difficulty breathing: at rest, when lying flat, and/or at night. Daily weights and symptom monitoring provided early identification of cardiac decompensation and minimized potential for re-hospitalization . Resident 57 Review of the electronic health record (EHR) showed Resident 57 admitted to the facility on [DATE] with diagnoses that included heart failure, lymphedema (a chronic condition that causes swelling in the body's tissues) and an open wound to the left lower leg. The resident was able to make needs known. Review of the EHR showed an order dated 11/28/2024 to check the resident's weight daily and notify the provider if the resident gained more than five pounds in a week or three pounds in a day. Review of the EHR showed an order, dated 12/11/2024, for staff to apply a kerlex (gauze) wrap as needed for drainage to the left lower leg. The treatment administration record showed no documented bandages had been applied. Review of the EHR showed no care plan was initiated for lymphedema or heart failure. Review of a provider note, dated 01/03/2025, showed increasing swelling with redness and warmth in the left lower extremity. Appears to be developing infection in the left lower extremity. Nursing staff was requesting a vascular and wound team referral and adjustment of Lasix. Resident was noted to have swelling in the left lower extremity with bruising/redness and a draining wound in the calf. Review of a provider note dated 01/04/2025 at 7:43 AM showed, Continue local wound care. Wound care referral to assist with management of the wound. Elevate limb as tolerated. During an interview and observation on 01/07/2025 at 1:29 PM, Resident 57 stated the nurses did not do anything with their legs. The resident stated their recliner chair did not work and they could not raise their legs. The resident had bilateral lower extremity edema (swelling to both legs), drainage was pooling on the floor under the left leg, the skin was red, and there was no dressings/bandages present. Observation on 01/08/2025 at 2:15 PM, showed Resident 57 sitting in a recliner at the side of their bed and their legs were not elevated. There was a bandage wrapped around the left calf with drainage noted soaking through. Observation on 01/09/2025 at 9:27 AM, showed Resident 57 laid in bed with an incontinence pad under both legs, no bandages were present, and drainage was noted on the pad. Observation and interview on 01/10/2025 at 2:15 PM, showed Resident 57 sat in their recliner chair and their legs were not elevated. The bandages present on the left lower leg were saturated with pink and green drainage dripping on the floor. Resident 57 stated they wished the recliner would work. During an interview and observation on 01/13/2025 at 9:36 AM, Resident 57 stated staff sometimes put bandages on and sometimes they did not. A white cloth blanket was on the floor under the resident's feet and was saturated with wound drainage. Both legs were red and very swollen. The recliner was not plugged in, and the resident was unable to elevate legs. Resident 57 stated they rested in bed at night but during the day they did not have a way to elevate their legs. Review of the weight record showed Resident 57 weighed 252.8 pounds on 01/04/2025 and 258.4 pounds on 01/11/2025, a gain of 5.6 pounds in seven days. Review of the EHR on 01/13/2025 showed no documentation of provider notification of increased drainage, swelling, and redness to the left lower leg or weight gain. Review of the EHR on 01/13/2025 showed no documentation the resident was referred to wound team, vascular clinic or the lasix being adjusted. During an interview on 01/13/2025 at 1:34 PM, Staff P, Registered Nurse, stated Resident 57 was not being seen by a wound care provider and that the dressings should be more than 'as needed.' Staff P stated they had not notified the provider yet but would now. Resident 71 Review of the EHR showed Resident 71 admitted to the facility on [DATE] with a diagnosis of CHF. The resident was able to make needs known. Observation on 01/07/2025 at 12:10 PM showed Resident 71 sat in an electric reclining chair that was unplugged with both feet on the floor and was noted to have swollen, red feet and ankles with drainage present on the socks. Observation and interview on 01/08/2025 at 2:13 PM, showed Resident 71 sat in the reclining chair with both feet on the floor. There was drainage present on their socks and both feet and ankles were swollen and red. Resident 71 stated they would like to elevate their legs, but they could not because the facility would not let them plug in the reclining chair. Resident 71 stated the facility turned all electric recliners off because someone fell , and it has been off for the last 14 days at least. Observation and interview on 01/09/2025 at 9:18 AM, showed Resident 71 sat in the electric recliner with their legs elevated and stated they plugged in the recliner. If the chair worked my feet would have been up. The sock on the right leg was saturated with fluid with thick white scabs that appeared wet. Observation on 01/10/2025 at 2:57 PM, showed Resident 71 sat in the recliner with feet elevated. They were red and swollen and drainage was noted on right leg ankle. Observation and interview on 01/13/2025 at 9:44 AM, showed Resident 71 sat in the recliner with their legs elevated, socks on both feet were saturated with drainage and redness was noted to the right leg. Resident 71 stated staff did not do any treatments to it and the redness was getting worse. Review of the EHR showed an order dated 12/27/2024 to check the resident's weight daily and notify the provider if the resident gained more than five pounds in a week or three pounds in a day. Review of the medication administration record (MAR) showed Resident 71 weighed 282.3 pounds on 12/31/2024 and 293.6 pounds on 01/07/2025, an 11.3 pound gain in seven days. Review of the EHR on 01/12/2024 showed no documentation that the provider was notified of the weight gain, no orders to monitor edema, and no care plan for CHF or edema. During an interview on 01/13/2025 at 9:49 AM, Staff K, Registered Nurse, stated if a resident had increased drainage, swelling and redness in their legs and/or had a weight gain of greater than five pounds in a week they would notify the provider and get orders for treatments. During an interview on 01/10/2024 at 1:45 PM, Staff B, Director of Nursing Services (DNS), stated the recliners had been unplugged related to a different resident's fall. The residents should be assessed for safety with use of the recliner if they needed it to elevate their legs. Staff B stated their expectation was for nursing staff to notify the provider of changes such as increased redness, swelling, drainage, and weight gain. <Bowel Management> Review of a document titled, Bowel Protocol dated 09/16/2024, showed that it was the policy of the facility to provide effective interventions for signs and symptoms of constipation that were consistent with current standards of practice. The licensed nursing staff were to record, in the electronic health record (EHR), each time a resident had a bowel movement (BM) and in coordination with the resident's attending practitioner implement standing orders to address a lack of BM. Resident 57 Review of the EHR showed Resident 57 admitted to the facility on [DATE] with diagnoses that included heart failure. The resident was able to make needs known. Review of the EHR showed a provider order for Miralax to be given as follows: 17 gram by mouth as needed for constipation daily. Mix with 4-8 ounces water or juice after 72 hours with no bowel movement. Review of December 2024 MAR showed Resident 57 had no bowel movement on the 28, 29, 30 and 31. Further review showed Miralax was not administered. Resident 7 Review of the EHR showed Resident 7 admitted to the facility on [DATE] with diagnoses including diverticulitis (abnormal folding of the intestines/bowel) and constipation. The resident was able to make needs known. During an interview on 01/07/2025 at 1:53 PM, Resident 7 stated they had been constipated recently and the staff had not administered any medications to help with it. Review of the bowel movement documentation showed no documented bowel movement from 12/20/2024 through 12/24/2024. Review of the December 2024 MAR showed as needed or scheduled laxatives were not administered to Resident 7 in that month. Resident 40 Review of the EHR showed Resident 40 admitted to the facility on [DATE] with diagnoses to include dementia and traumatic subarachnoid hemorrhage (a bleed in the brain) with cognitive communication deficit. Review of the provider orders showed an order, dated 11/29/2024, for Miralax (a laxative medication) as needed for constipation to be administered after 72 hours with no bowel movement. Milk of Magnesia Suspension if Miralax ineffective given on day five. Review of the EHR showed no documented bowel movements from 12/14/2024-12/17/2024, and no laxative was documented as administered as ordered. Review of a provider note dated 12/18/2024 showed Patient was noted to have distention and is noted to be constipated. Bowel tones present in all 4 quadrants. Per nursing patient had bowel movement recently; provide encourage nursing to start bowel protocol. Review of the EHR showed Resident 40 had a documented bowel movement on 12/18/2024 at 11 AM. Resident 40 received laxative medications on 12/19/2024 which were documented as ineffective. Review of the EHR showed no documented bowel movement from 12/22/2024-01/01/2025. On 12/26/2024 milk of magnesia (MOM) was documented as given with unknown results and on 12/31/2024 with ineffective results. Review of a progress note dated 01/01/2025 at 3:01 PM, showed Resident 40 had a distended abdomen. During an interview on 01/09/2025 at 11:13 AM, Staff K, Registered Nurse, stated the staff should start the bowel protocol after 72 hours with no bowel movement. During an interview on 01/10/2025 at 10:57 AM, Staff R, Advanced Registered Nurse Practitioner (ARNP), stated the bowel protocol should be implemented after three days or 72 hours without a bowel movement and if ineffective they should notify the provider. During an interview on 01/09/2025 at 1:24 PM, Staff B, DNS, stated it was their expectation that staff review clinical alerts daily and if a resident had gone 72 hours or greater without a bowel movement, they would start the bowel protocol and follow the provider's orders. Staff B stated Residents 7 and 40 should have had the bowel protocols started after 72 hours without a bowel movement. 34567 Resident 78 Review of the admission minimum data set (MDS, a required assessment tool) dated 11/04/2024, showed that Resident 78 admitted on [DATE] with multiple diagnoses to include dysphagia (a condition related to difficulty or discomfort in swallowing) and constipation. The MDS showed the resident was able to make needs known and was dependent upon staff with activities of daily living (ADLs). During an interview on 01/07/2025 at 2:20 PM, Resident 78 stated they had problem with constipation. Review of Resident 78's care plan, dated 10/31/2024, for activities of daily living, showed the resident had or had potential for problems related to constipation. Review of Resident 78's EHR task section documentation for BM results for Resident 78 showed staff had documented the resident had no BM greater than 72 hours twice from 12/26/2024, 8:29 PM to 12/30/2024, 1:35 AM and no BM recorded from 12/30/2024, 8:34 PM to 01/03/2025, 5:25 AM. Review of the MAR, dated 12/01/2024 to 12/31/2024, showed that Resident 78 had several physician orders to administer medication for constipation. The following, as needed, medication for the treatment of constipation included: MiraLAX as needed for no BM after 72 hours and Senna as needed for constipation at bedtime. Reivew of the December 2024 and January 2025 MARs showed the ordered constipation medications were not administered as needed during the time in which no BM was documented for the resident from 12/26/2024 to 12/30/2024 and again from 12/30/2024 to 01/03/2025 dates. During an interview on 01/09/2025 at 11:29 AM, Staff T, Assistant Director of Nursing (ADON), stated their expectation would be for the licensed nurses (LNs) to start the bowel program whenever the resident had greater than 72 hours without a BM. 46067 <Hospice Care Plan> Resident 40 Review of the EHR showed Resident 40 admitted to the facility on [DATE] with diagnoses that included cerebrovascular disease (condition that impacts the blood vessels in your brain) and diabetes (too much sugar in the blood). Resident 40 received hospice services and was able to make needs known. Review of EHR and medical record showed there was no hospice provider Plan of Care. During an interview on 01/08/2025 at 12:32 PM, Staff M, Registered Nurse/Unit Care Coordinator (RN/UCC), stated they were unable to locate the hospice provider Plan of Care in the medical record. Staff M stated the Plan of Care should have been in the medical record. During an interview on 01/10/2025 at 1:53 PM, Staff B, DNS, stated the expectation was that hospice residents had the Plan of Care in the medical record to ensure a comprehensive care plan. 38344 <Speech Evaluation> Resident 32 Review of the EHR showed Resident 32 readmitted to the facility on [DATE] with diagnoses that included heart failure, kidney failure, and dysphagia (difficulty swallowing foods or liquids). Resident 32 was able to make needs known. Review of Resident 32's modified annual MDS, dated [DATE], showed the resident received dialysis (treatment to filter wastes and water from the blood) and received a mechanically altered/therapeutic diet (a meal plan that is designed to treat a medical condition or symptom). Review of the EHR showed Resident 32 was hospitalized on [DATE] and returned to the facility on [DATE]. Review of Resident 32's care management progress note dated 12/31/2024 at 3:08 PM showed, Hospital orders say diet texture is regular for safety of resident and Speech eval in facility recommendation is to be on mechanical texture and a referral to speech to evaluate accurate diet texture. Review of Resident 32's skilled progress note, dated 12/31/2024 at 11:56 PM, showed/included Admitting DX [diagnosis] of pneumonia and Able to eat independently with tray set-up. Review of Resident 32's EHR showed no documentation that that a speech evaluation had been completed after readmitting to the facility on [DATE]. During an interview on 01/10/2025 at 11:46 AM after reading Resident 32's care management progress note dated 12/31/2024, Staff N, Director of Rehabilitation Services, stated this should have been brought up in their clinical meeting so a screen could have been completed and orders obtained as needed and that did not happen for Resident 32. Staff N stated somehow the communication from the progress note got missed getting to rehabilitation services. Staff N stated Resident 32's last speech evaluation was completed on 11/16/2024 (prior to readmission to facility on 12/31/2024). During an interview on 01/10/2025 at 2:22 PM, Staff B, DNS, stated there should have been a speech evaluation upon Resident 32's return to the facility on [DATE] or by the next day. Reference WAC 388-97-1060 (1)

Based on observation, interview, and record review, the facility failed to ensure medications and biologicals were securely locked for 3 of 26 sampled residents (Residents 90, 9, and 64) when reviewed for environment. This failure placed the resident at risk for consuming non-prescribed medications, unintended side effects of medications, medical complications, and a diminished quality of life. Findings included . Review of the facility policy titled Storage and Expiration of Medications, Biologicals revised on 08/07/2023, showed under General Storage Procedures Store all drugs and biologicals in locked compartments. Resident 90 Review of the electronic health record (EHR) showed Resident 90 admitted to the facility on [DATE] with multiple diagnoses that included fracture of right leg, respiratory failure and muscle weakness. Resident 90 was able to make needs known. Observation and interview on 01/07/2024 at 11:10 AM showed Resident 90 had multiple medications in pill form, inhalers, and nebulizing prescriptions at their nightstand and the sink countertop in their room. Resident 90 stated they took some of them. Observation on 01/08/2025 from 8:30 AM until 3:00 PM showed the medications continued unsecured in Resident 90's room. Resident 64 Review of the EHR showed Resident 64 admitted to the facility on [DATE] with diagnoses that included repeated falls, asthma, and lung cancer. Resident 64 was able to make needs known. Observation on 01/07/2025 at 9:50 AM showed Resident 64 had an inhaler medication at bed site on over the bed table. Resident 9 Review of the EHR showed Resident 9 admitted to the facility on [DATE] with diagnoses of laminectomy (surgical procedure that removes part or all the laminate of the spinal canal) in the lumbar low back region, urinary tract infection, and chronic kidney disease. Resident 9 was able to communicate needs. Observation on 01/10/2024 at 9:50 AM showed Resident 9 had a topical pain patch at bedside on an over the bed table. During an interview on 01/10/2025 at 1:48 PM, Staff B, Director of Nursing Services, stated the expectation was for medications to be securely stored and locked. Reference WAC 388-91-1300(2)

Based on interview and record review, the facility failed to periodically review residents advanced directive (AD, a legal document that states your wishes for medical care if you are unable to make decisions for yourself) for 1 of 4 sampled residents (Resident 32) when reviewed for advanced directive. This failure placed the resident at risk of not having an established decisionmaker, lack of ability to direct care, and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 32 readmitted to the facility on [DATE] with diagnoses that included heart failure and kidney failure. Resident 32 was able to make needs known. Review of a document titled Attachment H showed Resident 32 received information regarding establishing an AD on 02/26/2024. During an interview on 01/08/2025 at 2:07 PM, Staff F, Social Services Director (SSD), stated the facility informed residents of their right to formulate an AD on admission and the residents signed Attachment H once they received this information. Staff F stated the facility periodically reviewed the AD during care conferences. During an interview on 01/10/2025 at 10:43 AM, Staff F stated Resident 32 received information about formulating an AD on 02/26/2024 and had not had periodic review until 01/08/2025. During an interview on 01/13/2025 at 9:56 AM, Staff C, Regional [NAME] President, stated residents were informed of their right to formulate an AD on admission and the AD was reviewed quarterly. Reference WAC 388-97-0280 (3)(c)(i-ii), -0300 (1)(b), (3)(a-c)

Based on observation, interview, and record review, the facility failed to ensure residents' personal items were safe for 1 of 5 sampled residents (Resident 64) when reviewed for Personal Property and failed to ensure residents' rooms were homelike for 1 of 6 sampled residents (Resident 50) when reviewed for environment. These failures placed residents at risk of financial exploitation, feelings of worthlessness, decreased mood, and a diminished quality of life. Findings included . Resident 64 Review of the electronic health record (EHR) showed Resident 64 admitted to the facility on [DATE] with diagnoses of dementia (a group of brain conditions that cause a decline in mental abilities) and cognitive communication deficit (difficulty in communicating). Review of the modification of quarterly minimum data set assessment (MDS), an assessment tool, dated 11/25/2024, showed Resident 64's vision was adequate with corrective lenses. During an interview and observation on 01/09/2025 at 10:57 AM, Resident 64 stated they lost their glasses approximately a week prior and told facility staff they were missing. Observation showed a clear glasses case on the resident's overbed table which was empty. During an interview on 01/10/2025 at 11:18 AM, Resident 64 stated their glasses were still lost and they could not read without them. Review of an inventory list, dated 08/05/2024, showed Resident 64 admitted to the facility with glasses which were black with multicolor on the side. Observation on 01/13/2025 at 9:31 AM, showed Resident 64 in bed with eyes closed. Observation showed the clear glasses case was empty on the overbed table. Review of the facility grievance log from July 2024 to 01/13/2025 showed no grievance logged for Resident 64's missing glasses. During an interview on 01/13/2025 at 11:03 AM, Staff X, Certified Nursing Assistant (CNA), stated Resident 64 had lost their glasses a few days ago. Staff X stated they had not initiated a grievance for Resident 64's missing glasses. During an interview on 01/13/2025 at 11:12 AM, Staff F, Social Services Director (SSD), stated missing items should be written on a grievance form for Staff A, Administrator, to process. Staff F stated Staff A was currently out of the building and the grievance process was being handled by Staff T, Assistant Director of Nursing Services (ADON). During an interview on 01/13/2025 at 11:14 AM, Staff T stated when a missing item was reported to facility staff a grievance form should be generated. Staff T stated there was no grievance for Resident 64's missing glasses and this did not meet expectation. During an interview on 01/13/2025 at 11:57 AM, Staff C, Regional [NAME] President, stated facility staff should fill out a grievance form when a resident reported missing items. Staff C stated when Resident 64 reported their missing glasses facility staff should have completed a grievance form so the facility could search for them and coordinate obtaining new glasses, if needed. 38344 Resident 50 Review of Resident 50's EHR showed the resident admitted to the facility on [DATE] with diagnoses to include muscle weakness, need for assistance with personal care, depression, and was able to make needs known. Multiple observations on 01/07/2025, 01/08/2025, 01/09/2025, 01/10/2025 and 01/13/2025 showed Resident 50's over the bed light fixture metal pull cord had a clear plastic garbage bag tied to the end of a metal pull cord. During an interview on 01/07/2025 at 11:36 AM, Resident 50 stated that a staff member had tied the plastic bag to the overbed light cord so they could reach the cord to turn off and on the light fixture. During an interview on 01/13/2025 at 11:40 AM, Staff H, Floor Technician, stated they worked in the housekeeping and maintenance departments for about three years. Staff H stated that Resident 50's plastic bag attached to the overbed light fixture pull cord should not be there because it was not a cleanable surface. Staff H stated they were not aware that the bag was there. Reference WAC 388-97-0880

Based on observation, interview, and record review, the facility failed to implement pressure ulcer care for 2 of 4 sampled residents (Residents 78 and 72) reviewed for pressure injuries (injuries to skin and underlying tissue resulting from prolonged pressure on the skin). This failure placed the resident at risk for worsening pressure injuries, pain, and a decreased quality of life. Findings included . Review of a policy titled, Skin Integrity and Pressure Ulcer/Injury Prevention and Management, dated 07/09/2024, showed staff were to provide treatment and care of the resident wounds utilizing professional standards of the National Pressure Injury Advisory Panel (NPIAP). The facility must ensure resident care was provided to pressure ulcers consistent with professional standards of practice to promote healing and prevent infection. Resident 78 Review of the admission minimum data set (MDS, a required assessment tool), dated 11/04/2024, showed Resident 78 admitted on [DATE] with multiple diagnoses to include heart disease, stroke, muscle weakness, dysphagia (a condition related to difficulty or discomfort in swallowing), and constipation. The MDS showed the resident was able to make needs known and was dependent upon staff with activities of daily living (ADLs). The electronic health record (EHR) showed the resident had a pressure ulcer to the sacrum (the area of the lower back at the base of the spine and in the center of the pelvis). Review of Resident 78's focus care plan, dated 11/21/2024, showed the resident was at risk for unavoidable pressure injury development and interventions directed licensed nurses (LNs) to provide treatment as ordered. Observation and interview on 01/07/2024 at 2:18 PM, showed Resident 78 sat up in a wheelchair within their room. The resident stated they had a pressure wound on their buttocks area and staff provided wound treatment to that area but was unable to state whether it was healing, how large the wound was to the area or the treatment that was being provided. Review of Resident 78's providers orders showed they had a referral to outside wound provider for evaluation and treatment as indicated, dated 11/14/2024. The provider ordered additional wound care treatment (12/16/2024) to be provided to the resident's sacrum pressure wound with wound cleanser, allow to dry and apply medi honey (a wound mixture which contains compounds which contributes to antibacterial wound activity) every day and when necessary. Review of the outside wound provider notes dated 01/02/2025 and 01/09/2025 showed the provider had provided extensive treatment to Resident 78's sacral pressure wound that consisted of wound debridement (a procedure that removes dead or unhealthy tissue form a wound to help it heal). The outside wound provider had ordered a change in the resident's wound treatment that consisted of LNs to clean the resident's sacral wound with Dakins (a disinfectant wound cleanser) and for the LN to apply skin prep to the peri wound (area around the wound) and allow to dry, apply Santyl (a treatment method that assists in removing dead tissue from the wound bed while preserving healthy tissue) and fill the sacral cavity with moistened gauze and cover with a dry dressing every shift and when necessary if dislodged. Review of Resident 78's Treatment Administration Records (TAR) on 01/10/2025 at 10:46 AM, showed the outside wound provider's new treatment orders had not been transcribed / updated and the resident continued the previous sacral pressure wound orders. During an interview on 01/10/2025 at 9:04 AM, Staff U, Licensed Practical Nurse/Unit Care Coordinator (LPN/UCC), stated they did not follow the outside wound provider recently on 01/02/2025 or 01/09/2025 when they had provided treatment to Resident 78's sacral wound; however, Staff U stated the usual process would be for the facility LN to assist the outside wound provider in repositioning the residents for wound care and outside wound provider provided the actual wound measurements and treatment during these rounds. Staff U stated the outside wound provider faxed or emailed one of the Resident Care Mangers (RCM) who printed off the recommendations and updated the residents' orders. During an interview on 01/10/2025 at 9:47 AM, Staff V, LPN, stated the outside wound provider's additional recommendation was received on Thursday 01/09/2025 and they did not have access to those outside wound provider recommendations, but they had received them this AM from another LN. Staff V stated the medication orders that were recommended recently by the outside wound provider had been placed on hold by the facility's provider until an x-ray was obtained first for the resident; however, Staff V was unaware of the changes in the outside wound provider's treatment orders. During an interview on 01/10/2025 at 10:33 AM, Staff B, Director of Nursing Services, stated the expectation would be for the LN's who had received the recommendation from the outside wound provider on 01/02/2025 and 01/09/2025 would implement those orders as directed so that the LNs could start the correct treatment to the resident's (sacral) wound. 46148 Resident 72 Resident 72 admitted to the facility on [DATE] with diagnoses of left tibial vein thrombosis (a blood clot in the left leg), chronic obstructive pulmonary disease (COPD, a disease that effects one's ability to breath), peripheral vascular disease (PVD, a disease that restricts the flow of blood in the legs), pulmonary edema (fluid buildup in the lungs) and Alzheimer's disease (a disease that effects one's memory). Review of the admission skin assessment, dated 12/03/2024, showed the resident had red mushy heels on admission. Review of the admission MDS, dated [DATE], showed Resident 72 had no unhealed pressure injuries. Review of the weekly skin assessments dated 12/10/2024, 12/17/2024, 12/24/2024 and 12/31/2024 showed Resident 72 had blanchable redness to the right heel and a black bruise to the left heel. There was no weekly skin assessment completed on 01/07/2025. Observation on 01/07/2025 at 1:20 PM showed Resident 72 sat on the edge of the bed with both feet appearing swollen and red. A bandage was noted on the left lower leg with drainage visible. The resident was grimacing and holding their left leg. Observation on 01/08/2025 at 2:09 PM showed Resident 72 sat in a wheelchair in the day room watching TV. There was a dressing in place to the left shin with discolored drainage on sock. The resident had on a pair of tennis shoes. Observation on 01/09/2025 at 10:26 AM showed Resident 72 up in a wheelchair independently moving down the hall. The resident's sock was wet with drainage on the left ankle. Observation and interview on 01/10/2025 at 10:27 AM showed Resident 72 with Staff J and an unidentified therapy staff who raised the resident's feet and both heels were noted to have round black/brown hard areas with the left larger than the right. Both staff stated these were new wounds. Review of the EHR on 01/13/2025 showed no documentation that the provider was notified of Resident 72's black/brown heels. There was no documentation found of Staff R, Advanced Registered Nurse Practitioner, assessing the resident. Review of the EHR on 01/13/2025 showed no wound assessment or notes addressing pressure injuries to bilateral heels. During an interview on 01/13/2025, Staff B, Director of Nursing Services, stated they had not been notified of a new or worsened pressure injury for Resident 72. It was their expectation the provider be notified, and an incident investigation be started and care plan or orders be updated for any new or worsened pressure injuries but this did not happen for Resident 72. Reference WAC 388-97 -1060 (3)(b)

Based on observation, interview, and record review, the facility failed to provide adequate fluids to maintain hydration for 1 of 2 sampled residents (Resident 40) when reviewed for hydration and failed to monitor and accurately document fluids consumed to ensure fluid restrictions were implemented per provider's orders for 1 of 5 sampled residents (Residents 32) reviewed for nutrition and/or dialysis (treatment to filter wastes and water from the blood). This failure placed residents at risk for over hydration, avoidable discomfort, and a diminished quality of life. Resident 40 Review of the electronic health record (EHR) showed Resident 40 admitted to the facility on [DATE] with diagnoses to include dementia and traumatic subarachnoid hemorrhage (a bleed in the brain). Review of the care plan, dated 12/04/2024, showed the resident was at risk for dehydration and had a diet which included regular thin liquids. The resident required assistance of two staff for transfers out of bed. Observation on 01/07/2025 at 1:11 PM, showed the resident sitting on the bedside. There were no fluids available in the room. The resident had dry lips and was frequently licking them while talking. Observation on 01/08/2025 at 9:01 AM, showed Resident 40 in bed. They were noted to be licking their lips and appeared to have a dry mouth when talking. There were no fluids available in the room. Observation on 01/09/2025 at 9:11 AM, showed Resident 40 in bed. There were no fluids available at the bedside. During an interview on 01/09/2025 at 11:04 AM, Resident 40 stated, I am so thirsty. My mouth is bone dry. During an interview on 01/09/2025 at 11:02 AM, Staff G, Certified Nursing Assistant (CNA), stated staff provided a water pitcher to residents during rounds twice a shift unless they had a fluid restriction. Staff G stated Resident 40 should have a water pitcher at the bedside. During an interview on 01/09/2025 at 1:37 PM, Staff B, Director of Nursing Services (DNS), stated it was their expectation that staff provide water at the bedside for Resident 40 and this did not meet their expectations. 38344 Resident 32 Review of the EHR showed Resident 32 readmitted to the facility on [DATE] with diagnoses that included heart failure, kidney failure, and diabetes (too much sugar in the blood). Resident 32 was able to make needs known. Review of Resident 32's modified annual minimum data set assessment (MDS, a required assessment), dated 12/11/2024, showed the resident received dialysis and received a mechanically altered and therapeutic diet (a meal plan that is designed to treat a medical condition or symptom). During an interview and observation on 01/08/2025 at 8:46 AM, Resident 32 stated they did not think they were on a special diet and did not think they were on a fluid restriction; however, there was a sign posted on the wall above the resident's bed that showed, No Water Pitcher at bedside Fluid Restriction. Review of the provider order, dated 01/03/2023, showed Resident 32 was prescribed an 1800 milliliter (ml) fluid restriction. Nursing to provide 240 ml on day shift, 240 ml on evening shift, and 240 ml on night shift. Fluids from the kitchen for meals: Breakfast 360 ml, lunch 360 ml, dinner 360 ml related to end stage renal disease (kidney failure). Review of Resident 32's January 2025 medication administration record (MAR) from 01/01/2025 - 01/08/2025, showed the provider order dated 01/03/2025 for 1800 ml per day fluid restriction which included what should be provided by nursing (for each shift) and the kitchen (for each meal) had missing documentation. Fifteen out of seventeen opportunities were documented with an X and not the ml of fluid consumed. During an interview on 01/09/2025 at 1:30 AM, Staff W, CNA, stated they did not document how much residents drank that were on fluid restrictions but was to inform the nurse how much they drank during their shift. Staff W stated they knew that Resident 32 was on fluid restrictions and only gave fluids provided during meals. Staff W did not know how much fluids Resident 32 was allowed to consume during their shift. During an interview on 01/09/2025 at 1:38 PM, Staff L, Registered Nurse, stated they documented how much fluid a resident consumed that was on fluid restrictions during medication administration in the resident's MAR. Staff L stated the CNA kept track of what residents drank during meals but was not sure where the CNA documented what they gave. Staff L stated they did not document what fluids the CNA gave to residents during meals on the MAR. During an interview on 01/09/2025 at 2:08 PM, Staff M, Registered Nurse/Unit Care Coordinator (RN/UCC), stated the CNA were to report to the nurses how much fluids were consumed during their shift for residents on fluid restriction and the nurses were to document total fluids consumed for medication pass and what fluids the CNA provided in the MAR. Staff M stated that Resident 32's January 2025 MAR documentation did not meet expectations because fluids consumed should have been documented and that did not happen for Resident 32. During an interview on 01/09/2025 at 3:57 PM Staff B, DNS, stated the January 2025 MAR was missing documentation of fluids consumed by Resident 32 and this did not meet expectations. Reference WAC 388-97-1060 (3)(h)(i)

Based on interview and record review, the facility failed to provide care and services according to professional standards of practice to prevent pressure injury for 1 of 3 residents (Resident 1) reviewed for pressure injuries. Resident 1 experienced harm when the facility failed to monitor the integrity of Resident 1's skin under a removable leg/knee immobilizer brace which developed into a lower leg pressure injury that was unstageable and contained dead tissue in the wound bed. Findings included . Review of the facility policy titled, Documentation and Assessment of Wounds dated 03/31/2023, showed that, based on the comprehensive assessment of the resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Resident 1 was readmitted to the facility on [DATE] after a hospitalization where they received treatment for dislocated hip. Review of nursing progress Note, dated 08/01/2023, documented Resident 1 returned from the emergency department wearing a left leg/knee immobilizer brace. Review of the Risk for Break in Skin Integrity Care Plan, dated 08/01/2023, did not show identification of pressure, friction or rubbing from leg/knee immobilizer brace as risk factors for the development of pressure injury and the interventions did not include removal of the brace daily to check skin integrity. Review of Skin Assessment, dated 08/15/2023, documented Resident 1's skin conditions included mushy heels, reddened skin at tailbone, a surgical wound at the hip and bruising on the stomach from injections. Nursing progress Note, dated 08/25/2023, documented Resident 1's daughter reported the resident had a wound under the immobilizer brace. Progress Note described wound as a pressure area that was purple and about two inches long by less than one inch wide. Review of a Weekly Wound Observation note, dated 09/05/2023, 11 days after Resident 1's wound was discovered, documented the wound was not stageable as it contained 11-25% slough (dead tissue separating from living tissue). Review of a Weekly Wound Observation note, dated 09/07/2023, documented Resident 1's leg wound now contained 76-100% slough and continued to be unstageable. On 10/26/2023 at 3:08 PM, Staff C, Resident Care Manager, stated an order, instructions for care of Resident 1's immobilizer and daily inspections of skin under the immobilizer could not be found. Staff C stated that the benefit of daily monitoring would be to identify the effect of pressure from the immobilizer on the skin early so that preventive interventions could be implemented. On 10/26/2023 at 3:30 PM, Staff B, Interim Director of Nursing, stated the standard of care was that when a resident was admitted with an immobilizer brace an order would be obtained, the risk for injury related to pressure would be identified and care planned to include daily skin inspection. On 10/26/2023 at 4:00 PM, Staff A, Interim Administrator, stated the facility recently identified a need for performance improvement in wound management program and was making necessary changes. Reference WAC 388-97-1060 (3)(b)

Based on observation, interview and record review the facility failed to ensure resident environments were free from accident hazards for two of 10 residents (Resident 278 and 1) reviewed for falls and accidents. Failure to assess identified risk factors and ensure adequate supervision resulted in actual harm for Resident 278 when the resident had multiple falls and sustained a fracture. In addition, the facility failed to identify, assess, obtain an order and care plan for an assistive/enabling device for Resident 1, and placed that resident at risk of avoidable injuries and a diminished quality of life. Findings included . Review of the facility Fall Management Policy dated 06/04/2020, showed that the facility will assess the resident upon admission/readmission, quarterly, with change in condition and with any fall event for any fall risks, and will identify appropriate interventions to minimize the risk of injury related to falls. RESIDENT 278 Review of the admission Minimum Data Set (MDS, a required assessment tool) dated 02/17/2021 showed that Resident 278 was admitted on [DATE] with diagnoses of [CONDITION(S)], diabetes, metabolic [CONDITION(S)] (a disease in the brain caused by a chemical imbalance in the blood from another health condition, that results in changes in thought process or personality), [CONDITION(S)] brain injury (lack of oxygen to the brain that results in the death of brain cells), cognitive communication deficit, dysarthria and anarthria (slurred and/or slowed speech impacting word production due to lack of muscle control/coordination in the face/mouth), [CONDITION(S)] (BPH, a prostate gland enlargement that can cause urinary difficulty), and urine retention. The MDS further showed that the resident had difficulty making needs/wants known, sometimes understood others, highly impaired vision and did not wear glasses. Resident 278 had short term memory loss. In addition, the MDS showed that the resident was a two-person physical assistance for bed mobility, transfers, dressing, personal hygiene and did not walk or toilet during the time period. The resident's balance was not steady and was only able to stabilize with staff assistance. In addition, the resident was frequently incontinent of bladder and continent of bowel. Review of a care plan dated 04/13/2021 showed that Resident 278 was identified at risk for falls on 02/12/2021. The goal was for the resident to not sustain serious injury requiring hospitalization through the review date of 03/02/2021. Interventions included completing a fall risk assessment, orient the resident to his room, and occupational therapy/physical therapy (OT/PT) orders (02/12/2021), initiate falling leaf program (03/25/2021), remind the resident to ask for help before transferring (03/26/2021), a low bed (03/30/2021) and frequent checks for safety (04/14/2021). The care plan further showed the resident was a one person assist from staff for toileting. Resident 278 was to be toileted before meals, at bedtime and as needed (revised on 03/16/2021). Review of the care plan dated 04/25/2021 showed that staff needed to remind Resident 278 to use the call light and anticipate his needs. The comprehensive assessments and care plan did not address the resident's ability to use the call light. Although the care plan included that Resident 278 was expected to ask for help, the resident was unable to ask for help and staff were expected to anticipate his care needs. Review of the Discharge MDS dated [DATE] showed that Resident 278 was discharged on [DATE] to an acute care hospital. Review of the Fall Risk Evaluation dated 02/11/2021, showed that Resident 278 had a recent change in cognition, had adequate vision, and required continence elimination with assistance. The score of the fall assessment indicated a score of 10, which was high risk for falls. The fall risk assessment also showed additional questions were not answered which contributed to the score, including age of the resident, if there was a drop in his systolic blood pressure and any high risk medications prescribed. Review of the end of therapy MDS dated [DATE] showed that Resident 278 required maximum assistance with toileting and lower body dressing, dependent on staff for footwear placement, required supervision to contact guard assistance (CGA, hands-on assistance) for moving from a lying position to sitting on the side of the bed, from a sitting to standing position, transferring to the toilet, walking 150 feet with a walker on even surfaces and picking up an object. Review of the Speech Therapy progress notes dated 02/12/2021 showed that Resident 278 was started on services to develop and train strategies to improve communication of wants and needs due to severe [CONDITION(S)]. The resident's risk factors included moderate memory loss, falls, aspiration, weight loss and dehydration. According to the Speech Therapy Discharge Summary dated 03/17/2021, showed that Resident 278 was able to progress in making needs known from <25% to 95% of the time verbally or gesturing. Review of the Occupational Therapy Progress Notes dated 03/11/2021 showed that Resident 278 needed the therapist to correct his balance. Education was provided for safe transfers and fall prevention. In addition, the resident required assistance for carry-over during training due to poor insight and safety awareness. Precautions for participation included being a high fall risk and able to follow one-step directions. Review of the Occupational Therapy Discharge Summary dated 03/16/2021 showed that Resident 278's functional skills and results of treatment were reviewed with the interdisciplinary team. Review of March and April 2021 incident and accident log showed that Resident 278 had four unwitnessed falls on 03/25/2021 at 4:30 PM, 03/27/2021 at 3:45 AM, 04/07/2021 at 9:30 AM and 04/13/2021 at 3:12 AM. 03/25/2021 Fall Review of the fall that occurred on 03/25/2021, showed that Resident 278 was found on the floor in the bathroom in front of the toilet after he voided both urine and bowel movement. His brief was dry. The resident transferred himself without assistance and did not use his call light. The resident was reassessed for fall risk, resulting in a score of 16, identifying him as a high fall risk (10+ was high fall risk). Interventions included putting Resident 278 on falling leaf program and reminding him to use his call light for assistance. However there was no evidence that Resident 278 was assessed for his ability to use the call light. Review of the document titled, Kardex Report dated 03/26/2021, showed that staff needed to encourage Resident 278 to use his bell to call for assistance. It was unclear if the resident regularly used his call light for assistance as the report did not address it. Furthermore, the investigation showed that the resident was able to answer simple yes/no questions, was a one-person assistance with toileting, was unable to make toileting needs known, was always incontinent and staff were to anticipate his needs. Review of the EHR showed that Resident 278 was continent of bowel and bladder on day shift on 03/11/2021, 03/20/2021, 03/24/2021 and evening shift on 03/04/2021, 03/18/2021, 03/23/2021 and 03/25/2021. It was unclear if the facility met his toileting needs as the report did not indicate the last time he was toileted, the fact he demonstrated he was able to be continent and was not reassessed, and regular routine was not identified. In addition, the falling star intervention was initiated at the time of the fall, not at the time the resident was first identified as a high fall risk. 03/27/2021 Fall Review of the investigation of the fall that occurred on 03/27/2021 showed that Resident 278 was found next to his bed facing his wheelchair and his call light was not activated. The roommate put the call light on for the resident after the fall. Resident 278 was last seen at 3:00 AM, restless and incontinent. He pointed to his wheelchair and needed to use the bathroom. The resident was placed back in bed. It was unclear why the resident was restless and if toileting reduced the restlessness before putting him back to bed. The investigation further showed that staff were to anticipate his needs. The Fall Risk Evaluation was updated to a score of 18, which increased 2 points from last assessment. The fall evaluation also showed that the resident's continence was coded as elimination with assistance. The summary included that the resident was feeling better and getting stronger each day. Review of the incident investigation for the 03/27/2021 fall showed that new interventions included reminding the resident to use the call light, frequent checks and a low bed. Resident 278's needs were not reassessed to include daily routine, toileting or ability to use the call light. 04/07/2021 Fall Review of the investigation for the fall that occurred on 04/07/2021 showed that Resident 278 was found in the doorway to his room as staff walked past. When asked, the resident did not recall what happened (or unable to verbalize). The resident was last toileted and voided at 7:30 AM and last seen at 9:15 AM after breakfast, but the report did not state where he was, what he was doing, or if staff asked/assessed his needs at that time. The investigation further showed that when asked, Resident 278 said yes to the bathroom. It was not clear if the current care plan was followed as it was not identified. The fall risk evaluation was updated and increased two points to score a 20. New interventions included a tap call light, a therapy screen, bed alarm and floor mat at bedside. There were no previous assessments if the resident had physical or cognitive difficulties activating the previous call light button. 04/13/2021 Fall Review of the investigation for the fall that occurred on 04/13/2021 showed that Resident 278 was found on the floor next to his bed, with a pad under him, blankets partially on the bed and floor. No adult brief was on. The resident was not able to articulate what happened, how he fell and what or where he was trying to go or do. Another staff member and the Licensed Nurse (LN) picked him up under each arm and placed him on the bed. The investigation further showed that the resident then moaned and pointed to his left buttocks and said pain. Upon examination, Resident 278 had a large reddened area on his lower left back. The report did not state why Resident 278 did not have a brief on at the time of the fall. Staff replaced the brief. The incident report showed that the resident was last seen 20 minutes prior as he was found wet and was standing in his room. At that time, the resident was cleaned and assisted back to bed. The fall evaluation was updated and scored a 20, remaining a high fall risk. Resident 278's call light was not activated. The investigaion did not include the resident's abiltiy to use the call light. Review of Resident 278's progress notes and alert charting dated 04/13/2021 to 04/16/2021 showed that the resident did not sustain any latent injuries from the fall. In further review of the progress notes dated 04/15/2021 showed that the resident exhibited increased weakness in his lower extremities, unable to move his left lower extremity, had [CONDITION(S)] to his left lower extremity and unable to stand during a transfer. Resident 278 was transferred to the hospital for evaluation and treatment due to a change in condition. The hospital completed labs and a CT scan, and ruled out a stroke and urinary tract infection. Review of weekly skin evaluation dated 04/16/2021 upon return from the hospital showed that Resident 278 had a very large bruise on his front inner left thigh. Size and color were not described. The facility did not identify a bruise upon discharge to the emergency department on 04/15/2021. Continued review of the progress notes showed that Resident 278 demonstrated increased pain and decreased mobility on 04/19/2021. The resident was sent to the hospital on 04/25/2021, where It was identified and diagnosed with a left hip fracture and referred for surgical repair. During an interview on 06/11/2021 at 9:14 AM, Collateral Contact Q, stated that Resident 278 sustained several falls while in the facility, with one which resulted in a pelvic/hip fracture and surgery. Collateral Contact Q further stated that the resident was able to tell when he had to use the bathroom, but was not able to initiate the request until staff asked him. In addition, he wore briefs for staff convenience and fell because he had to go to the bathroom. During an interview on 06/11/2021 at 11:30 AM, Staff B, Director of Nursing Services (DNS), stated that a toileting program or bladder assessment were not considered for Resident 278 as he did not show the ability to be aware of the need to void. A standard toileting program was provided before meals, at bedtime and as needed for those frequently incontinent. When asked about the timing of the falls, Staff B, DNS, identified that all the falls occurred on the long term care unit, West North. In addition, Staff B, DNS, stated that the resident was feeling stronger and was more mobile. When asked if the facility reassessed Resident 278's needs or the changes in the environment that may have impacted the resident to include supervision, staffing levels, staff familiarity or ability to anticipate needs, Staff B, DNS, stated she did not assess those factors when investigating the falls. RESIDENT 1 Review of the facility's document titled, Best practice for enabling devices, undated, showed that an enabling device was a device that helped enable the resident in an activity or activity of daily living (ADL). It further showed, This may include enabler bars, transfer poles, electric recliners, tilt and space wheelchairs, etc. The document showed that when an enabling device is ordered, there should be an order placed in the resident's electronic health record (EHR), an assessment of the enabling device and an informed consent completed and signed by either the resident or the resident's responsible party. Review of the admission MDS dated [DATE], showed that Resident 1 admitted on [DATE] with diagnoses to include high blood pressure, [CONDITION(S)] (a condition that causes widespread muscle pain and tenderness), diabetes, anxiety disorder and a history of falling. The MDS further showed Resident 1 was able to make needs known, had impairment on one side of the upper body (shoulder, elbow, wrist, hand) and required extensive physical assistance of one person for bed mobility, transfers and toilet use. Observation and interview on 06/02/2021 at 11:21 AM, showed Resident 1 sitting in the room in a wheelchair with bare feet on the floor and stated, I don't want to wear the non-skid socks all the time but I will use them when I transfer and they help me when I need to transfer to the toilet. Resident 1 further stated that about a week ago, I fell , to the floor from the facility's electric recliner chair after leaning too far forward and the facility called the paramedics to get the resident up because the resident refused to be lifted by the mechanical lift. During an interview on 06/02/2021 at 11:47 AM, Resident 1 stated, I have been sleeping in this wheelchair with my feet elevated on the bed. Resident 1 stated that the recliner chair that the resident purchased had not yet arrived and that the resident's preference was to sleep in a recliner chair and refused to sleep in the bed. Review of Resident 1's care plan on 06/03/2021 at 7:09 AM, showed no documentation that the resident chose to sleep in a wheelchair after falling from the recliner on 05/28/2021 and not in a bed, while waiting for another recliner. However, the care plan for Activities of Daily Living (ADL) self-care performance dated 06/01/2021 showed an intervention for, Prefers to sleep in recliner, and showed that Resident 1 required one-person assist by staff to turn and reposition in bed as needed. The care plan further showed that Resident 1 had an actual fall on 05/28/2021. Review of Resident 1's medical record on 06/11/2021 at 1:54 PM, showed no documentation that Resident 1 had a recliner chair assessment completed, a physician's order or an informed consent obtained, or a care plan in place for a recliner chair prior to the fall from the recliner chair on 05/28/2021. During an interview on 06/11/2021 at 2:39 PM, Staff B, DNS, stated that when Resident 1 first used the recliner chair (prior to the fall on 05/28/2021), the facility did not obtain an informed consent or a physician's order, complete a recliner chair assessment or care planed the use of a recliner chair and they should have. Reference WAC 388-97-1080 (3)(g)

Based on observation, interview and record review the facility failed to identify hazards and risks, assess and implement measures to reduce risk of injury when serving hot, reheated coffee for one of four residents (Resident #1) reviewed for risks related to hot beverage service. The facility also failed to ensure staff consistently followed verbalized practice to not reheat beverages in a microwave. Harm occurred when staff served a large pitcher of hot coffee to Resident #1, and the lid popped off and contents spilled on the resident's lap resulting in second degree burns, pain and hospitalization . Findings included . Facility policy titled Reducing Risk [MEDICAL CONDITION] Residents from hot Beverages showed staff should serve hot beverages away from the edge of a table within reach of a resident's dominant hand. The policy also stated to evaluate a resident's ability to manage hot beverages, provide needed assistance, ensure care plans were current and utilize an individualized approach with each resident to ensure safety. Resident #1 resided in the facility since (YEAR). Resident [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set assessment dated [DATE] (MDS, a required assessment tool), showed the resident had functional range of motion limitations of both upper and lower extremities and required extensive assistance from staff to eat, dress, transfer and toilet. A care plan for self-performance deficit dated 07/02/15 showed the resident needed assistance with all activities for daily living due to fatigue, neurological disease progression, muscle weakness and chronic pain. A care plan for risk for falls dated 07/02/15 showed the resident used an electric wheelchair that maneuvered with head controls. Occupational Therapy Progress Notes dated 03/14/19 to 04/11/19 showed precautions for Resident #1 included fall risk, warm/heat temperature sensitivity; poor trunk control. Observation on 01/25/19 at 10:59 AM showed Resident #1 had an air mattress on the bed and was unoccupied. There was an empty 32 ounce pink pitcher with large straw in it on the resident's over bed table. At the time of this investigation and observation, Resident #1 remained hospitalized . An Order Summary Report showed on 12/10/18, the physician ordered the air mattress with bolsters. The report showed the physician also prescribed medications to treat muscle spasms and an opioid pain patch for pain management. A facility investigation dated 01/24/19 showed at 8:45 AM, Resident #1 asked Staff M, Certified Nursing Assistant (NAC), for coffee. Staff M obtained the coffee from the kitchen and then heated it up in the microwave in the breakroom for 45 seconds when the resident stated it wasn't hot enough. The investigation showed as Staff M placed the mug in Resident #1's hand, the lid popped off the container and contents spilled onto the resident's lap. Staff provided emergency intervention and Staff N, Advanced Registered Nurse Practitioner (ARNP) evaluated Resident #1. The investigation showed the resident developed blisters and redness on hand, arms, between legs and thigh region and staff sent the resident to the hospital. The investigation also showed due to hand and arm weakness it was easier for Resident#1 to hold on to the mug and drink through a straw and was particular how hot he wanted the beverage. The facility investigation showed Staff A, Administrator, reenacted the scenario of reheating coffee in the microwave for 45 seconds based on the starting coffee temperature of 134 degrees Fahrenheit (F) taken in the carafe in the dining room at 7:00 AM on 01/24/19. The reenactment showed the temperature of coffee in the pink container measured 152.2 degrees F when taken to Resident #1's room. Professional reference titled State Operations Manual Chapter 7-Survey and Enforcement Process for Skilled Nursing Facilities and Nursing Facilities dated 11/28/2017, showed exposure to 148 degrees (F) of hot water could cause a third degree burn in two seconds. A third degree burn could occur in one second following exposure to water measuring 155 degrees F. A nursing note dated 01/24/19 showed following the coffee spill, Resident #1 was in severe pain at the time of the incident, yet remained calm and cooperative during application of cold towels and linen change. During interviews on 01/25/19 at 1:12 PM, Staff L Certified Nursing Assistant (CNA), and Staff K Certified Nursing Assistant (CNA), both stated they provided care to Resident #1 and heated the resident's coffee in the microwave in the staff lounge in the past. Both staff stated that the resident liked coffee in the pink water pitchers and demonstrated how the pitcher had a lid that snapped on the top with two holes in it. One circular hole fit an oversized straw. There was a second short elongated hole across from the circular hole in the lid. Staff L demonstrated how Resident #1 sat upright in bed to drink and had staff place a pink handled mug filled with (hot) coffee directly onto the resident's lap and had to position the resident's right hand around the mug handle to hold it. Staff L stated that the resident would then lean forward and drink hot coffee through a straw. Both Staff K and Staff J stated that no one told them not to heat coffee in the microwave and did not report to the nurse when they did. During an interview on 01/24/19 at 1:19 PM, Staff M, Certified Nursing Assistant (CNA) stated that the resident preferred drinking hot coffee for quite a while and everyone knew he liked coffee hot, and had not discussed use of heating in a microwave with nursing staff. During an earlier interview on 01/25/19 at 10:44 AM, Staff J, Licensed Practical Nurse (LPN), stated that Resident #9 liked milk served hot, ( another resident who preferred hot beverages.) Staff J stated that she used to heat the milk in the breakroom microwave and now had the kitchen heat it. During an interview on 01/24/19 at 1:40 PM, Staff H, Resident Care Manager (RCM), stated the resident directed staff where to place the coffee pitcher and liked to drink coffee really hot for over a year. Staff H also stated that the resident had difficulty holding onto things and feeding himself. Staff H did not know staff were heating up the resident's coffee in the microwave and assumed they took it to the kitchen when not hot enough. During interviews on 01/24/19 between 2:00 PM and 2:25 PM, Staff D Licensed Practical Nurse, (LPN); Staff E Licensed Practical Nurse, (LPN); Staff F Licensed Practical Nurse, (LPN) and Staff G Registered Nurse (RN), all stated that if a resident wanted their coffee reheated staff should take it to the kitchen for assistance. During an interview on 01/24/19 at 2:30 PM Staff O, Non Certified Nursing Assistant (NAR) stated he also cared for Resident #1 prior to the incident and microwaved coffee in the resident's pink pitcher and placed it on the resident's lap. Staff H also stated that a nurse who worked at a medication cart told him it was okay to microwave the resident's coffee. Resident #1 had multiple safety risks when drinking hot coffee that included drinking coffee while seated on an air mattress; weakness and impaired upper extremity mobility, use of high risk medications; preference for hot coffee and placement of large coffee container and seating on a non-solid surface (resident lap and air mattress.) Review of Resident #1's medical record did not contain evidence staff assessed Resident #1 for safety hazards of serving and drinking hot coffee per resident preference of placement of coffee container on lap while in bed, or interventions to assist with reducing risks of spills and burns. The resident's record did not contain evidence staff informed Resident #1 of increased safety hazards associated with this practice or discuss alternatives to reduce risks from burns. Facility policy and procedure titled Reducing Risk [MEDICAL CONDITION] Residents from Hot Beverages did not identify staff should take beverages to the kitchen if residents did not find them hot enough and to not reheat beverages in a microwave. During an interview on 01/24/19 at 1:24 PM, Staff B, Director of Nursing stated that she did not know staff were reheating coffee for Resident #1 in the microwave and did inform residents of increased risks when practices increased safety hazards. Following a request for a safety assessment, care plan and evidence staff informed Resident #1 of increased safety risks, Staff B stated that she would have to look. During an interview on 01/25/19 at 1:57 PM, Staff H RCM, stated that she did not know of any assessment conducted for Resident #1 that addressed resident safety related to drinking hot coffee. The facility provided no further evidence staff thoroughly assessed and identified risks associated with how staff placed a pitcher of hot reheated coffee over Resident #1's lap. Staff did not consistently follow facility practice to bring beverages to the kitchen when residents voiced they were not hot enough instead of microwaving them. Resident #1 received [MEDICAL CONDITION] a pitcher of hot coffee spilled onto his lap causing pain and second [MEDICAL CONDITION] hospitalization .