Every finding on record at Crystal Cove Post Acute

Based on observation, interview and record review the facility failed to serve food at appropriate temperatures for 3 of 4 halls reviewed. This failure placed residents at increased risk for foodborne illnesses and decreased quality of life. Findings included . Review of the facility policy, titled Food Safety Requirements, undated, documented Holding.staff shall monitor food temperatures while holding for delivery to ensure proper hot and cold holding temperatures are maintained.Ready-to-eat foods that require heating before consumptions must be heated to at least 135 degrees F [Fahrenheit].Observation of dining service for the dining room on 07/17/2026 at 12:00 PM, with Staff A, Director of Nursing showed residents eating their lunch meal. Observation of the lunch meal served to Resident 4 showed the temperature of the meat was 130 degrees. Staff A was asked if the temperature was adequate to serve to the resident and they stated yes and staff served the lunch meal to Resident 4. Staff A took food temperatures of numerous lunch trays and food temperatures were below 135 degrees F. Staff A instructed staff to return the trays to the kitchen to be reheated.Observation of dining service for Hall B on 07/17/2026 at 12:20 PM, with Staff A, showed several trays had been passed to residents in Hall B. Staff A took food temperatures of numerous lunch trays and food temperatures were below 135 degrees F. Staff A instructed staff to return the trays to the kitchen to be reheated.Observation of dining service for Hall C on 07/17/2026 at 12:30 PM, with Staff A. Staff A took food temperatures of numerous lunch trays and food temperatures were below 135 degrees F. Staff A instructed staff to return the trays to the kitchen to be reheated.Observation of dining service for Hall D on 07/17/2026 at 12:45 PM, with Staff A. Staff A took food temperatures of numerous lunch trays and food temperatures were 135 degrees F or above and trays were served to residents. During an interview on 07/16/2026 at 1:10 PM, Resident 1 was asked if he had concerns with his care at the facility. He stated he does not get the food he likes to eat and the food is not served hot. During an interview on 07/17/2026 at 3:45 PM, Resident 3 was asked if food was served hot. Resident 3 stated the food was generally served cold.During an interview on 07/17/2026 at 3:48 PM, Resident 2 was asked if food was served hot. Resident 2 stated no the food was not served hot.During an interview with Staff A on 07/17/2026 at 4:00 PM, he stated usually the admissions coordinator completed the food temperatures during meal service and he forgot the temperature had to be 135 degrees to be served to the residents. Staff A acknowledged the food temperatures were below 135 degrees for 3 of 4 resident halls at the lunch meal. Reference WAC 388-97-1100(3)

Based on observation, interview, and record review, the facility failed to ensure new interventions were appropriately developed or timely initiated in an effort to prevent future falls and failed to supervise residents to prevent falls for 3 of 4 sampled residents (Residents 1, 2 and 3) reviewed for accidents. These failures placed residents at risk of injuries, and a diminished quality of life.Findings included .Review of the facility policy, titled Fall Management, dated 10/05/2025, showed .The facility will assess the resident upon admission/readmission, quarterly, with significant 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.The interventions to reduce the risk of falls should be individualized based on the resident's risk factors and fall history.Resident 1Resident 1 was admitted to the facility on [DATE] with diagnoses including dementia (a decline in mental ability that is severe enough to interfere with daily life) with behavior disturbance for respite care (short-term relief for caregivers by offering temporary care for a loved one, allowing caregivers to rest, travel, or attend to personal needs).Resident 1's admission summary, dated [DATE], documented the resident was forgetful, ambulated with a cane, required limited assistance/supervision to go to the bathroom for safety and had bilateral hearing aids.Resident 1's fall risk assessment, dated 06/02/2026, showed a score of 25 indicating the resident was moderate risk of falling.Resident 1's care plan, dated 06/16/2026, documented the resident was low risk for falls with a score of 25. The care plan showed an intervention to encourage the resident to use the call light for assistance. (Resident 1 with diagnoses of dementia). No other intervention was implemented on the care plan to prevent falls.Resident 1's progress note, dated 06/05/2026, documented the resident had an unwitnessed fall in the resident's room at approximately 3:45 AM and sustained numerous skin tears to the right side of the body.Resident 2Resident 2 was admitted to the facility on [DATE] with diagnoses including Diabetes, Spinal Stenosis (narrowing of the spaces between the spine which puts pressure on the spinal cord and nerves) and Fibromyalgia (a chronic condition characterized by widespread muscle pain, profound fatigue and cognitive issues). The resident's admission Minimum Data Set (MDS), an assessment tool, dated 04/20/2026, showed mild cognitive impairment, required staff supervision for transfers, ambulation and bathing/showers.Fall #1Resident 2's fall risk assessment, dated 04/22/2026, showed the resident was at high risk for falls.Review of the facility falls investigation, dated 04/22/2026, showed the resident was taken to the shower room and left unattended. The resident had an unwitnessed fall in the shower and was found by staff with no injuries.Fall #2Review of Resident 2's falls investigation, dated 05/04/2026, showed the resident had an unwitnessed fall in the resident's bathroom without injury. The intervention implemented was to complete a medication review.Fall #3Review of Resident 2's falls investigation, dated 05/29/2026, showed the resident had an unwitnessed fall in the resident's room without injury. The intervention implemented was to post a reminder sign in the resident room. Observation of Resident 2 on 06/17/2026 at 2:45 PM, with Staff E, Licensed Practical Nurse showed Resident 2 lying on the bed. A walker was in front of the bathroom door and no reminder sign was posted in the resident's room. Resident 2 was unable to answer any questions and appeared very confused.Fall #4Review of Resident 2's falls investigation, dated 06/04/2026, showed the resident had an unwitnessed fall in the resident's room without injury. The care plan, revised date 06/17/2026, documented an intervention not to leave the resident in the bathroom unattended. (13 days post fall)Resident 3Resident 3 was admitted to the facility on [DATE] with diagnoses including End Stage Renal Disease, Diabetes and Dementia. The resident's 5-day MDS, dated [DATE], showed the resident had cognitive impairment, impairment to upper extremities, was dependent on staff for transfers, bathing and toileting, was occasionally incontinent of bladder and frequently incontinent of bowel.Resident 3's falls risk assessment dated [DATE] showed the resident was high risk for falls.Review of the facility falls investigations showed Resident 3 had 5 falls from 04/20/2026 - 06/13/2026 without injury.Review of Resident falls investigation dated 05/02/2026 documented the resident had an unwitnessed fall in the resident's room. No intervention was implemented timely on the resident's care plan after the fall on 05/02/2026.Review of Resident 3's falls investigation dated 06/13/2026 documented the resident had a witnessed fall in the resident's room. No intervention was implemented timely on the resident's care plan after the fall on 06/13/2026.During an interview on 06/17/2026 at 3:35 PM, Staff B, Assistant Director of Nursing (ADON) acknowledged staff are required to supervise residents in the shower who require supervision and interventions are to be implemented timely after a fall by nursing.During an interview on 06/22/2026 at 2:30 PM, Staff A, Administrator acknowledged nursing is responsible for initiation of a falls investigation and implementing an intervention after a fall. He stated daily rounds are to be completed by nurse managers to ensure interventions are in place.Reference WAC 388-97-1060(3)(g)

Based on observation and interview, the facility failed to ensure a comfortable homelike environment by not providing adequate temperatures in resident rooms in 1 of 4 hallways reviewed for comfortable temperature. This failure placed residents at risk for diminished quality of life.The findings included.During the facility tour with Staff C, Maintenance Director, room temperatures were checked in four halls. The following temperatures were noted:room [ROOM NUMBER] - 84.4 degrees Fahrenheit (F)room [ROOM NUMBER] - 80 degrees [NAME] 4 - 80.2 degrees [NAME] 6 - 82.2 degrees [NAME] 7 - 84.5 degrees [NAME] 9 - 82 degrees [NAME] 11 - 84 degrees FDuring an interview on 06/15/2026 at 4:20 PM, Resident 9 stated her room was too warm.During an interview on 06/15/2026 at 4:22 PM, Resident 7 stated to Staff C the room was too hot and requested the window open. During an interview on 06/15/2026 at 4:25 PM, Resident 11 stated the room was too warm. The resident stated the fan that was in the room burnt out and the facility did not have another fan to replace it.During an interview on 06/15/2026 at 4:30 PM, Staff C acknowledged air conditioning was in the hallways of the facility and resident rooms did not have air conditioning units. Staff C stated the outside temperatures had been warm. Staff C said the facility did not have access to fans for resident rooms at that time. He said he had just ordered 10 fans this day. Staff C acknowledged resident room temperatures should be kept between 71 - 81 degrees F and several rooms in the A hallway were above 81 degrees.During an interview on 06/22/2026 at 2:30 PM, Staff A, Administrator, acknowledged resident room temperatures were to be maintained between 71-81 degrees, and several resident rooms were above 81 degrees. Reference WAC 388-97-0880 (3)

Based on review of the facility policy, observation, interview and record review the facility failed to document timely dishwasher temperatures, failed to complete dishwasher chemical sanitation testing and failed to serve food at appropriate temperatures for 2 of 4 halls reviewed. This failure placed residents at increased risk for foodborne illnesses and decreased quality of life. The findings included.Review of the facility policy titled, Dishwasher Temperature, undated showed .4. For low temperature dishwashers (chemical sanitation) .The wash temperature shall be 120 [degrees] F [Fahrenheit].The sanitizing solution shall be 50 ppm (parts per million) hypochlorite (chlorine) (solution used for widespread disinfection) on dish surface in final rinse.5. Chemical solutions shall be maintained at the correct concentration, based on periodic testing, at least once per shift, and for the effective contact time according to manufacturer's guidelines. Results of concentration checks shall be recorded.6. Water temperatures shall be measured and recorded prior to each meal/or after the dishwasher has been emptied or refilled for cleaning purposes.Observation of the kitchen on 06/17/2026 at 12:45 PM, with Staff D, Dietary Manager showed a dishwasher temperature log for June 2026 was completed from June 1 through June 20th (date of observation 6/17/26). No log for the chemical testing of the dishwasher for June 2026 was found. The Dietary Manager requested a Staff F, Dietary Aid responsible for dishwashing to assist in finding the chemical strips. Staff F retrieved test strips from under the dishwasher. Staff D acknowledged Staff F had been using the wrong test strips and was unable to find the correct test strips at this time. Staff D acknowledged the log for the chemical testing of the dishwasher for June 2026 was missing and the dishwasher temperature logs were filled out incorrectly and should not have been filled out before the date the temperature was taken. Staff D stated he contacted the company who maintains the dishwasher to check the dishwasher and bring the appropriate test strips. Observation in the dining room on 06/17/2026 at 12:20 PM, with Staff D. The food temperatures of the last tray to be served in the dining room were checked by Staff D. The meat (chicken) temperature was 131 degrees. Staff served the food tray to Resident 13 in the dining room.Observation of dining service for Hall B on 06/17/2026 at 12:40 PM, with Staff D. The tray cart was delivered, and staff were passing food trays. Staff D took food temperatures of numerous food items on the tray and food temperature were below 135 degrees. Staff D returned the food cart to the kitchen to be reheated.Observation of dining service for Hall D on 06/18/2026 at 12:40 PM, with Staff D. The tray cart was to be delivered to Resident 4's room. Staff D took food temperatures of the chicken and it was 129 degrees. Staff D took food temperatures of numerous food items on several food trays for Hall D and all food temperatures were below 135 degrees. 1 tray had been delivered to a resident on Hall D prior to Staff D taking food temperatures. Staff D returned the food cart to the kitchen to be reheated.During an interview on 06/17/2026 at 1:00 PM, Resident 4 stated he does not like the food. He said the food is under or overcooked, served cold and sometimes the dishes are dirty.During an interview on 06/22/2026 at 3:00 PM, Staff A Administrator, acknowledged staff did not follow the facility policy for chemical testing for the dishwasher. Staff A acknowledged the facility was having problems maintaining food temperatures at the appropriate temperature and the facility was taking measures to correct the issue. Reference WAC 388-97-1100(3)

Based on interview and record review the facility failed to submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS- a federal agency managing healthcare programs and health insurance standards) for Quarter 3 (Q3, July 2025, August 2025, September 2025) reviewed for Payroll Based Journal (PBJ-mandatory reporting of staffing information based on payroll data) submission. This failure affected the accuracy of Nursing Home (NH) staffing level data collected by CMS and had the potential to impact provisions of resident care and services. Findings included. Review of the June 2022, CMS Long-Term Care Facility PBJ Policy Manual, showed long term care facilities were required to electronically submit direct care staffing information based on payroll and auditable data. The data can be used to not only report on the level of staff in each nursing home, but reports staff turnover and tenure, that can impact the quality of care delivered at the facility. The policy manual showed the facility must electronically submit complete and accurate information by the required deadline to include; direct care staff, the category of work for each direct care staff member, resident census data, and direct care staff turnover and tenure. Review of the PBJ data submitted by the facility for Q3, dated July 1, 2025 through September 30, 2025 showed a reported shortage of 0.06 hours per resident day. After providing additional information to the department their hours per resident day was adjusted to 3.4, meeting the threshold and eliminating the associated fine but showing the originally reported PBJ data was inaccurate.During a telephone interview on 06/10/2026 at 1:47 PM, Staff A, acting Administrator confirmed the facility failed to ensure accurate data for PBJ was submitted for quarter 3, 2025.Reference WAC 388-97-1090(1)(2)(3)

Based on interview and record review, the facility failed to timely recognize and respond to an acute clinical change in condition, contact on-call clinical leaership if the resident's condition does not clearly support in-house monitoring, and contact emergency medical services timely when the resident's condition appeared unstable or life threatening for 1 of 3 residents (Resident 1) reviewed for an acute change of condition. Resident 1 experienced harm when the facility delayed obtaining emergency medical services and access to a higher level of care despite signs and symptoms consistent with a significant change in neurological status. The resident was subsequently transferred to the hospital where they were diagnosed with a non-operable intracranial hemorrhage (brain bleed). Findings included.Resident 1 was admitted to the facility on [DATE] with diagnoses of rib fractures related to a fall (prior to facility admission) and a pulmonary embolus (clot in lung).In an interview on 05/27/2026 at 12:53 PM, Collateral Contact 1 (CC1), hospital staff member, said that Resident 1 discharged from their hospital to the skilled nursing facility on 05/22/2026 after a fall with fractured ribs and sternum. CC1 said Resident 1 was brought back to the hospital on [DATE] at 7:28 PM unresponsive and on mechanical ventilation/life support. CC 1 said the facility staff informed the emergency responders that Resident 1 was last seen responsive on 05/23/2026 between 4:00 PM and 5:00 PM and was not responsive thereafter and they did not call emergency medical services (EMS - 911) until 05/24/2026 at 6:50 PM. CC 1 said Resident was expected to pass away at the hospital.Resident 1's admission evaluation, dated 05/22/2026, showed Resident 1 needed extensive assistance with bed mobility and transfers, was independent with eating and was alert and oriented to person, place, time, situation and verbally appropriate.Resident 1's progress notes, dated 05/23/2026 at 4:28 PM, showed Resident 1 was alert and oriented times three [person, place and time] and made their wants and needs known and showered with assist.On 05/27/2026 at 4:10 PM, Staff A, Registered Nurse, said they were assigned to care for Resident 1 on the day shift on 05/24/2026. Staff A said their shift started at 6:00 AM. Staff A said they received report from the night shift, Resident 1 had slept through the night and there were no concerns reported. Staff A said the nursing assistant reported to Staff A that Resident 1 did not was up for breakfast. Staff A said they went to check on Resident 1 and they could not wake Resident 1 up. Staff A said Resident 1 would stretch, Staff A demonstrated the stretch by extending their arms down in front of them extended. Staff A said Resident 1 appeared to stay sleeping and made snoring sounds. Staff A said Resident 1's vital signs (clinical measurements to include heart rate, respirations and blood pressure) were stable, and they thought Resident 1 was exhausted. Staff A said eventually the staff took Resident 1's breakfast tray away because it had been two hours and Resident 1 still had not woken up. Staff A said they told their nursing assistants to let them know when they changed Resident 1's briefs. Staff A observed Resident 1 during the brief change and the brief was wet, the resident appeared to be sleeping and did not wake up during the care. Staff A said they called the medical provider and told the provider that Resident 1 was a new resident to them but let the provider know the resident had participated in care the day before. Staff A said they painted the picture; vital signs were stable (VSS), oxygen saturation (amount of oxygen circulating in blood) was 94% (normal range is 95-100%), respirations were even, regular and the resident was snoring. Staff A said they notified the provider that they were in Resident 1's room and were unable to wake the resident up. Staff A said they notified the provider they had assessed Resident 1's neurological status by using the Glasgow Coma scale (GCS - a clinical scoring tool used to objectively measure a person's level of consciousness with a score of three to eight points indicating severe brain injury/coma), because that was the only way to assess the resident. Staff A said they reported Resident 1 had a GCS score of four and continued to stretch their arms when Staff A touched the resident. Staff A said they knew a GCS score of four was a low score and it was abnormal but beyond that they would need to be educated. Staff A said they asked the provider if they wanted Resident 1 sent back to the hospital. Staff A said the provider said not to send the resident back to the hospital, ordered lab tests STAT (urgently processed), and to call the provider back if Resident 1's vital signs became abnormal. Staff A said they continued checking Resident 1's vital signs every hour and they remained within normal limits and Resident 1 sustained 90% oxygen saturation on room air all day long. Staff A said Resident 1 slept through lunch and dinner and after dinner Staff A said they felt uncomfortable because they still could not wake Resident 1. Staff A called emergency services and paged the provider. Staff A said emergency services responded and asked how long Resident 1 had been nonresponsive and Staff A reported Resident 1 had slept through the night and had not woken up since Staff A started their shift at 6:00 AM.Resident 1's progress notes, dated 05/24/2026 at 9:13 AM, showed the resident slept through AM vitals and breakfast, respirations are regular and even, appears to be snoring, mouth breathing, mouth is dry, does not response to touch, response to water drop on their lips by stretching but does not wake up, VSS and will continue to closely monitor for any changes.Resident 1's progress notes, dated 05/24/2026 at 10:54 AM, showed the resident slept through brief being changed, GCS eye opening response was one (indicating no response), verbal response was one (indicating no response), motor response was two (indicating abnormal extension). The provider was paged and the vital signs were stable.Resident 1's progress notes, dated 05/24/2026 at 2:14 PM showed nursing was unable to wake resident to administer medication, the provider was notified, new orders for a complete blood count and complete metabolic panel [diagnostic laboratory tests] were ordered STAT and to only administer medication if resident could wake up and swallow safely.Resident 1's progress notes, dated 05/24/2026 at 2:16 PM, showed the provider was asked if the resident should be sent out and provider stated, no just keep monitoring.Resident 1's progress notes, dated 05/24/2026 at 6:45 PM showed the resident was unresponsive to voice, touch, external stimuli, the provider was paged, and 911 called.On 05/28/2026 at 3:08 AM, Staff B, Certified Nursing Assistant, said they were assigned to care for Resident 1 during the night shift on 05/23/2026. Staff B said that Resident 1 was a new resident at the facility and did not have a Kardex (care instructions for nursing assistants) completed yet, so they did not know Resident 1's usual behavior or status except what they received in report from the outgoing shift. Staff B said they were told in report by evening shift that Resident 1 had slept the entire shift. Staff B said Resident 1 was in bed when they started their shift, snoring and extremely sleepy. Staff B said Resident 1 would open their eyes briefly when they said their name and look at Staff B but would not say anything and go back to sleep. Staff B said Resident 1 did not say anything the entire shift and slept through Staff B changing their briefs. Staff B said they thought Resident 1 was just exhausted from admission and did not notify their nurse that Resident 1 could not stay awake and/or did not speak.On 05/28/2026 at 8:53 AM, Staff C, Licensed Practical Nurse, said they were assigned to Resident 1 on 05/23/2026 at 6:00 PM to Sunday 05/24/2026 at 6:00 AM. Staff C said when they took over from the previous shift the nurse reported Resident 1 was a new resident and was not wanting to eat much and just wanted to sleep. Staff C said they encouraged Resident 1 to eat but they did not want to. Staff C said they administered Resident 1's medications at 7:45 PM and the resident went back to sleep. Staff C said they checked on Resident 1 during their routine rounds, but the resident was sleeping and they did not wake them.On 05/28/2026 at 10:08 AM, Staff D, Medical Director, said they did not exam and/or see Resident 1. Staff D said they had reviewed the medical record. Staff D said they did not know what Staff A had actually reported to the medical provider but if they received a report that a resident was alert and oriented the prior evening, the staff were unable to wake them, the GCS showed no eye opening, no verbal response and the resident went into extension when touched the course of action would be to send the resident to the hospital. Staff D said they would consider it a medical emergency.On 05/28/2026 at 3:26 PM, Collateral Contact 2 (CC2), Supervisor of On-Call Medical Provider, said their Medical Provider group provides on-call providers for the facility. CC2 said they have a call system that logs all calls coming in from facilities. CC2 said on 05/24/2026 the system logged one call from the facility for Resident 1. CC2 said the call came in at 10:53 AM and was responded to at 10:59 AM by Staff E, Physician Assistant. CC2 said that was the only call logged from the facility for Resident 1.On 06/01/2026 at 12:30 PM, Staff E Physician Assistant, said they were the medical provider on call for the facility on 05/24/2026. Staff E said they received a page regarding Resident 1 at approximately 10:59 AM. Staff E said the nurse from the facility reported that Resident 1 was somnolent (excessively sleepy) and would be due for their pain medication soon. Staff E said they began asking the nurse questions and the nurse responded that Resident 1 responded when they went into the room to complete vital signs, the neurological checks were normal, and Resident 1 was responding to stimuli. Staff E said they instructed the nurse to hold the pain medications due to Resident 1's ongoing somnolence, complete hourly neurological checks, escalate if abnormal vital signs or neurological findings, ordered stat labs and to call if there were any changes. Staff E said at the time of the call they were not aware of Resident 1's diagnosis and/or reason for the admission to the facility. Staff E said they had not reviewed the chart and due to Resident 1 being a new admission there were no chart notes available. When asked if the nurse had reported that Resident 1 was snoring, staff were not able to wake them, and they had completed an assessment using the GCS with a score of four with the resident in extension when touched, Staff E said, absolutely not. Staff E said if the nurse would have reported that Resident 1 had a GCS of four, they would not have asked any further questions and sent them immediately to the emergency room. Staff E said if they had an assessment of snoring, unable to wake a resident, no response to verbal stimuli, no eye response and when they were touched, they went into extension, it could indicate the resident was having a stroke embolus (clot) given the history of a fracture and fall. Staff E said it would be a medical emergency and a delay in care could possibly affect the outcome for a resident presenting that way, it is why we sent out STAT.Review of emergency responder statement dated 06/01/2026, regarding a 911 call on 05/24/2026 for Resident 1, showed the emergency responders arrived at the patient's bedside, the patient presented with unconsciousness, sonorous respirations (breath sounds in an unconscious person that typically indicate a partial airway obstruction often caused by the tongue relaxing and falling back into the throat or by secretions), unequal and non-reactive pupils, and decorticate posturing (an involuntary, rigid body reflex indicating severe damage to the brain or spinal cord), leading them to suspect a possible intracranial hemorrhage and the resident was expeditiously transported as their condition was deemed critical.Resident 1's emergency room medical provider notes, dated 05/24/2026, showed Resident 1 was intubated (a tube placed in your throat to open the airway and connected to a machine to help with breathing) by the emergency services due to oxygen saturation at 70% on room air when they arrived at the facility. Resident 1's CT (computed tomography, a medical imaging test that takes pictures of bones, blood vessels and soft tissues inside the body) scan showed they had a large-volume subdural hematoma (collection of blood between the brain and the brain's outer covering), intraparenchymal hemorrhage (bleeding inside the brain) and evidence of herniation (increased pressure inside the skull forces brain tissue to shift from its normal position into an adjacent space). The note showed given the patient's clinical status, anticoagulation, prolonged downtime, decorticate posturing, blown left pupil, the patient would not benefit from surgical management.Resident 1's hospital provider notes, dated 05/27/2026, showed that Resident 1's hemorrhage was non-surgical and non-survivable, and Resident 1 was transitioned to comfort care (end of life care) on 05/26/2026.On 06/02/2026 at 9:41 AM, Staff F, Assistant Director of Nursing, said if a resident was unresponsive to touch and staff were unable to wake them, they expected the nurse to call 911 and then continue their assessment because time is of the essence. Staff F said some residents could have deep sleep and if vital signs were stable staff might call the provider. Staff F said if a resident sounded like they were snoring, but they could not be awakened, it could indicate an airway that was partially obstructed. Staff F said if a resident is observed stretching, and in extension when they are touched it could indicate abnormal neurological finding. Staff F said an unresponsive resident was an urgent medical issue.Review of the facility's Change in Condition Inservice, dated 05/29/2026, showed that residents exhibiting an acute change in condition, including unresponsiveness or decreased level of consciousness, must be treated as a potential medical emergency and licensed nurses are responsible for immediate clinical assessment and appropriate escalation of care. The in-service showed while provider notification is required, activation of emergency medical services must not be delayed for provider direction when the resident's condition appears unstable or life-threatening. The in-service showed if a provider issues an order to monitor in house the licensed nurse must reassess the resident for clinical stability, clarify specific parameters, frequency of monitoring and transfer criteria, escalate concerns to the provider and/or on-call clinical leadership if the resident's condition does not clearly support in-house monitoring and if the resident remains unresponsive, deteriorates or does not demonstrate clearly reversible cause that is promptly resolved, the nurse is expected to initiate EMS transfer, the nursing staff are accountable for both carrying out provider orders and exercising clinical judgement to ensure timely interventions when a resident's condition exceeds the level of care that can be safely managed in the facility.On 06/02/2026 at 10:57 AM, Staff G, Administrator, said the change of condition in-service was initiated because of the incident with Resident 1 and review of the case. Staff G said after reviewing the case they felt Resident 1's condition could have been addressed sooner and reviewed it with staff, so they are empowered to make decisions. Staff G said they would have expected staff to escalate the call to the provider faster if at 9:13 AM Resident 1 was unresponsive and the staff did not page the provider until 10:54 AM.Reference WAC 388-97-1060 (1)-(3)

Based on record review and interview the facility failed to provide restorative nursing services for 1 of 3 residents (Resident 3) reviewed for therapy services. This failure placed residents at risk for decline in mobility, functional ability and a decreased quality of life.Findings included.Review of the facility policy, titled Restorative Nursing Programs undated, documented .It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable test.Residents, as identified during the comprehensive assessment process, will receive services from restorative aides when they are assessed to have a need for restorative nursing services. These services may include. Passive or active range of motionSplint or brace assistance.Bed mobility training and skill practice.Training and skill practice in transfers and walking.Training and skill practice in dressing and/or grooming.Training and skill practice in eating and/or swallowing.Amputation/prosthesis care.Communication training and skill practice.The discharging therapist, Restorative Nurse, or designated licensed nurse will communicate to the appropriate restorative aide, the provisions of the resident's restorative nursing plan, providing any necessary training to carry out the plan.Resident 3 was admitted to the facility on [DATE] with diagnoses including right below the knee amputation. The quarterly Minimum Data Set (MDS), an assessment tool, dated 10/23/2025 showed the resident had mild cognitive impairment, had no behaviors, required staff assistance for activities of daily living, transfers and mobility and used a wheelchair.Review of the Physical Therapy (PT) Discharge Summary with dates of service from 08/18/2025 through 09/30/2025, documented recommendations for the RNP (Restorative Nursing Program) and to follow up with prosthetic company for further fittings.Review of Resident 3's medical record showed no physicians order for Resident 3 to receive RNP services.During an interview and review of Resident 3's medical record on 02/26/2025 at 12:20 PM, Staff D, Physical Therapist (PT) was asked if the record showed a recommendation for the resident to receive RNP services after the resident was discharged from PT services. Staff D acknowledged there was a PT recommendation for Resident 3 to receive RNP services and there was no documentation Resident 3 received RNP services.Reference WAC 388-97-1060(3)(d)(j)(ix)

Based on review of the facility policy, interview and record review the facility failed to provide written notice of bed holds (holding or reserving a resident's bed while the resident was absent from the facility) given at the time of hospital transfer for 2 of 7 residents (Resident 11 and 13) reviewed for discharge process. This failure placed residents at risk of not being informed of their rights. Findings included .Findings included.Review of the facility policy, titled Bed Hold Notice, undated, documented .in the event of an emergency transfer of a resident, the facility will provide written notice of the facility's bed-hold policies to the resident and/or the resident representative within 24 hours.The facility will keep a signed and dated copy of the bed-hold notice information given to the resident and/or resident representative in the resident's file and/or medical record.Resident 11Resident 11 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS), an assessment tool, dated 11/10/2025 showed the resident was cognitively intact.Review of Resident 11's medical record, dated 01/19/2026, documented the resident requested to be transferred to the hospital for treatment and evaluation. Continued review showed no documentation a bed hold notice was provided to Resident 11.During an interview with Collateral Contact (CC) A, hospital staff, on 02/19/2026 at 3:12 PM, she stated Resident 11 had been a resident at the facility prior to his admission to the hospital. CC-A stated the facility was notified the resident was ready for discharge. She stated the facility told her he could return to a room with four beds. (The resident had previously been in a room with only two beds). CC-A said Resident 11 did not want to return to a room with four beds. CC-A stated the facility told her Resident 11's previous semiprivate bed was no longer available and a room with four beds was the only available bed. CC-A stated the hospital had to find another facility for the resident to be discharged to.Resident 13Resident 13 was admitted to the facility on [DATE]. The admission MDS dated [DATE] showed the resident had mild cognitive impairment.Review of Resident 13's medical record, dated 02/08/2026, showed the resident was transferred to the hospital by ambulance and admitted to the hospital. Continued review showed no documentation a bed hold notice was provided to Resident 13.During an interview with Staff B, Director of Nursing (DNS) on 03/03/2026 at 2:00 PM, he acknowledged a bed hold form was not signed and there was no documentation to indicate a bed hold notice was provided to Resident 11 and 13. Staff B acknowledged it was a nursing responsibility to ensure a bed hold notice was provided to the resident or resident representative when a resident was transferred to the hospital and return was expected.Reference WAC 388-97-0120(1)(2)(a)-(d)(3)(a)(4)(b)(5)

Based on interview and record review, the facility failed to have a system that ensured residents were screened, educated and offered the COVID-19 (a contagious disease caused by the coronavirus SARS-CoV-2) vaccine for 2 of 5 residents (Residents 15 & 7) when reviewed for immunizations. This failure precluded residents from the opportunity to make an informed decision regarding receiving Covid-19 vaccines. Findings included . Review of the facility's undated Infection Prevention and Control Program policy showed residents would be screened to see if they were prior immunized or had medical contraindications prior to being offered the COVID-19 vaccination. Once screened, education about the vaccine, risks, benefits, and potential side effects would be given to the resident/resident representative and the COVID vaccination offered. If the resident/resident representative consented, the COVID vaccination would be administered. The resident's electronic health record (EHR) would include documentation that indicated, at a minimum, the resident /resident representative was provided education about the risks and benefits associated with the vaccine, whether the resident did not receive the vaccine due to contraindications or refusal, and/or documentation of each COVID-19 vaccination that was administered.1) Resident 7 was admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS, an assessment tool), dated 12/11/2025, showed the resident was cognitively intact and their COVID-19 vaccination was not up to date.Review of Resident 7's EHR showed no documentation present that the resident was provided education about the risks and benefits of the COVID-19 vaccination.2) Resident 15 was admitted to the facility on [DATE]. Review of the admission MDS, dated [DATE], showed the resident was cognitively intact and their COVID-19 vaccination was not up to date.Review of Resident 15's EHR showed no documentation present that the resident was provided education about the risks and benefits of the COVID-19 vaccination.On 01/13/2025 at 12:48 PM, when asked if there was documentation to show Resident 7 and Resident 15 were provided education about the risks and benefits of the COVID-19 vaccination, Staff C, Infection Preventionist, stated, No. Staff C said a COVID-19 vaccination informed consent form should have been completed and filed in Resident 15 and Resident 7's EHR but acknowledged that did not occur.Reference WAC 388-97-1320

Based on interview and record review, the facility failed to ensure residents approved of a 15-hour mealtime gap and were served a nourishing snack at bedtime, when the time between the dinner and breakfast meals was increased to 15 hours. This failure placed residents at risk of feelings of hunger and inadequate nutrition.Findings included.Review of the Resident Council (a self-governed, resident-led group) Minutes, dated 08/07/2025, included the following mealtime schedule:a) The Main Dining room was served dinner at 4:30 PM and breakfast at 7:30 AM (for a total of 15 hours in between meals).b) The A Hall was served dinner at 5:00 PM and breakfast at 8:00 AM (15 hours in between meals).c) The B Hall was served dinner at 5:20 PM and breakfast at 8:20 AM (15 hours in between meals).d) The C Hall was served dinner at 5:40 PM and breakfast at 8:40 AM (15 hours in between meals).e) The D hall was served dinner at 6:00 PM and breakfast at 9:00 AM (15 hours in between meals).Further review of the Resident Council Minutes, dated 08/07/2025, showed the dining time had been changed, and a flyer had been passed out and explained to each resident, done by Staff H, Activity Director. On 01/12/2026 at 9:04 AM, Resident 6, a member of Resident Council, was asked if the 15-hour gap between meals was voted on by resident council or if they were informed of the change. Resident 6 said the resident council was just told what the new mealtimes would be. Resident 6 said the facility told them the change was happening, the council did not vote, and if voting had been an option they would have voted against it. Resident 6 said this was why the facility put out snacks, but the residents had to ask for the snacks. On 01/12/2026 at 9:45 AM, Resident 25, when asked if they were offered a snack every evening said, it was hit and miss, and staff would say there were no snacks available.On 01/12/2026 at 12:38 PM, Resident 66, when asked if they were offered a snack every evening, said they had to ask for snacks and they never got them, staff would say they were out. On 01/08/2026 at 2:50 PM, Staff G, Dietary Manager, when asked about snacks said Certified Nursing Assistants (CNAs) and residents could come to the kitchen door to request them. Staff G said they would put a snack tray out after breakfast where the coffee was at the front desk and again at night before the last people leave. When asked about residents that were bed bound, Staff G said they were trying to think of a great system, CNAs or nurses could come get snacks for residents, but she would like to start a program for people that they did not see.On 01/09/2025 at 9:54 AM, Staff G was asked about the 15-hour gap between meals and if a substantial snack was offered, Staff G said that sandwiches, juice, milk were available. When asked if these were offered to residents in their rooms, Staff G said in the evening the CNA or nurse would get the sandwich for the residents, and she did not know if staff was going room to room offering them.On 01/12/2026 at 9:35 AM, Staff H, Activities Director, with Staff J, Activity Aide, present for interview. When asked if snacks were offered to residents in the evening, Staff H said she offered snacks throughout the day from her activities cart, at about 11:00 AM and 2:00 PM and that Staff J, would be doing it again at 6:00 PM. Staff H said there was a refrigerator that was stocked at night for the residents that they had access to with sandwiches and items for diabetics. On 01/12/2026 at 11:44 AM, Staff A, Administrator, when asked if a nourishing snack was served at bedtime, said yes, we have a cart, after dinner at 8:00 PM. When told residents reported they had to request a snack, Staff A said, they had got hit with this before and that was part of the adjustment, now CNAs and activities handed out snacks. Staff A said CNAs were supposed to go around with water and offer snacks, and activities went around with snacks at 8:00 PM. Staff A said Staff J, Activity Aide, would do an offering at 8-8:30 PM. When asked if there was documentation of the 8-8:30 PM snack, Staff A said there was no documentation.On 01/12/2026 at 12:23 PM, Staff J, Staff H, and Staff I, Admissions Coordinator, were interviewed. Staff J said they would do a snack cart at 3:00 PM and 8:00 PM. Staff H then said they just implemented new snack times, they would be 10:00 AM, 3:00 PM, and 8:00 PM. Staff H confirmed these new times were started that day.On 01/12/2026 at 12:30 PM, Staff K, Registered Dietician, when told the facility had 15 hours between dinner and breakfast and asked if anyone had made her aware of that, Staff K said no, but she knew the facility had evening snacks available. Staff K said she was unaware that when the time between mealtimes goes beyond 14 hours a nourishing snack must be served.On 01/13/2026 at 9:13 AM, an email request for facility policies to include snack policy was sent. At 11:54 AM, a return email was received from the facility that the policy for snacks was not included, due to them currently revising the offering/serving bedtimes snacks policy. Reference WAC 388-97-1120(1)(3)(a)(b)

Based on observation, interview, and record review, the facility failed to ensure medication was stored in manners that met professional standards of practice, for 1 of 1 medication storage rooms (A&B Medication Room) and 2 of 2 medication carts (Halls C &B) reviewed. This failure placed residents at risk of receiving expired medications, cross-contamination, and a diminished quality of life. Findings included.During an observation of the A&B Medication Room on 01/06/2026 at 9:26 AM, Staff C, Infection Preventionist/ Licensed Practical Nurse (LPN), was present for review of the medications. A purified protein derivative (PPD, a test for Tuberculosis) multiuse vial was missing an open date. Staff C confirmed this and said it looked empty (had been used). An emergency kit, with medication in it, had an expiration date listed of 12/2025. Staff C confirmed this. The posted medication refrigerator log for January 2026, had columns that specified staff were to check temperature in the morning and at night due to the Centers of Disease Control and Prevention recommendation for if vaccines were present (vaccines were kept in this refrigerator), and showed there was no morning temperature recorded for the 1st, 3rd, or 4th. Staff C acknowledged the holes seen on the log. During an observation of the C Hall Medication Cart on 01/06/2026 at 9:46 AM, Staff P, LPN, was present. In the top drawer, one container had rectal suppositories (stimulate a bowel movement) that were being stored with three different oral medications. Staff P confirmed the suppository box had been previously opened and was not new. The bottom drawer was reviewed and had 7 pill packets for a resident being stored in this drawer, along with treatment cart supply items with creams. Staff P said the resident had gone to the hospital and came back, and they did not know why these pills were being stored in the bottom drawer. In the narcotic drawer, a liquid pain medication had been opened, without an open date listed on it. During an observation of the B Hall Medication Cart on 01/06/2026 at 10:10 AM, Staff Q, LPN, was present. In the top drawer, a container had batteries kept with two oral medications. The top drawer, storing medications, also had tape and scissors kept in it. In a middle drawer, a confiscated hair, skin, and nails gummies container was being stored, without a label on it to identify which resident it belonged to. Staff Q said they were storing them there until they could confirm with the doctor if the resident could have them. In the bottom drawer, this was observed to have treatment supplies in it. One resident's six boxes of eye drops were being kept in this drawer, not separated from the treatment supplies. Staff Q said they had moved the boxes to the medication room, but someone had brought them back out to the cart. Staff Q acknowledged the bottom drawer was being used as a treatment drawer. During an interview on 01/07/2026 at 11:11 AM, Staff B, Director of Nursing Services, was told of the observations from the previous day. Staff B said the PPD vial should have been dated, and the emergency kit was replaced yesterday (after the observation). Staff B said the expectation for suppository and oral medication storage was for them to have been separated by route of administration (oral, topical, etc.). Staff B said the bottom drawer of the carts should not have had treatment supplies, staff should have used a treatment cart instead. Staff B said that medication should not have been stored on the bottom drawer with treatment supplies present. Staff B said the pain medication should have been dated with the date opened, batteries should not have been in the medication cart, and neither should the tape/scissors have been stored in the medication drawer. Staff B said the confiscated vitamin gummies should have had a label with the resident's name. Reference WAC 388-97 -1300 (2),-1300 (2)

Based on interview and record review, the facility failed to ensure residents remained free of unnecessary drugs for 3 of 5 residents (7, 22, and 6) reviewed for unnecessary drugs. This failure placed residents at risk for increased sedation, inadequate pain relief, and a decreased quality of life.Findings included .Resident 7Resident 7 was admitted to the facility on [DATE] with a malignant neoplasm (cancerous tumor) of the large intestines. The admission Minimum Data Set (MDS- an assessment tool), dated 12/11/2025 documented Resident 7 was cognitively intact and had pain that occasionally affected sleep, therapy and day to day activities. A review of the electronic health record (EHR) showed orders:-Monitor pain every shift and non-pharmacological interventions for pain management A -Reposition; B -Rest; C - Apply Ice (with MD [Medical Director] order); D -Quiet Environment; E – Other (Document in progress note) dated 12/25/2025.-Hydromorphone give 3 tablets by mouth every 4 hours as needed for pain and non-pharmacological interventions: 1. reposition, 2 Apply ice, 3 apply warm compress. 4, Other dated 12/31/2025. A review of January 2026 medication administration record (MAR) showed no documentation on both orders of non-pharmacological interventions (NPIs) had been provided. On 01/13/2026 at 8:04 AM, Staff B, Director of Nursing Services said the staff were not documenting non-pharmacological interventions and they should be. Resident 22 Resident 22 was admitted to the facility on [DATE]. Review of the Quarterly MDS, dated [DATE], showed the resident was cognitively intact at intact, had a diagnosis of chronic lung disease and received oxygen (O2) therapy during the assessment period. Record review showed Resident 22 had the following oxygen therapy orders:- O2 at two liters per minute via nasal canula (2L/min via NC), dated 12/08/2025.- Administer O2 to maintain oxygen saturation (SpO2) greater than 90%, dated 10/08/2024. - Check SpO2 on room air (RA) on the 27th and 28th of every month, dated 10/27/2024. Review of the November 2025 Medication and Treatment Administration Record (MAR/TAR) showed on 11/28/2025 Resident 22's Spo2 was 94% on RA. Review of the December 2025 MAR/TAR showed on 12/28/2025 Resident 22's SpO2 was 95% on RA. Review of the SpO2's recorded on the vital sign flowsheet in the EHR showed from 11/02/2025 - 01/13/2026, Resident 22's SpO2 was checked on RA on the following dates:11/03/2025- 95% on RA11/04/2025- 97% on RA11/07/2025- 97% on RA11/08/2025- 94% on RA11/14/2025- 96% on RA.11/17/2025- 97% on RA.11/21/2025- 95% on RA.11/26/2025- 96% on RA11/28/2025- 95% on RA12/01/2025- 97% on RA12/08/2025- 95% on RA12/14/2025- 95% on RA12/23/2025- 91% on RA12/28/2025- 95% on RA01/01/2026- 91% on RA.01/05/2026- 96% on RA.01/08/2026- 93% on RA.01/12/2026- 95% on RA.01/13/2026- 98% on RA. During an interview on 01/08/2026 at 9:25 AM, when asked how the facility assessed a resident's need for continuous O2 therapy, Staff M, Resident Care Manager, explained that residents receiving supplemental oxygen, periodically would have the O2 removed and their SpO2 checked on RA. If the resident maintained a SpO2 (in this case greater than 90% as ordered by the physician), then the physician would be contacted to trial the resident on RA. When asked if that occurred for Resident 22, whose SpO2 was checked on RA and remained above 90% 19 consecutive times, between 11/02/2025 - 01/13/2026, Staff M stated, No. Resident 6 Resident 6 was admitted to the facility on [DATE], with a diagnosis of chronic pain. Review of the Quarterly MDS, dated [DATE], showed Resident 6 was cognitively intact. Review of Resident 6's orders, ordered on 10/29/2025, showed they were taking oxycodone (a strong pain medication), ordered for two tablets to be given for pain management of pain 7-10/10 (on a scale of 0-10, with zero being no pain and 10 being worst pain) or one tablet for pain of 3-6/10. The order specified for NPIs to be attempted, such as applying ice, redirecting, repositioning, and a quiet environment. Resident 6's Medication Administration Record (MAR) was reviewed for November 2025, which showed oxycodone, one tablet, was only given one time for pain of 3-6/10. Resident 6's oxycodone, two tablets, was given outside of the ordered 7-10/10 pain parameters. The following dates Resident 6 received two tablets for less than 7/10 pain: 1. 11/02/2025, 6/10 2.11/11/2025, 0/10 3. 11/12/2025, 6/10 4. 11/16/2025 6/10 Further review of this MAR showed although the oxycodone order had a location for interventions, an x showed for each administration for NPIs. Resident 6's Medication Administration Record (MAR) was reviewed for December 2025, which showed oxycodone, one tablet, was not given for pain of 3-6/10. Resident 6's oxycodone, two tablets, was given outside of the ordered 7-10/10 pain parameters. The following dates Resident 6 received 2 tablets for less than 7/10 pain: 1. 12/04/2025, 4/10 2. 12/15/2025, 6/10 3. 12/16/2025, 6/10 4. 12/21/2025, 6/10 5. 12/31/2025, 5/10 Further review of this MAR showed there was no location for licensed nursing staff to document NPI interventions. This MAR showed there was an order for nursing to document on a monitor for pain, with NA [not applicable] written under NPI, despite pain scores of 2 on this monitor and receiving pain medications. During an interview on 01/07/2026 at 1:39 PM, Staff D, Resident Care Manager/Registered Nurse, said NPIs should be done with pain medication administration and documented on the order. When asked to confirm the oxycodone was given outside of parameters in December, Staff D confirmed this and said staff were not paying attention to the verbiage. During an interview on 01/12/2026 at 2:11 PM, Staff B, Director of Nursing Services, said their expectation for NPI and documentation for pain meds, was for NPI to be attempted before giving medications if the resident agreed to them, for staff to document that they were used or if NPIs were refused. Staff B said their expectation for pain medications with parameters, was for the staff to follow the order. Reference WAC 388-97-1060 (3)(k)(i)

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 7 of 21 sampled residents (Resident 22, 8, 12, 11, 15, 6 & 94) reviewed care plans. This failure placed residents at risk of not receiving needed services, unmet care needs and a diminished quality of care.Findings included .Resident 22Resident 22 was admitted to the facility on [DATE]. Review of the electronic health record (EHR) showed Resident 22 had orders for the following psychotropic medications (drugs that alter brain chemistry to treat mental illness by affecting the central nervous system).- Wellbutrin (an antidepressant) once daily for major depressive disorder, dated 11/12/2024.- Lexapro (an antidepressant and anxiolytic) once daily for depression, dated 10/08/2024- Eszopiclone (a sedative hypnotic) once daily at bedtime for insomnia, dated 09/25/2025.- Seroquel (an antipsychotic) twice daily for bipolar disorder, dated 02/04/2025. A psychotropic medication used for bipolar (a mental health condition characterized by significant mood swings, including manic (or hypomanic) episodes and depressive episodes) disorder care plan, target date 03/27/2026, identified a goal that Resident 22 would not experience adverse side effects associated with psychotropic medication. The care plan failed to identify what the goal of psychotropic medication therapy was, to identify what psychotropic medication the resident received, and the specific target behaviors the medication was initiated to target. During an interview on 11/12/2026 at 10:24 AM, Staff C, Infection Preventionist (IP), confirmed the care plan should have identified what the goal of the psychotropic medication therapy was, what psychotropic medication the resident received (Seroquel) and what behavior(s) the medication was initiated to target. A mood problem related post-traumatic stress disorder (a mental health condition that's caused by an extremely stressful or terrifying event — either being part of it or witnessing it ), depression (serious mood disorder characterized by persistent feelings of sadness, loss of interest, and a range of emotional and physical problems), anxiety (a mental health condition characterized by excessive, uncontrollable worry about everyday issues, affecting daily functioning and quality of life) disorder, obsessive compulsive disorder (features a pattern of unwanted thoughts and fears known as obsessions), panic disorder (are sudden, intense feelings of fear that cause physical symptoms like a racing heart, fast breathing and sweating) and insomnia (common sleep disorder that can make it hard to fall asleep or stay asleep) care plan, target date 03/27/2026, documented Resident 22 was prescribed Abilify (an antipsychotic), melatonin (a sedative hypnotic), Lexapro and Wellbutrin. The identified goal was for Resident 22 to have an improved mood state, be happier, have a calmer appearance and have no signs and symptoms of depression, anxiety or sadness through the next review. Staff were directed to monitor for the following target behaviors: tearfulness; unrealistic worries; and refusal of care. The care plan did not identify what diagnosis each medication was associated with or the specific behaviors they were initiated to target. Additionally, review of the EHR showed Resident 22's Abilify order was discontinued on 11/12/2025. During an interview on 11/12/2026 at 10:24 AM, Staff C, IP, said the care plan needed to be updated to reflect the residents current medication orders and should have identified what medication(s), were associated with what diagnosis, and identified what behavior(s) each medication was initiated to target. Staff C acknowledged Resident 22's target behaviors did not accurately reflect the behaviors associated with their bipolar diagnosis, noting that, when manic, Resident 22 would become hyper-focused or perseverate on something, such as obtaining an order for a medication they saw on a commercial. Staff C acknowledged those types of resident specific behavioral manifestations that should be identified in the plan of care. Staff C confirmed multiple different psychiatric diagnoses, treated with multiple different psychotropic medications, should not have the exact same three target behaviors. Review of the comprehensive care plan, initiated 08/02/2024, showed there was no direction to staff that Abnormal Involuntary Movement Scale (AIMS) testing was required a minimum of every six months due to antipsychotic medication use, and the residents use of Eszopiclone and Seroquel were not identified or addressed. During an interview on 11/12/2026 at 10:24 AM, Staff C, IP, said because the resident received an antipsychotic medication, and AIMS testing was required, it should have been care planned. An antibiotic use for an infection to the second toe on the left foot care plan, initiated 11/20/2025, had an identified goal that Resident 22 would be free from discomfort and adverse side effects of antibiotic therapy through the next review. No goal was established for the use of an antibiotic medication (e.g. the resident's infection to left foot second toe will resolve without complication by next review). Review of the EHR showed Resident 22's order for doxycycline for an infected second toe on the left foot was completed on 11/30/2025. During an interview on 11/12/2026 at 10:24 AM, Staff C, IP, said the care plan needed to be updated. Resident 8 Resident 8 was admitted to the facility on [DATE], with diagnoses that included unspecified dementia (the specific type of dementia cannot be clearly identified, despite the presence of cognitive decline and memory loss) and major depressive disorder. The admission MDS, dated [DATE], documented Resident 8 was cognitively intact and had current tobacco use. Mental Health Care Plan Review of Resident 8's mental health care plan, initiated on 10/31/2025, showed no mental health care plans for unspecified dementia or major depressive disorder. On 01/08/2026 at 12:04 PM, Staff M, Licensed Practical Nurse (LPN), with Staff N, Market Resource/Registered Nurse (RN) present, were asked to review Resident 8's mental health care plan that included unspecified dementia and major depressive disorder. Staff M and Staff N confirmed they could not find a care plan regarding either mental health diagnoses. When asked if there should have been care plans for both diagnoses, both Staff M and Staff M said yes. On 01/12/2026 at 9:58 AM, Staff B, Director of Nursing Services (DNS), with Staff O, Market Resource Leader present, was asked to review Resident 8's mental health care plans that included unspecified dementia and major depressive disorder. Staff B confirmed they could not find a care plan regarding either mental health diagnoses. When asked if there should have been care plans for both diagnoses, Staff B said yes. Smoking Care Plan A review of Resident 8's care plan did not show a focus, goal, or intervention for smoking. On 01/12/2026 at 8:30 AM, Staff D, Resident Care Manager (RCM)/(RN) said there should have been a smoking care plan and he created and saved a smoking care plan at that moment. Resident 12 Resident 12 was admitted to the facility on [DATE] with diagnoses that included paraplegia (paralysis of the legs or lower body), fracture to left tibia and Schizophrenia (a severe mental disorder that affects how a person thinks, feels, and behaves, often leading to hallucinations, delusions, and disorganized thinking). The admission MDS, dated [DATE], documented Resident 12 was cognitively intact. Review of Resident 12's mental health care plan, initiated on 11/11/2025, showed no mental health care plan for schizophrenia diagnosis. Review of Resident 12's restorative care plan, initiated on 12/29/2025, documented Resident 12 would participate in restorative services 5 days a week for upper extremity strengthening. No other details provided. On 01/08/2026 at 12:04 PM, Staff M, LPN, with Staff N, Market Resource/RN present, were asked to review Resident 12's mental health schizophrenia care plan. Staff M and Staff N confirmed they could not find a care plan regarding schizophrenia. When asked if there should have been care plan for Resident 12's schizophrenia diagnoses, both Staff M and Staff N said yes. Staff M and Staff N were asked to review Resident 12's restorative care plan. Staff M read Resident 12's restorative care plan aloud. When asked if the care plan was individualized or person-centered, with goals/dates, both Staff M and Staff N said no and that it should have been. On 01/12/2026 at 9:58 AM, Staff B, DNS, with Staff O, Market Resource Leader present, was asked to review Resident 12's mental health schizophrenia care plan. Staff B confirmed they could not find a care plan regarding schizophrenia. When asked if there should have been care plan for Resident 12's schizophrenia diagnoses, both Staff B said yes, there should have been a care plan. Staff B was asked to review Resident 12's restorative care plan. When asked if the care plan was individualized or person centered, with goals/dates, both Staff B said Resident 12's restorative was not individualized or person-centered and it should have been. Resident 11 Resident 11 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented the resident was severely cognitively impaired and needed substantial to maximal assistance with activities of daily living including eating. On 01/06/2026 at 8:21 AM, an observation of a sign posted about Resident 11's bed read Head of bed elevated 30 degrees or higher at all times. A review of Resident 11's care plan did not show a focus, goal, or intervention for the head of bed to be elevated. On 01/12/2026 at 8:33 AM, Staff D, RCM/RN, acknowledged the sign in Resident 11's room and said, yes it should be in the care plan especially since it was part of Resident 11's plan of care. Staff D said he added it to the care plan at that moment under activities of daily living (ADLs). On 01/06/2026 at 8:58 AM, a staff person was observed one-on-one feeding Resident 11. Resident 11's ADL care plan initiated on 11/18/2021 said Resident 11 needed to be supervised/assisted to eat at mealtimes, assisted with setup of their tray and seasoning added to their meal with salt/pepper/butter. The care plan documented Resident 11 could feed themselves finger foods. On 01/12/2026 at 8:33 AM, Staff D, RCM/RN said Resident 11's ADL care plan had not been updated, and he said he would correct it at that moment. Resident 15 Resident 15 was admitted to the facility on [DATE], with a diagnosis of end stage renal disease (where the kidneys were no longer able to filter the blood). The admission MDS, dated [DATE], showed Resident 15 was cognitively intact. Review of Resident 15's dialysis (procedure that uses a machine to filter the blood) order, dated 12/15/2025, showed they were going to dialysis on Monday, Wednesdays, and Fridays from 6:00 PM to 11:00 PM. Review of Resident 15's dialysis care plan, dated 12/05/2025, showed their dialysis schedule was Monday, Wednesday, and Friday from 6:00 AM to 11:00 PM. The care plan documented, Do not draw blood or take BP [blood pressure] in arm with graft and When resident returns from dialysis, evaluate blood flow for Fistula or Grafts on either side of dressing. (To assure that dressing is not too tight) Palpate side of Fistula or Graft for thrill. During an interview on 01/08/2026 at 2:30 PM, Staff D, RCM/RN, acknowledged Resident 15's dialysis care plan did not have an accurate schedule, as Resident 15 went to dialysis in the evenings from 6:00 PM to 11:00 PM. Staff D said Resident 15 did not have a graft or fistula for access. Staff D acknowledged the care plan did not have details of Resident 15's port (access for dialysis). During an interview on 01/12/2026 at 2:11 PM, Staff B, DNS, said their expectation for dialysis care plans was for it to have included the dialysis center, the date and time they went to dialysis, pickup time, dialysis site with interventions to check the dressing and site, vitals, bloodwork, follow up appointments, to check for edema, and the name and phone number if they have a nephrologist. Resident 6 Resident 6 was admitted to the facility on [DATE], with diagnoses of bipolar disorder, depression and anxiety. Review of the Quarterly MDS, dated [DATE], showed Resident 6 was cognitively intact. Review of Resident 6's medications on 01/06/2026, showed they currently had orders for an antidepressant for depression and anxiety, a beta blocker for anxiety, and an antipsychotic (used to treat psychosis, which could include delusions, hallucinations, paranoia, or disordered thought) used to treat bipolar disorder. Review of Resident 6's psychotropic medication care plan for behavior management, showed it was initiated on 07/09/2025. This care plan included information on anti-psychotic medication usage, however, it did not specify any antianxiety medication. Resident 6 also had an antidepressant care plan for depression (did not list it was also for anxiety), initiated on 07/09/2025. Both care plans were found to have the same behaviors observed and non-pharmacological interventions listed for the antidepressant and antipsychotic medications. Both said behavior observed: sadness, tearful, isolation, exit seeking, wandering, resisting care, inappropriate touching staff/other residents, sexually inappropriate statements, aggressive behavior, and statements of self-harm, with only auditory/visual hallucinations listed under the antipsychotic care plan. Both had the interventions of redirect, remove from situation/ensure safety, calm environment, activity, reapproach, one on one staff to resident interaction, food/drink, toileting, repositioning, and not applicable. During an interview on 01/07/2026 at 1:39 PM, Staff D, RCM/RN, said care plans for psychotropic medications need to be able to identify specific behaviors and interventions, should be individualized. Staff D acknowledged there should have been an individualized care plan based on what medication was being treated, including an antianxiety care plan when taking beta blockers for anxiety or an antipsychotic care plan if taking for bipolar disorder. Staff D confirmed there was no care plan for Resident 6's anxiety/beta blocker usage. When looking at the psychotropic care plan, Staff D said it should have been changed to clearly say antipsychotic. When asked if they would expect Resident 6's diagnosis of bipolar disorder to be mentioned on the care plan, Staff D said they would expect it, the care plan said behavior management and was not specific for bipolar behaviors. Staff D said the behaviors on the care plan should also be listed in the physician's order. During an interview on 01/12/2026 at 2:11 PM, Staff B, DNS, said their expectation for psychotropic care plans was for them to be specific of the medication. For Resident 6, Staff B said the care plans should have been specific with listing the medication, behavior, diagnosis and use. Resident 94Resident 94 was admitted to the facility on [DATE]. Record review showed a physician's order, dated 09/29/2025, that directed staff to monitor closely for signs of fluid overload twice a day. Review of the comprehensive care plan, initiated 04/09/2025, showed there was no direction to staff to monitor the residents for signs and symptoms of fluid volume overload. On 01/12/2025 at 10:34 AM, Staff C, IP, said monitoring the resident for signs and symptoms of fluid volume overload, should have been incorporated into the comprehensive care plan. Reference F605, F698 Reference WAC 388-97 -1020(1), (2)(a)(b)

Based on interview and record review, the facility failed to ensure psychotropic medications (any drug that alters the brain affecting mood, behavior, perception and thought processes) were regularly monitored and documented on for 3 of 5 residents (Residents 22, 6, and 9) reviewed for unnecessary medication. This failure placed residents at risk of unnecessary medication usage and a diminished quality of life.Findings included .Resident 22 Resident 22 was admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS, an assessment tool), dated 10/16/2025, showed the resident was cognitively intact, had diagnoses of post-traumatic stress disorder (a psychiatric condition that may occur in people who have experienced or witnessed a traumatic event or series of traumatic events), bipolar disorder (mental health condition causing extreme mood swings), depression (persistent feelings of sadness and loss of interest), and anxiety (intense, excessive and persistent worry or fear). The MDS showed Resident 22 was administered antipsychotic (used to treat psychotic disorders), antidepressant (used to alleviate depression), and sedative hypnotic medications (class of drugs that depress the activity of the central nervous system to produce calming or drowsy effects) during the assessment period. Record review showed Resident 22 had orders for the following psychotropic medication (drugs that alter brain chemistry to treat mental illness by affecting the central nervous system) and monitoring orders. Psychotropic Medication orders: - Wellbutrin (an antidepressant) once daily for major depressive disorder, dated 11/12/2024. - Lexapro (an antidepressant and anxiolytic) once daily for depression, dated 10/08/2024 - Eszopiclone (a sedative hypnotic) once daily at bedtime for insomnia, dated 09/25/2025. - Seroquel (an antipsychotic) twice daily for bipolar disorder, dated 02/04/2025. -Melatonin (sedative hypnotic) once daily at bedtime for insomnia, dated 08/20/2025 Monitoring orders: - Monitor for adverse side effects of antidepressant medications twice daily for the use of Wellbutrin, Lexapro and trazadone. If side effects are observed, enter a chart note and notify the physician, dated 10/08/2024. - Monitor for adverse side effects of antipsychotic medications twice daily for the use of Abilify (an antipsychotic). If side effects are observed, enter a chart note and notify the physician, dated 10/08/2024. -Monitor for adverse side effects of sedative hypnotic medications twice daily for the use of sedative hypnotics. If side effects are observed, enter a chart note and notify the physician, dated 11/01/2025. -Behavior Monitor: monitor for 1) tearfulness 2) unrealistic worries 3) refusing care 4) no behaviors observed, every shift related to obsessive-compulsive disorder, anxiety disorder, bipolar disorder, and major depressive disorder. A mood problem related to post-traumatic stress disorder, depression, anxiety disorder, obsessive compulsive disorder, panic disorder and insomnia care plan, target date 03/27/2026, documented that Resident 22 was prescribed Abilify, melatonin, Lexapro and Wellbutrin. The identified goal of the psychotropic medication use was for Resident 22 to have an improved mood state, be happier, have a calmer appearance and have no signs and symptoms of depression, anxiety or sadness through the next review. Staff were directed to monitor the following target behaviors: tearfulness; unrealistic worries; and refusal of care, and to monitor the resident's hours of sleep. The mood care plan cited the same three target behaviors to justify the use of multiple psychotropic medications initiated to treat the behavioral symptoms of multiple psychiatric diagnoses. The care plan did not include any diagnosis-specific symptom identification and did not include Resident 22's diagnosis of bipolar disorder or the behavioral manifestations associated with it. A psychotropic medication use for bipolar disorder care plan, target date 03/27/2026, identified a goal that Resident 22 would not experience adverse side effects through the next review. No goal was identified for the use of the unidentified psychotropic medications, nor were the behaviors that the psychotropic medications were targeting. The care plan did not include diagnosis-specific symptom identification. There was no identification of what resident specific behaviors were demonstrated during mania (e.g. elevated mood, reduced sleep, impulsivity etc.) versus their behavioral symptoms when depressed. On 01/12/2026 at 10:24 AM, Staff C, Infection Preventionist (IP), explained the purpose of identifying specific target behaviors that a medication was initiated to treat, was to, through behavior monitoring, be able to objectively assess the effectiveness of the medication by determining if a resident's target behaviors were decreasing in frequency. When asked what behaviors Resident 22 demonstrated when manic, Staff C said Resident 22 would become hyper focused on things. An example provided was that Resident 22 would see a medication commercial and become hyper focused on obtaining an order for the medication approaching staff multiple times a day. When asked if that type of resident specific symptom of bipolar should have been included in the care plan and identified as a target behavior, Staff C said yes, and acknowledged it was not. On 01/12/2026 at 11:00 AM, when asked how staff could assess the effectiveness of each psychotropic medication and determine if there was an indication for continued use if each medication had the same behaviors, Staff C, IP, indicated it would be difficult to determine which medication, if any, was effective. When asked if continued intermittent refusals of showers (refusal of care was identified as a target behavior for all psychotropic medications with exception of sedative hypnotics) would justify the continued use of Seroquel, Lexapro and Wellbutrin, Staff C stated, I see what you are saying. Staff C acknowledged the facility did not identify the diagnosis-specific symptoms that each psychotropic medication was introduced to target which detracted from the ability to determine each medications effectiveness and/or need for continued use. On 01/12/2026 at 11:27 AM, Staff Z, Social Worker, said when Resident 22 was manic, they would become more sexual, in the sense that they would become very focused on their appearance, applying makeup every day, wouldn't sleep very much etc., and when depressed would sleep in late. When asked if that type of resident specific bipolar behavior should have been identified on the care plan and identified as a target behavior, Staff Z said that it should have and acknowledged it was not. Resident 6 Resident 6 was admitted to the facility on [DATE], with diagnoses of bipolar disorder, depression, and anxiety. Review of the Quarterly MDS, dated [DATE], showed Resident 6 was cognitively intact. Review of Resident 6's medications on 01/06/2026, showed they currently had the following orders: 1. Zoloft, an antidepressant, being used to treat depression and anxiety. 2. propranolol, a beta blocker, being used to treat anxiety. 3. Seroquel, an antipsychotic. Review of Resident 6's behavior monitors, ordered 07/24/2025, showed they only had one behavior monitor in place, which did not differentiate which medication (antidepressant, anti-anxiety, or antipsychotic) was treating which behavior. The behavior monitor showed they were monitoring for: 1. Upset 2. Un-redirectable 3. Sleeplessness 4. Sad 5. Sleeplessness 6. No behavior observed The behavior monitor showed staff interventions, non-pharmacological interventions (NPIs, interventions that were not medication), were to encourage Resident 6 to listen to their music album, offer them to go outside if weather and time permitted, and to offer ear plugs. Review of the December 2025 Treatment Administration Record (TAR), showed there was no area for licensed nurses to document NPIs provided. Behaviors were noted on 12/01/2025, 12/17/2025, and 12/18/2025. No documentation was found for 12/10/2025 (day shift), 12/16/2025 (day shift), 12/26/2025 (night shift), and 12/30/2025 (day shift). Review of Resident 6's Abnormal Involuntary Movement Scale (AIMS, used for monitoring for side effects [dyskinesias, orofacial movements and extremity and truncal movements] for residents on antipsychotics) assessments, found no AIMS assessment was done around admission [DATE]), not until 09/29/2025. During an interview on 01/07/2026 at 1:39 PM, Staff D, Resident Care Manager/Registered Nurse, said Resident 6 was being monitored for target behaviors related to being upset, un-directable, sleeplessness, and sadness. Staff D said this resident was admitted before they had started working at this facility, behavior monitors was a topic they were working on, and it looked like Resident 6's behavior monitor order had not been updated yet. Staff D confirmed there was no behavior monitor for propranolol being used for anxiety. Regarding the behavior monitor charting for December 2025, Staff D acknowledged that behaviors were noted and no NPI was documented, and that there were blanks (no documentation by the licensed nurses) for the 10th, 16th, 26th, and 30th. Staff D said AIMS should be done on admission, to know a baseline score. Staff D confirmed Resident 6 was on an antipsychotic medication during admission, and they were not yet working at this facility to have caught this. During an interview on 01/12/2026 at 2:11 PM, Staff B, Director of Nursing Services, said their expectation for target behaviors for psychotropic medications, was for them to be individualized. When asked if there should be separate target behaviors for different classes of drugs, such as antidepressants or antianxiety medications, Staff B said for target behaviors they had one order and they put numbers for the behavior being monitored. Regarding how the facility knows which medication needed to be adjusted, Staff B said they had numbers so they could easily tell. Staff B said Resident 6's number 5 was insomnia/sleeplessness, which helps them tell. Staff B was unable to find a current medication that sleeplessness was being monitored for as a target behavior. Staff B said Resident 6 was taking a stimulant, which could affect sleep. When asked if that would be a side effect monitor (not a target behavior), Staff B stated, It can affect sleep. Staff B said AIMS assessments should be done on admission. Resident 9 Resident 9 was admitted to the facility on [DATE] with diagnoses of bipolar disorder, major depressive disorder and anxiety. Review of the Significant Change MDS, dated [DATE], showed Resident 9 was cognitively intact. Review of the orders for Resident 9 showed they had orders for hydroxyzine (antihistamine often used to treat anxiety), dated 12/31/2025, three times a day for pruritis (itching)/anxiety and mirtazapine (antidepressant), dated 12/31/2025, one time a day for depressive disorder. Review of Resident 9's Electronic Health Record (EHR) did not show documentation that target behaviors were being monitored for the hydroxyzine or the mirtazapine. On 01/12/2026 at 12:41 PM, Staff D, Resident Care Manager/Registered Nurse, said for psychotropic medications they would expect adverse side effect monitoring and monitoring of behavior interventions and this included monitoring of target behaviors. When asked if Resident 9 was being monitored for target behaviors for the prescribed hydroxyzine, Staff D looked in the EHR and said there was nothing there for target behaviors and they should have been monitored. When asked if Resident 9 had target behaviors being monitored for the prescribed mirtazapine, Staff D said it did not look like it and they should have been. Reference F656 Reference WAC 388-97-0620 (1)(a)

Based on observation and interview, the facility failed to ensure the shower rooms were clean and in good condition, for 4 of 4 shower rooms (Hall A & Hall C [two shower rooms each]) reviewed. This failure placed residents at risk of feeling their showers were not homelike or clean, and a diminished quality of life. Findings included.During an interview on 01/05/2026 at 1:02 PM, Resident 66 said the shower rooms were dirty, that if you went into any of the shower rooms you would see how dirty they were. Resident 66 said they asked for garbage bags to be put on their feet because of how gross the shower rooms were. During an observation on 01/05/2026 at 1:25 PM, Hall A's shower, between rooms [ROOM NUMBERS], were checked. Observation showed the painted tiles were peeling, near the shower controls, bar, and sides. Paint along the baseboard was peeling. Two pieces of trash were seen on the floor, one appeared to be a seal flap (of an opened container), and the other object was a thin peel of debris (looked like it had come from the wall peeling). The flooring material appeared to have been put over a tiled floor, which led to square outlines that were stained by a dark brown/black appearance (resembling dirt). The shower room on Hall C, between rooms [ROOM NUMBERS], was observed to have the same dark brown/black staining between the texture of the flooring. The flooring, between the wall with the shower head and drain on the floor, had a large stain noted. The shower knobs/controls had a yellow stain going down the wall. Peeling of the painted tiles was noted to be prevalent near the base of the shower, with dark brown/black appearance between the shower tiles.During an observation on 01/12/2026 at 9:40 AM, Staff T, Certified Nursing Assistant, had been seen taking a resident out of the Hall A shower room, between rooms [ROOM NUMBERS]. The shower room door was left opened, and the room was observed to have towels draped over the shower wall side, a plastic cup was on the ground on the right side of the shower room on the floor, and a small brown item, with the appearance of stool, was seen near the shower drain (the room had not yet been cleaned). The shower chair was currently in the resident's room as staff assisted them. During an observation and interview on 01/12/2026 at 11:09 AM, Staff S, Maintenance Director, reviewed two shower rooms on Hall A. The first shower room reviewed was between rooms [ROOM NUMBERS]. The baseboards were peeling around the perimeter of the room, and the peeling painted shower tiles was confirmed by Staff S. The next shower room reviewed was between rooms [ROOM NUMBERS]. The tile's paint was observed to be peeling and the floor had brown/black staining between the texture lines. Staff S said the floor needed deep cleaning, needed to be cleaned better or deep cleaned or resealed. The room had appeared to have been cleaned since the prior observation, as the towels had been removed, the plastic cup had been removed, and the shower chair had been returned to the shower room. However, the small brown item was seen on the floor of the shower room, under the shower chair. Staff S told Staff E, Registered Nurse, that it looked like stool was on the floor in the shower room. Staff E stated, Yeah it looks like it. Staff S removed the item. During an interview on 01/12/2026 at 11:23, Staff T said they had cleaned the shower after the prior resident's shower and had not seen the brown item. During an observation on 01/12/2026 at 12:10 PM, Hall C showers were observed. The shower room, between rooms [ROOM NUMBERS], was still how it looked on 01/05/2026. The shower room, between rooms [ROOM NUMBERS], had a necklace/jewelry hanging in the corner of the room. The shower had blue paint that was peeling off the shower walls/tiles. The baseboards were noted to be missing some paint. The right corner of the room had baseboards with a large brown stain on it. The baseboard on the other side of the shower room also had the same stained appearance. During an observation and interview on 01/12/2026 at 12:23 PM, Staff B, Director of Nursing Services, reviewed Hall A's showers. Staff B confirmed the baseboards paint was peeling for the shower room between rooms [ROOM NUMBERS]. Staff B confirmed the tile was peeling paint for the shower between rooms [ROOM NUMBERS], and said the floors needed to be fixed. Both the C hall showers were reviewed with Staff B. Staff B said the tile's paint peeling needed to be fixed, needed more paint. Staff B said the floors needed to be cleaned with the stains, especially the shower room between 22 and 23. Regarding the jewelry, Staff B said they would need to check to see if someone left it in there. When asked if Staff B considered these shower rooms to be homelike, Staff B said yes. Reference WAC 388-97 -0880

Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for 2 of 21 sampled residents (Resident 33 & 6) reviewed. This failure placed residents at risk of a lack of care or services related to the assessments, and a diminished quality of life. Findings included .Resident 33 Resident 33 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented Resident 33 was cognitively intact and relied on staff for all cares. The MDS documented Resident 33 did not complain, have difficulty and or pain with swallowing or chewing food. On 01/05/2026 at 3:10 PM, Resident 33 reported they had missing and broken teeth and a number of their teeth had fallen out. Resident 33 said it had been almost a year since they had been to a dentist and they wanted to get their teeth fixed, because it was causing pain when they ate. Resident 33 said they could not chew meat, it had to be cut up very small, or sugar, due to causing pain and missing fillings, and this had been going on for months with no follow up. Review of the electronic health record (EHR) showed Residents 33's last dental visit was on 05/09/2025. It was documented Resident 33 had five decayed teeth, one broken tooth, with nine lower teeth and five upper teeth missing. Referral for X-rays, evaluations and extraction for all upper teeth was recommended. Review of Resident 33's dental care plan, revised 09/15/2025, documented Resident 33 had swallowing problems related to (r/t) complaints of difficulty or pain with chewing/swallowing. Resident 33 has potential/oral/dental health problems r/t he has his own natural teeth; they are in poor condition. On 01/08/2026 at 9:40 AM, Staff L, MDS Coordinator/Licensed Practical Nurse, said when they completed section L of the MDS (dental), they would go directly to the resident to obtain information, they would also review nursing assessments, dietary assessments and any other assessments that pertain to that care area. Staff L was asked to review Resident 33's dental care plan and Section L of the MDS. Staff L confirmed Resident 33's care plan documented Resident 33 was having pain and difficulty chewing/swallowing. Staff L said the MDS was incorrect, it should have documented that Resident 33 was having pain and difficulty swallowing when chewing. On 01/08/2026 at 12:04 PM, when asked who reviewed care plans after updates were made, Staff M, Licensed Practical Nurse, with Staff N, Market Resource/Registered Nurse present, said the whole interdisciplinary team (IDT) that included the Assistant Director of Nursing, Resident Care Managers, and the MDS Coordinator. Staff M and Staff N were asked to review Resident 33's dental care plan and most current MDS. When asked if the MDS was accurate, Staff M, said they could not answer the question, they did not complete MDSs, Staff N interjected and said no, the MDS was incorrect. On 01/12/2026 at 9:58 AM, Staff B, Director of Nursing Services (DNS), with Staff O, Market Resource Leader present, said when a dental care plan was updated, the entire IDT would review the update and act accordingly to the update, including setting up dental appointments, notifying the transport manager, and speaking with the Registered Dietitian (RD) about dietary changes. Staff B was asked to review Resident 33's dental care plan and the most recent MDS, Staff B confirmed the dental care plan was updated in September 2025 with reports that Resident 33 was having pain and difficulty chewing. Staff B said the MDS only looks at a specific time frame, the look back period and if Resident 33 did not report concerns during that time, then the MDS would be correct. When Resident 33's interview was explained, he was still reporting pain and the documentation supported that Resident 33 had reported pain and difficulty chewing since September 2025, Staff B said yes, the MDS was incorrect and it should have been documented correctly. Resident 6 Resident 6 was admitted to the facility on [DATE]. Review of their Quarterly MDS, dated [DATE], showed they were not receiving any therapy, including occupational therapy (OT). Review of December 2025 OT sessions for Resident 6, showed they had received OT sessions on the 1st, 3rd, 5th, 8th, 10th, 12th, and 15th. During an interview on 01/12/2026 at 8:58 AM, Staff L, MDS Coordinator/ Licensed Practical Nurse, said the observation window for therapy services for Resident 6 would have been the 16th of December and seven days prior. Staff L said Resident 6's therapy minutes should have shown up, and they would have to amend the MDS assessment (12/16/2025). During an interview on 01/12/2026 at 2:11PM, Staff B, DNS, when asked their expectation for Resident 6's 12/16/2025 MDS recording OT sessions, Staff B confirmed the MDS should have shown Resident 6 was receiving OT services. Reference WAC 388-97- 1000 (1)(b)

Based on observation, interview and record review, the facility failed to thoroughly investigate a fall with injury for 1 of 2 residents (Resident 52) reviewed for falls. The facility's failure to identify and assess the location where a fall occurred, to identify and consider what environmental factors such as uneven surfaces, and insufficient lighting, were present at the time of the fall and to interview all residents and staff with knowledge about the incident, prevented facility staff from identifying the external factors that were present and led to the residents fall. These failures detracted from the ability to identify what interventions needed to be implemented to prevent reoccurrence and placed residents at risk for continued falls and injuries. Findings included . Resident 52 was admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS, an assessment tool), dated 11/10/2025, showed the resident was cognitively intact, was independent with activities of daily living, able to ambulate at least 150 feet independently with walker, and had fallen once since the prior assessment.On 01/07/2026 at 12:33 PM, Staff CC, Helping Hands (supervises resident smoking), reported management had turned off the lights to the smoking area due to the behaviors of a few residents. Staff CC said the first night the lights were off Resident 52 fell while walking back from the smoking area. Staff CC indicated they were not present at the time of the fall but Resident 52 told them the next day. Resident 52, who was present and listening, said they were walking back from the smoking area, and it was pitch black because the lights were off and then suddenly, they were on the ground, and a female came and helped them. Resident 52 said they were not sure why or what caused them to fall because they couldn't see.A progress note, dated 12/18/2025, showed when the nurse came on shift, they were notified that Resident 52 had an unwitnessed fall outside, and had already been assisted up, and was being wheeled back to their room by a nursing assistant. Resident 52 said they did not know or remember how they fell but reported it happened while they were ambulating back from the smoking area, then suddenly, they were on the ground. Resident 52 was assessed with mild swelling and scrapes above the left eyebrow, an abrasion to the left deltoid, a small bump on the left elbow, and a minor cut on the left knee. Neuro checks were initiated per facility protocol, the provider was notified and no new orders were given.A provider note, dated12/18/2025, documented Resident 52 fell on his left side in the parking lot on 12/17/2025, when his walker got caught and sustained mild abrasions to his left temple, shoulder, elbow and knee.A level two preadmission screening and resident review care plan, initiated 05/20/2025, directed staff to ensure Resident 52 was in a well-lit space as he was a high fall risk since his stroke.Review of the facility's December 2025 incident log showed on 12/17/2025 Resident 52 fell outside, sustained superficial injuries, the cause of the fall was established, and that care plan revisions were made.The facility's fall investigation, dated 12/17/2025, documented Resident 52 fell at 6:10 PM. The nurse was notified by Staff FF, Certified Nursing Assistant, that Resident 52 fell outside. The nurses post fall assessment showed Resident 52 reported they fell while walking back from the smoking area. They were alert and oriented to person, place, time and situation, and had mild swelling and scrapes above the left eyebrow, an abrasion to the left deltoid, a small bump on the left elbow, and a minor cut on the left knee. A statement provided by Staff FF said they were approached by a (unidentified) resident who informed them Resident 52 fell outside. When Staff FF arrived in the courtyard, Resident 52 was already up and then the nurse came and assessed him. Under the investigative sections titled Injuries Observed at Time of Incident and Injuries Reported Post Incident staff documented no injuries were observed. Under the section Predisposing environmental factors staff documented none were present. The investigation concluded the cause of Resident 52's fall was unknown. The intervention implemented to prevent recurrence was patient education about changing positions slowly. The investigation did not include, identify or address: a statement from the resident who initially found Resident 52 and reported the fall to Staff FF; Resident 52's statement to the provider that his walker got caught causing/contributing to the fall; identify where along the path back from the smoking area the fall occurred; identify and address that the fall occurred after dark on the night the facility stopped turning lights on for the smoking area; assess if there were uneven surfaces or tripping hazards on the path back from the smoking area; or include interviews with other staff or residents (smokers) who may have knowledge or information about the incidentOn 01/13/2026 at 2:28 PM, Staff A, Administrator, acknowledged the facility stopped turning on the lights for the smoking area but said prior to doing so, they placed solar lights in the courtyard so residents would have light and could still safely access the smoking area but indicated the solar lights malfunctioned. When asked why this was not addressed in the investigation, Staff A indicated they were unsure what date the facility stopped turning the smoking area lights on and stated, We didn't document it. No response was provided for why the investigation didn't identify the location of the fall, why the resident who reported the incident was not identified or interviewed, or why other residents (who smoke) or staff who may have had knowledge of the incident were not interviewed. Receipts for the solar lights the facility reportedly placed to ensure residents could safely access the smoking area were requested. On 01/15/2025 at 3:19 PM, an email was received from Staff B, Director of Nursing Services, with an attached statement from Staff FF dated 01/15/2025. The statement was the same as the statement attached to the fall investigation except it now included a statement that The sidewalk night light was on.On 01/15/2026 at 4:36 PM, an email was received with two attached receipts. One receipt showed a four pack of solar path lights that was purchased on 01/09/2026 and the other showed a two head motion sensor light that was purchased on 01/14/2026. These purchases occurred after the lighting for the smoking area had been reinstated. Refer to F689Reference WAC 388-97-0640 (6)(a)(b)

Based on interview and record review, the facility failed to ensure residents received their personal funds (money kept for the resident by the facility) within 30 days of discharge for 1 of 1 residents (Resident 107) reviewed for personal funds with discharge. This failure placed residents at risk of delay in access to their money and a diminished quality of life. Findings included .Review of the facility policy titled Resident Personal Funds, dated 2025, showed upon discharge, eviction, or death, a resident with personal funds deposited with the facility, would receive from the facility within 30 days, their funds and a final account of those funds. Review of the refund request form for Resident 107, showed they were discharged on 06/24/2025. Review of the facility's copy of the check they provided Resident 107 to return their money after discharge, showed the check was written on 07/29/2025. During an interview on 01/07/2026 at 9:38 AM, Staff R, Business Office Manager, confirmed Resident 107 was discharged on 06/24/2025 and was not written a check within 30 days, until 07/29/2025.During an interview on 01/12/2026 at 3:04 PM, Staff A, Administrator, said their expectation regarding personal funds being released back to the residents after discharge, was for it to be returned within 30 days. Staff A reviewed the calendar and confirmed that Resident 107's personal funds were not released within 30 days.Reference WAC 388-97-0340(5)

Based on interview and record review, the facility failed to communicate resolutions about the concerns brought forward by the resident council (RC) for 6 of 6 months (July, August, September, October, November and December 2025) of RC minutes reviewed. These failures resulted in RC members feeling frustrated, unheard and powerless to affect their care.Findings included .Review of the facility's Resident and Family Grievances policy, dated 2025, showed In accordance with the resident's right to obtain a written decision regarding his or her grievance, the Grievance Official will issue a written decision on the grievance to the resident or representative at the conclusion of the investigation. The written decision will include at a minimum:i. The date the grievance was received. ii. The steps taken to investigate the grievance.iii. A summary of the pertinent findings or conclusions regarding the resident's concern(s).iv. A statement as to whether the grievance was confirmed or not confirmed.v. Any corrective action taken or to be taken by the facility as a result of the grievance.vi. The date the written decision was issued.During a meeting with the RC on 01/07/2026 at 11:00 AM, when asked if the facility considered concerns brought up in RC, Resident 6, RC President, said Staff H, Activities Director, notified the facility of the RC's concerns, but they were not informed of what happened, what the results were, and if there were any changes. On 01/09/2026 at 10:00 AM, Staff A, Administrator and Staff O, Market Resource Leader were asked if they notified the RC of the results of the grievances, they both replied no, and said they could start having another meeting with the residents in RC to go over the results of their specific concerns in the grievances.On 01/13/2026 at 11:15 AM, Staff A, Administrator, Staff H, Activities Director, and Staff Z, Social Services, were asked if they had documentation that they went over the results of the specific grievances from RC. Staff H said they would go over old business and new business at every RC meeting. On 01/13/2026 at 2:31 PM, an observation with Staff H, Activities Director, of the RC meeting minutes, dated 12/26/2025, 11/17/2025, 10/13/2025, 09/15/2025, 8/18/2025, and 07/17/2025 showed the Discussion of Old Business and Discussion of New Business sheets were blank with nothing written on them.On 01/13/2026 at Staff 2:31 PM, Staff H, Activities Director, said while looking at the RC meeting minutes, she did not fill out the Discussion of Old Business form. Staff H said, I don't document anything on that form about the concerns from the previous month. And Staff H said What I do is take the minutes from the previous RC and ask the RC, for that month, if they still have the same concerns. Staff H said she was going to start documenting this on the Discussion of Old Business form.On 01/13/2026 at 2:53 PM, Staff H, Activities Director, provided copies of the form titled Discussion of Old Business for the dates 12/26/2025, 11/17/2025, 10/13/2025, 09/15/2025, 8/18/2025, and 07/17/2025 which now had documentation not previously observed. The first sentence on the form Old Business: Minutes of Last month's meeting were read aloud and were approved was now circled yes and a handwritten statement had been added Read Previous/Follow up Form.Reference WAC 388-97-0920(1-6)

Based on interview and record review the facility failed to ensure dignity was provided to 2 of 2 Residents (6 & 79) reviewed for resident rights during a meeting with Resident Counsel. This failure placed the residents at risk for diminished self-worth and a decreased quality of life.Findings Included.Resident 6Resident 6 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS-an assessment tool), dated 12/16/2025, documented Resident 6 was cognitively intact. On 01/07/2026 at 11:00 AM Resident 6 said they felt harassed when Staff R, Business Office Manager, asked them why aren't you paying your bill? Resident 6 said if your bill is not paid [Staff R] will hassle you. Resident 79Resident 79 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented Resident 79 was cognitively intact.On 01/07/2026 at 11:00 AM Resident 79 said they also felt harassed by Staff R, Business Office Manager, when they had asked about a bill not being paid one month. On 01/07/2026 at 3:14 PM Staff R, Business Office Manager was asked what their process was when a resident had a bill. Staff R said on the third and fifth of the month they would jokingly say I want your money, it is rent day.The facility investigation dated, 01/7/2026, documented, It was discovered through the investigation process that [Staff R, Business Office Manager] could benefit from additional training regarding the language [Staff R] uses when discussing the billing process with resident and resident representatives.On 01/09/2026 at 10:00 AM, Staff O, Market Resource Leader/Acting Administrator, said they discussed customer service practices and provided training with Staff R on the facility's policies and expectations.Reference WAC 388-97-0180(1-4)

Based on observation, interview, and record review, the facility failed to provide staff supervision and implement fall prevention strategies for a resident assessed at high fall risk for 1 of 3 residents (Resident 1) reviewed for falls. Resident 1, who had at least three prior unwitnessed falls from their bed, experienced harm when they were positioned on the edge of their bed unsupervised, was subsequently found on the floor and required transfer to the hospital where they were diagnosed with multiple fractures at the right wrist. This failure placed resident at risk for falls, injury and decreased quality of life. The findings included.Resident 1 was admitted to the facility on [DATE] with diagnoses including end stage renal disease (ESRD) (kidneys are failing and can no longer filter waste from the blood and requires dialysis or a kidney transplant), and atrial fibrillation (irregular and often rapid heart rhythm). The resident's Minimum Data Set assessment, dated 10/16/2025, showed the resident was cognitively intact, had no behaviors, used a wheelchair (w/c) and required substantial staff assistance for rolling, sit to lie positioning, dependent on staff for chair to bed transfers and was frequently incontinent of bladder and bowel.Review of Resident 1's Physical Therapy (PT) Evaluation, dated 04/26/2025, showed .Patient presents with balance deficits, decreased safety awareness, decreased static balance (trouble staying steady while standing still), joint mobility/integrity deficits, postural alignment/control and strength impairments which requires skilled PT services .Review of Resident 1's PT Discharge summary, dated [DATE], showed .Roll left and right .Partial/Moderate Assist .Sit to lying .Substantial/Maximal Assist .Lying sitting on side of bed .Substantial/Maximal Assist .Sit to stand .Partial/Moderate Assist .Patient has reached maximum potential with skilled services .Review of a facility document titled Therapy RA [Restorative Aid] Referral Form, undated showed .Precautions R [right] shoulder chronic dislocation .Comments .Requires frequent rest breaks, easily fatigued .Fall #1Review of Resident 1's progress note, dated 08/13/2025, showed the resident had an unwitnessed fall in his room and sustained a laceration to the right temple. The resident was transferred to the hospital for evaluation and treatment and received sutures to the laceration.Review of Resident 1's progress note, dated 08/14/2025, showed the resident stated he sat near the edge of the bed and slid to the floor. The intervention implemented was to ensure the resident was not sitting at the edge of the bed, offer resident to sit in w/c or go to the dining room for meals.Fall #2Review of a facility documentation for Resident 1's fall dated 09/20/2025 showed the resident had an unwitnessed fall from the resident's bed and was found on the floor leaning on his bed with an abrasion to his left knee. The documentation showed predisposing physiological factors include loss of balance. Resident 1 was assessed and assisted back to bed using a mechanical lift. Facility investigation showed the resident was unable to describe what happened and sustained an injury [abrasion] to the left knee. New intervention to do frequent checks when the resident was in bed.Resident 1's Fall Assessment, dated 09/20/2025, showed score of 80 (high risk 45 and higher).Review if Resident 1's care plan, revised 9/22/2025, showed resident at risk for falls with intervention to encourage resident to be up in w/c for meals in dining room and reposition resident in the middle of the bed.Fall #3Review of the facility documentation, dated 10/22/2025, showed Resident 1 had an unwitnessed fall and was found on the floor in the resident's room, near his bed by the window. Resident 1 stated they slid down to the floor. The investigation showed the resident continuously leaned on his left side, despite being repositioned. The resident reported the mattress shifted causing him to slide to the floor. Intervention implemented was to ensure mattress was securely fastened to the bed frame and resident positioned away from the edge of the bed when sleeping. Resident 1's Falls Assessment, dated 10/22/2025, showed score 60 (high risk for > 45).Review of Resident 1's care plan, revised 10/24/2025, showed during safety rounds ensure the mattress was well secured.Fall #4Review of the facility investigation, dated 11/29/2025 at 5:55 PM, showed Resident 1 had an unwitnessed fall in the resident's room. The resident returned from dialysis around 12:00 PM. At 4:30 PM, Staff C, Certified Nursing Assistant (CNA) offered to transfer Resident 1 to his w/c but the resident stated he preferred to have dinner in his room while sitting at edge of the bed. The resident was served his meal seated at the edge of the bed. Resident 1's roommate notified staff Resident 1 was on the floor. The fall resulted in the resident sustaining a non-displaced (cracked but stays in alignment) right distal radial (forearm bone on the thumb side) metaphysis (weaker section of bone) fracture.Review of hospital documentation, dated 12/01/2025, showed the resident sustained a non-displaced distal right radial metaphysis fracture and suspected non-displaced ulnar metaphysis fracture without joint malalignment. A splint was applied to the right wrist and pain medication prescribed for pain control.Review of Resident 1's progress note, dated 12/08/2025, showed a splint was removed and cast applied.During an interview on 12/31/2025 at 12:28 PM, Staff C, Physical Therapist, was asked if Resident 1 required staff assistance to transfer. Staff C said Resident 1 required 2 staff and a mechanical lift to transfer the resident from bed to chair. He acknowledged Resident 1 should be out of bed and seated in a w/c for meals and activities. Staff C stated Resident 1 had weakness to his left side, leaned to the left side and did not tolerate sitting in the w/c for long periods. He stated the resident preferred to sit at the edge of the bed. Staff C was asked if it was safe for Resident 1 to be left seated at the edge of his bed without staff present? Staff C said .no it is not safe for Resident 1 to be seated at the edge of the bed without staff.he has already had a few falls.During an interview on 01/02/2026 at 9:25 AM, Staff B, Certified Nursing Assistant (CNA) acknowledged they were the CNA that assisted Resident 1 on 11/29/2025, the resident required 2 staff and a mechanical lift to transfer, had problems with his balance, leaned to his left side all the time and had returned from dialysis on 11/29/2025. Staff B stated the resident was very tired and did not want to transfer to the w/c for his meal. Staff B acknowledged she positioned the resident at the side of the bed, served the resident his meal and left the resident seated at the bedside unattended. She acknowledged the resident fell and sustained a fracture. Staff B acknowledged Resident 1 requires staff assistance with eating his meals now due to a cast to his right arm.During an observation and interview on 01/02/2026 at 9:30 AM, Resident 1 was observed lying in his bed with a cast to his right forearm. Resident 1 was asked if he recalled falling and injuring his arm. The resident said, Yes I do.I fell out of bed. When asked if he was seated at the side of the bed when the fall occurred, the resident responded, yes. The resident became drowsy, closed his eyes and was unable to continue the interview.During an interview on 01/02/2026 at 11:53 AM, Staff C, Restorative Aid stated she worked with Resident 1 with bilateral strengthening and standing. Staff D said Resident 1 always leaned to the left and was frequently drowsy during most therapy sessions. Staff D stated the resident was very tired when he returned from dialysis. Staff D was asked if she had observed Resident 1 seated at the edge of the bed? Staff D stated sometimes. Staff D was asked if Resident 1 was safe to be seated at the edge of the bed unattended? Staff D stated, No it isn't safe because of his balance issues and fatigue.During an interview on 01/02/2026 at 2:20 PM with Staff A, Director of Nursing Services (DNS), he said Resident 1 was high risk for falls and had three previous falls from his bed. Staff A stated if a resident had balance issues, was fatigued and high falls risk the resident should have been left in bed or assisted to the w/c for his meal and should not have been left at the side of the bed unattended. Staff A said the resident fractured their arm and required transfer to the hospital, had a cast applied and returned to the facility.

Based on interview and record review the facility failed to ensure staff performed Cardio-Pulmonary Resuscitation (CPR/an emergency procedure consisting of chest compressions combined with giving breaths of air) and failed to assure required staff had unexpired CPR certifications for 1 of 1 resident (Resident 1) who was found unresponsive and had a physician's order for CPR. The failure of facility staff to initiate CPR placed all residents who chose to have CPR initiated at risk for serious injury, harm, impairment or death and represented an Immediate Jeopardy (IJ) situation. On [DATE] at 2:45 PM, the facility was notified of an IJ at CRF 483.24 (a)(3), F678 CPR, the IJ was determined to have begun on [DATE] when the facility failed to perform CPR. The facility's failure placed residents at risk for serious injury, harm, impairment or death. The facility removed the immediacy on [DATE] with an onsite verification by the investigator by review of staff education, verification staff obtained active CPR certifications, conducting staff interviews related to staff re-education regarding CPR policies and procedures which ensured an effective system was in place to safeguard, protect and prevent residents who require CPR. Findings included . Review of the facility's policy, titled Medical Emergency Response, undated showed the following: 1. The employee who first witnesses or is first on site of a medical emergency, that are trained, will initiate immediate action, including CPR as appropriate, basic first aid and summon for assistance. 2. CPR will continue unless: a. There is a DNR [Do Not Resuscitate] in place b. There is obvious signs of clinical death c. Initiating CPR could cause injury or peril to the rescuer. 3. A licensed nurse will: a. Assess the situation and determine the severity of the emergency. b. Stay with the resident. c. Designate a staff member to announce a Code Blue, if necessary, notify the physician and call 911 as needed . 8. If the resident experiences cardiac arrest, the facility must provide basic life support, including CPR, prior to the arrival of emergency medical services, and: a. In accordance with the resident's advanced directives, or b. In absence of advanced directives or a Do Not Resuscitate order, and c. If the resident does not show obvious signs of clinical death . Resident 1 was admitted to the facility [DATE] with diagnoses including bladder cancer and diabetes. The quarterly Minimum Data Set (MDS), an assessment tool, dated [DATE], showed the resident was alert and oriented and required staff assistance for activities of daily living. Resident 1's POLST (Physicians Order for Life Sustaining Treatment) form, dated [DATE], showed to attempt resuscitation/CPR, full treatment, use intubation, advanced airway interventions, mechanical ventilation, cardioversion (medical procedure used to restore a normal heart rhythm by delivering electrical shock) as indicated, transfer to hospital if indicated, including intensive care treatment. Resident 1's nurse's note, dated [DATE] at 7:02 AM, showed at around 11:50 PM a Certified Nursing Assistant (CNA) checked on Resident 1 and noted the resident would not respond back to her. The CNA reported Resident 1 was not breathing. Staff C, Licensed Practical Nurse (LPN) assessed the resident and noted the resident had no chest movement and no pulse. Staff C called Staff E, Registered Nurse (RN), (who's CPR certification was not on file and could not be verifed as Staff E would not return calls from facility or state surveyor) to assess Resident 1. Staff E auscultated (listened with a stethoscope) to Resident 1 for a full minute and concluded Resident 1 had passed. Review of the facility investigation included the following statement, dated [DATE], by Staff D, CNA, showed I went to check on [Resident 1] and asked him to wake up. I went to find the nurse and ask her to check on [Resident 1] and she realized he had passed away. Review of the facility investigation showed the following statement by telephone on [DATE] by Staff C: [Staff C] stated at 10:30 PM she was called to [Resident 1's] room by a CNA who said [Resident 1] was not responding to verbal or tactile stimuli. [Staff C] said she went to [Resident 1's] room and found the resident unresponsive. [Staff C] stated she went to get [Staff E]. [Staff E] came to [Resident 1's] bedside and observed [Resident 1] had no signs of life. [Staff C] said [Resident 1] was cool to touch and his jaw was stiff. [Staff C] said there had been a conversation earlier in the day regarding a change of code status but was unsure if that had been completed. In an interview on [DATE] at 4:02 PM, Staff A, Administrator and Staff B, Director of Nursing (DNS)/Registered Nurse said Resident 1 had a POLST which indicated full CPR. They said Resident 1 was found unresponsive by Staff D who left the resident to find a nurse and did not initiate CPR. Staff A and B said Staff C came to Resident 1's bedside, found the resident unresponsive and did not initiate CPR or activate emergency response, and left Resident 1's bedside to find a nurse (Staff E). They said CPR was not initiated and 911 was not notified and the facility did not follow their emergency response protocol and Resident 1 expired in the facility. Staff A and B said during the investigation they noted numerous staff did not have current CPR certification. In an interview on [DATE] at 1:43 PM, Staff C said she was the nurse responsible for Resident 1 on the night he expired. Staff C said she finished passing medications and a CNA reported they thought the resident wasn't breathing. Staff C said she went to Resident 1's room and watched for chest movement and saw no chest movement. Staff C said she called Staff B and they didn't answer. Staff C said she left Resident 1's room to find another nurse to check the resident. Staff C said Staff E, Registered Nurse came to Resident 1's room and agreed Resident 1 had expired. Staff C was asked why they didn't initiate CPR. Staff C said I thought they changed his [Resident 1]'s code status. Reference WAC [DATE] (1)

Based on observation, interview and record review, the facility failed to ensure adequate care and services were provided to promote wound healing and prevent pressure ulcers from developing or worsening by implementing and following care interventions timely for 4 of 7 sampled residents (Residents 1, 2, 5 and 6) reviewed for pressure ulcers. Resident 1 experienced harm when the resident's skin was not assessed, and they developed an unstageable pressure ulcer to the left heel with no treatment initiated for 12 days. These failures placed residents at risk for worsening pressure ulcers, infection, medical complications and diminished quality of life. Findings included . <Facility Policy> Review of the facility policy, titled, Skin Assessment, undated showed a full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, daily for three days, and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury. The policy showed documentation of the skin assessment would show the type of wound, describing the wound's measurements, color, type of tissue in the wound bed, and presence of drainage, odor and pain. <Resident 1> Resident 1 was admitted to the facility on [DATE] with diagnoses including palliative care (specialized medical care for people living with serious illness), dementia, malnutrition and a pressure ulcer to the sacrum (pelvis area). The admission Minimum Data Set (MDS), an assessment tool, dated 12/09/2024, documented Resident 1 was cognitively impaired, had impairment to their upper and lower extremities and was frequently incontinent of bladder and bowel. The Admission Assessment, dated 12/04/2024, showed coccyx [tailbone] pressure. The assessment did not indicate the size or description of the pressure injury/wound. A Skin Assessment, dated 12/06/2024, documented a deep tissue injury (DTI/damage is below the skin's surface, the extend of damage is unknown, these injuries are often caused by sustained pressure or trauma) to the sacral/coccyx with description of deep purple red. Resident 1's medical record showed no skin assessments were documented from 12/07/2024-01/15/2025 (39 days). Review of hospice documentation, dated 01/15/2025, noted the following: -Sacrum initial assessment 12/02/2024, pressure injury, Stage 3. -Bilateral Buttocks Stage 2 wounds -Left heel Stage 2, scabbed heel, apply betadine (antiseptic) and leave open to the air and float heels. New pressure injury noted. Reviewed skin care and updated skin care orders for nursing. An Administration note, dated 01/18/2025, documented blue boots to relieve pressure to bilateral heels. On at all times while in bed. Resident 1's Skin Assessment, dated 01/24/2025, documented an unstageable pressure injury to the sacrum which measured 2 centimeters (cm) length x 2 cm width x 2 cm depth. Resident 1's Electronic Medication Administration Record (EMAR) dated 01/2025 showed a Physician's order, dated 01/27/2025, for betadine [used to dry out the wound] to the left heel and to leave open to the air. Hospice noted a pressure injury to the left heel on 01/15/2025 and no treatment was initiated until 01/27/2025 (12 days later). On 02/03/2025 at 1:21 PM, Resident 1 was observed lying in bed on his right side. The resident did not have protective boots on his feet at the time. The boots were observed on the floor beside the bed. On 02/03/2025 at 2:30 PM, Resident 1's room was observed with Staff C, Licensed Practical Nurse (LPN). The resident did not have protective boots on his feet at the time. Resident 1's left heel was observed with as an unstageable pressure ulcer. Staff C applied the heel protector boots to Resident 1's feet. On 02/04/2025 at 9:35 AM, Resident 1 was observed sleeping in bed. The resident did not have protective boots on his feet at that time. Resident 1 was observed lying on his right side. Resident 1's heels were not floated on pillows. At 10:24 AM, Resident 1 was observed sleeping in bed. The resident did not have protective boots on his feet at the time. Resident 1 was lying on his right side. Resident 1's heels were not floated on pillows. <Resident 2> Resident 2 was admitted to the facility on [DATE] with diagnoses including paraplegia (partial or complete paralysis of the lower half of the body with involvement of both legs) and fracture to the right femur. The admission MDS, dated [DATE], documented Resident 2 was cognitively intact, had impairment to bilateral lower extremities. Resident 2's care plan, dated 11/14/2024, showed a stage 2 pressure injury (wound caused by pressure that has broken through the top layer of the skin and part of the layer below) to the coccyx. Interventions included to monitor and document location, size and treatment of skin injury. Weekly treatment documentation to include measurement of each area of skin breakdowns and width, length, depth, type of tissue and exudate (drainage). Review of a provider note, dated 11/24/2024, documented to use enabler bars and air mattresses and refer to wound consultant if worsens. Review of Resident 2 skin assessments showed the following: Skin assessment, dated 11/14/2024, showed a Stage 2 pressure ulcer to the spine 1.5 cm length x 0.6 cm width. Skin assessment, dated 11/21/2024, showed a Stage 2 pressure ulcer to the spine 1.7 cm x 0.2 cm. Skin assessment, dated 11/27/2024, showed a Stage 2 pressure ulcer measured 0.3 width x 6.1 cm length. No skin assessments documented from 11/28/2024-12/16/2024 (18 days). Skin assessment, dated 12/17/2024, showed a Stage 1 wound on sacrum. There was no description or measurement of wound. No skin assessments documented from 12/18/24 - 01/07/2025 (21 days). On 01/03/2025 at 12:54 PM, during a telephone interview Resident 2 said she had been a paraplegic for [AGE] years and the facility was supposed to supply an air mattress, and the resident said she did not have one yet. On 01/06/2025 at 1:45 PM, observation of Resident 2's pressure ulcer with Staff C, showed an intact dressing, dated 01/05/2024, and with a pressure ulcer to the left buttocks with slough (dying cells/debris that hinders wound healing and can increase risk of infection) in the wound bed. Staff C acknowledged she was not aware of what stage the resident's pressure ulcer was and there was not an air mattress on Resident 2's bed at that time. Skin assessment, dated 01/08/2025, showed a Stage 2 pressure ulcer to the spine and measured 0.9 cm length x 0.6 width x 0.3 depth. Review of a Wound Consultant's assessment, dated 01/08/2025, showed a healing Stage 3 pressure ulcer (wound under second layer of skin and into the fat tissue) that measured 0.9 x 0.5 x 0.3. Wound debridement (removal of dead or infected tissue to promote healing) was completed. Review of a Physician's Order dated 01/10/2025 (59 days after admission to the facility) documented, Wound # 3 sacrum pressure with treatment recommendations. -Cleanse wound vigorously to patient tolerance with house wound cleanser and gauze -Treat periwound with emollient to dry skin areas daily. -Pack with calcium alginate (wound dressing) -Cover with bordered dressing -Change: Every other day and as needed for accidental removal, saturation and/or soiling. <Resident 5> Resident 5 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction (blood flow to brain was interrupted, causing brain cells to die), Hemiplegia and Hemiparesis (muscle weakness or partial paralysis to one side of the body), Chronic Pain and Failure to Thrive. The Significant Change MDS, dated [DATE], documented Resident 5 was cognitively intact, was at risk for developing pressure ulcers and was frequently incontinent of bladder and bowel. Resident 5's Care Plan, revised 11/29/2024, showed the resident was at risk for pressure injury and had a lesion to the spine which was resolved. No skin assessments documented from 11/29/2024 - 01/01/2025 (34 days). Skin assessments, dated 01/06/2025 - 01/13/2025 showed a healing scar to the vertebrae. Skin assessments, dated 01/21/2025, showed a skin tear to the upper back. On 01/23/2025 at 1:09 PM, observation of Resident 5's wound on her back with Staff F, Certified Nursing Assistant (CNA), and Staff G, Registered Nurse (RN), showed a dressing covered the wound. Staff G, RN, said the wound was from a skin tear. Staff F, CNA, said the wound was from a few weeks prior from tucking a sling under the resident and a fingernail snagged her back. The resident's wound had drainage on the dressing and the site appeared to be reddened. On 01/29/2025 at 10:15 AM, observation of Resident 5's wound with Staff E, LPN showed an undated wound dressing was intact to the resident's spine. Staff E removed the dressing and noted a small wound with yellow slough to the wound bed. Staff C, RCM, said she was unsure if there were orders for Resident 5's wound and would review the orders and notify the provider. Staff C said the wound measured 0.6 cm width x 1 cm length. Review of wound consultation documentation and subsequent physicians order, dated 01/29/2025 after discussion with Staff C, showed Resident 5 had an unstageable pressure ulcer to the thoracic spine that measured 0.9 cm by 0.7 cm by 0 cm with orders to clean the wound with wound cleanser, apply Medi honey (a wound treatment) to wound base and apply a bordered dressing every other day. On 01/29/2025 at 10:50 AM, Staff C, RCM, acknowledged there were incomplete skin assessments for Resident 5 in December 2024 and skin assessments were to be completed weekly. Staff C said she was notified yesterday that the wound had opened up again and there were no current treatment orders for this wound. <Resident 6> Resident 6 was admitted to the facility on [DATE] with diagnoses including Cerebral Palsy (group of neurological disorders that appear in early life and permanently affect body movement and muscle coordination) and Polyneuropathy (peripheral nerve disorder). The Quarterly MDS, dated [DATE], documented Resident 6 was at risk for developing pressure ulcers and was frequently incontinent of bladder and bowel. Resident 6's Admission Assessment, dated 09/10/2024, showed a skin tear to the groin, and MASD to the sacrum. Resident 6's care plan, dated 09/10/2024, showed the resident had an alteration in skin integrity related to skin tears to the testicles and a closed blister to the right buttocks. Resident 6's progress note, dated 01/16/2025, showed the resident was discharged from the facility. Resident 6's record showed no skin assessments were completed after the initial assessment throughout the resident's admission (128 days). On 02/06/2025 at 3:15 PM Staff B, Director of Nursing and Registered Nurse, acknowledged skin assessments were not completed weekly for Residents 1, 2, 5 and 6 and should have been completed weekly by nursing. Staff B said the facility did have a wound nurse that was coming into the facility to assess wounds and also worked remotely. The wound nurse stopped working at the facility in December 2024 and skin assessments were not being completed after that time. Staff B acknowledged Resident 1 developed second pressure ulcer after admission, skin assessments were not completed weekly and there was a delay in treatment of the pressure ulcer for Resident 1. Reference WAC 388-97-1060 (3)(b)

Based on observation, interview and record review the facility failed to ensure their systems were in place to address and monitor weight loss experienced by 2 of 4 residents (Resident 71 and 65) reviewed for nutrition and failed to monitor and implement accurate fluid restrictions for 3 of 4 sampled residents (Residents 1, 6, and 12) reviewed for fluid restrictions. Resident 71 experienced harm when the facility failed to obtain weekly weights per their care plan, update the physician with the registered dietician's recommendations to add an appetite stimulant and calorie supplement and failed to offer supplemental food when the resident consumed less that fifty percent of their meal that resulted in a significant weight loss of 14.41 percent in 55 days. Resident 65 experienced harm when the facility failed to ensure adequate supplement intake or modify dietary interventions, that resulted in a significant weight loss of 16.64 percent in 113 days. These failures placed residents at risk of fluid imbalances, weight loss, medical complications and a decreased quality of life. Findings included . <Weight Loss> The facility policy titled, Weight Monitoring, undated, showed Residents with weight loss should have weekly monitoring of weight and defined a significant change in weight as a five percent change in weight in one month (30 days), 7.5 percent change in weight in three months (90 days), and a 10 percent change in weight in six months (180 days). The policy directed staff to inform the physician when residents had a significant change in weight. <Resident 71> Resident 71 admitted to the facility on [DATE]. According to the Admission Minimum Data Set (MDS, an assessment tool), dated 12/09/2024, Resident 71 was severely cognitively impaired with diagnoses of heart failure, cerebrovascular accident (stroke), and malnutrition or was at risk for malnutrition. Resident 71 had a mechanically altered diet (a change to food texture for individuals with difficulty chewing or swallowing), a feeding tube (a small tube that delivers nutrition, fluids, and medicine directly into the stomach) and did not have weight loss of five percent or more in the previous month or loss of ten percent or more in the previous six months. >Weights< Review of Resident 71's weight record showed: On 12/05/2024, upon admission to the facility, Resident weighed 118 pounds On 01/29/2025 (55 days later) Resident 71 weighed 101 pounds. This demonstrates a significant weight loss of 14.41%. On 02/04/2025 (6 days later and 61 days since admission), Resident 71 weighed 99.2 pounds, a 15.93% total weight loss in 61 days since admission. Review of Resident 71's care plans, showed weight monitoring interventions of: 1. weigh on admission, daily and as indicated, revised on 12/06/2024 2. weekly weights, initiated on 12/05/2024 Review of Resident 71's weight record showed no weights were taken from 12/23/2024 to 01/14/2025, a period of 21 days. Although it was care planned, review of Resident 71's orders showed no orders for weekly weights. During an interview on 1/30/2025 at 11:57 AM, Staff C, Resident Care Manager (RCM), said residents who were at risk for malnutrition or were experiencing significant weight loss should be weighed weekly. When asked if Resident 71 had weekly weights ordered since they were experiencing significant weight loss, Staff C said no and that weekly weight orders should have been put in. Staff C said it was not acceptable that Resident 71 did not have a weight taken for 21 days while experiencing significant weight loss. >Dietician Recommendations< Review of a Significant Weight Loss Nutrition Progress Note, dated 12/16/2024, documented [Resident 71] had significant weight loss x7 days .Recommend consulting MD about need for an appetite stimulant. Recommend adding Benecalorie [supplement to add calories to food] to oatmeal or yogurt at breakfast. Review of a nutrition/dietary progress note, dated 01/25/2025, showed it took over five weeks after the significant weight loss was identified, before the facility documented provider notification and provider ordered interventions, provider updated and agrees with recommendations. Provider gave new order Mirtazapine [appetite stimulant], start Benecal [Benecalorie] daily via Gtube [feeding tube]. During an interview on 1/30/2025 at 1:27 PM, when asked if she could provide documentation that the physician was updated prior to documentation on 01/25/2025, based on the 12/16/2025 nutrition recommendations, Staff C could not provide documentation. Staff C said it was not acceptable that the provider was not updated for over five weeks on the recommendations. During an interview on 01/31/2025 at 11:38 AM, when asked about the Registered Dietician's 12/16/2024 recommendations for Resident 71 not being conveyed to the provider until over five weeks later, Staff B, Director of Nursing Services (DNS), said it did not meet expectations, it should have happened sooner. Staff B said there should have been weekly weights in place for Resident 71 while they were experiencing significant weight loss, that orders should have been put in for this, and it did not meet expectations that a weight had not been obtained for 21 days. During a phone interview on 02/06/2025 at 9:44 AM, when asked about her recommendation from 12/16/2024 for an appetite stimulant and Benecalorie supplement, Staff P, Registered Dietician said the provider not being notified of the recommendations until 01/25/2025 did not meet expectations. >Meal Monitoring and Alternative Food/Supplement< Certified Nursing Assistants (CNAs) were tasked in Point of Care, a computer program used mostly by NA to document resident care, to document and record percentage of each meal eaten for breakfast, lunch, and dinner, and if the resident ate 50 percent or less they were to offer an alternative food (alternative options included Boost (a supplemental drink), house shake, Mighty shake, sandwich, cottage cheese, yogurt, other), and to document what percentage of the alternative was eaten. During a 30-day lookback review, between 01/01/2025 to 01/30/2025, the following date/times were found to have not offered Resident 71 an alternative although they met the threshold, ate between 0% to 50% of their meal: 01/01/2025 at 10:16 AM, 25-50% of meal eaten - No alternative needed ate > 50% 01/03/2025 at 2:06 PM, 25-50% of meal eaten - No alternative needed ate > 50% 01/04/2025 at 10:19 AM, 25-50% of meal eaten - No alternative needed ate > 50% 01/04/2025 at 1:22 PM, 25-50% of meal eaten - No alternative needed ate > 50% 01/05/2025 at 1:52 PM, 25-50% of meal eaten - No alternative needed ate > 50% 01/06/2025 at 11:59 AM, 0-25% of meal eaten - Not applicable 01/12/2025 at 7:45 AM, 25-50% of meal eaten - Not applicable 01/12/2025 at 11:30 AM, 25-50% of meal eaten - Not applicable 01/13/2025 at 6:39 PM, 25-50% of meal eaten - No alternative needed ate > 50% 01/16/2025 at 10:26 AM, 0-25% of meal eaten - Not applicable 01/25/2025 at 2:23 PM, 25-50% of meal eaten - No alternative needed ate > 50% 01/28/2025 at 2:13 PM, 25-50% of meal eaten - Not applicable During an interview on 01/31/2025 at 11:38 AM, when asked about CNA documentation that Resident 71 ate 0% to 50% of meals and then documenting Resident 71 ate greater than 50% of meals resulting in no supplemental food being offered, Staff B said it did not meet expectations, and a supplement should have been offered. 42960 <Resident 65> Resident 65 was admitted to the facility on [DATE] with a diagnosis of severe protein-calorie malnutrition (a condition where the body doesn't get enough protein and energy) and muscle wasting and atrophy (loss of muscle mass and strength, typically caused by a lack of physical activity, injury, malnutrition, or certain medical conditions). The quarterly MDS, dated [DATE], showed Resident 65 was moderately cognitively impaired and had a loss of five percent or more in the previous month or loss of ten percent or more in the previous six months and was not on a doctors' prescribed weight loss plan. <Weight Loss> A review of the electronic health record (EHR) documented Resident 65 weighed 129.8 pounds on 09/27/2024 and weighed 109.5 pounds on 01/18/2025 which was a 15.64 percent loss in 113 days. On 01/27/2025 at 8:37 AM Observations of Resident 65 showed she has eaten the hot cereal but did not eat the other items on her breakfast tray. On 01/27/2025 at 12:48 PM Observations of Resident 65's lunch plate appears mostly full with 1-3 bites off her plate. Resident 65 did not touch her corn bread, pineapple and ate some of the roast beef and potatoes. On 01/28/2025 at 8:02 AM Observations of Resident 65 sitting in the dining room in her wheelchair eating her breakfast. Resident 65 ate all of her hot cereal and fruit, but did not eat the eggs, ham and toast. A review of the eating and meal intake sheet for 30 days from 12/31/2024 through 1/28/2025 showed on: 01/01/2025 at 6:35 PM, Resident 65 ate 0-25% and it was documented no alternative needed ate >50% 01/04/2025 at 2:10 PM, Resident 65 ate 0-25% and it was documented no alternative needed ate >50% 01/05/2025 at 9:53 AM and 1:11 PM, Resident 65 ate 25-50% and it was documented no alternative needed ate >50% 01/06/2025 - Resident 65 ate 25-50% for all three meals and it was documented no alternative needed ate >50% 01/21/2025 at 12:12 PM and 6:39 PM, Resident 65 ate 0-25% and it was documented no alternative needed ate >50% 01/22/2025 at 11:32 AM and 1:59 PM, Resident 65 ate 25-50% and it was documented no alternative needed ate >50% On 01/30/2025 at 12:42 PM, Staff B said while looking at the eating and meal intake sheet, the staff should have offered an alternative or supplement to Resident 65 when eating 0-25 percent and for 25-50 percent of their meals. Staff B said the resident was still losing weight and the interventions didn't seem to be effective from looking at the trending. <Interventions> A review of the EHR showed an order dated 11/05/2024 for a liquid nutritional supplement 120 milliliters (MLs - a measure of volume in the metric system) three times a day. A review of the medication administration record (MAR) showed blanks or a lack of documentation for 11/21/2024 and 12/22/2024 at bedtime. On 01/30/2025 at 12:42 PM, Staff B, DNS said while looking at the MAR there should not have been blanks and her expectation was for the nurse to document if the resident took it or refused it. A review of the January 2025 MAR showed the amount of total 120 MLs (approximately 4 ounces) of liquid nutritional supplement consumed was 30 MLs, 60 MLs or refused as follows: Morning: Refused 10 of 27 times 30 MLs was consumed 5 of 27 times 60 MLs was consumed 12 of 27 times Midday: Refused 11 of 25 times 30 MLs was consumed 3 of 25 times 60 MLs was consumed 11 of 25 times At bedtime: Refused 5 of 27 times 30 MLs was consumed 7 of 27 times 60 MLs was consumed 13 of 27 times On 01/30/2025 at 12:42 PM, while looking at the MAR, Staff B said Resident 65 was not drinking the full amount of the liquid nutritional supplement and her expectation would be for this to be in the Nutrition at Risk meeting and look at other interventions. <Resident 1> Resident 1 was admitted to the facility on [DATE] with a diagnosis of heart failure (a condition where the heart cannot pump blood effectively enough to meet the body's needs) and chronic kidney disease (a long-term condition where the kidneys gradually lose their ability to filter waste products from the blood). The quarterly MDS, dated [DATE], documented Resident 1 was cognitively intact. A review of the EHR showed an order, dated 01/13/2023, for a fluid restriction of two liters (a measure of volume in the metric system) per day to include 1600 MLs to be consumed with meals and 100 MLs for each med pass (for total of 400 MLs with medications per day) for hyponatremia (a condition where the sodium level in the blood is lower than normal). On 02/03/2025 at 2:15 PM, when asked if Resident 1 was on a fluid restriction, Staff F, CNA said, I will check with the nurse today. At 2:32 PM, when asked how the CNAs knew when a resident was on a fluid restriction, Staff E, Licensed Practical Nurse (LPN), said, the nurse should tell them to make sure they know. A review of the task documentation for 01/05/2025 - 02/03/2025 showed staff documented no for all entries when asked is resident on a fluid restriction? except on 01/15/2025, it was documented resident refused and on 01/21/2025 it was documented not applicable. A review of the task documentation for 01/05/2025 - 02/03/2025 showed the amount of fluid taken field on the document was left blank on the following dates: 1/14/2025, 1/19/2025, 1/20/2025, 1/23/2025, 1/24/2025, 1/25/2025, 1/28/2025, 1/30/2025, and 1/31/2025. On 02/04/2025 at 10:32 AM, Staff B said she would provide education to the CNAs and make sure they knew how to document when a resident was on a fluid restriction. A review of the MAR for January 2025 showed on 01/17/2025 at night and 01/23/2025 in the evening there were blanks with no documentation for MLs for each medication pass. On 02/04/2025 at 10:32 AM, Staff B, DNS said she would expect the nursing staff to document something there even if it was a refusal. When how they'd know when Resident 1 had reached their fluid restriction of two liters, Staff B said they would have to find out what dietary was documenting and what nursing was documenting and if the CNAs were also documenting and that she wasn't seeing any total amounts. 50945 <Resident 6> Resident 6 was admitted to the facility on [DATE] and had diagnoses including kidney disease that required dialysis (treatment to filter blood and remove excess fluid and waste buildup). Resident 6 had an order for a fluid restriction, initiated on 11/21/2023, for one liter per day. Resident 6's care plan also documented the resident was on a one liter fluid restriction. Further review of the EHR showed the CNA had a task that documented the fluid restriction as 1.5 liters. Review of the January 2025 records by licensed nurses (LNs) and task records inputted by CNAs showed: 01/03/2025: 500 MLs recorded by LN plus 735 MLs recorded by CNA for total of 1,235 MLs 01/11/2025: 440 MLs recorded by LN plus 840 MLs recorded by CNA for total of 1,280 MLs 01/24/2025: 600 MLs recorded by LN plus 960 MLs recorded by CNA for total of 1,560 MLs. The active order was for one liter which is 1,000 ML. The three sampled dates reviewed for all had totals exceeding 1000 MLs or one liter. During an interview on 01/31/2025 at 11:52 AM, Staff C, Resident Care Manager (RCM), after reviewing the above three days, said it did not meet expectations that Resident 6's fluid intake went over one liter. After the above interview, documentation was provided of a progress note from 04/19/2024, which showed the registered dietician documented Resident 6 was on a 1.5 liter per day fluid restriction. This was not consistent with the order and the order was not updated. The dietician noted that during their review of the past 30 days, the intake ranged from 270 ml to 1440 ml and requested to ensure staff is documenting all fluids accepted by residents (for meals and meds). During a follow up interview on 02/03/2025 at 11:51 AM, Staff C, RCM, said the point of a fluid restriction was to prevent fluid overload (when there is too much fluid in the body, causing increase in blood pressure, swelling, and possibly impact organ function) when kidneys were not functioning at full capacity. Staff C acknowledged that totaling the daily fluid intake was not occurring and was an issue. When asked about the conflicting fluid restriction information in the EHR, Staff C said they would contact the provider to clarify. After the above interview, Resident 6 had an updated fluid restriction order, initiated on 02/03/2025 at 12:18 PM, for a fluid restriction of 1.2 Liters per day. During an interview on 02/04/2025 at 11:18 AM, Staff B, Director of Nursing Services (DNS), said their expectation regarding fluid restrictions was that the orders, care plan, and everything else in the EHR would say the same thing and match. Staff B said it did not meet expectations staff were not totaling fluid intake, and that Resident 6 went over the one liter fluid restriction when it was the active order. 37044 <Resident 12> Resident 12 admitted to the facility on [DATE]. A 01/01/2025 physician's order showed the resident was placed on a two liter per day fluid restriction. The dietary department was to provide 1500 ML per day with meals, and nursing was to provide a total of 500 ML per day, or 250 ML per shift. On 01/22/2025 at 1:43 PM, Staff D, Resident Care Manager (RCM), said the facility placed stickers next to resident names outside their door to communicate specific care needs to staff. A sticker key was provided and showed a cactus was used to show a resident was on a fluid restriction. On 01/24/2025 at 1:13 PM and 01/28/2025 at 3:01 PM, observation showed a cactus sticker was not placed next to Resident 12's name outside their door. A nutrition problem care plan, initiated 01/01/2025, showed Resident 12 was on two liter per day fluid restriction, the kitchen provided 1500 MLs per day and nursing provided 500 ML per day for a total of two liters per day. Resident 12's EHR showed staff documented the resident's fluid intake in three separate locations. NA's charted: 1. In Point of Care, under 'meal monitor' for fluid intake with meals 2. In Point of Care, under 'additional fluids' Facility nurses charted: 3. under the MAR for fluids provided with medications The January 2025 meal monitor showed there was incomplete documentation of the resident's fluid intake with meals. Staff failed to document Resident 12's fluid intake for 21 of 93 meals. The second fluid intake with meals question asked staff is the resident on a Fluid restriction? Review of the documentation showed facility staff documented No or Not Applicable on 31 of 31 days. The January 2025 MAR showed each nurse recorded the amount of fluid they provided Resident 12 each shift, but there was no direction to, or place provided for nursing to reconcile the fluid intake recorded on the meal monitor, and under additional fluids, with the amount of fluids provided by nursing to calculate/evaluate the resident's 24-hour fluid intake. Resident 12's EHR showed no documentation was present to show facility nurses had calculated the resident's 24 hour fluid intake since admission to the facility. On 01/28/2025 at 3:08 PM, Staff D validated a cactus sticker was not placed next to Resident 12's name outside their door to alert staff the resident was on a fluid restriction. Staff D, RCM, explained that facility nurses were expected to assess/evaluate the resident's 24-hour fluid intake to determine if they were adherent or non-adherent with the fluid restriction. If Resident 12 was non-adherent, they would be educated about the risks/benefits of the non-adherence, and the physician would be notified. When asked if facility staff could determine if the resident was adherent with the fluid restriction without calculating the resident's 24-hour total fluid intake, Staff D stated, No. On 02/04/2025 at 3:12 PM, Staff D said Resident 12's fluid intake documentation on the meal monitor was incomplete; staff had erroneously documented on 31 of 31 days in January that the resident was not on a fluid restriction; staff failed to place a cactus sticker outside the resident's door next to their name to alert staff of the fluid restriction; and that facility nurses failed to reconcile the fluids provided by dietary with the fluids provided by nurses to calculate the resident's 24 hour fluid intake. Reference WAC 388-97-1060 (3)(i)

Based on observation, interview and record review the facility failed to provide timely assessment and treatment by a qualified professional in response to a significant and acute change in condition for 1 of 3 residents (Resident 5) reviewed for death in the facility. Resident 5, who had a recent history of aspiration (inhalation of foreign material into the lungs), experienced harm when they vomited, and experienced a sudden change in breathing pattern with bluing around the lips and eventually expired. These failures placed residents at risk of not receiving basic life support and a delay of care and treatment, serious harm, impairment or death and constituded an Immediate Jeopardy (IJ). On [DATE] at 4:02 PM, the facility was notified of an IJ at CFR 483.25, F684, Quality of Care, related to the facility's failure to provide timely assessment and/or treatment by qualified personnel (nursing) when there was a delay in locating nursing staff due to lack of a working emergency response system determined to have began on [DATE]. The facility removed the immediacy on [DATE] with onsite verification from investigator by conducting staff observation of staff wearing walkie talkies for communication and interviews regarding re-education of all staff on emergency response plans which ensured an effective system was in place to safeguard, protect and prevent residents at risk for requiring an immediate response. Findings included . Facility Foreign Body Airway Obstruction Management (Chocking) policy, undated showed, timely intervention to relieve obstruction is imperative to offset complications. Facility Emergency Operations Plan, undated, showed instructions for 'rapid response' to a situation that placed residents' health or safety at risk to activate overhead codes or facility emergency alert systems as appropriate Resident 5 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, Chronic Obstructive Pulmonary Disease (breathing difficulty with cough, wheezing and often excess mucus), dementia, gastroesophageal reflux disease (condition in which stomach acid repeatedly flows back up into the tube connecting the mouth and stomach), and dysphagia (swallowing difficulties). Resident 5's Minimum Data Set (MDS), an assessment tool, dated [DATE], showed Resident 5 was rarely understood and had no behaviors. Review of Resident 5's POLST (Physician Orders for Life Sustaining Treatment), dated [DATE], showed resident was a (DNAR), Do Not Attempt Resuscitation, allow natural death. The POLST showed choosing DNAR would include appropriate comfort measure and may include a range of treatments including use of oxygen, oral suctioning and manual treatment of airway obstruction. Resident 5's nutritional assessment, dated [DATE], showed the resident was receiving a regular diet with pureed texture and honey thick liquids, had difficulty chewing and difficulty swallowing with a recent aspiration incident. Resident 5's Speech Language Pathologist (SLP) evaluation and treatment, dated [DATE], showed the resident had chronic, severe oropharyngeal dysphagia (swallowing problem occurring in the mouth and or throat). Staff reported coughing with puree intake when puree was separated, and a thin layer of liquid was present. Resident 5's care plan, dated [DATE], showed Resident 5 was at high risk of aspiration and was dependent on staff for assistance with meals with a documented intervention to, ensure sitting upright for all meals and fluid intake. During an interview on [DATE] at 4:35 PM, Staff F, Certified Nurse Aid (CNA) provided their recollection of the timeline of events on [DATE] as follows: Staff E, CNA came out of Resident 5's room and told Staff F Resident 5 was vomiting and to get a nurse. Staff E came out in the hall again and asked Staff F what to do and said, it was getting bad Staff F told Staff E to put the head of the bed up and get a basin. Staff F said she could not find the nurse, she was on break or something Staff F said she had a walkie talkie for communication but did not use it. Staff F said she texted the assigned nurse, Staff D, Registered Nurse, that Resident 5 was vomiting. Staff F said she went to look for a nurse and found Staff C, Staff C responded to the resident's room with a code cart. Staff F said a nurse attempted to suction the resident's mouth, but the resident was already gray in color. Staff F said Staff D returned from break and pronounced the resident's death. Staff F said it may have taken eight or nine minutes for the nurse to come into the room, which occured at approximately 12:40 AM, making the time the resident started struggling about 12:31 PM. During an interview on [DATE] at 6:25 PM, Staff E provided their recollection of the timeline of events on [DATE] as follows: Resident 5 had been assisted with the lunch meal in the dining room by another staff member and was assisted back to bed and resting on his side. Staff E said he was assisting Resident 5's roommate with the lunch meal and heard Resident 5 coughing. Staff E said the resident started vomiting while lying down. Staff E said they went into the hallway and told Staff F Resident 5 had vomited and to find a nurse. Staff E said they raised the head of the bed when the resident vomited and left the resident to go into the hallway and asked Staff F to find a nurse again. Staff E said Resident 5 vomited three times. Staff E said his walkie talkie used for communication was not charged and not functioning. Staff E said Resident 5's skin color changed and appeared bluish around the mouth and Resident 5 wasn't breathing normally. Staff E said the nurse came into Resident 5's room to assist but the resident had expired. On [DATE] at 2:55 PM, Staff C, Resident Care Manager (RCM) said Resident 5 had been on aspiration precautions and on [DATE] Staff F, CNA came to their office and said Resident 5 was vomiting profusely. The RCM said she retrieved the code cart with suction and immediately went to Resident 5's room, arriving at approximately 12:40 PM. Staff C said she radioed for a RCM to respond to Resident 5's room. Staff C said Resident 5 was seated at 90 degrees in bed and had vomit on the resident's shirt and blanket and Staff E was at bedside. Staff C said she attempted to suction the resident's mouth but could tell [Resident 5] was already gone and yellow in color. Staff C said the assigned nurse, Staff D, came in and assessed for signs of life and called time of death. Staff C said she was not sure why the CNAs did not use the walkie talkies as they were issued on hire and were part of their uniform. Staff C confirmed when there was a change in a resident's respiratory status or bluish color around the residents mouth it was emergent and needed immediate response. Staff C said there was a delay in responding to the resident vomiting and was unsure of how much time elapsed before a nurse responded. Staff C said the CNA should have stayed with the resident and used the walkie to call for immediate response from a nurse, stating, this is why walkie talkies are needed. On [DATE] at 9:55 AM, Staff D said she was the assigned nurse for Resident 5 on [DATE]. Staff D said she saw Resident 5 before lunch and the resident had been assisted with his meal in the dining room and was brought back to his room and laid down after lunch. Staff D said she went on her lunch break and received a text message from Staff F, CNA that a resident was vomiting. The nurse said she didn't know it was an emergency and came back from her break when she saw the message. Staff D said she saw Staff C going down the hall with the code cart and Staff D followed and went into Resident 5's room. Staff D said she saw Resident 5 was in bed with the head of the bed elevated with vomit on the resident's shoulder and two RCMs were at the resident's bedside and had suctioned the resident's mouth. Staff D said Resident 5 was nonresponsive and had no signs of life. Staff D said Resident 5 had DNR documentation, so staff did not resuscitate the resident. Staff D said the facility had implemented walkie talkies for communication to be used by all staff, but some staff wouldn't wear them and agency staff weren't issued one. At 10:50 AM, Staff J, agency CNA was observed in the resident care area. The CNA did not have a walkie talkie radio. Staff J said they work for an agency and had worked at this facility for approximately two weeks and had not been issued a radio. At 11:00 AM, Staff K, agency RN was observed in the resident care area. The RN did not have a walkie talkie radio. The RN said they were not issued a radio. At 11:01 AM, Staff H, agency CNA was observed in the resident care area. The CNA did not have a walkie talkie radio. Staff H said they worked for an agency and were not issued a radio for communication. At 11:06 AM, Staff I, CNA was observed in the resident care area. The CNA did not have a walkie talkie radio. Staff I said, That's on me, I forgot to grab one. On [DATE] at 3:15 PM, Staff A, Administrator, acknowledged Resident 5 was at risk for aspiration and was assessed on [DATE] by a Dietician which indicated the resident had problems with swallowing and choking and that the resident was vomiting and had a change in their breathing and discoloration around their mouth and there was a delay in nursing emergency response and the resident expired at the facility. Staff A said the facility did not have the ability to overhead page from resident rooms and that walkie talkies were the method intended to be used and were not used as expected. Reference WAC [DATE](1)

Based on observation, interview, and record review, the facility failed to ensure residents were free from avoidable accidents during a resident transfer for 1 of 3 residents (Resident 1) reviewed for accidents. Resident 1 experienced harm when facility staff did not follow recommended procedures for transportation and the resident sustained a fracture and laceration requiring hospitalization and surgery. This failure placed residents at risk for injury and a diminished quality of life. Findings included . Review of the undated facility policy, titled Recommended Safe Procedure for Transporting People who use Wheelchairs showed when loading and unloading passengers in a side loading van, the resident should be facing away from the vehicle. The policy reference emergency safety procedures and identified staff should immediately call 911 if a person in a wheelchair (w/c) was injured or if there was any question of an injury. Resident 1 was admitted to the facility on [DATE] with diagnoses including End Stage Renal Disease (ESRD), subdural hematoma (serious condition where blood collects between the skull and surface of the brain), heart failure and anemia. Resident 1's admission Minimum Data Set (MDS), an assessment tool, dated 06/26/2024, showed Resident 1 had cognitive impairment, exhibited no behaviors, required use of a w/c, required substantial staff assistance for toileting, dressing, personal hygiene and dependent for chair to bed transfer. Resident 1's nursing note, dated 07/04/2024, showed Resident 1 returned from dialysis in the facility bus and Staff G, Maintenance Director, who had transported the resident, reported Resident 1 had injured their left big toe while on the lift of the transport bus and that it was bleeding. The nursing note showed Resident 1 was not showing any signs of pain and denied pain. Resident 1 had loss of feeling in bilateral lower extremities and was unable to recognize their foot had slipped off the foot pedal while being lifted up into the bus from dialysis. First aid was initiated to left toe to stop the bleeding and then Resident 1 was transported to the hospital by Staff G and Staff A, Administrator. Resident 1 was admitted to hospital for further treatment. Resident 1's hospital record showed the resident was admitted to the hospital on 07/03/2024 for a left big toe crush injury and required surgery to amputate the left big toe. An x-ray report, dated 07/03/2024, showed a suspected occult fracture (broken bone not easily seen on x-ray). On 08/06/2024 at 2:00 PM, the facility bus was observed with Staff G, Maintenance Director and Staff G demonstrated use of the w/c lift. Staff G said Resident 1 was in a w/c and was very tall and weak after the dialysis treatment. Staff G said he placed the resident's feet on the footrest and both feet kept popping out as the resident consistently slid down in the w/c seat. The maintenance director said he pushed the resident's w/c onto the ramp (face first) and proceeded to use the button on the right side of the ramp to lift the ramp with the w/c. Staff G said he couldn't fully see the resident's feet and as the lift was going up the ramp came down onto the resident's toe. Staff G said when the w/c was lifted to the top, Staff G got back into the bus and pulled the resident's w/c off the lift and into the bus. Staff G said he saw the resident's sock and realized the resident's foot was injured and released his foot. Staff G said he was unaware the resident's toe got caught as the resident had poor sensation and did not call out or indicate the foot was caught. Staff G then transported the resident back to the facility, where the resident's foot was assessed by nursing and then Staff G and Staff A transported the resident to the hospital. Staff G said the facility had two staff go on the bus with the resident the previous two times the resident was transported to and from dialysis. Staff G said on this occasion to/from dialysis, we were short staffed, and I volunteered to pick him up on this day by myself. I wished I had not. On 08/13/2024 at 3:15 PM, Staff A, said Resident 1 was weak after dialysis and Staff G should have asked for help and not transported the resident by himself. Staff A acknowledged the resident was injured during the transfer process and the resident required evaluation and treatment at the hospital. Reference WAC 388-97-1060 (3)(g)

Based on interview and record review, the facility failed to prevent the development and worsening of a skin conditions when assessment, monitoring, treatment and interventions were not implemented timely for 1 of 2 sampled residents (1) reviewed for quality of care related to skin breakdown. This failure placed residents at risk for skin breakdown, medical complications and diminished quality of care. This caused harm to Resident 1 when he developed unidentified wounds to his left foot (great toe, sole of foot and heel), from partial thickness to full thickness, and numbness in his left great toe. Findings included . The facility's undated Skin Care Policy and Procedures documented weekly skin assessments would be completed, and any new wounds would be reported to the provider, care manager and family if appropriate. Wound treatment would be provided, weekly assessments ongoing and if no improvement made within 14 days, the provider would be notified and assist with a new treatment. The facility Skin committee would follow the healing progress for wounds determined to be high risk for non-healing or worsening. Information of wounds progress, changes and treatments would be documented in the resident's medical record. Resident 1 was admitted to the facility on [DATE] with diagnoses including diabetes, right below knee amputation and cognitive deficits. The quarterly Minimum Data Set (MDS), an assessment tool, dated 11/09/2022, showed the resident was able to make needs known and required assistance with activities of daily living including transfers, and bed mobility. The MDS showed the resident had a history of pressure ulcers (wounds caused by consistent prolonged pressure against the body) and remained at high risk for development of ulcers and other skin conditions. Review of Resident 1's medical record showed physician orders, dated July 2022, on admission included weekly skin assessments were to be completed. The July 2022 Medication Administration Record (MAR) and July 2022 Treatment Administration Record (TAR) showed documentation was recorded by nursing and initialed on the form date completed with a minus sign indicating of no new issues and a positive sign as new issue. Review of the record showed on 10/23/2022 Resident 1 resided on B Wing. Review of nurse progress note, dated 10/23/2022, showed Staff E, Licensed Practical Nurse (LPN), documented the residents left big toe and foot were scraped and the resident reported he had no feeling in his left big toe. The note showed no care plan changes were needed, and nursing would monitor the wound for infection. Review of nurse progress notes, dated 10/23/2022 to 11/14/2022, showed no additional entries related to monitoring of the left foot wounds for infection, wound changes, and if the foot numbness warranted further assessment. The October 2022 and November 2022 MAR and TAR showed no new issues. A progress notes, dated 11/14/2022, showed an entry by Staff I, Medical Provider. The provider noted the resident had a history of sacral redness and no other skin concerns. Resident 1's medical record showed the resident was transferred from Unit B Wing to Unit D Wing on 11/16/2022. A progress note; dated 11/17/2022, by Staff G, LPN; showed Resident 1 had a foul-smelling open area with necrotic (dead) tissue on his left big toe. Staff G noted the wounds were cleaned and the medical provider was notified. A progress note; dated 11/17/2022 by Staff J, Medical Provider; showed the resident had foul-smelling necrotic tissue on the tip of his left great toe and 2 areas of early necrosis to the sole of his foot. The provider initiated treatments and referred Resident 1 for wound care consultation. A skin and wound consultation evaluation, dated 11/21/2022, showed the resident had Partial thickness wounds (confined to skin layers) and Full thickness wounds (loss of all layers of skin to include bone) with serosanguineous fluid (type of wound drainage or exudate, secreted by an open wound in response to tissue damage) as follows: -Partial thickness wound 1.5 x 1.5 x 0 centimeters (cm) on his left anterior hallux (large toe) with no exudate or odor. -Partial thickness wound 2.3 x 2.4 x 0 cm on his left lateral foot with no exudate or odor -Partial thickness wound 1 x 0.4 x 0 cm on left lateral fifth toe with no exudate or odor -Full thickness wound 4.1 x 5.1 x 0 cm on left heel with moderate seorsanguinous exudate and putrid odor. The skin and wound evaluation, dated 11/30/2022, showed Resident 1's heel wounds were debrided and the procedure revealed exposed bone with possible osteomyelitis (bone infection). New orders were written for labs and treatment. The evaluation showed wounds were identified on 11/17/2022, 25 days after the resident moved from B wing to D wing. On 12/12/2022 at 12:50 PM, Staff H, Registered Nurse, said Resident 1's wounds began on Unit B and were facility acquired. Staff H said all residents, when transferred from Unit to Unit, are assessed like new admissions. Staff H said when Resident 1's wounds were found, treatments were immediately initiated. On 12/12/2022 at 4:45 PM, Staff B, Director of Nursing Services, said Resident 1's wounds were facility acquired and tests were underway to determine if the wounds were vascular in nature. Staff B said the providers were reevaluating the resident's wounds and planned adjustment of treatment to prevent potential amputation of the limb. Staff B said staff on Unit B failed to follow the facility wound protocol for Resident 1. Reference WAC 388-97-1060 (3)(b)

Based on observation, interview and record review, the facility failed to maintain acceptable parameters of nutrition when the facility failed to consistently monitor residents' weights, provide adequate assistance and/or set up with meal service and implement new interventions in a timely manner for two of 10 residents (2 & 5) reviewed for nutrition. This failure placed residents at risk of weight loss, nutritional complications and a diminished quality of life. This caused harm to Resident 2 when she experienced a severe weight loss, 16% weight loss in seven months and 12% weight loss in three months. Findings included . 1) Resident 2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Alteration in Nutrition care plan, initiated 06/12/2021, documented an intervention for eating assistance: setup meal tray, provide verbal encouragement to eat as needed . weekly weights. Review of Resident 2's weights record documented the following weights: On 06/12/2021 of 132 pounds. No weights documented in July. On 10/27/2021 of 126 pounds. On 01/14/2022 of 110 pounds showing a 16% weight loss in seven months (June 2021 to January 2022) and a 12% weight loss in 3 months (October 2021 to January 2022). The weights record had numerous missing weights. A Nutritional Risk Assessment, dated 09/15/2021, documented, Resident . with dementia, which may impact her cognition and eventually her ability to feed herself. Dietician Progress note, dated 12/22/2021, documented intake may have been inadequate AEB [as evidenced by] weight loss over the course of admission. On 01/18/2022 at 11:02 AM, when asked if she had concerns about residents not getting enough assistance with eating, Staff D, Registered Nurse (RN) and Resident Care Manager (RCM), said no, there was enough staff that could assist like the social worker or staff development coordinator and the nurses. From 12:30 PM to 12:46 PM, Resident 2 was observed sitting in her room in her wheelchair with her overbed table in front of her and her meal tray/plate on her table. The resident was yelled out, oh Lord, help me, and continually trying to pull the blanket from her lap and set it on her plate of food. Resident 2 was not eating. Staff were not in the room. Staff D walked by Resident 2's door when the resident said, I don't know what to do, and was trying to put the blanket on her tray. Staff D stated, Eat your lunch, and left the hall. At 1:00 PM, Resident 2 was observed continuing to try and put her blanket on her tray and yelled out, oh God, help me Lord, what do I do. Resident 2 had not eaten any food. Resident 2 tipped over her juice and her hollering became louder and more pressured, and said, oh[OBSCENITY] God damn it. Nursing assistant documentation for how much the resident consumed for the meal was not completed for lunch on 01/18/2022. For the 30 day look back, the percentage of meal consumption was varied (0% to 100%) and documentation was missing for multiple meals. On 1/25/2022 at 2:00 PM, when asked what was included in tray set up, Staff D said opening the lids, ensuring everything was in line of site, putting utensils on the plate so the resident could easily grasp them and placing the straw in a cup. When asked if there was a time limit for when additional staff would step in to assist the aides on the hall with assisting residents with eating, Staff D said no, but they should have stepped in sooner on the day observations were made (01/18/2022) and that they would try and be more mindful of that. On 01/26/2022 at 3:30 PM, when asked what was included in tray set up, Staff F, Nursing Assistant, said taking the lids off cups, opening cartons, cutting up meats and sometimes cutting the veggies down if they were too big. When asked if Resident 2 could eat without assistance, Staff F said if Resident 2 tried to eat by herself most of her meal would end up on the floor. Staff F said Resident 2 required supervision during meal times. 2) Resident 5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Alteration in Nutrition care plan, initiated 08/11/2020, documented intervention for set up assistance with eating [and] weekly weights. Review of Resident 2's weights record showed the following: On 07/14/2021 of 173 pounds. On 01/19/2022 of 155 pounds showing a 10.4 % weight loss in six months. The weights record showed numerous missing weights. A weight change note, dated 10/06/2021, documented, Resident suffered sig[nificant] weight loss during acute illness [COVID 19]. A Nutritional Assessment, dated 11/10/2021, documented, she benefits from assistance with tray set up and would benefit further from cueing and possibly assistance at meals . Intake is poor and likely inadequate . Cont[inue] to provide assistance/cueing at meals. On 01/18/2022 at 12:50 PM, Resident 5 was observed in bed with her overbed table in front of her with her meal tray on it, which was delivered approximately 20-30 minutes before. The resident had eaten 2-3 bites and was sitting in bed, looking at her tray. When asked how her lunch was, Resident 5 said, It's food. The resident's lunch consisted of a large, uncut sausage, potatoes, mixed veggies, and drinks on a styrofoam plate with plastic utensils. Nursing assistant documentation for how much the resident consumed for the meal was not completed for lunch on 01/18/2022. For the 30 day look back, the percentage of food consumption varied (0% to 100%) and documentation was missing for multiple meals. Reference WAC 388-97-1060 (3)(h)

Based on observation, interview and record review, the facility failed to implement and monitor a system to consistently and accurately reconcile controlled medications and failed to follow manufacturer's specifications for insulin administration for six of seven sampled residents (1, 2, 3, 5, 9 & 11) reviewed for pharmacy services. This failure placed residents at risk of not having needed medications available, a decrease in health status, potential for drug diversion, and a diminished quality of life. This failure caused harm to Resident #5 when insulin was administered one hour before the resident's meal was provided and resulted in a hypoglycemic event. Findings included . <Insulin Administration> Facility Administering Medications Policy, revised 04/2019, documented medications are administered in accordance with providers orders, including time frames. Timeframe of administration is based on therapeutic benefit of medication, avoiding potential medication interactions. DailyMed - Insulin [MEDICATION(S)] Injection, Solution, U.S. National Library of Medicine, National Institutes of Health, website updated 06/11/2020, drug label information documents for adults with diabetes mellitus administer [MEDICATION(S)] (insulin [MEDICATION(S)]), a rapid-acting insulin, by subcutaneous (under the skin) injection within 15 minutes before or immediately after meals. Insulin [MEDICATION(S)] starts working about 15 minutes after injection and peaks in about 1 hour. DailyMed - INSULIN [MEDICATION(S)] Injection, Solution, U.S. National Library of Medicine, National Institutes of Health, website updated 11/15/2019, drug label information documents for adults with diabetes mellitus administer insulin [MEDICATION(S)], a rapid-acting insulin, by subcutaneous (under the skin) injection within 5 - 10 minutes before a meal. Insulin [MEDICATION(S)] starts working within 15 minutes after injection and peaks within about 1 hour. 1) Resident #5 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus. The admissions Minimum Data Set (MDS), an assessment tool, dated 01/14/2021, documented the resident had moderate cognitive impairment, required extensive assistance with activities of daily living (ADLs), and received insulin daily of the assessment period. Resident #5's care plan, revised 02/01/2021, identified the resident was at risk for an alteration in nutrition and hydration. The care plan documented staff would monitor the resident for signs and symptoms of [CONDITION(S)]. The January 2021 Diabetic Administration Record (DAR) showed the following order: [MEDICATION(S)] Solution 100 unit/ml, inject as per sliding scale subcutaneously before meals, scheduled for 7:00 AM, 11:00 AM and 4:00 PM, starting on date 01/07/2021: If 0 - 70 (blood sugar level) = 0 units (of insulin). Notify MD (medical doctor); follow Facility [CONDITION(S)] protocol; 71 - 149 = 0 units; 150 - 200 = 1 units; 201 - 250 = 2 units; 251 - 300 = 3 units; 301 - 350 = 4 units; 351 - 400 = 5 units; 401 - 999 = 6 units Notify MD The January 2021 DAR showed the following order: [MEDICATION(S)] Solution 100 unit/ml Inject 5 unit subcutaneously two times a day, scheduled at 11:00 AM and 4:00 PM daily, starting on 01/12/2021. The January 2021 DAR, dated 01/21/2021, documented Resident #5 received 1 unit of [MEDICATION(S)] sliding scale insulin and 5 units [MEDICATION(S)] at 4:11 PM for a blood sugar of 165. Progress note, dated 01/21/2021, showed Resident #5 was found at 5:15 PM listless, lethargic, with clammy cold skin, and a blood sugar level of 21. Staff called provider and obtained orders for [MEDICATION(S)] (a medication used to raise blood sugar in an emergency) 1 mg IM (injection into the muscle) now, and may repeat in 20 minutes if resident was still hypoglycemic. The first dose of [MEDICATION(S)] was given at 5:20 PM raising the Resident #5's blood sugar to 34. At 5:40 PM, an additional dose of [MEDICATION(S)] was required, raising the resident's blood sugar to 67. At 6:01 PM, Resident #5 was alert and able to converse with staff. The provider was notified and ordered LN to give [resident] her evening meal as well as some apple juice with a sugar packet at this time and hold all insulin for remaining of the day. Progress note, dated 01/22/2021, documented Resident # 5's blood sugar was rechecked at 3:01 AM and was 110, no signs and symptoms of [CONDITION(S)], resident unable to remember earlier event of [CONDITION(S)]. Progress note, dated 01/22/2021, Staff C, former Director of Nursing Services (DNS) and Registered Nurse (RN), documented, Last evening the charge and medication nurses contacted this writer regarding a potential medication error that resulted in a low blood sugar of 21. Resident's needs were addressed immediately and when condition was stabilized the DNS called. An investigation was begun immediately. Nurse responsible for error [was] place on investigatory leave and has not cared for resident since incident of low blood sugar. Physician was notified last evening and gave orders for [MEDICATION(S)], two doses. All further insulin was held last evening. Nurse practitioner has been in the facility all day and has keep a close eye on resident . state hotline [called] following medication error protocols. Resident continues on alert status with close observation and monitoring of blood sugars. Review of the resident's January 2021 DAR showed Resident #5 received both scheduled and sliding scale insulin, outside of manufacturer's instructions, related to insulin administration being outside the meal timeframe, 16 times out of a total of 81 insulin administrations, and the February 2021 DAR shows four out of a total of 60 insulin administrations. On 03/15/2021 at 10:23 AM, Staff A, DNS and RN, said meal times were between 7:30 AM and 8:00 AM, 11:45 AM and 12:00 PM, and 4:45 PM and 5:00 PM daily. On 03/18/2021 at 12:38 PM, Staff H, LPN, said she would not give insulin until either the resident was about to eat or was in the process of eating. Staff H said currently, she tries to give insulin within 30 minutes of meals. At 1:08 PM, Resident #5 said she was a brittle diabetic, and that you wouldn't believe how low her blood sugars go sometimes. Resident #5 said she has had some low blood sugars in the facility, and sometimes does not like the food. At 1:10 PM, Staff O, RN, said she administered insulin to residents just before or once a resident was eating to avoid [CONDITION(S)]. On 03/19/2021 at 4:37 PM, Staff J, LPN, said on 01/21/2021 he was summoned to Resident #5's room, by Staff H, and found the resident clammy, diaphoretic (excessive sweating), with an elevated pulse. Staff J said the resident's vital signs and blood sugar were checked. When Resident #5's blood sugar was found to be low, the medical provider was contacted and provided an order for [MEDICATION(S)] administered IM. Staff J said she was told by Staff H that the resident was found in this state when aides were delivering her dinner. On 03/22/2021 at 1:34 PM, when asked about Resident #5's hypoglycemic episode on 01/21/2021, Staff H said nursing assistants found the resident and came to get me. Staff H said the resident's blood sugar was very low, and she notified the charge nurse (Staff J) and ended up giving the resident [MEDICATION(S)]. On 03/25/2021 at 1:44 PM, Staff A said insulin should be administered within an hour of resident meals. Staff A said Resident #5 has had multiple episodes of [CONDITION(S)] and was fragile with her blood sugars. Staff A said Resident #5 did receive sliding scale and scheduled [MEDICATION(S)] insulin at approximately 4:00 PM on 01/21/2021. Staff A said timing of insulin administration should be reviewed with the medical provider. Staff A said she was not sure if insulin administration practices were reviewed as part of the investigation into Resident #5's hypoglycemic event and insulin administration. Staff A said they were being reviewed now. 2) Resident #9 was admitted to the facility on [DATE] with diagnoses including diabetes. The MDS, dated [DATE], documented the resident was cognitively intact, required limited to extensive assistance with ADLs, and received insulin daily of the assessment period. Resident #9's care plan, undated, identified the resident was at risk for an alteration in nutrition and hydration. The care plan documented staff would monitor the resident for signs and symptoms of [CONDITION(S)]. The February 2021 DAR showed an order for Insulin [MEDICATION(S)] Solution 100 unit/ml inject subcutaneously before meals at 7:00 AM, 11:00 AM and 4:00 PM starting 12/15/2020. inject as per sliding scale: If 0 - 200 = 0 units; 201 - 250 = 2 units; 251 - 300 = 4 units; 301 - 350 = 6 units; 351 - 400 = 8 units; For CS > 400 Call Call MD/ARNP Review of the resident's February 2021 DAR showed Resident #9 received sliding scale insulin outside of manufacturer's recommended administration timelines, related to insulin administration being outside the meal timeframe, 35 times out of a total of 69 insulin administrations. On 03/25/2021 at 1:44 PM, when asked if the facility administration practices were being reviewed as part of the investigation, Staff A said she was not sure, but we will now. <Narcotic Discrepancy> 1) Resident #1 was admitted to the facility on [DATE] with diagnoses including dementia, [CONDITION(S)], and adult failure to thrive. The MDS, dated [DATE], documented the resident was severely cognitively impaired, required extensive assistance with ADLs, and received no scheduled or as needed pain medications on the days of the assessment period. The resident's physician orders documented an order for [MEDICATION(S)] Tablet 5-325 MG ([MEDICATION(S)]-Acetaminophen) give 1 tablet by mouth every 6 hours as needed for pain with a start date of 08/20/2019 and discontinued date of 02/09/2021. The physician orders showed an order for [MEDICATION(S)] Tablet 5-325 MG ([MEDICATION(S)]-Acetaminophen) give 1 tablet by mouth every 8 hours for pain with a start date of 02/09/2021 and discontinued date of 02/13/2021. Resident #1's narcotic ledger, page 104, documented 37 tablets of [MEDICATION(S)]/acetaminophen 5/325 MG, a narcotic pain medication, was added to the ledger on 12/15/2020. On 02/05/2021, the narcotic ledger showed 22 tablets as quantity remaining. The medical record showed Resident #1 passed away in the facility on 02/12/2021. 2) Resident #2 was admitted to the facility on [DATE] with diagnoses including [CONDITION(S)] of the liver and chronic pain syndrome. The MDS, dated [DATE], documented the resident had cognitive impairment, required limited to extensive assistance with ADLs, had frequent pain, and received a scheduled and as needed pain medications during the assessment period. Resident #2's physician orders showed an order for [MEDICATION(S)] Tablet 5-325 MG ([MEDICATION(S)]-Acetaminophen) give 1 tablet by mouth every 4 hours as needed for pain - moderate with a start date of 05/31/2019 and discontinued date of 11/14/2020. Physician orders showed an order for [MEDICATION(S)] Tablet 5-325 MG ([MEDICATION(S)]-Acetaminophen) give 2 tablets by mouth every 4 hours as needed for pain - severe with a start date of 05/31/2019 and discontinued date of 11/14/2020. Resident #2's narcotic ledger, page 102, documented 60 tablets of [MEDICATION(S)]/acetaminophen 5/325 MG, a narcotic pain medication, was added to the ledger on 11/06/2020. On 11/13/2020, the narcotic ledger showed 56 tablets as quantity remaining. The medical record showed Resident #2 discharged from the facility on 11/13/2020. 3) Resident #3 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, dementia and depression. The MDS, dated [DATE], documented the resident had cognitive impairment, required limited to extensive assistance with ADLs, did not have pain, and received scheduled and as needed pain medications during the assessment period. The resident's physician orders showed an order for [MEDICATION(S)]-Acetaminophen Tablet 5-325 MG, give 0.5 tablet by mouth every 4 hours as needed for low back pain, to hold for sleeping or sedation, with a state date of 11/16/2020 and discontinued date of 12/28/2020. Resident #3's narcotic ledger, page 97, documented 60 tablets of [MEDICATION(S)] 5/325 MG, a narcotic pain medication, was transferred to this page of the ledger on 11/25/2020. The ledger showed no tablets were administered and quantity remained at 60. The ledger did not document if received quantity of medication was in full or half tablet form to correlate with the order. An email communication (summary of the investigation) from Staff C, former DNS, dated 03/02/2021, documented several staff came forward with concerns regarding missing narcotic cards and indicated the narcotic medications may have been inadvertently destroyed without proper documentation. Medication destruction documentation, reviewed by staff, found no documentation of destruction related to missing medications. The communication did not include witness statements from staff with possible direct knowledge about the missing medications. On 03/15/2021 at 4:51 PM, Staff F, Licensed Practical Nurse (LPN), said she took over the cart from the medication nurse at around 10:00 am on 02/06/2021 because they were working a short shift. They did not count narcotics prior to the medication nurse leaving and Staff F ended up conducting the noon medication administration. While pulling another resident's narcotic medication, Staff F noticed a different resident's medication was missing. Staff F said she searched for the missing medication without results. Staff F had the other hall's charge nurse help with the search and they decided to go page by page in the narcotic log book and they identified additional narcotics missing. Staff F said at this time, they notified the DNS. Staff F said one of the missing narcotics, and it's corresponding narcotic log book ledger page, had an administration entry the day before, and assumed that other missing medications were destroyed due to the medications were for residents who had been discharged . When asked about counting narcotics with the nurse going off shift on 02/06/2021, Staff F stated, I did not count with the nurse that was filling in and left work mid shift. Staff F said the process for destroying narcotics involved two nurses, signing the book and crossing it out. They must also fill out the bottom of the narcotic log book page. On 03/18/2021 at 10:43 AM, Staff G, RN and Resident Care Manager (RCM), said the expectation for nurses was they count narcotics at shift change. One nurse is on the narcotic log book while the other counts the actual medications. That is to ensure there are no narcotic medications missed. They are to go page by page in the narcotic log books. Staff G said nursing staff received in-service training on how narcotics should be counted, and she believed the training was facility wide. Staff G said there were no policy changes required, just enforcement of current policies and procedures. At 10:53 AM, Hall C and Hall D medication carts were observed. Both carts had a key to unlock the cart and a separate key to unlock the narcotic lock box. The nurse office was observed with a refrigerator with a pad lock on it, as it often contained narcotics that required refrigeration. The door to the office was locked when not occupied. The office had a sliding glass window that was observed to be open at 10:57 AM, when the room was unoccupied. The opening was large enough for someone to climb in and bypass one of the locks. At 12:19 PM, two narcotic ledger books were observed on the medication cart for Hall B. The books were full of narcotics, dated back to 2019. Many of the book's pages listed narcotics no longer in use. 4) Resident #11 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease and dementia. The MDS, dated [DATE], documented the resident had severe cognitive impairment and required extensive assistance with ADLs. Resident #11's Physician Orders, dated 10/11/2020, documented the resident was prescribed [MEDICATION(S)], a pain medication, 50 mg tablets ½ tablet to 1 tablet every 6 hours as needed for pain. Resident #11's narcotic ledger documented 60 half tablets of [MEDICATION(S)] were added to the ledger on an undocumented date. On 12/31/2020, 17 tablets remained. Below the last entry, staff signed and drew a line through the Balance (Qty/) Transferred to Unit section of the ledger indicating [MEDICATION(S)] tracking was moved to Book B on 12/30/2020. No page number was noted to indicate where to find the ongoing tracking of the remaining [MEDICATION(S)] tablets. On 03/18/2021 at 12:35 PM, after reviewing the narcotic ledger, Staff G, RN, said the ledger for Resident #11 was missing all the pertinent information to track the disposition of the narcotic. Staff G said the ledger should include the page number when a medication was transferred to a different narcotic ledger book. Staff G said staff should be aware of the process. at 12:35 PM, Staff H, LPN, said the process for counting narcotics at shift change was one nurse had the narcotic log book and the other nurse the cards in the narcotic lock box. The nurse at the narcotic lock box calls out the card number that corresponds to the narcotic log book page number so the nurse on the narcotic log book can turn to that page. The two nurses then verify the count between the book and the card. Staff H said they would know if a medication was missing from memory as they were in the carts all the time. Staff H said she had not had any training on narcotic reconciliation and storage practices. When asked if she goes through each page in the narcotic log book when counting narcotics at shift change, Staff H stated, No. We do not go through every page, just count the narcotics in the box only. At 1:10 PM, Staff O, RN, said when counting narcotics at end of each shift, one nurse would verify count on the medication card, and the other would go page by page and verify count was current on the ledger. When a resident was discharged or a narcotic was discontinued, the card would stay in the locked drawer and continue to be counted until it was destroyed. Staff O said it can take a while to destroy narcotics. Staff O said there was no timeframe as to when to destroy the narcotics, but she tried to find another licensed staff to assist her when it needed to be done. Staff O said the narcotic ledger should show the date a narcotic was destroyed, the amount of narcotics destroyed and signatures of staff who destroyed the medication. On 03/22/2021 at 1:20 PM, Staff K, LPN, said we count narcotics with the outgoing nurse, count every class of narcotic medication, and count the number of cards in each class. Staff K said when she comes on shift, she counts the medication cards and the off coming nurse has the narcotic log book. When leaving shift, she would have the narcotic log book. Staff K said staff had recently just started going through each page of the ledger book to make sure everything was accounted for and no narcotics were missed being counted. Staff K said previously they would just call out the narcotic page number that was on the card in the narcotic box and just count the cards in the narcotic lock box. Staff K said she had received training on counting narcotic cards in each class and properly document that each medication was there. Staff K said a DNS led the training about reconciliation of narcotics. On 03/25/2021 at 2:05 PM, Staff A said if she was conducting an investigation into a missing narcotic medication, the first interview would be the nurse who came off shift immediately prior to finding the narcotic was missing, and then interview anyone who had access to the medication. Interviews would be documented on a facility investigation form while having another nurse as a witness. Staff A said she would have each interviewed staff write a witness statement. When asked if interviews were part of the missing narcotic medications investigation from 02/06/2021, Staff A stated, I only have what was given to me, and there should be other statements from the nurses who gave urine samples and most definitely the night shift nurse. Reference (WAC) 388-97-1300 (1)(b)(i)(ii)(3)(a)(4)(d)

Based on observation, interview and record review, the facility failed to ensure newly admitted residents were quarantined from other residents for three of five sampled residents (#1, 2 & 3) reviewed for infection control. The facility failed to ensure staff maintained infection control practices to prevent the spread of infection and disease by staff and contractors failing to utilize full personal protective equipment (PPE) in three of four halls (Hall B, C & D). The facility failed to assess the risk associated with Continuous Positive Airway Pressure ([MEDICAL CONDITION]) devices and aerosolizing procedures that increase the risk of COVID-19 transmission for two of four sampled residents (#4 & 5). These failures placed residents, staff and visitors at risk for the spread of the COVID-19 Virus and a diminished quality of life. This failure resulted in harm to Resident #2 when he died after contracting COVID-19. Findings included . The facility's policy entitled Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures, revised [DATE], documented, Staff wear facemasks at all times while in the facility . and Staff wear eye protection during any resident-care encounters or procedures. The facility's policy entitled Coronavirus Disease (COVID-19) - Identification and Management of Ill Residents, revised [DATE], documented, Residents with suspected COVID-19 are placed in a private room, moved to a dedicated unit, or cohorted with another resident who is suspected to have COVID-19 pending the results of [DIAGNOSES REDACTED]-CoV-2 testing. Residents with confirmed COVID-19 are separated from residents who do not have confirmed COVID-19, or have an unknown status. <New Admissions> 1) Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS, dated [DATE], documented Resident #3 had no cognitive impairment and required assistance with ADLs. 2) Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS, dated [DATE], documented Resident #2 had severe cognitive impairment and required assistance with ADLs. Upon admission, Resident #2 was placed in a room with Resident #3. 3) Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool, dated [DATE], documented Resident #1 had moderate cognitive impairment and required assistance with activities of daily living (ADLs). Resident #1's progress notes, dated [DATE], documented the resident was admitted from the hospital to a shared room with Resident #2 and Resident #3. The medical record did not note an assessment or evaluation of the resident's respiratory status, risk for exposure to COVID-19, or quarantine precautions and isolation while ruling out COVID-19. Progress notes, dated [DATE], documented Resident #2 tested positive for COVID-19. On [DATE] at 3:30 PM, Resident #1, Resident #2, and Resident #3 were observed sitting in their shared room. Progress notes, dated [DATE], documented Resident #1 tested positive for COVID-19. Progress note, dated [DATE], documented Resident #2 had oxygen levels of 82%, was without a temperature, and complained of being cold. Family was notified of condition change, and family requested the resident be sent to the hospital (where he later died the next day). On [DATE] at 3:00 PM, Staff B, Director of Nursing Services and Registered Nurse (RN), said the facility did not isolate or quarantine new admissions due to the challenges with space in the facility. Staff B said a staff member was asymptomatic but tested positive for COVID-19 on [DATE]. Staff B said she believed this was how the residents were exposed. Staff B said the facility did routine staff testing. Staff B said they required testing of residents prior to admission. Progress notes, dated [DATE], documented Resident #3 tested positive for COVID-19. <Facemasks and Eye Protection> On [DATE] at 1:30 PM, numerous staff on Hall B, Hall C and Hall D were observed without wearing a face shield or wearing eyeglasses that did not fully protect the eyes. At 1:40 PM, therapy staff was observed walking a resident in the hall wearing prescription style eyeglasses, and without using goggles or a face shield. At 1:42 PM, staff was observed coming out of room [ROOM NUMBER], Hall D, wearing prescription style eyeglasses, and without using goggles or face shield. At 2:10 PM, Staff F, Certified Nursing Assistant (CNA), said the required PPE to be worn on the hall was facemasks, gloves and goggles. Staff F said wearing eyeglasses was okay on the non COVID unit; and if on the COVID unit, you needed to wear goggles. At 2:10 PM, Staff B said staff should be wearing face shields or glasses. Staff B said she would clarify further if glasses were acceptable to shield the face. At 2:15 PM, Staff H, Licensed Practical Nurse (LPN), said staff should be wearing a facemask and faceshield as personal protective equipment (PPE) while in the facility. At 2:22 PM, Staff D, RN and Resident Care Manager (RCM), said the required PPE for her units were N-95 masks and goggles or face shields. Staff D said the expectation was staff should be wearing a face shield or goggles over their glasses. At 3:10 PM, Staff G, RN, was observed walking down a hall without a face mask or face shield. Staff B was observed stopping Staff G before she walked into a resident care area, reminding staff to put on appropriate PPE. At 3:25 PM, Staff B said Staff G should have PPE on when entering the building. Staff B said staff should be wearing a face shield; and if wearing glasses, should wear goggles that protect the eyes. On [DATE] at 1: 20 PM, several staff were observed on Hall C and Hall D without wearing a face shield or with eyeglasses and no goggles. At 1:26 PM, a staff was observed exiting room [ROOM NUMBER], Hall C, not wearing eye protection. At 1:36 PM, a visitor was observed talking to Staff D, RCM, at the nurse station outside C/D Hall; wearing a facemask, but not wearing eye protection. After having a conversation with Staff D and Staff N, LPN, the visitor was observed interacting with residents. When asked about the visitor, Staff D said the visitor was a visiting x-ray technician. At 1:43 PM, Staff E, Nursing Assistant (NA), was observed coming out of a resident's room with her facemask down around her chin and wearing glasses with no face shield or goggles. At 1:47 PM, Staff D said N-95, and face shields/goggles were required to be worn on the unit. At 1:49 PM, Staff D said she was not sure why the visiting x-ray technician was not wearing a face shield or goggles. At 2:10 PM, Staff E said she did have her facemask down when coming out of a resident's room because it is difficult to breath, tight, and uncomfortable. Staff E said she has not been educated on wearing goggles or a facemask over her glasses. At 3:00 PM, Staff B said all staff had been educated on the importance of wearing facemasks and face shields or goggles over glasses. <Aerosolizing Procedures> 1) Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS, dated [DATE], documented Resident #4 had no cognitive impairment and required assistance with ADLs. Resident #4 was admitted into a room with Resident #5. 2) Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS, dated [DATE], documented Resident #5 had no cognitive impairment and required assistance with ADLs. Physician orders, dated [DATE], documented Resident #4 required a continuous positive airway pressure ([MEDICAL CONDITION]) device (a device fitted over the nose applying mild air pressure to keep airway open) as needed at bedtime. The [DATE] Treatment Administration Record (TAR) documented Resident #4 used the [MEDICAL CONDITION] on [DATE], [DATE] - [DATE], [DATE] - [DATE], and [DATE]. During this time, staff monitored Resident #4 for signs and symptoms of COVID-19 and showed no signs and symptoms. Progress notes, dated [DATE] at 4:21 AM, documented Resident #4 experienced nausea and gagging. Progress notes, dated [DATE] at 11:52 AM, documented Resident #4 had decreased oxygenation at 80% (Normal range ,[DATE]) and difficulty breathing. Staff transferred Resident #4 to the hospital. Progress notes, dated [DATE], documented Resident #5 tested positive for COVID-19. On [DATE] at 3:00 PM, Staff B said Resident #4 was in the hospital for non-COVID-19 related illness. Staff B said Resident #4 was the only resident with a [MEDICAL CONDITION] and a roommate. Staff B said they had not considered potential exposures related to devices that can aerosolize droplets and the risks related to COVID-19. Staff B said Resident #4 had not returned to the facility since the COVID-19 outbreak in the resident's wing. Staff B said there was no alternative plan to modify rooms of residents. Reference WAC [DATE] (1)(a)

Based on observation, interview and record review, the facility failed to prevent the development and worsening of, implement interventions for and monitor a pressure ulcer for 1 of 2 sampled residents (#26) reviewed for pressure ulcers. This failure placed residents at risk for development of pressure ulcers and a diminished quality of life. This caused harm to Resident #26. Findings included . Resident #26 was admitted to the facility on [DATE] with multiple diagnoses. The Minimum Data Set, an assessment tool, dated 11/30/18, showed the resident had severe cognitive impairment, was dependent on staff for bed mobility and was not out of bed during the assessment period. A pressure ulcer was not documented. A skin care plan, revised on 09/03/18, documented Resident #26 was at risk for skin issues due to impaired mobility. Interventions included repositioning on rounds. The Care Directive (instructions for resident care needs), dated 12/05/18, showed the resident was on bed rest for comfort and was dependent on staff to assist with bed mobility. A physician communication form, dated 12/26/18, documented an open area was found on the resident's lower lumbar area (lower back). A nurse progress notes, dated 12/26/18, documented the identification of the pressure ulcer and that staff was reminded to reposition the resident every two hours. A care plan, dated 12/27/18, identified the problem as a Stage II (superficial wound caused by unrelieved pressure) on the sacral area (base of the spine near the tail bone). Interventions included reposition on rounds and EZ graph (wound measuring guide) weekly. An EZ graph form, dated 12/27/18, documented a Stage II pressure ulcer measuring 0.5 centimeters (cm) long and 0.6 cm wide. Nurse progress note, dated 01/19/19, documented Resident #26 was repositioned two times during an eight (8) hour evening shift. A nurse progress note, dated 01/20/19, documented reinforced to CNAs to make sure and reposition resident every 1.5 - 2 hours to preserve skin integrity. Nurse progress notes, dated 01/20/19, 02/01/19, 02/03/19 and 02/08/19, documented Resident #26 was repositioned two times during an eight hour night shift. The (MONTH) 2019 Treatment Administration Record (TAR) documented weekly EZ graph assigned to evening shift. The TAR boxed out 01/17/19, 01/23/19 and 01/30/19 for the weekly EZ graph. The box for 01/23/19 was initialed. The other two boxes were blank. There were no assigned dates between 01/01/19 to 01/17/19. A weekly EZ graph form was not found from 12/27/18 until 01/23/19. At 1:31 PM, Staff B, Registered Nurse and Director of Nursing Services, said pressure ulcers were measured weekly to assess the healing process; and if there was no improvement, the physician would be notified. An EZ graph form, dated 01/23/19, documented the Stage II sacral pressure ulcer had increased in size to 4.5 cm long and 2.5 cm wide. An EZ graph form, dated 01/29/19, documented the Stage II sacral pressure ulcer had increased in size to 4.5 cm long and 3.5 cm wide. An EZ graph form, dated 02/05/19, documented the pressure ulcer was not stageable due to eschar (dead tissue). On 02/06/19 at 8:30 AM, Resident #26 was observed in bed positioned on her back. At 10:29 AM, the resident was observed in bed and appeared to be positioned on her back. On 02/07/19 at 8:34 AM, Resident #26 was observed in bed and appeared to be positioned on her back with pillows tucked under her right and left torso. At 10:21 AM, the resident was observed in bed and appeared to be on her back with pillows on each side of her body. At 1:23 PM, the resident was observed in bed and appeared to be to be positioned on her back with pillows on each side of her. At 2:32 PM, the resident was observed in bed and appeared to be positioned on her back with pillows on each side of her. On 02/08/19 at 7:26 AM to 10:30 AM, Resident #26 was observed in bed and appeared to be positioned slightly on her right side with a pillow behind her back. At 7:56 AM, 8:42 AM, 9:31 AM and 9:35 AM, staff entered her room. The resident was not repositioned during the three hours of continuous observations. At 10:16 AM, Staff K, Nursing Assistant, said Resident #26 was repositioned more than three and a half hours earlier, between 6:30 to 7:00 AM that morning. On 02/08/19 at 10:30 AM, Staff H, LPN, said residents should be repositioned every two hours. On 02/12/19 at 11:19 AM, Staff C, Licensed Practical Nurse (LPN) and Charge Nurse, said pressure ulcers were monitored weekly using an EZ graph. Staff C said Resident #26 should be repositioned every 2 hours. Staff C said Resident #26's pressure ulcer had gotten worse since it was identified. Reference WAC 388-97-1060 (3)(b)

Based on interview and record review, the facility failed to utilize the appropriate number of staff for safe transfers for 1 of 3 sampled residents (#1). This failure resulted in harm to Resident #1 when a controlled fall occurred resulting in a fracture of Resident #1's right leg. Findings include: Resident #1 was admitted to the facility 01/16/17 with multiple health conditions. Resident #1's Minimum data sheet (MDS), a comprehensive assessment tool dated 01/12/17, documents a minimum of 2 staff are required for transfers. On 2/08/17 at 1:40 p.m., NA B stated that on 1/16/17 she transferred Resident #1 from her bed to her wheelchair. She then pulled the call light to have NA A come in to help her transfer Resident #1 from her wheelchair to her commode. While waiting for NA A to come, Resident #1 began to slide out of her wheelchair because her wheelchair cushion had become unsecured during the transfer. NA B assisted Resident #1 to the floor. When NA A came into the room they picked Resident #1 up from the floor and placed her on the commode. NA's A and B then transferred Resident #1 back to her wheelchair when she was finished. NA A then left the room and NA B then transferred Resident #1 from her wheelchair to her bed. When Resident #1 was back in bed, NA B noticed that Resident #1's right knee Didn't look right and went to get a licensed nurse to assess. Record review of nurses notes dated 1/16/17, documents that at 1:05 p.m. Licensed Nurse (LN) A noted a protruding area above the right knee when assessing resident #1. LN A called 911 to transport Resident #1 to the emergency room for evaluation. Review of hospital records dated 1/16/17 indicated Resident #1 sustained a fracture above her right knee. On 1/18/17 Resident #1 had surgery to repair the fracture to the right leg. On 2/08/17 at 2:10 p.m., the Director of Nursing indicated NA B should have had another staff member help transfer Resident #1 from her bed to her wheelchair. When Resident #1 slid to the floor a licensed nurse should have been notified by the NAC's at that time. After getting Resident #1 back in her wheelchair, NA A should have stayed to help transfer resident #1 back to bed.

Based on observation, interview and record review, the facility failed to provide activities to meet the interests and enhance the psychosocial well-being for 1 of 3 sampled residents (#106) reviewed for activities and 10 residents observed for pre-dining activity involvement. This failure placed the residents at risk for a decreased quality of life and caused harm to Resident #106. Findings include: Resident #106 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set an assessment tool, dated 1/23/16, indicated the resident used a wheelchair and required extensive, one person, assistance to move between his room and adjacent corridors. Resident #106 had short and long term memory problems with moderately impaired decision making skills. The care plan for alteration in thought process and mood, dated 1/24/16, noted interventions important to Resident #106, .picking out his own clothes, showers, snacks between meals, family involved in his care, magazines, music, the news, favorite activities, going outside if the weather is nice and religious services . Brief one on one (1:1) visits were listed as an intervention to be done throughout the month, as well as, to keep the television on channels like Hallmark or cooking shows and the resident was very religious. A care plan goal was for the resident to tolerate 2-3 activities a week. On 3/22/16 at 10:30 a.m., Resident #106 was seated in the Assisted Dining Room (ADR) with large, plastic building blocks on the table in front of him. The resident was not engaged in using the blocks. A music activity was in progress in the main dining room. At 11:25 a.m., the resident was seated in the same location and position. At 11:56 a.m., the plastic blocks had been removed from the table and the resident sat in his wheelchair with his eyes closed. On 3/24/16 at 11:16 a.m., Resident #106 stated he was okay and he did not play bingo. The resident was seated in the ADR, no other residents or staff present. The resident attempted to wheel himself away from the table, a nursing assistant (NA) entered the room, pushed the resident back to the table then left the room. At 11:21 a.m., the resident was seated at a table in the ADR with crackers on his lap tray. At 1:21 p.m., a NA entered the room and asked the resident if he wanted to face the television. The resident replied, No. The NA stated, Okay, you can just stay there then. At 2:09 p.m. and 2:34 p.m., the resident was observed in bed with eyes closed. At 3:50 p.m. and 4:14 pm., Resident #106 was seated in the ADR, gazing down and leaned slightly forward. The television was on with the volume off. One other resident was in the room, asleep in her wheelchair. A music activity was in progress in the main dining room that began at 3:00p.m. On 3/25/16 at 9:15 a.m., Resident #106 was seated in his wheelchair with his chin to his chest, eyes closed, at a table in the ADR. A bead manipulation toy was on the table. Two other residents were in the room engaged in watching television. At 9:22 a.m.-9:36 a.m., the resident was seated in his room, his wheelchair faced towards a wall. The resident was awake and looking at his clasped hands. Resident #106 smiled when the surveyor entered his room. When asked if he wanted something to do, Resident #106 nodded, indicating yes. He was then asked what he wanted to do, he shrugged his shoulders and stated, I don't know. When asked, the resident indicted he liked to watch television. He shrugged and shook his head No. when asked if he liked to go outside. Resident #106 smiled, and whispered Yes. when asked if he liked having visitors, the resident then reached out for the surveyor's hand and held it tightly. At 10:03 a.m., a NA wheeled Resident #106 from his room to the ADR. The NA placed him at a table, alone, with a bead manipulation toy on the table. A gardening activity was occurring in the main dining room. At 10:32 a.m., the resident was seated at a table in the ADR with a newspaper out of his reach and a bead manipulation toy in front of him. The resident poked at a bead on the manipulation toy. At 11:35 a.m. and 11:51 a.m., Resident #106 was seated in the ADR at the table with a bead manipulation toy. The resident gazed down at his hands placed on the edge of the table. On 3/28/16 at 10:42 a.m., Resident #106 was in the ADR, seated in his wheelchair with his head hanging down and eyes closed. A bible study had taken place at 10:00 a.m. in the main dining room that he was not involved in. At 11:22 a.m. and 11:39 a.m., the resident was in the ADR, in his wheelchair, staring down at his hands. Five other residents were in the room, three (3) sleeping and two (2) watching television. At 1:43 p.m., Resident #106 was in his wheelchair at the shelf beneath the television in the ADR. He reached for a decorative dish containing sand and seashells. On the lower shelf were large plastic building blocks and bead manipulation toys. The resident,when asked by the surveyor, reported he was bored and wanted something to do and continued to reach for the seashells. When offered the blocks and bead toy, he frowned and shook his head no. At 1:46 p.m., a maintenance staff entered the ADR stating to the resident, You wanna get your hands out of there so you don't spill that. The staff left the room. At 4:00 p.m. and 5:15 p.m., the resident sat alone with his hands on the table in the ADR, not facing the television which was on. On 3/29/16 at 9:30 a.m., Resident #106 was in the ADR, seated at a table alone, looking down at his hands. The television was on with no sound. When the resident was asked if he was watching television, he reached for the Surveyor's hand. At 9:50 a.m., Resident #106 sat at a table in the ADR, looking down at his hands. A magazine was opened on the table, not within the resident's line of gaze. An exercise activity was to begin in the main dining room at 10:00 a.m., he did not attend. At 2:06 p.m., the Activity Assistant (AA) stated calendars are used to record resident participation in activities. Each resident has a monthly calendar. Activities highlighted in yellow demonstrated active participation and green indicated passive participation in the activity. Residents are informed of activities via the dry erase boards on each hallway and activity staff go around to remind and ask resident to participate prior to each activity. If a resident refused/declined to attend an activity there was no documentation of the refusal unless the resident regularly refused, then it would be documented on the back of the calendar page. The AA stated 1:1 visits were done for residents if they do not participate in group activities. Activity staff might take food from an activity, play music, watch television or read to a resident. On weekends the volunteer staff provided the 1:1 visits. The volunteers knew who to visit by asking the weekend activity staff person. When asked about Resident #106, AA stated she usually did 1:1 with the resident using blocks or the bead toys. She indicated he liked the ball/trivia game, food activities, bingo, music and he really enjoyed 1:1 visits. The AA stated she tried to do 1:1 visits twice a week and maybe the weekend activity staff would have a volunteer go in on the weekends. The yellow highlight on Tv on the activity calendar indicated the resident watched television in the Sunshine room on that day as his independent activity. At 2:18 p.m., the March 2016 activity tracking calendar, was copied and verified by the AA to be highlighted the same as the original in the record. The March calendar documented Resident #106 attended one (1) group activity on 3/2, and had two 1:1 visits on 3/19 and 3/26 both Saturdays. There were no refusals were documented. Each day of the resident's monthly activity calendar included independent activities listed as Tv/music/1:1 Resident #106's calendar had Tv highlighted in yellow each day from 3/1/-3/21 and 3/26 -3/27. No other activities were documented for Resident #106. On 3/29/16 at 10:36 a.m., the Activity Director (AD) indicated daily activities were posted in each hallway and activity staff invited residents to each activity. She stated, Television can be in their rooms or out and about. In general, there was not a set schedule for 1:1 visits. They could be done anytime and for any resident, we try to do them 2-3 times a week for each resident. The AD stated all residents are invited to all activities. The AD stated Resident #106 liked the 1:1 visits and he liked attention. He did better with 1:1 visits than group activities. She indicated the resident had magazines, manipulative toys and blocks he liked. He engaged in those activities sometimes. This resident was observed daily not actively engaged in any activity related to his documented interests nor those activities that he was able to verbally express an interest in. He liked to go outside and liked visitors. There was no indication that the facility had advocated or provided, for this resident, opportunities to be involved in activities that he had expressed interest in. He was not afforded the opportunity to be engaged in maintaining his highest psychosocial well-being. This represented harm to Resident #106. <Assisted Dining Room > On 3/22/16 at 11:25 a.m., eight residents (#s 89, 118, 63, 40, 35, 106, 124, and 11) were seated in the ADR waiting for their lunch meal. Resident #35 was engaged in watching a TV program. The remaining 7 residents were not engaged in any activity. There was no staff present in this dining room. Between 11:44 a.m.-11:55 a.m., the eight residents continued to be seated in the ADR, no staff were present to engage the residents or offer any type of stimulation while they waited for their lunch meal. Overall, residents in the ADR waited an hour in the ADR with nothing going on, there was no activity, music, staff interaction, resident socialization or drinks offered prior to being served and/or assisted to eat their meals. On 3/24/16 at 5:15 p.m., six residents (#s 35, 89, 118, 40, 92 and 43) were seated in the ADR waiting. No staff was present in the dining room. Residents were observed to wait up to 71 minutes with no staff, social interaction or activity involvement while they waited for their meals. On 3/28/16 at 4:47p.m.-5:53 p.m., four residents (#s 35, 106, 40, and 90) were seated in the ADR, waiting for their dinner meal. There was no activity, music, staff interaction, resident socialization or drinks offered prior to being served their meals.

Based on observation, interview and record review, for one of four residents, the facility failed to protect Resident #1 from falling out of her bed during the provision of personal care. This failure brought harm to Resident #1 through injury to her carotid artery. Findings include: Resident #1 was admitted to the facility on [DATE], according to the resident records. The resident's [DIAGNOSES REDACTED]. Resident #1 was unable to participate in her personal care and did not communicate verbally or with her hands. Resident #1 was 64 inches tall and weighed approximately 122 pounds. Resident #1 was at risk for skin breakdown and interventions and preventions for skin breakdown that were in place, included an egg crate type sponge placed on the top of the resident's mattress. Resident#1 had been assessed as a one-person assist with incontinence care which included the use of disposable briefs. Review of the facility investigation documentation revealed, on 2/6/15 at approximately 10:30 p.m., Resident #1 was receiving incontinence care prior to going to sleep. As the NAC (Staff # A) was changing her, he positioned her on her right side facing away from him and as he pulled the brief from under her, she rolled off the bed onto the floor hitting the left side of her neck on the walker next to the bed. A hematoma appeared over Resident #1's carotid artery and the resident was immediately sent to the emergency room (ER). In interview on 2/25/25, Staff A said he pulled too hard on the brief which sent the resident over the edge of the bed. Review of resident records revealed, Resident #1 was on a 81 mg aspirin (blood thinner, prolonging the time for her blood to form a clot) daily since admission. The ER physician's note revealed that the hematoma to the left carotid artery may at sometime in the future cause Resident #1 to have a stroke or for the carotid artery to dissect (come apart). Resident #1 returned from the ER with dressing over the area which currently looks like a small scabbed area with steri stips across it.