Every finding on record at Eliseo

Based on interview and record review, the facility failed to have measures in place to prevent the growth of Legionella and other opportunistic waterborne pathogens in building water systems. This failure placed residents, visitors and staff at an increased risk of waterborne illnesses. Findings included.Review of the facility provided water management program dated 11/02/2024 and updated 07/02/2026 failed to show the following items were in place: 1. Identify adequate program team members (infection preventionist was not included in the plan). 2. Accurately describe building water systems.3. Identify areas Legionella or other waterborne pathogens could grow/spread. 4. Identify control measures used to monitor for the presence of pathogens. 5. Identify corrective actions if control measures are not met. 6. Show who will monitor their control measures. 7. Show how facility identifies and would investigate waterborne pathogen cases. 8. Show their contingency response plan. During an interview on 07/06/2026 at 11:53 AM, Staff A, Administrator, stated they were aware that the facility did not currently have a water management plan in place as of January 2025 and this did not meet their expectations. Reference WAC 388-97-1320(2)(a)

Based on observation, interview, and record review, the facility failed to ensure residents were given showers based on their choices for 5 of 8 sampled residents (Residents 5, 65, 9, 36 and 11) reviewed for choices and unnecessary medications. This failure placed the residents at risk of receiving unnecessary medications, feeling unclean, and diminished quality of life. Findings included.Resident 5Review of the electronic health record (EHR) showed Resident 5 was admitted to the facility on [DATE] with diagnoses to include cerebral infarction (when a blood clot disrupts blood flow to the brain and causes brain cell death), dementia, and disorder of psychological development (childhood disorder affecting cognitive, social, emotional, speech and motor skills). Resident 5 was able to communicate some of their needs. Review of the 30-day lookback of shower documentation, dated 07/02/2026, showed Resident 5 was scheduled to be given showers at nighttime, and Resident 5 had had only one bed bath documented at 2:20 AM, and six refusals documented between midnight and 3:52 AM. During a phone interview on 07/02/2026 at 12:10 PM, Collateral Contact L, stated Resident 5 needed to have their showers and having the nighttime schedule was purely for staff convenience and explained why Resident 5 was refusing. Resident 65Review of the EHR showed Resident 65 was admitted to the facility on [DATE] with diagnoses to include hemiplegia (paralysis of one side of the body), depression and anxiety. Resident 65 was able to communicate needs. Observation and interview on 07/06/2026 at 10:14 AM showed Resident 65 was laying in their bed with greasy hair. Resident 65 stated I can't refuse showers if nobody comes and offers me one. I have not had a shower this Saturday and last Saturday. Resident 65 stated that they were assigned to a schedule and had absolutely no choice about the showers. Review of the EHR showed Resident 65 was assigned to be given showers on Tuesday and Saturday. Review of the documentation showed Resident 65 refused 6 of 8 showers/baths and had been provided only 2 bed baths. Resident 65 reported that was when wet towels were used to wipe them in bed. During an interview on 07/02/2026 at 2:08 PM, Staff N, Nursing Assistant Certified (NAC), stated the residents had a choice to accept or refuse the scheduled shower. Resident 91Review of the EHR showed Resident 91 was admitted to the facility on [DATE] with diagnoses to include end stage renal disease (when kidneys are not working), chronic pulmonary obstructive disease (airflow obstruction), and depression. Resident 91 was able to communicate their needs. During an interview on 06/30/2026 at 9:08 AM, Resident 91 stated they did not have a choice about their shower schedule. During an interview on 07/01/2026 at 9:49 AM, Resident 91 stated they had not had a shower in a week. During an interview on 07/01/2026 at 9:59 AM, Staff O, NAC, stated Resident 91 was assigned to the night shift for showers. Staff O stated the nursing assistants were responsible to do their own showers for their assigned rooms, and there was a schedule, and they were not aware of Resident 91's preferences. During a phone interview on 07/02/2026 at 9:22 AM, Collateral Contact M stated Resident 91 would have never chosen to have a shower at nighttime as they were tired and liked to go to bed around seven in the evening. Resident 36Review of the EHR showed Resident 36 was admitted to the facility on [DATE] with diagnoses to include Alzheimer's (a progressive, irreversible brain disorder destroying memory and cognitive skills), bipolar disorder (mental health condition characterized by extreme, unpredictable shifts in mood, energy, activity levels, and concentration) and heart failure. Resident 36 was not able to communicate needs. Review of the shower documentation from 06/05/2026 to 07/05/2026 showed Resident 36 had two bed baths given at 9:47 PM and 5:59 AM, and seven refusals documented between the hours of 9:27PM and 3:30AM. Resident 11Review of the EHR showed Resident 11 was admitted to the facility on [DATE] with diagnoses to include dementia (decline in cognitive function affecting memory, thinking and ability to perform everyday activities), anxiety and chronic pain. Resident 11 was able to communicate needs. During an interview on 07/06/2026 at 9:58 AM, Resident 11 stated, They come and get me, but I don't remember getting a shower. I do what I am told. Review of shower documentation from 06/06/2026 to 07/06/2026 showed Resident 11 had one bed bath at 2:06 AM, and five refusals between the times of 10:42 PM and 5:59 AM. During an interview on 07/06/2026 at 10:01 AM, Staff P, Licensed Practical Nurse, stated every room and bed was assigned to a shower schedule. Staff P stated, We try to split it between the shifts. When a new resident comes to the bed they are not asked, but if they don't want it we can change it, or if they are refusing we should find out why and change it. During an interview on 07/06/2026 at 11:18 AM, Staff B, Director of Nursing Services, stated staff were to have a conversation on admission and ask about shower choices. Staff B stated there was a schedule and residents could request to change. Reference WAC 388-97- 0180(2)

Based on interview and record review, the facility failed to ensure residents receiving psychotropic (affecting the mind) medications had appropriate diagnosis for medication use, behavior monitoring, gradual dose reduction, and/or nonpharmacological interventions and as-needed psychotropics were not used for greater than fourteen days for 4 of 5 sampled residents (Residents 36, 11, 10, and 3) reviewed for unnecessary medications. This failure placed residents at risk of unintended side effects, avoidable sedation, chemical restraint, and a diminished quality of life. Findings included.Resident 36 Review of the electronic health record (EHR) showed Resident 36 was admitted to the facility on [DATE] with diagnoses to include Alzheimer's (a progressive, irreversible brain disorder destroying memory and cognitive skills), bipolar disorder (mental health condition characterized by extreme, unpredictable shifts in mood, energy, activity levels, and concentration) and heart failure. Resident 36 was not able to communicate needs. Review of the quarterly minimal data set (MDS, a required assessment) dated 05/11/2026 showed Resident 36 was not experiencing psychosis, signs and symptoms of delirium, and had no changes in behaviors. Review of the provider orders showed Resident 36 was ordered venlafaxine (antidepressant) dated 09/25/2025 for bipolar disorder, olanzapine (antipsychotic/mood altering with black box warning -older adults with dementia-related psychosis who take antipsychotics like olanzapine have an increased risk of stroke, mini-stroke, or death) with increased dose dated 04/27/2026 for Alzheimer's with end stage psychotic disturbance and lorazepam (antianxiety) medication on as need basis dated 02/20/2026 without a stop date. Review of the June 2026 medication administration record (MAR) showed Resident 36 was given lorazepam 19 times. During an interview on 07/06/2026 at 11:18 AM, Staff B, Director of Nursing Services (DNS), stated the as need medications for anxiety should be only for 14 days. Resident 11 Review of the EHR showed Resident 11 was admitted to the facility on [DATE] with diagnoses to include dementia (decline in cognitive function affecting memory, thinking and ability to perform everyday activities), anxiety and chronic pain. Resident 11 was able to communicate needs. Review of the providers orders showed Resident 11 was ordered Seroquel (mind altering antipsychotic) with increased dose from 03/11/2026, sertraline (antidepressant) dated 08/21/2025, buspirone (antianxiety) with increased dose from 03/11/2026 and hydroxyzine (medication given for anxiety) as needed dated 03/24/2026 for six months for restlessness/agitation. Review of the June MAR showed Resident 11 was experiencing positive serotonin syndrome (a potentially life-threatening drug reaction caused by too much serotonin in your body. It usually occurs when you combine or increase medications like antidepressants) on 06/09/2026, 06/12/2026, 06/13/2026 and 06/26/2026. Review of progress notes for June 2026 showed no nursing documentation about the side effects. Review of social services progress notes dated 06/18/2026 showed gradual dose reduction recommended for potential adverse side effects. During an interview on 07/06/2026 at 9:58 AM, Resident 11 stated they were not feeling well, were dizzy, their brain was not working and it was not connecting, and Resident 11 was sure their nurse knew that. During an interview on 07/06/2026 at 11:18 AM, Staff B, DNS, stated the psychotropic medications were prescribed for behaviors such as delusions and certain diagnoses. Staff B stated the expectation was for the nurses to follow orders and notify providers of adverse side effects and follow gradual dose reductions. Resident 10 Review of the EHR showed Resident 10 admitted to the facility on [DATE] with diagnoses of dementia without behavioral disturbance (a group of symptoms affecting memory), depression, and anxiety. The resident was unable to make needs known. Review of the provider orders showed Resident 10 was prescribed an antipsychotic medication (Seroquel) twice a day for dementia with behavioral disturbances. This diagnosis was not included in the resident's diagnosis list. Review of the active care plan on 07/03/2026 showed no care plan had been initiated for the use of an antipsychotic medication. During an interview on 07/01/2026 at 9:36 AM, Staff D, Social Services Director (SSD), stated it was their expectation that Resident 10 had an appropriate diagnosis and care plan in place for the use of antipsychotic medications. During an interview on 07/01/2026 at 9:57 AM, Staff B, DNS, stated Resident 10's lack of diagnosis and care plan for the use of an antipsychotic medication did not meet their expectations. Resident 3 Review of the EHR showed Resident 3 admitted to the facility on [DATE] with diagnoses of depression and anxiety. The resident was not able to make needs known. Review of the provider orders showed Resident 3 was prescribed an antidepressant medication (sertraline) daily with a start date of 07/07/2026 and an antianxiety medication (Buspar) twice a day with a start date of 05/06/2026. Review of the EHR showed an order to monitor Resident 3 for adverse side effects of the antidepressant and antianxiety medications with start dates of 05/28/2026, an order to monitor behaviors related to the antidepressant and antianxiety medications with start dates of 05/28/2026, and an order to attempt nonpharmacological interventions (NPI) for behaviors with a start date of 05/28/2026 (25 days after the start date of the medications). During an interview on 07/01/2026 at 9:36 AM, Staff D, SSD, stated it was their expectation that Resident 3 should have had the side effects, behavior monitors and NPI in place when the medications were prescribed. During an interview on 07/01/2026 at 10:02 AM, Staff B, DNS, stated Resident 3's delay in side effect monitoring, behavior monitoring, and NPI implementation did not meet expectations. Reference WAC 388-97-1060(3)(k)(i), -0620(1)(a)

Based on observation, interview, and record review the facility failed to ensure food preferences related to portion sizes were honored for 8 of 18 sampled residents (Residents 85, 67, 11, 115, 84, 24, 144 and 1) reviewed for resident rights. This failure placed the residents at risk for dissatisfaction, unintended weight loss, and diminished quality of life. Findings included .During an interview on 06/29/2026 at 12:23 PM, Resident 1 stated the facility rarely accommodated their preference for small meal portion sizes. Resident 1 stated they did not eat very much and the food mostly went to waste. Observation of the lunch tray line showed the following: Observation on 07/06/2026 at 11:10 AM showed Resident 85 preferred small meal portions. Staff T, Dietary Cook, plated one full biscuit and #12 scoop (regular serving size) of turkey pot pie on Resident 85's plate. Observation on 07/06/2026 at 11:12 AM showed Resident 67 preferred small portions. Staff T, Dietary Cook, used the size #12 scoop to plate a regular portion size and one full biscuit on Resident 67's plate. Observation on 07/06/2026 at 11:30 AM showed Resident 11 preferred small portions. Staff T, Dietary Cook, used the size #12 scoop to plate a regular portion size and one and a half biscuits on Resident 11's plate. Observation on 07/06/2026 at 11:31 AM showed Resident 115 preferred small portions. Staff T, Dietary Cook, plated a full slice of bread, a large amount of roast beef, and a large portion of potato wedges. Observation on 07/06/2026 at 11:49 AM showed Resident 84 preferred small portions. Staff T, Dietary Cook, plated a full slice of bread, a large amount of roast beef, and a large portion of potato wedges. Observation on 07/06/2026 at 12:09 PM showed Resident 24 preferred small meal portions. Staff T, Dietary Cook, used the size #12 scoop to plate a regular portion size and two biscuits on Resident 24's plate. Observation on 07/06/2026 at 12:12 PM showed Resident 144 preferred small meal portions. Staff T, Dietary Cook, used the size #12 scoop to plate a regular portion size and one biscuit on Resident 144's plate. Observation on 07/06/2026 at 12:16 PM showed Resident 1 preferred small portions. Staff T, Dietary Cook, plated a full slice of bread, a large amount of roast beef, and a large portion of potato wedges. During an interview on 04/10/2026 at 9:30 AM, Staff U, Chef, stated the regular portion size for the lunch meal was one biscuit and one scoop of turkey pot pie. The regular portion size for the hot roast beef sandwich was one slice of bread and one scoop of the roast beef with gravy. Staff U stated when residents requested smaller portion sizes the expectation was for staff to provide half the regular serving size as requested. Reference WAC 388-97-1100(1)

Based on observation, interview, and record review, the facility failed to ensure residents using psychotropic medications (affecting the mind) or pressure alarms had provided consent for their use for 2 of 8 sampled residents (Residents 36 and 77) reviewed for unnecessary medications/physical restraints. This failure placed residents at risk of not being able to inform their care, being physically restrained, and a diminished quality of life. Findings included.Resident 36 Review of the electronic health record (EHR) showed Resident 36 was admitted to the facility on [DATE] with diagnoses to include Alzheimer's (a progressive, irreversible brain disorder destroying memory and cognitive skills), bipolar disorder (mental health condition characterized by extreme, unpredictable shifts in mood, energy, activity levels, and concentration) and heart failure. Resident 36 was not able to communicate needs. Review of June 2026 medication administration record (MAR) showed Resident 36 was prescribed and administered Venlafaxine (antidepressant) medication started on 09/25/2025 for bipolar depression, and lorazepam (antianxiety medication) dated 02/20/2026 as needed for anxiety. Review of the EHR showed no documented written consent explaining risk and benefits of the medications. During an interview on 07/06/2026 at 11:00 AM, Staff G, Registered Nurse/Unit Manager (RN/UM), stated medication consents were documented in templates in progress notes. Staff G stated the nurses should obtain consent prior administering the medication initially. During an interview on 06/07/2026 at 11:18 AM, Staff B, Director of Nursing Services (DNS), stated lack of consent for Resident 36's antidepressant and antianxiety medications did not meet expectations. Resident 77 Review of the EHR showed Resident 77 admitted to the facility on [DATE] with diagnoses to include metabolic encephalopathy (brain malfunction), muscle weakness, and high blood pressure. Resident 77 was sometimes able to make needs known. Observation on 06/29/2026 at 2:34 PM showed Resident 77 sat in their wheelchair with a sensor alarm (a device used to alert caregivers when a seated individual attempts to stand up or leaves their seat) attached to their wheelchair and a sensor alarm was on the side rail attached to the bed (used to alert staff when an individual attempts to leave their bed). Review of the admission minimum data set assessment (MDS) dated [DATE] showed Resident 77 utilized bed and chair alarms daily. Review of the provider order dated 06/01/2026 showed Resident 77 was prescribed a bed and wheelchair pressure alarms to alert staff of residents attempting to get up without assistance and to check for placement and proper functioning and ensure the cord was zip tied to the bed every shift. Review of Resident 77's EHR showed no informed consent with risks and benefits in place for the use of the wheelchair and bed alarms. During an interview on 07/06/2026 at 8:58 AM Staff C, Licensed Practical Nurse/Unit Manager Nurse (LPN/UM), stated residents with a pressure sensor alarm should have a provider order, be care planned, and have an informed consent with risks and benefits in place. Staff C stated they were unable to locate documentation of an informed consent for Resident 77's use of wheelchair and bed alarms and this did not meet expectations. During an interview on 07/06/2026 at 9:55 AM, Staff B, DNS, stated they were unable to find an informed consent for Resident 77's chair and bed alarms and this did not meet their expectations. Reference WAC 388-97-0260, -0300(3)(a), -1020(4)(a)(b)

Based on interview and record review, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR, a mental health screening tool) assessments were accurately completed for 1 of 5 sampled residents (Resident 6) reviewed for PASRRs and unnecessary medications. This failure placed the resident at risk for inappropriate placement and unidentified mental health care needs. Findings included .Findings included . Review of the electronic health record (EHR) showed Resident 6 admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbances (a decline in mental ability that interferes with daily life), depression, anxiety (emotional state characterized by feelings of fear or worry) and diabetes (too much sugar in the blood). Resident 6 was able to make needs known. Review of Resident 6's EHR showed no PASRR for the 01/30/2026 admission date. During an interview on 07/06/2026 at 2:14 PM, Staff D, Social Services Director (SSD), stated Resident 6 was admitted to the facility from assisted living and a PASRR should have been completed but was not. During an interview on 07/06/2025 at 2:59 PM, Staff A, Administrator, stated the expectation was for PASRR to be completed prior to admission. Staff A stated upon admission, PASRR information should be checked for accuracy and corrected if there was missing or incorrect information. Reference WAC 388-97-1975

Based on interview and record review, the facility failed to address issues raised by the Resident Council group for 2 of 3 months (May and June of 2026) of meeting minutes reviewed. Failure for administrative staff to act upon concerns/grievances voiced by the resident council and failure to report back to the council in writing a response and rationale and action taken on concerns/grievances placed residents at risk for the Resident Council process being ineffective in improving resident quality of life. Findings included.Review of the Resident Council meeting agenda and minutes dated 05/20/2026 showed the following concerns were brought to the attention of the Administrator, Director of Nursing Services, Maintenance, and the Housekeeping/Laundry Director who were in attendance: Vitals were not being taken or charted on the night shift, the wheels on the lifts were not good, and the shower ponchos were damaged. The agenda showed there was no Old business, to discuss. Review of the Resident Council meeting agenda and minutes dated 06/17/2026 showed the following concerns were brought to the attention of the Director of Nursing Services, Maintenance, Housekeeping/Laundry Director, and Life Enrichment staff who were in attendance: call lights were not being answered in a timely matter, there was no water pressure in the 800-hall shower room, could a closet rod be lowered so residents could reach their clothes, one resident reported a missing item, and bingo was getting done early. The agenda showed there was no Old business, to discuss. However, there were concerns brought up at the previous meeting. Review of the grievance logs for May and June 2026 showed no concerns/grievances logged for concerns received on 05/20/2026 or 06/17/2026. In a resident council meeting on 07/01/2026 at 1:00 PM, when asked if the facility promptly followed up on grievances brought forward by the Resident Council, 4 of 4 residents (Residents 68, 69, 115, and 122) all replied not always and that they were not provided with a rationale as to why. Resident 69 stated that bingo was getting done early and did not always start on time. The residents all stated that old business was not being addressed during the meetings. During an interview on 07/02/2026 at 10:01 AM, Staff E, Life Enrichment Documentation Specialist (LEDS), stated when a resident voiced concerns/grievances during the Resident Council meetings they would document it in the Resident Council minutes; however, they did not file a grievance. Staff E stated that the minutes got sent to the interdisciplinary team (IDT/department heads) for review. Staff E stated they had not been reviewing old business during the meetings. Staff E stated that concerns voiced during Resident Council meetings were not being logged in the Grievance log and should have been. Staff E stated that each concern brought up during the Resident Council meetings should have been filed as a grievance and followed up on until resolved and then discussed as old business during the next meeting. During an interview on 07/02/2026 at 10:48 AM, after reviewing Resident Council meeting agenda/minutes and the grievance logs, Staff A, Administrator, stated issues/concerns brought up during Resident Council meetings should have been filed as a grievance, logged and followed up on, and then discussed as old business during the next meeting. Staff A stated this did not happen and it did not meet their expectations. Reference WAC 388-97-0920(1)-(6)

Based on interview and record review, the facility failed to obtain advanced directives (AD, a written instruction, such as a living will or Durable Power of Attorney [DPOA] for health care-a document delegating to an agent the authority to make health care decisions in case the individual delegating the authority subsequently becomes incapable to do so), or a guardianship (a legal relationship established by a court that grants an individual or organization the authority to make decisions for someone else who is no longer able to manage their own personal, medical, or financial affairs) for 1 of 3 sampled residents (Resident 54) reviewed for advanced directives. This failure placed the resident at risk of not having an established decision-maker, lack of ability to direct care, and a diminished quality of life. Findings included .Review of the electronic health record (EHR) showed Resident 54 initially admitted to the facility on [DATE] with diagnoses that included coronary artery disease (the narrowing or blockage of the major blood vessels that supply the heart with blood, oxygen and nutrients), bipolar disorder (a mental health condition that causes extreme, unpredictable shifts in mood, energy, activity levels, and concentration), and anxiety disorder. Review of the quarterly minimum data set assessment (MDS) dated [DATE] showed Resident 54 had diagnoses to include dementia (decline in mental ability severe enough to interfere with daily life) and adult failure to thrive. Resident 54 was usually able to make needs known. Review of Resident 54's General Durable Power of Attorney, for financial dated 09/07/2012 showed, Health Care Decisions - The Principal has signed a separate heath Care Durable Power of Attorney for Health care purposes. Review of Resident 54's Physician's Statement Regarding Capacity/Competency with dates of treatment or examination on 07/07/2016, signed by the provider 07/12/2016 and signed by the DPOA on 09/20/2016 showed Resident 54 no longer had the capacity to handle their own property, financial affairs and health care decision-making due to mental illness. Review of Resident 54's EHR on 06/30/2026 at 11:06 AM showed no AD in place for healthcare. However, there were documented MDS quarterly/annual review notes that showed the following:- Dated 01/30/2025 and 03/21/2025 showed Resident 54 had power of attorney (POA) on file.- Dated 06/09/2025 showed POA for healthcare not on file, education and resources provided, family not able to provide healthcare POA documentation, and facility was to apply for guardianship. - Dated 08/22/2025 showed POA not on file, education and resources provided, and working on guardianship.-Dated 01/28/2026 showed POA not on file, education and resources provided guardianship submitted. During an interview on 07/06/2026 at 11:31 AM, Staff D, Social Services Director (SSD), stated they had not been able to obtain a POA for healthcare due to failed attempts to obtain from the family. Staff D stated they had been working on obtaining guardianship for Resident 54. Staff D stated Resident 54's AD should have been in place prior to now and proper healthcare decision maker documentation needed to be obtained. During an interview on 07/06/2026 at 12:40 PM, Staff A, Administrator, stated the expectation was to have an AD in place as required. Staff A stated Resident 54 should have had a healthcare POA or legal guardianship in place prior to now and this did not meet their expectations. Reference WAC 388-97-0280(3)(c)(i)(ii), -0300(1)(b)(3)(a)-(c)

Based on observation and interview, the facility failed to ensure personal privacy was protected for 1 of 5 sampled residents (Resident 32) reviewed for resident rights. This failure placed the residents at risk for embarrassment, a violation of their privacy, and a diminished quality of life. Findings included .Review of the electronic health record (EHR) showed Resident 32 admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbances (a decline in mental ability that interferes with daily life), depression and anxiety (emotional state characterized by feelings of fear or worry). Resident 32 was able to make needs known. Observation on 06/30/2026 at 12:27 PM showed Resident 32's roommate had an Amazon [NAME] (electronic artificial intelligence digital assistant device with recording capabilities). Review of the Resident 32's EHR showed no documentation of consent to the electronic device in their room. During an interview on 07/02/2026 at 11:10 AM, Staff D, Social Services Director (SSD), stated the facility was unaware Resident 32 had an [NAME]. Staff D stated electronic recording devices were prohibited in the facility. During an interview on 07/07/2025 at 11:35 AM, Staff A, Administrator, stated the residents were not allowed to have any recording devices in the facility. Staff A stated when staff saw the [NAME], it should have been reported to management so they could speak with the resident/resident representative to find an alternative device for entertainment. Reference WAC 388-97-0360, 0500(1)

Based on interview and record review, the facility failed to initiate, investigate, and resolve a grievance for 1 of 4 sampled residents (Residents 87) reviewed for resident rights. This failure placed the residents at risk for emotional distress and a diminished quality of life. Findings included .Review of the electronic health record (EHR) showed Resident 87 admitted to the facility on [DATE] with diagnoses that included chronic inflammatory demyelinating polyneuropathy (nerve disorder), heart failure, kidney disease, and diabetes (too much sugar in the blood). Resident 9 was able to make needs known. During an interview on 06/29/2026 at 3:16 PM, Resident 87 stated their sleep was disrupted daily due to their roommate's behaviors. Resident 87 stated their roommate would repeatedly say Don't hurt me or You're hurting me while staff were providing care throughout the day. Resident 9 stated they had told numerous staff, but nothing had been done. Review of the EHR showed no documentation related to Resident 87's concern. Review of the Grievance logs dated January 2026 through June 2026 showed no documentation related to Resident 87's concern. During an interview on 07/01/2026 at 9:46 AM, Staff S, Social Services Coordinator, stated they had spoken with Resident 87 who expressed their roommate concern. Staff S stated and offered to move Resident 87; however, they declined but they could not locate documentation or a grievance showing a resolution. During an interview on 07/02/2026 at 11:57 AM, Staff D, Social Services Director, could not locate documentation of Resident 87's roommate concern. Staff D stated Resident 87's concern should have been documented and resolved with a room change or offering of ear plugs or headphones. During an interview on 07/06/2026 at 2:48 PM, Staff A, Administrator, stated the expectation was that resident concerns were documented and resolved in a timely manner. Reference WAC 388-97-0460

Based on observation, interview, and record review, the facility failed to ensure all required care and services were included in residents' plans of care for 3 of 26 sampled residents (Residents 32, 65, and 77) reviewed for comprehensive care plans. This failure placed residents at risk of unmet needs, lack of specific care, and a diminished quality of life. Findings included.Resident 32 Review of the electronic health record (EHR) showed Resident 32 admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbances (a decline in mental ability that interferes with daily life), depression, and anxiety (emotional state characterized by feelings of fear or worry). Resident 32 was able to make needs known. During an interview on 06/29/2026 at 2:24 PM, Resident 87 stated Resident 32 would yell out You're hurting me during care provided by facility staff. Resident 87 reported the behavior would occur daily at all times of the day. Observation on 06/30/2026 at 10:05 AM showed Resident 32 yelling, You're hurting me while staff provided care behind a drawn curtain. Resident 32 was then seen sitting in their wheelchair calmly being pushed to the nurse's station. During an interview on 07/01/2026 at 1:33 PM, Staff X, Nursing Assistant Certified (NAC), stated Resident 32 consistently yelled or screamed Leave me alone. You're hurting me or Don't hurt me when staff was providing care. Review of Resident 32's care plan, initiated 01/08/2026, showed no interventions related to the behaviors observed and reported. During an interview on 07/01/2026 at 2:15 PM, Staff G, Registered Nurse/Unit Manager (RN/UM), stated they were aware of Resident 32's behaviors and they were not care planned but should have been. During an interview on 07/06/2026 at 1:45 PM, Staff B, Director of Nursing Services (DNS), stated the expectation was that Resident 32's behaviors related to their diagnosis were care planned and monitored. Resident 65 Review of the EHR showed Resident 65 was admitted to the facility on [DATE] with diagnoses to include hemiplegia (paralysis of one side of the body), depression, anxiety and post-traumatic stress disorder (PTSD, a psychiatric condition that can develop after experiencing or witnessing a life-threatening or deeply traumatic event, such as combat, abuse, or serious accidents). Resident 65 was able to communicate needs. Review of the quarterly minimum data set (MDS, a required assessment) dated 05/21/2026 showed Resident 65 was coded with PTSD. Review of the comprehensive care plan, initiated 12/22/2025, showed Resident 65 was not care planned for past trauma or PTSD. During an interview on 07/02/2026 at 12:54 PM, Staff D, Social Service Director, stated Resident 65 should have had a care plan for PTSD. Resident 77 Review of the EHR showed Resident 77 admitted to the facility on [DATE] with diagnoses to include metabolic encephalopathy (brain malfunction), muscle weakness, and high blood pressure. Resident 77 was sometimes able to make needs known. Observation on 06/29/2026 at 2:34 PM showed Resident 77 sat in their wheelchair with a sensor alarm (a device used to alert caregivers when a seated individual attempts to stand up or leaves their seat) attached to their wheelchair and a sensor alarm was on the side rail attached to the bed (used to alert staff when an individual attempts to leave their bed). Review of the MDS dated [DATE] showed Resident 77 utilized bed and chair alarms daily. Review of the provider order dated 06/01/2026 showed Resident 77 was prescribed bed and wheelchair pressure alarms to alert staff of residents attempting to get up without assistance, to check for placement and proper functioning, and ensure the cord was zip tied to the bed every shift. Review of Resident 77's care plan on 07/02/2026 showed no documentation for the use of bed or chair alarms. During an interview on 07/06/2026 at 8:58 AM, Staff C, Licensed Practical Nurse/Unit Manager (LPN/UM), stated they were unable to locate the use of bed or chair alarms in Resident 140's care plan, and it should have been care planned. During an interview on 07/06/2026 at 9:55 AM, Staff B, DNS, stated Resident 140's pressure sensor bed and wheelchair alarms had not been care planned and this did not meet their expectations. Reference WAC 388-97-1020(1)(2)(a)(b)

Based on interview and record review, the facility failed to thoroughly investigate an allegation of abuse for 1 of 4 sampled residents (Resident 87) reviewed for abuse. This failure placed residents at risk for potential ongoing abuse, psychological harm, and a diminished quality of life. Findings included .Review of the electronic health record (EHR) showed Resident 87 admitted to the facility on [DATE] with diagnoses that included chronic inflammatory demyelinating polyneuropathy (nerve disorder), heart failure, kidney disease, and diabetes (too much sugar in the blood). Resident 87 was able to make needs known. During an interview on 06/29/2026 at 2:24 PM, Resident 87 stated Staff P, Licensed Practical Nurse (LPN), made hurtful comments related to Resident 87 having dementia. Resident 87 stated they voiced a complaint to staff about not getting sleep due to their roommate's behaviors (up at night talking to themself and yelling out during care). Resident 87 stated Staff P made the comment, You have the same diagnosis and will have the same type of behavior someday. Resident 87 stated they reported the comments to Staff V, Speech Language Pathologist (SLP), and there was never any follow-up. During an interview on 07/01/2026 at 9:30 AM, Staff V, SLP, confirmed Resident 87 Tearfully expressed they were anxious due to staff making hurtful comments about their dementia diagnosis. Staff V stated Resident 87 was not aware of the diagnosis and did not fully understand what the diagnosis meant. Staff V stated they reported the allegation to the social services department, the unit manager and left a note about a possible room change due to Resident 87 not sleeping well. During an interview on 07/01/2026 at 9:46 AM, Staff S, Social Services Coordinator, stated they spoke with Resident 87 who reported Staff P, LPN, was telling them they had dementia, and it was making Resident 87 upset that Staff P stated they were going to be forgetful. Staff S stated they did not follow up but should have because it could have been considered verbal abuse. During an interview on 07/01/2026 at 10:40 AM, Staff G, Registered Nurse/Unit Manager (RN/UM), stated Staff V, SLP, informed them of a concern Resident 87 had with Staff P, but they never followed up for additional information. During an interview on 07/06/2026 at 1:43 PM, Staff B, Director of Nursing Services, stated the expectation was when allegations of abuse were identified, management should have been informed and a thorough investigation conducted. Reference WAC 388-97-0640 (6)(a-c)

Based on interview and record review, the facility failed to provide written bed hold notice, at the time of transfer to the hospital, for 2 of 4 sampled residents (Residents 6 and 138) reviewed for hospitalization and failed to provide written notice of transfer/discharge and notify the Ombudsmen for 3 of 5 sampled residents (Resident 6, 138 and 140) when reviewed for discharge. This failure placed the residents at risk for lacking knowledge regarding their right to hold their bed while in the hospital and diminished quality of life. Finding included.Resident 6 Review of the electronic health record (EHR) showed Resident 6 admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbances (a decline in mental ability that interferes with daily life), depression, anxiety (emotional state characterized by feelings of fear or worry) and diabetes (too much sugar in the blood). Resident 6 was able to make needs known. Review of Resident 6's EHR showed a hospitalization on 04/24/2026 and readmission to the facility on [DATE]. Review of the EHR showed no documentation a written bed hold notice, or transfer/discharge notice were provided to Resident 6. During an interview on 07/02/2026 at 12:30 PM, Staff F, Health Information Director (HID), stated they could not locate Resident 6's bed hold notice or transfer/discharge form. Staff F stated the Ombudsman was not notified of Resident 6's discharge. Resident 138 Resident 138 was admitted to the facility on [DATE] with diagnoses of heart failure and chronic kidney disease. Resident 138 was able to make needs known. Review of Resident 138's EHR showed a hospitalization on 04/29/2026 with no readmission date. Review of the EHR showed no documentation a written bed hold notice, or transfer/discharge notice were provided to Resident 138. During an interview on 07/02/2026 at 12:30 PM, Staff F, HID, stated they could not locate Resident 138's bed hold notice or transfer/discharge form. Staff F stated the Ombudsman was not notified of Resident 138's discharge. During an interview on 07/06/2026 at 3:00 PM, Staff A, Administrator, stated the expectation was for bed hold notices to be offered, completed, provided and thoroughly documented when a resident was transferred to the hospital. Staff A stated Resident 6 and 138 should have received a transfer/discharge notice and the Ombudsman should have been notified. Resident 140 Review of the EHR showed Resident 140 admitted to the facility on [DATE] with diagnoses that included coronary artery disease (the narrowing or blockage of the major blood vessels that supply the heart with blood, oxygen and nutrients), diabetes, and chronic kidney disease (long term loss of kidney function). Resident 140 was able to make needs known. Review of the EHR resident profile tab showed Resident 140 was their own responsible party healthcare decision maker. Review of the progress note dated 05/20/2026 showed during grand rounds/care conference meeting, Resident 140 expressed that they wanted to leave against medical advice (AMA) because they wanted to be with their spouse. In attendance was the facility's interdisciplinary team (IDT), the provider, Resident 140, and the resident's family member. It showed the family member would be taking Resident 140 home. It showed AMA paperwork was reviewed and signed by Resident 140. Review of the facility's May 2026 grievance log showed no grievance filed for Resident 140. Review of the Resident Discharge Without Medical Authorization, form dated 05/20/2026 showed it was completed and signed by Resident 140 and two witnesses on 05/20/2026. Review of the EHR showed no documentation that the Ombudsman or Resident 140 had received in writing the notification of discharge from the facility. During an interview on 07/06/2026 at 10:54 AM, Staff F, HID, stated the Ombudsman was not notified in writing of Resident 140's AMA discharge on [DATE]. Staff F stated they were not aware the Ombudsman needed to be informed if a resident left AMA. During an interview on 07/06/2026 at 11:04 AM, Staff B, Director of Nursing Services (DNS), stated the Ombudsman should be notified of all transfers/discharges from the facility. Staff B stated they were not aware that Staff F had not been notifying the Ombudsman of residents that left AMA and this did not meet their expectations. During a follow up interview on 07/06/2026 at 1:31 PM, Staff B, DNS, stated they were unable to locate a DSHS Nursing Home Transfer or Discharge Notice form completed in Resident 140's EHR and the form should have been provided to the Ombudsman and Resident 140 when discharged . Reference WAC 388-97-0120(1)(2)(a), -(d)(3)(a)(4)(b)(5), -0080, -0140(1)(a)-(c)(i)-(iii)

Based on observation, interview and record review, the facility failed to secure/lock 1 of 7 medication carts (500 hall medication cart) and failed to destroy expired insulin for 1 of 4 medication carts (1000 medication cart) when reviewed for medication storage. This failure placed residents at risk for avoidable side effects, missing medications, and diminished quality of life. Findings included. Observation on 06/29/2026 at 10:05 AM showed the 500 hall medication cart unlocked in the hallway parked next to room [ROOM NUMBER]. After a few minutes the nurse was called from a different room to lock the medication cart. During an interview on 06/29/2026 at 10:09 AM, Staff Q, Licensed Practical Nurse (LPN) stated the cart should have been locked. Observation on 07/06/2026 at 1:29 PM with Staff R, LPN, showed the 1000 hall medication cart had a Humalog insulin dated 04/09/2026 (expired in May 2026). Staff R stated it should have been discarded. During an interview on 07/06/2026 at 1:39 PM, Staff B, Director of Nursing Services, stated the medication carts should be locked when not in sight of a nurse and expired medications should be destroyed. Reference WAC 388-97-1300(2), -2340

Based on observation, interview, and record review, the facility failed to implement individualized fall prevention interventions following resident falls or ensure fall interventions functioned appropriately for 2 of 5 sampled residents (Residents 6 and 10) reviewed for accident hazards. These failures placed the residents at risk for additional falls, injuries, pain, and a diminished quality of life. Findings included . Resident 6 Review of the electronic health record (EHR) showed Resident 6 admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbances (a decline in mental ability that interferes with daily life), depression, anxiety (emotional state characterized by feelings of fear or worry), and diabetes (too much sugar in the blood). Resident 6 was able to make needs known. Review of the incident/accident log showed Resident 6 had falls on 04/12/2026, 04/17/2026, and two falls on 04/18/2026. Review of the fall investigation for the second fall on 04/18/2026 showed interventions of bed and wheelchair alarm. Review of a safety device screening dated 04/18/2026 showed the devices were to be utilized at all times. Observation on 07/01/2026 at 12:40 PM showed Resident 6 transferred from their wheelchair to their bed. When the wheelchair alarm sounded, Resident 6 was observed turning it off. No staff responded to the alarm. During an interview and observation on 07/02/2026 at 2:19 PM, Staff C, Licensed Practical Nurse/Unit Manager (LPN/UM), was asked if Resident 6's bed alarm was functional. Staff C went to the room and stated the bed alarm was not on and was usually set by staff when they assisted Resident 6 to bed. Resident 6 stated, I get into bed myself when I feel like it. Resident 6 transferred from their wheelchair to their bed and turned off the wheelchair alarm after they were on the bed. Resident 6 stated, I don't need a bed alarm. I'm as strong as an ox. Staff C stated the sensor needed to be moved to an area out of Resident 6's reach and the bed alarm should have been on during the day since the resident was self-transferring. Observation and interview on 07/06/2026 at 8:03 AM showed Resident 6 was in bed with their call light on. When asked if the bed alarm was functioning, Staff W, LPN, assisted Resident 6 out of bed to their wheelchair and the alarm was heard. Staff W stated the bed alarm should have been set by staff who had assisted Resident 6 to bed. During an interview on 07/02/2026 at 2:23 PM, Staff N, Nursing Assistant Certified, stated Resident 6's bed alarm was rarely set. Staff N stated often they heard Resident 6's wheelchair alarm briefly because Resident 6 turned it off after transferring to the toilet or the bed. During an interview on 07/06/2026 at 1:44 PM, Staff B, Director of Nursing Services (DNS), stated when interventions were put in place, the alarms should have been on while the equipment was in use. Staff B stated since Resident 6 was adamant about self-transferring, the expectation was for the bed and wheelchair alarms to be on at all times. Resident 10 Review of the EHR showed Resident 10 admitted to the facility on [DATE] with diagnoses of dementia without behavioral disturbance (a group of symptoms affecting memory), depression, and anxiety. The resident was unable to make needs known. Review of the EHR showed Resident 10 had six falls in the prior 90 days on 04/26/2026, 05/01/2026, 05/11/2026, and two falls on 6/27/2026. Review of the accident investigation for the fall that occurred on 05/11/2026 showed Resident 10 had fallen next to their sink and sustained a skin tear to their left knee. Review of the summary listed no new interventions that were implemented to protect the resident from future injury related to falls. Review of the active plan of care on 07/01/2026 showed no new interventions were added to protect Resident 10 from injury related to falls. During an interview on 07/01/2026 at 1:20 PM, Staff B, DNS, stated staff should have identified an intervention to prevent injury/falls but did not see that one was implemented and this did not meet their expectations. Reference WAC 388-97-1060(3)(g)

Based on observation, interview, and record review, the facility failed to ensure oxygen services or medical devices were provided within professional standards for 3 of 26 sampled residents (Residents 142, 4, and 127) reviewed for professional standards. This failure placed residents at risk of receiving incorrect treatments, complications, and a diminished quality of life. Findings included.Resident 142 Review of the electronic health record (EHR) showed Resident 140 admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, a condition that causes restricted airflow and breathing difficulties) and anxiety disorder. Resident 142 was able to make needs known. Observation on 06/29/2026 at 3:40 PM showed Resident 142 received oxygen (O2) set to 3 liters (L) per minute via nasal canula (NC, a devise to deliver O2 through a tube into the nose) attached to an O2 concentrator (a device used to deliver O2 therapy). Review of the provider order dated 06/28/2026 showed Resident 142 was prescribed O2 at 2 L per minute per NC to maintain saturations (Sats, measuring the percentage amount of O2 in the blood) greater than 92% every day and night shift for shortness of breath. Review of Resident 142's provider order dated 07/01/2026 showed to wean off O2, if O2 Sats greater than 92% on room air, inform the provider and remove O2 from the room every day and night shift. Review of the June 2026 medication administration records (MAR) showed Resident 142 received O2 at 2 L per minute via NC every day and night shift; however, on 06/30/2026 day shift it was documented Resident 142's O2 Sats were at 98% and received 3 L of O2 (not 2 L as prescribed). Observation on 07/02/2026 at 11:36 AM showed Resident 142 sat in the dining room with an O2 tank (used to provide O2 therapy) attached to the back of their wheelchair, with O2 therapy being provided set at 3 L per minute via NC. During a joint observation and interview on 07/02/2026 at 11:39 AM, Staff H, Unit Coordinator/Charge Registered Nurse (UC/CRN), stated Resident 142's O2 tank was set at 3 L and O2 was being provided via NC; however, it should have been set at 2 L per provider's order. Staff H stated Resident 142's EHR showed no documentation as to why Resident 142 was being provided with O2 at 3 L and this did not meet their expectations. During an interview on 07/02/2026 at 12:10 PM, Staff J, Assistant Director of Nursing Services/Staff Development (ADNS/SD), stated the expectation was that nurses followed provider orders as required. Staff J stated Resident 142 should have been receiving O2 at 2 L and should have been getting weened of O2 per providers orders. Resident 4 Review of the EHR showed Resident 4 admitted to the facility on [DATE] with diagnoses of dementia (a group of symptoms that effects memory), kidney disease, and stage 4 (affecting bone and muscle) pressure injury. The resident was able to make needs known. During an observation and interview on 06/29/2026 at 10:31 AM, Resident 4 laid in bed; there was an indwelling foley catheter (a tube inserted into the bladder to drain urine) attached to the side of the bed. Resident 4 stated they had the catheter because of their pressure injury. Review of the provider orders on 06/29/2026 at 3:04 PM showed no order for the use of the catheter to include the size and diagnosis for its use. Resident 127 Review of the EHR showed Resident 127 admitted to the facility on [DATE] with diagnoses of hip fracture, urinary tract infection and kidney failure. The resident was able to make needs known. Observation and interview on 06/29/2026 at 2:18 PM showed Resident 127 sat at the side of their bed; an indwelling foley catheter was attached to the side of the bed. Resident 127 stated they thought they had it because they take water pills. Review of the provider orders on 06/29/2026 at 3:15 PM showed no order for the use of the catheter to include the size and diagnosis for its use. During an interview on 07/01/2026 at 1:57 PM, Staff G, Registered Nurse/Unit Manager (RN/UM) stated Residents 4 and 127 should have had orders in place for the use of the catheters but did not. During an interview on 07/02/2026 at 10:20 AM, Staff B, Director of Nursing Services (DNS), stated it was their expectation that Residents 4 and 127 had orders in place for the indwelling foley catheters to include the size and diagnosis. Reference WAC 388-97-1620(2)(b)(i)(ii)(6)(b)(i)

Based on interview and record review, the facility failed to report an allegation of abuse to the State Hotline for 1 of 4 sampled residents (Resident 87) reviewed for abuse. This failure placed residents at risk for potential ongoing abuse, psychological harm, and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 87 admitted to the facility on [DATE] with diagnoses that included chronic inflammatory demyelinating polyneuropathy (nerve disorder), heart failure, kidney disease, and diabetes (too much sugar in the blood). Resident 87 was able to make needs known. During an interview on 06/29/2026 at 2:24 PM, Resident 87 stated Staff P, Licensed Practical Nurse (LPN), made hurtful comments related to Resident 87 having dementia. Resident 87 stated they voiced a complaint to staff about not getting sleep due to their roommate's behaviors (up at night talking to themself and yelling out during care). Resident 87 stated Staff P made the comment, You have the same diagnosis and will have the same type of behavior someday. Resident 87 stated they reported the comments to Staff V, Speech Language Pathologist (SLP), and there was never any follow-up. During an interview on 07/01/2026 at 9:30 AM, Staff V, SLP, confirmed Resident 87 Tearfully expressed they were anxious due to staff making hurtful comments about their dementia diagnosis. Staff V stated Resident 87 was not aware of the diagnosis and did not fully understand what the diagnosis meant. Staff V stated they reported the allegation to the social services department, the unit manager, and left a note about a possible room change due to Resident 87 not sleeping well. Review of Speech Therapy treatment notes dated 06/05/2026 showed documentation that Resident expressed concern that staff have been telling them that they have dementia, and resident wants more information about this diagnosis and how that was determined. Resident 87 wished to wait to repeat MoCA [a brain function test] until next visit due to feelings of anxiety and sadness regarding some recent personal events. During an interview on 07/01/2026 at 9:46 AM, Staff S, Social Services Coordinator, stated they spoke with Resident 87 who reported Staff P, Licensed Practical Nurse, was telling them they had dementia, and it was making Resident 87 upset that Staff P stated they were going to be forgetful. Staff S stated they did not follow up but should have because it could have been considered verbal abuse. During an interview on 07/01/2026 at 10:40 AM, Staff G, Registered Nurse/Unit Manager (RN/UM) stated Staff V, SLP, informed them of a concern Resident 87 had with Staff P but they never followed up for additional information. During an interview on 07/06/2026 at 1:43 PM, Staff B, Director of Nursing Services, stated the first staff the allegation was reported to should have reported the allegation to the state hotline and then reported to management for an investigation to be conducted. WAC Reference 388-97-0640 (5)(a)

Based on observation, interview, and record review, the facility failed to accurately and daily post the nurse staffing data to include the actual numbers of nursing staff and actual hours worked for 5 of 5 observed days during the survey period (06/29/2026, 06/30/2026, 07/01/2026, 07/02/2026 and 07/06/2026) reviewed for nurse staff posting. This failure prevented the residents, family members, and visitors from exercising their rights to know the daily actual numbers of available nursing staff in the facility. Findings included .Observation on 06/29/2026 at 9:02 AM showed the posted daily nurse staff data located in the front lobby by the receptionist desk had the date of 06/28/2026 and not the current date of 06/29/2026. It showed, Previous, nurse numbers and hours, and showed, Projected, (scheduled) nurse numbers and hours worked. However, there was no documented spot on the form to show actual nurse numbers and hours worked for the current date. Observations of the posted daily nurse staff data on 06/30/2026 at 8:06 AM, 07/01/2026 at 8:30 AM, and 07/02/2026 at 8:40 AM showed Previous nurse numbers and hours worked and Projected (scheduled) nurse numbers and hours worked; however, did not show a spot for Actual nurse numbers and hours worked for the current date of 06/30/2026 to be documented and posted at the beginning of every shift. Observation on 07/06/2026 at 8:05 AM of the posted daily nurse staff data showed Previous, nurse numbers and hours, and showed, Actual nurse numbers and hours worked for all shifts documented for the day and night shifts; however, the day shift was still in progress, and the night shift had not yet started. There were no scheduled nurse numbers or hours worked posted. During an interview on 07/06/2026 at 2:33 PM, Staff K, Staffing, stated they created the daily nurse staff data postings and sent them out the day before they left at 5:00 PM to the receptionist, Director of Nursing Services (DNS), Assistant DNS, and Administrator for the next day. Staff K stated the receptionist who worked from 7:00 AM to 7:00 PM posted the nurse staff data in the morning. Staff K stated Projected on the postings meant scheduled and Previous meant actual nurse numbers and hours worked the previous day (not for the current day of the posting). Staff K stated the posting for the correct date of 06/29/2026 should have been posted and that did not meet their expectations. Staff K stated they were not aware the posting had been changed to show Actual for the posting dated 07/06/2026 but, those Actual numbers and hours worked for day and night shifts had not happened yet and could not be confirmed and should have not been posted. During an interview on 07/06/2026 at 3:06 PM, Staff B, DNS, stated the expectation was that nurse staff data postings were posted and revised/updated as needed and at the beginning of every shift. Staff B stated they had two shifts day and night shifts. Staff B stated they were not aware the 07/06/2026 nurse staff data postings had Actual noted on the posting and Projected removed and this did not meet their expectations. Staff B stated the nurse staff data forms needed to be corrected to ensure actual nurse numbers and hours worked were posted and updated at the beginning of each shift. Reference WAC 388-97-1620(2)(b)(i)

Based on interview and record review, the facility failed to provide complete medical records upon request for 2 of 3 residents (Resident 1 and 2) reviewed for medical records. This failure placed residents at risk of lack of knowledge of their medical condition, continuity of care and frustration.Findings included.On 02/04/2026 at 3:13 PM, Collateral Contact 1 (CC1) said their family had requested the complete medical records of Resident 1 and 2 and had received the records however they had missing documents and were not complete. CC1 said the records did not show the identity of some of the care staff.Resident 1's Authorization to Disclose Health Information, dated 10/21/2025, showed Resident 1's legal representative had requested Resident 1's entire record from the facility.Resident 2's Authorization to Disclose Health Information, dated 10/21/2025, showed Resident 2's legal representative had requested Resident 1's entire record from the facility. On 02/06/2026 at 12:42 PM, Staff A, Medical Records Assistant, said when a resident and/or resident representative requested their medical record they sent the entire record per their request. Staff A said Resident 1's and Resident 2's records were downloaded into a computer file and downloaded onto a flash drive. Staff A said the electronic software the facility used, Point Click Care, had a feature that allowed the records to be downloaded into a file.Review of the contents of the files sent to Resident 1's and Resident 2's representatives on 04/21/2026, showed incomplete medical records. Review of the Documentation Survey Report sent in the files showed no authentication of the Nursing Assistant documentation.On 04/21/2026 at 2:27 PM, Staff B, Director of Health Information, said they reviewed the medical records that were sent to Resident 1's and Resident 2's representatives and they were not the complete medical records. Staff B said they were missing some orders, progress notes, medical provider notes, assessments and other records. Staff B said they had contacted Point Click Care, their electronic medical record software provider, and discovered when the facility had configured their software, they did not configure it to download the complete medical record. Staff B said this had been configured years ago and no one had brought it to their attention until now.On 04/21/2026 at 2:43 PM, Staff C, Director of Nursing, said they reviewed the medical records and acknowledged Resident 1's and Resident 2's entire medical records were not sent to them. Staff C reviewed the Documentation Survey Report and acknowledged the report did not contain the identification of who completed the documentation of care and services. Staff C said the entire record should have been sent upon request and the documentation should be authenticated by the staff that provided the care and services.Reference WAC 388-97-0300(2)(a)(b)

Based on interview and record review, the facility failed to incorporate resident's and resident representative's preferences for medical oversight into the plan of care for 1 of 3 residents (Resident 2) reviewed for resident rights. This failure placed residents at risk of suboptimal clinical outcomes, medical complications and frustration.Findings included .Resident 2 was admitted on [DATE] with diagnoses including peripheral arterial disease (circulatory condition where narrowed blood vessels reduce blood flow to the limbs, most commonly the legs) and diabetes. The admission Minimum Data Set Assessment (MDS), an assessment tool, dated 10/13/2025, showed Resident 2 had moderate cognitive impairment, required substantial assistance from staff for dressing, bed mobility and transfers. The MDS showed it was very important for Resident 2's family to be involved in discussions about their care.Resident 2's hospital Podiatry Consult, dated 10/03/2025, showed Resident 2 had a history of diabetic ulcerations (wounds) on the right foot that continued to be stable with no open ulcerations. The consult showed the plan was for betadine (wound treatment) to be applied to all digits (toes), toenails and stable eschars (thick black layer of dead tissue that forms over wounds) on 1-5 toes with gauze in webspace (between toes) of toes 1-4 and sponge (type of dressing) over the toes and Kerlix (gauze) wrap of the foot for protection against any potential trauma from bumping the bed/sheet pressure. The consult showed upon Resident 2's discharge from the hospital they would continue outpatient care at the podiatrist's office.On 02/04/2026 at 3:13 PM, Collateral Contact 1 (CC1), said Resident 2 had been admitted to the facility with strict instructions from the podiatrist. CC1 said Resident 2's toe wounds had been treated by their podiatrist for a long time, and it was very important to follow their instructions to save Resident 2's toes. CC1 said the facility would not allow Resident 2's podiatrist to treat Resident 2 and/or they would not follow the recommendations until it was too late. CC1 said it was very frustrating, the nursing staff would not listen to them, and it caused the toe wounds to deteriorate.On 03/03/2026 at 10:00 AM, Collateral Contact 3 (CC3), said they had cared for Resident 2's toe wounds at home prior to hospitalization. CC3 said Resident 2's podiatrist had kept the wounds stable. CC3 said when they went to visit Resident 2 at the facility they observed there was no wrapping on the foot. CC3 was very concerned because the podiatrist had told them not to allow sheets to touch the wounds because it could cause issues. CC3 said they talked to the nurse and told them they wanted Resident 2's podiatrist involved and to follow their treatment orders, but they would not listen to them until it was too late and Resident 2's toe wounds became infected. Resident 2's physician orders, dated 10/06/2025, on admission, showed an order for nursing staff to put betadine on the toes, a dressing between toes 4 and 5 and cover with a light gauze dressing. The order was discontinued on 10/07/2025.Resident 2's Wound Consultant note, dated 10/07/2025, showed the treatment plan for the right toes was to paint the toes with betadine and leave them open to air.Resident 2's communication to the medical provider, dated 10/08/2025, showed CC1 was in the resident's room and was insisting the toes on the right foot need to be wrapped with gauze after they were painted with betadine.Resident 2's progress notes, dated 10/14/2025, showed CC3 was at the facility and discussed the treatment Resident 2 had with their podiatrist prior to admission and they were concerned about Resident 2's wound on their toes. The note showed CC3 felt the podiatrist knew Resident 2's right foot better and felt there was an infection in Resident 2's toes. The progress note showed facility staff informed CC3 that the resident's treatment plan may not have aligned with Resident 2's podiatrist but those recommendations were considered and the treatment plan was addressing the resident's needs at that time. Resident 2's wound consultant provider notes, dated 10/14/2025, showed the right toes were assessed and they were without signs of infection.Resident 2's progress notes, dated 10/14/2025, showed Resident 2 had an appointment with their podiatrist on 10/17/2025.Resident 2's physician orders, dated 10/15/2025, showed an order to paint the right toes with betadine apply gauze between the toes and wrap with gauze.Resident 2's podiatrist consult dated 10/17/2025, showed Resident 2 had an infected ulcer on their distal 1st right (toe) and an abscess with ulcer on distal 3rd right (toe). The consult showed an order for antibiotics.On 04/21/2026 at 12:18 PM, Staff F, Physician Assistant and Wound Consultant, said they did not remember if they were aware Resident 2 had long standing relationship with their podiatrist. Staff F said they changed Resident 2's wound care orders for the toes after admission because with eschar on wounds they typically leave them open to air. Staff F said they did not have in their notes that Resident 2's family wanted the toes wrapped in gauze per Resident 2's podiatrist on 10/08/2025, but that would have been fine. Staff F said they said it was fine if Resident 2 saw their podiatrist and they managed the chronic toe wounds.On 04/22/2026 at 2:03 PM, Staff G, Adult Gerontology Nurse Practitioner, said they cared for Resident 2 during their stay at the facility. Staff G said they did not manage wounds and deferred to the facility's Wound Consultant. Staff G said they had no issue if Resident 2's podiatrist was involved with their care.On 04/22/2026 at 12:46 PM, Staff C, Director of Nursing, said Resident 2's treatment recommendations from the podiatrist consult at the hospital should have been considered on admission and when the family raised concerns. Staff C said there was no documentation that Resident 2 and/or their representatives were consulted or notified of the wound care orders, dated 10/06/2025, on admission, were discontinued on 10/07/2025 and a new order that did not include wrapping the toes was initiated. Staff C said they should have been notified, and the new order should have been discussed with them.Reference WAC 388-97-0200(2) 0900(1)1000(1)(a)1020(2)(f)1880(2)(f)

Based on observation, interview and record review, the facility failed to evaluate the effectiveness of fall prevention interventions, need for additional action, and/or attempt to mitigate envionmental modifications preferred by the resident that presented a risk to safety for 1 of 3 sampled residents (Resident 1) reviewed for accidents and hazards. Resident 1 experienced harm when they fell out of bed and sustained a neck fracture. This failure placed residents at risk for falls, injury and a diminished quality of life. Findings included . Review of the facility Fall Prevention Program policy and procedure dated 03/2023 showed the facility used a standardized risk assessment for determining a resident's fall risk. The risk assessment categorizes residents according to low, moderate, or high risk. According to the policy, each resident's risk factors, and environmental hazards are evaluated when developing the resident's comprehensive plan of care. <Resident 1> Review of the 08/21/2024 Quarterly Minimum Data Set (MDS - an assessment tool) showed Resident 1 was assessed as cognitively intact, with no behaviors, required substantial assistance with bed mobility, transfers, toileting, was frequently incontinent and a toileting program of scheduled toileting had not been attempted. According to this MDS, Resident 1 had two non-injury falls and two falls with injury since the last Quarter's MDS. Review of Resident 1's Fall Risk Assessment showed they were assessed at High Risk with a score of 20 on 08/26/2024, a High Risk with a score of 21 on 09/19/2024, and 10/01/2024. Review of the 12/01/2021 Fall Care Plan (CP) showed Resident 1 fell on [DATE], 06/21/2024, 08/13/2024, 08/25/2024, 08/26/2024, 09/19/2024 and 10/01/2024. Staff were directed to maintain a clear pathway, free of obstacles. Review of the 06/04/2024 Incident Report showed Resident 1 was found on their bedroom floor, on their left side, between the table and bed. One hour before the fall, Resident 1 was observed in bed sleeping. Resident 1 sustained skin tears and bruising to their arms. The Fall CP was revised on 06/05/2024 to place bed in a diagonal position to create space for the resident. Review of the 06/21/2024 3:00 AM Fall Investigation showed Resident 1 woke up, sat at the bedside and slipped off the bed landing in the sitting position. The resident sustained no injuries. During an interview on 10/21/2024 at 3:00 PM, Staff E, MDS Nurse, stated at that time Resident 1's bed was in room [ROOM NUMBER], diagonal to the door and accessible from either side of the bed. Review of the census showed Resident 1 changed rooms on 08/08/2024. During an interview on 10/25/2024 at 11:40 PM Staff G, Social Services, stated that they believed Nursing staff did a deviation of care (care that does not follow the standard) regarding the diagonal bed when Resident 1 moved from the 900 to the 800 hall. During an interview on 10/25/2024 at 11:33 AM, Staff F, Resident Care Manager (RCM), stated that when Resident 1 moved to the 800 Hall they told the staff how they wanted their bed and where to put their stuff. Staff F said the Resident was their own decision maker. Staff F stated they did not review risks and benefits and did not do a deviation of care. Staff F could not find that either had been completed and placed in the resident's record. Review of 08/13/2024 11:30 PM Fall Investigation showed Resident 1 attempted to self-transfer from the edge of the bed, slid and fell . Resident 1 was found on their left side. Resident 1 sustained skin tears and bruising to their arms. Review of the 08/26/2024 3:55 AM Fall Investigation showed Resident 1 was found on the floor next to their bed. The resident reported they were trying to get out of bed. Review of the undated Incident Summary showed Resident 1's fall risk score was 19 indicating they were at high risk for falls. The fall risk was related to diagnoses, medications, cognition, deconditioning, poor awareness of personal safety, and a strong desire to remain independent. Fall interventions in place included lock wheelchair at bedside when not in use, encourage resident to use call light when needing assistance, encourage to wait for staff when attempting to transfer. The resident was independent with bed mobility and reminded to turn every two hours. Review of the 10/01/2024 4:20 AM Fall Investigation showed Staff H, Licensed Practical Nurse (LPN), documented they responded to the alarm from Resident 1's room, I did not find the resident on the bed, but the wheelchair was besides the bed. I started looking for her in the bathroom, but she was not there. Then I looked on the other side of the bed and found her laying on her neck with all her weight, lower body up . Review of the 10/01/2024 5:12 AM Fall Note written by Staff H showed the resident was found in a cumbersome position, the bed was also restricting the space. Review of the undated Incident Summary showed the nurse and nursing assistant repositioned the resident to relieve pressure off their head and neck and ensure they could breathe. The nurse called 911 and the resident was transported and admitted to the hospital. During an interview on 10/25/2024 at 10:24 AM, Staff C, Assistant Director of Nursing, stated Resident 1 was found with their head down and feet up. The staff moved the resident so the resident could breathe and called 911. Staff C stated the bed was at an angle because that was how Resident 1 wanted it. During an interview on 10/21/2024 at 10:10 AM Resident 1's representative stated they felt the facility was negligent in Resident 1's safety as the resident was a high fall risk and the facility left the bed diagonal from the wall, with no fall mats, and Resident 1 fell in that area. Resident 1's representative stated the way the dresser was placed left only a triangle of floor space and would not have allowed Resident 1 to get out if they fell in there. Resident 1's representative stated they were told Resident 1 had rights and wanted the bed placed at a triangle from the wall, but it was an entrapment risk and should not have been allowed. On 10/21/2024 at 3:54 PM, Staff I, Certified Nursing Assistant (CNA), stated the bed was angled because that was what the resident preferred. Staff I explained the space between the dresser, the mattress and the wall, was a tiny bit of space, not much space. Staff I stated they suggested placing the bed against the wall, but was told it would be a restraint. On 10/21/2024 at 3:54 PM, Staff J, CNA, stated the resident wanted the bed angled to have more room. Staff J showed where the dresser was placed. When asked if the resident could get around the dresser from the side of the bed, Staff J stated no. A 10/03/2024 Social Services Note showed Staff G called Resident 1's family member to see if it was okay for staff to pack up some of Resident 1's belongings to create more space in the room and make things more accessible for resident when they returned from the hospital. Review of the undated Incident Summary showed upon return to the facility on [DATE] the resident was placed in a low bed with a mat to the left side of the bed. During an interview on 10/25/2024 at 11:33 AM, Staff F said when Resident 1 returned from the hospital the bed was placed against the wall with a floor mat for safety. When asked why the bed had not been placed against the wall sooner, Staff F said because Resident 1 did not want it that way. Review of hospital records showed Resident 1 was hospitalized from 10/01/2024 to 10/04/2024, diagnosed with a Cervical (neck) Fracture, a Nondisplaced superior sternal body (breast bone) fracture, and left-sided rib fractures. REFERENCE: WAC 388-97-1060(3)(g).

Based on observation, interview and record review, The facility failed to ensure all chemicals were secured and not accessible to residents with cognitive impairments and wandering behaviors for 4 of the census of 141 (#41, 57, 96, and 356). The facility failed to ensure measures to reduce the risk of falls and injuries were implemented, to include adequate supervision and reevaluate for effectiveness for 2 of 17 residents (#234 & 355) reviewed for accidents. Failure to recognize and develop an action plan to mitigate the risk of known potential avoidable environmental hazards placed resident at risk of serious injury. Findings included: Record review of facility policy and procedures (P&P) entitled Chemical Hazard Communication Program, dated April 2014, showed the facility was committed to the prevention of exposures that resulted in injury and/or illness; and to comply with all applicable health and safety rules. The P&P did not specifically identify what measures to take to protect residents from chemical contact. During initial tour of the facility the following observations were made on 6/20/17. Multiple doors to shower rooms and utility rooms were unlocked and unsecured allowing easy access to residents and visitors. 1. At 7:08 p.m., the 500 hall shower room had an unlocked door. Inside was a 1 quart spray bottle of Virex, a cleaning solution, half full and accessible to residents. 2. At 7:17 p.m., the 500 hall soiled utility room had a key on a chain at waist height. The key was in the locking mechanism on the door making it easy to turn the door knob and enter. In an unlocked cabinet Clorox bleach spray was stored under the counter and a 1 gallon bottle of Virex with the cap off the top. A sign on the door stated Infectious Waste. The infectious waste bin and several full sharps containers were stored in this room. 3. At 7:18 p.m., the 500 hall clean utility room's door was found unlocked and unsecured. There was exposed wiring for the facility communication system on one wall. A supply of disposable razors and safety pins were stored inside a drawer in the unsecured room. 4. At 7:20 p.m., the 700 hall shower room had an unsecured door. A spray bottle of Virex and multi personal care products (shampoo and body wash) were stored at approximately 2 feet height above the floor. 5. At 8:06 p.m., the 1000 hall clean utility room was unsecured making it easily accessible to residents. A gallon bottle of Virex sat on the counter. On 6/20/2017 at 8:10 p.m., a label on a Virex bottle showed in bold lettering KEEP OUT OF REACH OF CHILDREN DANGER. The label provides recommendations for First Aid IF IN EYES: Hold eye open and rinse slowly and gently with water for 15-10 minutes. Remove contacts lenses if present, after the first 5 minutes, then continue rinsing eye. IF ON SKIN OR CLOTHING: Take off contaminated clothing. Rinse skin immediately with plenty of water for 15-20 minutes IF SWALLOWED: Call a poison control center or doctor immediately for treatment advice. Have person sip a glass of water if able to swallow. Do not induce vomiting unless told to do by poison control center or doctor. Do not give anything by mouth to an unconscious person. IF INHALED: Move person to fresh air. If person is not breathing call 911 or an ambulance, then give artificial respiration, preferably mouth-to-mouth if possible. On 6/20/17 at 8:08 p.m., when asked if there were any doors on the hall that should be locked, Staff V, Licensed Practical Nurse (LPN) stated, I am not sure. If you want the correct information you should ask the charge nurse at the nurse's station. At 8:10 p.m., when asked if there were any doors on the hall that should be locked, Staff DD, Nursing Assistant Certified (NAC) stated, Shower rooms and utility rooms should be locked. At 8:15 p.m., when asked if there were any doors on the hall that should be locked, Staff W, LPN stated, Utility rooms, housekeeping closet, and shower rooms should be locked. Most of the residents on this unit probably couldn't open the door even if key was in the lock, but we take the keys out of the lock so they can't get in. At 8:20 p.m., when asked if there were any doors on this hall that needed to be secured, Staff X, NAC stated, I do not know for certain, I have to ask my charge nurse. I do not usually deal with the shower rooms because I work swing shift, but they are usually open or unlocked. I think the utility rooms are supposed to be locked. At 9:53 p.m., Staff Y, Registered Nurse (RN), and Staff Z, RN, viewed the 500 hall clean utility rooms with surveyors. When asked if they knew what the exposed wires in the room go to, the staff said they were unsure what they were for and if they carry any voltage that would be dangerous to staff or residents. They were aware razors and safety pins were stored in drawers in this utility room and stated, Residents should not be in this room. At this time the door to clean utility room remained unlocked. The dirty utility room on the 500 hall was observed with the key in the locking mechanism of the door making it easy to enter by just turning the door knob. When biohazards, sharp objects and Virex were observed by staff, Staff Y stated, I would have concerns, if anyone was in here, a resident or a visitor. Upon exiting the utility room, the staff were observed to remove the key from the locking mechanism on the door, more than two and a half hours after the first observation when the key was first observed in the locking mechanism of the door. At 9:59 p.m., the 700 hall shower room with viewed with Virex and personal care items (shampoo and body wash) with Staff Y, RN and Staff Z, RN. The staff stated, Residents should not be in here unsupervised. Staff Y, RN and Staff Z, RN said there was not usually any wanderers on the Medicare unit. When asked if residents in the facility wander to this hall, the staff both said, Yes. The 700 hall shower room door remained unsecured as Staff Y and Staff Z walked away. On 6/20/2017 at 10:52 p.m., when asked what rooms needed to be locked on the units, Staff A, Administrator, and Staff B, Director of Nursing Services (DNS) stated, Utility rooms should be locked. Staff B said the shower rooms are locked from the inside when the aide gave the residents showers. We used to have a key on a chain like we do for the other doors but there was really nothing in there and no need to lock the door so we stopped using the key and took them down. When asked who in the facility had access to chemicals, Staff B said housekeeping had access to chemicals. The chemicals were locked in housekeeping carts and were locked in the housekeeping storage closets. When asked how the showers rooms were sanitized between uses, Staff B stated, I don't want to try to answer that because housekeeping does that and I am not certain of their procedure. When asked how bedpans and bedside commodes were cleaned, Staff B stated, Cleaning the bedpans and bedside commodes is a shared responsibility between nursing and housekeeping. When asked if residents should have access to those areas where chemicals are stored, Staff B stated, No, that is why we lock our utility rooms and storage closets. Staff B said there were some wandering residents in the facility and a list would be provided. Residents #96, #41, #358, and #57 were identified by staff as residents that were confused and wandered freely through the facility. On 6/20/2017 at 8:08 p.m., Staff LL, NAC on the 700 hall stated, Both utility rooms and shower room are to be locked. When asked if there were any residents that were confused and wander, Resident #96 was identified. Staff LL stated Resident #96 is confused and will self-propel in his wheelchair up and down the halls. Staff LL said the resident does not try to exit the facility but says he wants to go home and is often looking for his wife. At 8:23 p.m., Staff MM, NAC on 500 hall said the clean utility room should be locked and chemicals should be secured in a locked cabinet in the shower room. When asked if there are times then the doors are unlocked, Staff MM stated, I don't know. When asked who has access to chemicals, Staff MM stated, I would have to check with the nurse because I don't have access to any chemicals except the shower rooms. When asked if there were confused wandering residents in her care, Staff MM stated, No and identified Resident #41 from another hall that wanders throughout the facility. Resident #41 goes sight-seeing in her wheelchair up and down the halls, she wanders into the library and into the lunch room on the 900 hall. At 8:36 p.m., Staff NN, NAC on 500 hall stated, Utility rooms should be locked and I am not sure about shower rooms are locked or not because I don't give showers. When asked who has access to chemicals, Staff NN stated, I am still new and I am trying to remember, but I believe there are chemicals stored in both the clean and dirty utility rooms. Staff NN identified Residents #57 and Resident #356 as wandering, confused residents. Staff NN said these residents as both going up and down the halls. Staff NN said Resident #356 can get confused and wander into other residents rooms if not redirected. RESIDENT #41 Review of the quarterly assessment Minimum Data Set (MDS), a required assessment tool, dated 04/17/17, showed Resident #41 was readmitted to the facility from an acute hospital stay on 04/16/14 with multiple [DIAGNOSES REDACTED]. MDS showed that Resident #41 demonstrated severe cognitive impairment. RESIDENT #96 Review of the admission assessment MDS, dated [DATE], showed Resident #96 was admitted to the facility from an acute hospital on [DATE] with multiple [DIAGNOSES REDACTED]. MDS showed Resident #96 demonstrated moderate cognitive impairment. RESIDENT #57 Review of the annual assessment MDS, dated [DATE], showed Resident #57 was readmitted to the facility from an acute hospital stay on 04/18/16 with multiple [DIAGNOSES REDACTED]. MDS showed Resident #57 demonstrated severe cognitive impairment. RESIDENT #356 Review of the admission assessment MDS, dated [DATE], showed Resident #356 was admitted to the facility from an acute hospital on [DATE] with multiple [DIAGNOSES REDACTED]. MDS showed Resident #356 demonstrated severe cognitive impairment. Shower rooms on the 500 hall and 700 hall used Virex as a disinfectant cleaner. The Virex label identified potential hazard with exposure to the chemical. Shower room contained the hazardous chemical until staff removed them after surveyors informed the facility they were there. Utility room doors on the 500 hall and 100 hall remained accessible and unsecured to residents until staff were informed on 6/20/17 at 11:23 PM. RESIDENT #355 Record review of Admission MDS, dated [DATE], showed Resident #355 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident did not wear hearing aids or glasses. The resident was alert and oriented, had adequate memory recall. The MDS showed Resident #355 was continent, required assistance and supervision from staff for bed mobility, transfers, ambulation, toileting, and hygiene. The resident had an unsteady gait when walking and standing. Record review of the history and physical, dated 06/09/17, showed Resident #355 was identified as a high risk for falls, and high risk for injury, if a fall occurred. The resident had baseline limitations that included visual and hearing deficits, dementia and decreased balance. Record review of document titled, Physical Therapy Daily Treatment Note, dated 06/21/17, showed Resident #355's current level of function was supervised with transfers and ambulation on level surfaces. Precautions included fall risk. The resident's care plan was changed to supervision while using a four-wheeled walker, as she tended to speed up and slow down. Record review the 06/12/17 fall care plan, showed Resident #355 was at risk for falls related to deconditioning, scored as a moderate risk for falls on the fall assessment, visual and hearing impairments, prescribed and taking a medication for blood pressure, diuretic, a recent fall with a closed head injury, osteoporosis, and renal disease. Fall interventions included Resident #355 was to ambulate with one person assistance using a gait belt, anticipate the resident's needs, do not leave unattended on the toilet, and educate the resident, family and caregivers about safety reminders. Record review of care directive, dated 06/24/17, showed Resident #355 was a fall risk, had a sensor alarm in the bed and chair, instructed direct care staff to not leave the resident unattended on the toilet/commode, and required supervision with transfers and ambulation. Record review of June 2017 Incident and Accident Log showed Resident #355 sustained a fall with a hip fracture on 06/22/17. Record review of the 06/22/17 incident report, showed Resident #355 sustained a fall in the bathroom at 7:30 AM. Staff L, Nursing Assistant Certified (NAC), provided care for the roommate and heard Resident #355's sensor alarm sound that indicated the resident got up without assistance. Staff L, NA, responded and found the resident standing at the sink. Staff L turned the bed alarm off and left the room. Staff L left Resident #355 without supervision. When Staff L returned, in an unidentified amount of time, she found Resident #355 on the bathroom floor, on her left side. The resident stated she slipped and fell when she tried to get up off the toilet. The investigation showed Staff O, LPN, assessed the resident and discovered a skin tear on the left inner forearm and complained of left hip pain. Three staff assisted Resident #355 off the floor to her bed, where it was discovered the resident was not able to walk and the left leg was externally rotated. The resident was sent to the emergency room for evaluation and treatment, where it was discovered she had a left hip fracture. On 06/27/17, Staff G, Assistant Director of Nursing (ADON), RN, stated Resident #355 did sustain a fall with a fracture on 06/22/17 at 7:30 a.m. Staff L, NAC, was in the room performing cares for the roommate when she heard Resident #355's bed alarm go off. Staff L, NAC responded and found the resident in the bathroom. Staff L turned the alarm off, did not review and follow the care directive to ensure the resident was supervised when up, and left the room. Staff L responded to the bathroom call light and found Resident #355 on the bathroom floor. The resident stated she had gone to the bathroom, got up and fell . The nurse practitioner assessed the resident and the complaint of left hip pain, before she left for the hospital. Staff G, ADON, stated Staff L, NAC, did not follow Resident #355's care plan and care directive. She should not have left the resident unsupervised. The resident was identified with vision impairment, a fall risk, required the use of an alarm to remind the resident and staff to ask for assistance, and was on therapy case load to continue to work on balance and strengthening, with a discharge date to return to independent living on 07/03/17. The investigation outcome was identified as unintentional neglect. On 06/27/17 at 1:33 p.m., Staff L, NAC, stated she had been an employee for the facility for four months. Since she started employment, she has rotated hall assignments, and had been on Resident #355's run for one month. Staff L, CNA, denied any problems getting assistance from other staff when needed. At 6:00 p.m., Staff B, DNS, RN, stated she interviewed Staff L, CNA, on 06/27/17. Staff B, DNS, said Staff L, CNA, had worked with Resident #355 and was familiar with her needs. Resident #355 stated she was fine and did not need any additional assistance. Staff L, CNA, believed her, and left the room. The facility did not ensure the care plan and level of supervision was followed, which resulted in harm to the resident when she fell and fractured her hip. RESIDENT #234 See F225 for resident history and additional information. On 06/20/17 at 7:20 p.m., and 06/22/17 at 10:19 a.m., Resident #234 was observed sitting in his wheelchair in his room. On 06/23/17 at 11:03 a.m., Resident #234 was observed propelling himself down the hall, using a wheelchair as the primary means of mobility. On 06/22/17 at 10:19 a.m., Resident #234 stated he had to use the bathroom every hour, routinely, and was an urgent matter. I flood. When he went to the dining room for meals, he worried about getting served his meal toward the end, and had to rush back to his room with the chance of incontinence. The resident stated he did not attend many activities because of the length of participation. His day was planned around his toileting schedule and had been like that for a long time. Fall- 01/28/17 Record review of the incident report for the fall on 01/28/17 at 3:30 p.m., Resident #234 ambulated down the hall with a four wheeled walker, lost his balance and fell . The fall was determined to be related to Resident #234 not locking the brakes on the walker. The investigation did not explain why the resident did not lock the brakes. Interventions included to remind the resident to lock the brakes on the walker. It was unclear how staff were to ensure the cues were provided as Resident #234 ambulated and transferred himself independently. On 06/26/17 at 3:12 p.m., Staff G, ADON, RN, said she was not aware Resident #234 was able to ambulate with a walker until the report of the 01/28/17 fall. Staff G, RN, stated interventions prior to the fall included monitoring the resident on a daily basis. The new intervention was to provide cues to the resident to lock his brakes. When asked how the interventions was monitored to ensure the staff followed the care plan, Staff G, RN, stated, the aides completed a Stop and Watch form if there was a noted change in condition in the resident. A therapy referral was not considered as an intervention to evaluate balance or weakness. Level of supervision was not considered to ensure the resident consistently locked his brakes, determine if there were other contributing factors to the fall, and ensure the resident's safety. The facility did not consider an evaluation of the level of supervision Resident #234 was provided, as the resident was a fall risk, had a history of [REDACTED]. Fall- 04/02/17 Record review of the investigation for the fall that occurred on 04/02/17 at 7:30 a.m., the facility did not complete a thorough investigation, and identify the root cause of the fall. The intervention was to remind Resident #234 to ask for assistance when needing to toilet. The responsibility was on the resident, rather than the staff, despite the care plan intervention to anticipate the resident's needs. On 06/26/17 at 3:12 p.m., Staff G, ADON, RN, did not recall a staff member stated the resident's legs gave out during the transfer. In response, Staff G, RN, stated a therapy referral should have been made to identify the cause of the legs giving out. The investigation did not identify Resident #234's toileting needs, frequency or daily routine. The resident's cognitive and physical status were not evaluated to determine level of assistance or supervision were needed to ensure the resident's safety. Previous interventions were not re-evaluated for effectiveness. On 06/26/17 at 3:12 p.m., Staff G, ADON, RN, said she had not considered reviewing and adding the Foot Filament Test to the investigation to identify sensory impairment, as Resident #234 was identified as having decreased sensation in both feet, and more pronounced on the left, and placed the resident more at risk for injury. Diabetic/orthotic shoes were ordered on [DATE], but did not arrive and ensure they fit appropriately until 05/05/17. No additional interventions were in place to protect the resident's feet from injury, until the shoes arrived. Staff G stated it appeared no new interventions were initiated to prevent future occurrences or protect against recurrent injuries. The facility failed to consider additional protective devices (long sleeves, long pants), extent of vision impairment, and level of supervision needed to reduce the risk of injuries without the resident asking for assistance while maintaining his routine schedule and independence to assist with adjustment to current placement. WAC 388-97-1060 (3)(g)

Based on interviews and record review the facility failed to ensure residents were not subjected to abuse when forced against their will to receive treatment administered by licensed facility staff for 1 of 4 residents (#1) reviewed for abuse and neglect. This failure caused mental anguish, physical pain and psychological harm resulting from the abuse. Findings include: Resident #1 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The residents Brief Interview for Mental Status (BIMS) score was 04 indicating severe mental impairment. The Montreal Cognitive Assessment (MOCA) a tool to assess different types of cognitive abilities, to include short-term memory, was performed on 11/28/15 with a score of 6 of 30 indicating below normal ability with 27 indicating normal ability. Review of the facility investigation titled Tacoma Lutheran Home Resident Incident Report dated 2/17/16 at 11:05 p.m., revealed documentation of an interview on 2/18/16 at 9:03 a.m. with Staff E. S/he reported being called by the aide regarding rape allegations made by Resident #1. When entering the residents room, Staff E asked Resident #1 if s/he was okay, the resident stated, Someone came in here and raped me, it hurt so bad. The facility investigation revealed Staff C was assisted by Staff D when the rectal suppository was administered on 2/17/16 at 9:54 p.m. to Resident #1. The resident indicated verbally and non-verbally that s/he did not want the suppository but the medication was administered despite his/her refusal. Also present in the incident investigation was an untimed interview dated 2/18/16 with Staff C who admitted to the allegation stating, Last tonight around 2200 I had to give (Resident #1) a [MEDICATION NAME] rectal suppository and she had refused on the night before. Due to previous history of refusals and non-compliance I had asked Staff D to assist me. . I explained to (the resident) that we are going to give her a rectal suppository . We then asked her to turn toward the wall, assisted her in pulling down her pants. Resident #1 got angry and turned on her back. We asked her to turn towards the wall again and assisted in turning then I explained that we needed to check her brief to make sure that it was dry. After we pulled down her brief I gave her the rectal suppository and resident got angry again and said what are you doing? I again explained to her that I'm giving her a rectal suppository. Resident was still angry at us and I explained to her that we were done and I left the room. Staff D matched the description given by Resident #1 when the rape allegation was made. Staff D was placed on investigative suspension and returned to work 2/19/16 when the allegation was determined to be unsubstantiated. It was not until 4/25/16 that a Personnel Action Form (PAF) identified Staff C as the person the Resident #1 stated had raped her when administering the rectal suppository. The PAF indicated Staff C was brought to their attention by the complaint nurse and was initially overlooked due to the initial allegation of rape. Staff C acknowledged the day after Resident #1's report of rape (2/18/16) to administering the rectal suppository despite Resident #1's verbal and non-verbal refusal. The facility did not identify Staff C's actions as the root cause of the allegation of rape until 4/25/16, nor did the facility identify this action as abuse. The facility's' failure to identity, prevent, and protect the residents from the harmful care practices of Staff C, placed all residents under his/her care at risk for abuse.

Based on record review and interview, the facility failed to ensure medications were not given when the resident refused for 1 of 4 residents (#1) reviewed for the right to refuse treatment. This failure resulted in a violation of resident rights, and caused the resident to experience mental anguish and psych harm. Findings include: Refer to F223 for resident information and incident detail Review of the Nursing Notes for the period of January 1, 2016 through March 31, 2016 revealed frequent documentation of Resident #1's bowel tracking. Record review of the Provider Orders dated 2/17/16 revealed, multiple orders for bowel interventions to include the order If soft stool present give [MEDICATION NAME] 10 mg (milligram) rectal suppository (RS) on evening shift as needed for constipation. Review of the Medication Administration Record [REDACTED]. 2/3/16, 2/9/16, and 2/17/16, was given by Staff C. Staff C wrote in a statement of the incident dated 2/18/16 that Resident #1 had a history of [REDACTED]. Staff C admitted s/he then told the resident they were going to check her brief for wetness and when the brief was pulled down Staff C inserted the RS. The resident was recorded to have become angry and said what are you doing? and remained angry when told what had been done. A fax to the provider on 2/18/16 at 2:00 p.m. for an order change explained Resident apparently traumatized by receiving rectal suppository per BM (bowel movement) protocol. OK to d/c (discontinue) rectal supp(ository), give oral [MEDICATION NAME] 10 mg QD (daily) PRN (as needed) constipation? The provider agreed and wrote to Stop Suppository on 2/18/16. Review of the provider orders revealed orders for digital rectal stimulation and disimpaction (one or two fingers inserted through the anus into the lower bowel to remove stool from the rectum) had not been not removed from the Medication Administration Record [REDACTED]. In interview on 4/22/16 at 11:36 a.m. when asked what was done when a resident refused medications, Staff B said It depends on the resident. I will explain the need for the medication, ask if he or she understands and will answer their questions. I would not force the medication on the resident. I would chart it as a refusal. I would not distract the resident then give anyway. If the refusal is ongoing, the provider will talk with the resident and/or family and offer options. Prior to this incident, no record of resident refusals was documented in the chart or notification of the provider regarding medication refusals to address resident concerns and identify alternative options. In interview on 3/22/16 at 2:32 p.m., Staff A stated residents have a right to refuse medications. Ignoring the resident's refusal of a rectal suppository and administering it despite verbal and non-verbal objection caused the resident to believe s/he had been raped resulting in psychological harm.

Based on interview and record review, the facility failed to adequately monitor effects of [MEDICATION NAME] (anti-coagulant) drug therapy to ensure therapeutic and safe medication levels were maintained, for 3 of 12 Sampled Residents (#s 1, 2 & 3) reviewed for anti-coagulant therapy. These failures resulted in harm to Resident #1, when the resident developed excessive bleeding requiring hospitalization and blood [MEDICAL CONDITION], and placed Resident #2 at risk for bleeding, and Resident #3 at risk for development of a blood clot. Findings include: Refer to F 333 for additional information related to use of [MEDICATION NAME] medication, additional staff interviews and failure to ensure significant medication errors did not occur. Federal Regulation 42 CFR 483.25 which applies to unnecessary drugs advises facilities that use of anticoagulation therapy must be monitored by a lab test, [MEDICATION NAME] Time (PT)/International Normalization Ratio (INR), with frequency determined by clinical circumstances, duration of use, and stability of monitoring results. Multiple medication interactions can significantly increase PT/INR results to levels associated with life-threatening bleeding or decrease results of therapy to ineffective levels. [MEDICATION NAME] is an anticoagulant and inhibits blood clotting. A blood clot occurs when particles in the blood form a mass which could block blood flow to an area in the body. PT/INR lab tests are required and the dose of [MEDICATION NAME] prescribed by the physician may be adjusted frequently. INR is a blood test that tells the physician the time it takes for blood to form a clot and shows the effect of the dose of [MEDICATION NAME] on clotting. Depending on the person's health condition, ideal levels of INR may vary for different people and different medical conditions. Too much anti-coagulant medication increases the risk for bleeding, and could lead to complications related to abnormal bleeding such as stroke (bleeding into the brain) or death. Too low a dose of anticoagulant medication could increase risk for developing blood clots, and could lead to [MEDICAL CONDITIONS] embolism (clot in the lung), or death. During an interview on 1/21/16 at 12:50 p.m., Staff D explained that the charge nurse followed each resident who received [MEDICATION NAME], and had the responsibility of following the physician orders [REDACTED]. Staff D confirmed when the charge nurse did not communicate the order for lab work, none of the other staff would know when the lab needed to be done. RESIDENT #1 Resident #1 admitted to the facility on [DATE]. Medical [DIAGNOSES REDACTED].) DIC can be life threatening. Resident #1 had a history of [REDACTED].) A physician Post-Acute Care Services History & Physical dated 12/10/15, identified medication given to treat Resident #1 included [MEDICATION NAME]. December 2015 Physician order [REDACTED].#1 received a daily iron tablet from 12/11/15 to 12/29/15 to treat [MEDICAL CONDITION]. On 12/10/15, the physician ordered for staff to administer an injection of [MEDICATION NAME] once a week to treat [MEDICAL CONDITION]. [MEDICATION NAME] is a medication given to increase red blood cell production. STAFF FAILED TO MONITOR LAB ORDERS The facility [MEDICATION NAME] Flowsheet for Resident #1 identified the physician ordered Resident #1's therapeutic INR level to measure between 2.0 and 3.0. December 2015 Physician order [REDACTED]. The INR result obtained 12/17/15 measured 4.2, which was above the designated therapeutic level indicating an increased risk for bleeding. The physician ordered for staff to hold administration of [MEDICATION NAME] and to give Vitamin K as a one time treatment. The physician ordered Resident #1's INR lab value rechecked on 12/18/15; 12/19/15 and 12/21/15 and 12/23/15. The December 2015 MAR identified on 12/23/15, the resident's INR decreased to 2.3 and the physician ordered to begin administration of [MEDICATION NAME] 2.5 mg in the evening and to recheck the INR again on 12/26/15. Licensed staff entered an order on Resident #1's December 2015 MAR for nursing to call the lab and order a PT/INR in the morning on 12/26/15. Staff documented on the MAR they contacted the lab as ordered. On 1/21/16 at 12:20 p.m., Staff J stated Resident #1 was out of the building on 12/26/15 when the lab technician came to draw the INR. Resident #1's medical record did not contain evidence the facility completed the lab work the physician ordered for 12/26/15. Nursing staff entered previous lab orders for INR checks on the December 2015 MAR with a space for staff to initial when it was done and document the actual lab result. The MAR did not contain a space for staff to document the lab test ordered on [DATE] was completed or to show the result. The [MEDICATION NAME] Flowsheet and lab book did not identify staff completed the lab order. During an interview on 1/19/16 at 2:35 p.m., Staff J reported he/she did not enter a space on the MAR for staff to document when the INR was completed and the result when done by the outside lab provider. Staff J stated entries to document the lab and result were written on the MAR when the facility completed the lab test on the facility hand held machine and did not occur to him/her to flag it on the MAR when the outside provider did the lab test. Staff J reported completing the INR test on 12/26/16 was critical. During interviews on 1/21/16 at 2:45 p.m., Staff H explained, staff relied on day shift reporting to the next shift when an INR did not get done. Staff G said medication nurses were supposed to know the current INR value. Staff G stated if the day charge nurse did not get the lab done it did not automatically show up on the MAR for the next shift to do and the order needed to be reentered in the MAR. On 1/22/16 at 9:00 a.m., Staff N said medication nurses were taught to look at the INR result on the MAR. If the box on the MAR for the lab result was blank, it meant the INR did not get done that day. On 1/22/16 at 3:08 p.m., Staff B explained one nurse followed through with orders needed for INRs, contacted physicians for [MEDICATION NAME] orders, and documented orders on the MAR. Staff B stated the facility did not have another nurse follow and check to make sure all physician orders [REDACTED]. During an interview on 1/22/16 beginning 4:10 p.m., Staff A reported, Charge Nurse Staff C understood the system to order the lab but forgot to call the lab back and reorder it when it did not get done on 12/26/15. Staff A also stated Staff C should have re-entered the order on the MAR to have the lab return the next day for nurses to see. December 2015 MARs identified staff continued to administer 2.5 mg of [MEDICATION NAME] every evening on 12/26/15; 12/27/15 and 12/28/15 although the last test result for the INR was not obtained and reviewed by the physician prior to continuing [MEDICATION NAME] administration. Multiple steps were missed by licensed staff to ensure the INR was completed 12/26/15. Staff missed steps to reorder the lab for the next day when it was not done on 12/26/15; did not flag the MAR for all nurses to show the lab needed to be done and that licensed staff reported the previous INR value was done on 12/23/15, to oncoming shifts. Licensed staff who administered [MEDICATION NAME] relied on one nurse to ensure INR labs were done and all entries on the MAR were completed. Not all medication nurses reported they checked the record to ensure they were aware of current INR orders and results before they administered [MEDICATION NAME]. The physician discontinued Resident #1's [MEDICATION NAME] on 12/17/15 due to an elevated INR level and prescribed treatment with Vitamin K. A week later on 12/23/15, the physician ordered [MEDICATION NAME] restarted when the INR returned to a therapeutic level. Failure to monitor effects of restarting [MEDICATION NAME] and obtain the INR lab test on 12/26/15 and continued administration of the previously ordered dose of [MEDICATION NAME], resulted in complications of bleeding (nosebleeds and blood in urine) for Resident #1 requiring hospitalization and blood [MEDICAL CONDITION]. Hospital lab tests revealed the resident's INR level elevated to 7.7, above therapeutic range. RESIDENT #2 Resident #2 had a history of [REDACTED]. Review of Resident #2's medical record revealed a physician's orders [REDACTED]. Further review of Resident #2's medical record revealed there was no evidence the INR levels had been checked. During an interview on 1/22/15 at 3: 45 p.m. Staff B confirmed a charge nurse had not communicated the physician's orders [REDACTED]. Review of the facility investigation dated 12/15/15 revealed the missed lab work was not noted until Resident #2 developed a 10 centimeter long by 5 centimeter wide bruise on her abdomen. When Resident #2's INR was checked on 12/15/15 the lab called the facility to inform them the level was critically high at 10.4, more than three times the intended level of 2-3 (blood was more than three times thinner than it was intended to be). RESIDENT #3 Resident #3 had a history of [REDACTED]. Review of Resident #3's record revealed a physician's orders [REDACTED]. Further review of the record revealed no documentation to support the INR was checked on 7/15/15 as ordered. Review of a facility investigation dated 7/28/15 revealed staff did not note the INR had been missed until Resident #2 had an increased heart rate on 7/28/15. During an interview on 1/22/15 at 3:50 p.m., Staff B confirmed the INR was not checked as ordered, and that the missed order was not identified until two weeks later when the resident began having symptoms on 7/28/15. Resident #3's record indicated when her INR level was checked on 7/28/15, the level was low at 1.0 (blood too thick), putting her at increased risk for developing a blood clot. Failure to monitor the effects of [MEDICATION NAME] by checking INR levels placed residents at risk for having unnoticed levels that were too high or too low. Resident records indicated [MEDICATION NAME] was administered when staff did not have current lab levels, placing residents at risk for bleeding or developing blood clots.

Based on observation, interview and record review it was determined that the facility failed to ensure significant medication errors did not occur that included either run on dosing or prolonged discontinuance of [MEDICATION NAME] without timely lab monitoring for 4 of 12 Sampled Residents (#s 1, 2, 3 & 4) reviewed for anticoagulant therapy. Failure to ensure Resident #1 received the dose of anticoagulant medication based on a current ordered lab work when needed, resulted in abnormal bleeding requiring hospitalization , blood [MEDICAL CONDITION] and treatment. For this resident, there was harm. Failure to ensure correct doses of [MEDICATION NAME] were administered to Resident #2, Resident #3 and Resident #4 placed these residents at increased risk for bleeding or development of blood clots. Findings include: [MEDICATION NAME] is a prescription medication used to treat blood clots and lower the chance of forming blood clots (when products in the blood form a small mass.) Side effects of [MEDICATION NAME] include bruising easily and prolonged bleeding. Blood clots can travel in the blood stream to legs or organs such as lungs, heart and/or brain and can be life threatening. International Normalized Ratio (INR) is a lab test given that indicates the clotting tendency of blood. INR lab tests are conducted routinely and periodically when [MEDICATION NAME] is prescribed. Dosing for [MEDICATION NAME] is based on the current INR value and is frequently changed until stabilized on the medication. Review of a facility policy and procedure titled Guidelines for Anticoagulant Therapy-[MEDICATION NAME] Administration dated 10/2014 revealed, [MEDICATION NAME] administration occurred in the evening hours after lab draws were checked, and changes to orders were received from the physician. According to the guidelines, to prevent run on dosing of [MEDICATION NAME], and missed timely INRs, the LN (licenses nurse) documenting a [MEDICATION NAME] order would note the date of the next INR in a separate entry on the MAR, and block off the date of the INR for the medication and treatment licensed nurse to initial and to record the reported results. During an interview on 1/21/16 at 12:50 p.m., Staff D explained the charge nurse was responsible for reviewing doctor's orders for [MEDICATION NAME] doses, and would know when the doctor wanted lab testing done. According to Staff D, the charge nurse entered the dose of [MEDICATION NAME] ordered in the Medication Administration Record [REDACTED]. Staff D confirmed [MEDICATION NAME] doses were frequently changed and that it was the charge nurse's responsibility to discontinue the old dose and enter the new dose on the MAR. RESIDENT #1 Refer to F 329 for additional information related to Resident #1's medical history; failure to ensure an INR lab was completed 12/26/15 and consistently monitor effects of [MEDICATION NAME] therapy; facility investigation and development of medication related complications requiring hospitalization resulting in harm for this resident. Following an INR lab test conducted on 12/23/15, the physician ordered for staff to administer 2.5 mg of [MEDICATION NAME] in the evening, based on an INR level of 2.3. On 12/26/15 the physician ordered for staff to recheck the next INR on 12/26/15. According to facility policy and procedure for [MEDICATION NAME] Administration, licensed staff should check with the physician regarding the dose of [MEDICATION NAME] needed following the lab. Licensed staff failed to ensure they completed the lab draw ordered for 12/26/15, and did not check with the physician for any possible changes in [MEDICATION NAME] dose prior to continued run on dosing administration of the 2.5 mg dose, before administering the medication. The December 2015 MAR indicated [REDACTED]. On 1/19/16 at 2:15 p.m., Staff M reported he/she thought the charge nurse on day shift already checked to see if Resident #1's INR was done (12/26/15). Staff M stated he/she received the INR level of 2.3 during shift change report and assumed it was the latest INR and did not check the [MEDICATION NAME] Flowsheet. Staff M also stated the MAR indicated [REDACTED]. On 1/19/16 at 2:35 p.m., Staff J said Resident #1's MAR indicated [REDACTED]. Staff J stated a MAR indicated [REDACTED]. During interviews on 1/21/16 at 2:45 p.m., Staff G reported an order written [REDACTED]. If the lab did not get done on day shift the order would stay red in color and would not show up for the next shift to see. At this time, Staff H reported, most of the time, he/she relied on report from the day shift to find out what the current INR was. Staff H also stated if a resident had bleeding while on [MEDICATION NAME] he/she would hold the current [MEDICATION NAME] dose and notify the charge nurse and the physician and wait for further orders. On 1/22/16 at 11:27 a.m., Provider S reported staff notified him/her on 12/28/16, when Resident #1 had one nosebleed. Staff S stated he/she did not know the resident had a nosebleed before the one on 12/28/16 and would have checked the date on the last INR, repeated the lab and held administration of [MEDICATION NAME] until the lab result came back if he/she would have known. On 1/22/16 at 3:08 p.m., Staff B reported INR orders were obtained and completed by one nurse. Staff B also reported, before medication nurses gave [MEDICATION NAME], they obtained the INR result from the charge nurse or checked in the computer. When asked how the medication nurse would know if the INR result they received from the charge nurse was the most current one, Staff B stated, the nurse on the med cart wouldn't know. Staff B stated there was no written requirement to look at the flowsheet before administering [MEDICATION NAME] but a prudent nurse would check the INR. On 1/22/16 at 4:10 p.m., Staff A reported, when Resident #1 missed the lab draw when out of the facility on 12/26/15, Staff C forgot to reorder it and forgot to place a request for the lab technician to return for another attempt at a blood draw. When asked if there was a common thread to [MEDICATION NAME] related medication errors, Staff A stated, the nature of [MEDICATION NAME] had a higher risk of number of medication errors and not all were due to transcription or omission and no single cause for errors stood out. Following run on dosing of [MEDICATION NAME] 12/26/15 through 12/28/15, Resident #1 required hospitalization for bleeding and an elevated INR of 7.7. Treatment included blood and platelet [MEDICAL CONDITION] and administration of Vitamin K. Resident #1 required hospitalized from [DATE] through 1/2/16 before returning to the facility. Facility staff identified multiple incidents that occurred involving multiple nursing staff over multiple shifts which led to Resident #1's medication errors that included the following: -relying on verbal reports of INR levels being passed on between shifts; -medication nurses failed to check and confirm in Resident #1's medical record the INR value they received during report was the most current level before they administered [MEDICATION NAME]; - failure to enter a notation on the MAR indicated [REDACTED] -failure to re-notify the lab and reorder the lab test when not completed on 12/26/15 and make a new entry on the MAR indicated [REDACTED]. RESIDENT #2 Resident #2 had a history of [REDACTED]. When a [MEDICAL CONDITION] embolism occurs, oxygen rich blood cannot get to the heart and lungs, placing the resident at risk for [MEDICAL CONDITION] and death. Resident #2's doctor had prescribed [MEDICATION NAME] for history of [MEDICAL CONDITION] embolism. Review of Resident #2's record indicated that on 11/29/15, when her lab test showed a low level (blood too thick), her doctor increased the [MEDICATION NAME] dose to 5 mg and directed staff to re-check the lab level in 2 days. Further review of Resident #2's record revealed a physician's orders [REDACTED].#2 a [MEDICATION NAME] dose of 5 mg and to check her lab level again in 1 week. Upon review, there was no evidence in Resident's #2's record that the lab had been rechecked one week after the 12/1/15 order, but the daily dose of 5 mg was still being given. During an interview on 1/21/16 at 12:55 p.m. Staff D explained when the physician gives an order to change the dose and redraw the lab, the staff will call him/her in the morning and notify him/her of the result. Staff reported the medication would be held until the physician reviews the lab result and gives directives to continue the dose, increase, decrease or hold the medication. During an interview on 1/22/16 at 3:50 p.m., Staff B reported a licensed nurse should not give [MEDICATION NAME] until he/she knows the most recent lab results. Progress notes indicated that on 12/14/15, two weeks later, a staff member noted Resident #2 had developed a bruise that was described as 10 centimeters long and 5 centimeters wide that was dark purple in color. A facility investigation on 12/15/15, indicated staff was inquiring into potential causes of the bruise. Documentation indicated it was during the investigation that it was discovered the physician's orders [REDACTED]. Additionally, the medication was not held at the time the lab work should have been done; therefore nursing staff continued to administer [MEDICATION NAME] 5 mg daily. During an interview on 1/21/15 at 12:50 p.m. Staff E reviewed the chart and confirmed the physician's orders [REDACTED]. Further review of the investigation indicated the incident was a Level IV medication error. The result of the error was a critically high (blood too thin) INR level of 10.4, more than three times higher than her doctors recommended range of 2-3. The error of giving an increased dose of [MEDICATION NAME] over a 2 week period placed Resident #2 at risk of abnormal bleeding (as evidenced by her bruise due to blood being too thin) with a potential risk of not being able to stop the bleeding, resulting in stroke (caused by brain bleed) or death. RESIDENT #3 Resident #3 had been prescribed [MEDICATION NAME] to treat her history of [MEDICAL CONDITION] embolism (blood clot that had traveled in the blood stream to her lungs blocking blood flow). Review of Resident #3's record revealed, she readmitted to the facility 7/1/15 after being treated at the hospital for fractures to both legs. During an interview on 1/22/15 at 10:55 a.m., Staff P reviewed Resident #3's physical therapy notes and reported she had to wear a brace on her right leg that kept her from moving it and she was not able to put weight on it. Staff P additionally reported Resident #3 was not able to put much weight on her left leg due to the fracture. Staff P confirmed Resident #3 was no able to ambulate and had limited movement in her legs. According to Public Health Reports, Prevention of [MEDICAL CONDITION] and [MEDICAL CONDITION] Embolism at www.ncbi.nlh.gov/pmc/articles <http://www.ncbi.nlh.gov/pmc/articles>, by Steven Galson MD, MPH, RADM, July-August 2008, the lack of ambulatory movement raises the risk of developing a blood clot and/or [MEDICAL CONDITION] embolism. The article also explains that one third of blood clots will travel in the bloodstream to the lungs, creating a potentially life threatening situation. Resident #3's record indicated her [MEDICATION NAME] had been on hold after having higher than normal INR lab results (blood too thin). On 7/12/15 the physician ordered [MEDICATION NAME] 3 mg 7/12/15 through 7/15/15 and then recheck the INR. Review of Resident #3's MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Review of a facility investigation dated 7/28/15 revealed that Resident #3 had an increased heart rate on 7/27/15 and 7/28/15. While reviewing Resident #3's record to determine why her heart rate was elevated, staff discovered that she had not had [MEDICATION NAME] for 2 weeks, on 7/15/15. When staff discovered the error a lab test was done and indicated Resident #3's INR was low (blood too thick) During an interview on 1/22/16 at 3:45 p.m., Staff B confirmed the omission of [MEDICATION NAME] between 7/15/15 and 7/28/15 was considered a Level IV medication error. Staff B confirmed Level IV indicated the resident had a significant reaction because of the error. Failure to administer [MEDICATION NAME] placed Resident #3 at risk for having a low INR (blood too thick), which placed her at potential risk for developing another blood clot. RESIDENT #4 Resident #4 was receiving [MEDICATION NAME] to treat an irregular heart rate that is known to cause blood clots. Review of Resident #4's medical record revealed the physician ordered [MEDICATION NAME] 5mg to be given daily on 9/26/15 and then recheck the INR on 9/29/15. Review of a facility incident investigation revealed, the [MEDICATION NAME] had not been entered into the MAR. The error was noted by staff on 9/29/15; therefore, Resident #4 missed his medication on 9/27/15 and on 9/28/15. During an interview on 1/22/16 at 3:50 p.m., Staff B confirmed missing 2 days of [MEDICATION NAME] was considered a significant medication error. Failure to administer blood thinning medication for residents who are at risk for developing blood clots placed them at potential risk for embolism. Additionally, administering too much of blood thinning medications placed residents at risk for abnormally high amount of bleeding.

Based on interview and record review it was determined that the facility failed to timely consult with the physician and failed to provide accurate assessment findings to the physician when 1 of 5 residents (Resident #1) reviewed had a deteriorated condition. This failure prevented the physician from being fully aware of the deteriorating condition and the opportunity to alter treatment in a timely manner. This failure caused harm to Resident #1 who arrived at the hospital in active [MEDICAL CONDITION]. Findings include: Resident #1 was admitted to the facility on [DATE] from the hospital with multiple [DIAGNOSES REDACTED]. The resident was a full code meaning he desired full resuscitation efforts. Hospital discharge instructions included the following: Patient advised to return to the emergency department immediately if chest pain, shortness of breath, lightheadedness, passing out, weakness, fatigue, or any problems develop at all. Nursing progress note dated 12/4/13 at 3:30 a.m., documented, in part, "sleeping now, had back pain now relieved by Tylenol, respirations regular and even, oxygen saturation 94% on room air, skin color gray, feet white, fleeting pedal pulses." At 3:45 a.m., "Resident #1 was found on the floor and while sitting up, the resident's breathing became striderous (a physical sign which is produced by narrowed or obstructed airway path) and the resident then became unresponsive. The resident did not have a pulse and did not have an apical heart rate. The licensed nurse (Staff C) performed 3 chest compressions and the resident became responsive." At 6:08 a.m., approximately 2 1/2 hours after being unresponsive and becoming responsive after chest compressions, the resident stated, "It seems like it's harder to get air," Staff C administered 2 puffs of an [MEDICATION NAME] inhaler. Review of the record did not identify that the physician had been notified the resident was administered an [MEDICATION NAME] inhaler treatment due to stating "It seems like it's harder to get air" after receiving chest compressions for an unresponsive episode. On 12/18/13 at 6:20 a.m., during a phone interview, Staff C stated prior to the chest compressions, 911 was called, and when the resident became responsive she told a co-worker to cancel the 911 call. Staff C stated she cancelled the 911 call because the resident was talking, alert and oriented. According to Staff C she called the doctor at approximately 7 a.m. (more than three hours later) to inform him of the above events. Staff C stated she should have called the physician earlier. On 12/4/13 at 8:41 a.m., nursing note documented, in part, "resident refused his breakfast did drink shake. Resident color is off from yesterday. Resident breathing is labored. Resident is on 4 liters of oxygen via nasal cannula placed on the previous shift. Heart rate irregular, has chest discomfort over the sternum. MD expected in, will leave resident in bed till he arrives." Six hours after the resident being unresponsive and requiring chest compressions, review of the documentation did not reveal the physician had been notified of the labored breathing, skin color being off from the day before and irregular heart rate. On 12/16/13 at 10:51 a.m., during an interview, licensed nurse Staff E stated she received in report from Staff C that Resident #1 became unresponsive and required 3 chest compressions and the 911 call was cancelled because he became responsive. Staff E reported when the resident was assessed at 8:41 a.m. and noted to have labored breathing and an irregular heart rate with the color that was off from the day before, she did not call the doctor because the resident was on the nebulizer at the time and was not different from the time she arrived on day shift. Staff E stated the night shift nurse had already informed the doctor of her findings, and received an order for [REDACTED]. On 12/17/13 at approximately 11:00 a.m., during a phone interview, the physician stated he received a phone call at approximately 6 or so in the morning, and was told of an unresponsive event the resident had approximately 3 hours earlier. According to the physician, he was told the resident required some shaking and pushing before becoming responsive, not that the resident received chest compressions. The physician stated he was told the resident was currently in bed on oxygen talking and responsive. This information gave him the impression that the resident was stable, so he ordered an EKG. The physician stated that was the only call he received until later about 10 a.m., when the resident became unresponsive, and was sent to the hospital. The physician stated he was never told that 911 had been called and cancelled or of the resident's labored breathing, and stated as a whole the resident should have been out and at the hospital.

Based on interview and record review it was determined 2 licensed staff (Staff C and Staff G) failed to obtain emergent help and assessment of Resident #1's cardiac condition when the nurses called 911 then cancelled the call. This failure caused harm to Resident #1 whose urgent treatment was delayed approximately 6 hours when he experienced a 2nd unresponsive episode and arrived at the hospital in active [MEDICAL CONDITION]. Findings include: According to "Lippincott Manual of Nursing Practice," ninth edition, the nursing process is a "deliberate, problem-solving approach to meeting the health care and nursing needs of patients." The process "involves assessment (data collection), nursing diagnosis, planning, and evaluation, with subsequent modifications used as feedback mechanisms to promote the resolution of the nursing diagnoses. The process as a whole is cyclical, with the steps being interrelated, interdependent, and recurrent." Implementation includes coordinating care with other health team members. Resident #1 admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident was a full code. At 3:45 a.m., Resident #1 was found on the floor and while sitting up, the residents breathing became striderous and the resident then became unresponsive. The resident did not have a pulse and did not have an apical heart rate. Licensed nurse Staff C and staff G were with the resident, and Staff G left to call 911 while Staff C stayed with the resident and performed 3 chest compressions. The resident became responsive. While Staff G was on the phone with 911, Staff C called out for Staff G to cancel the call. Although the nursing staff assessed the resident to be pulseless, 911 who could have run an EKG strip and further assessed resident #1's cardiac status was called off. The resident who had a history of [REDACTED]. At 4:52 a.m., Staff C administered sublingual [MEDICATION NAME] for poor color perfusion. At 6:08 a.m., approximately 2 1/2 hours after being unresponsive and becoming responsive after chest compressions, the resident stated, "It seems like it's harder to get air," Staff C administered 2 puffs of an [MEDICATION NAME] inhaler. At 9:41 a.m., nursing note documented "resident oxygen saturation of 80% on 4 liters of oxygen. Resident lethargic and not responding to verbal stimuli. Called 911, obtained large tank oxygen and placed on 10 liters of oxygen. Unable to get oxygen saturation. 911 arrived at 9:45 a.m., and worked on resident. Resident transferred to the stretcher at 10:05 a.m., left with paramedics to the hospital." According to the hospital records the resident arrived to the emergency department in active [MEDICAL CONDITION] with compressions started at 10:15 a.m., in route to the emergency department, and pronounced dead at 10:48 a.m.

Based on interview and record review it was determined that the facility failed to provide the necessary timely care and services in response to deteriorated condition for 1 of 5 residents (Resident #1) reviewed. The resident had an unresponsive episode which required chest compressions. 911 was called and cancelled when the resident became responsive. Failure to provide adequate care and treatment caused harm to Resident #1 who was later sent to the hospital where he arrived in active [MEDICAL CONDITION]. Findings include: Resident #1 was admitted to the facility on [DATE] from the hospital with multiple [DIAGNOSES REDACTED]. The resident was a full code meaning he desired full resuscitation efforts. Hospital discharge instructions included the following: Discharge to Tacoma Lutheran Home for further rehabilitation Patient advised to return to the emergency department immediately if chest pain, shortness of breath, lightheadedness, passing out, weakness, fatigue, or any problems develop at all. The facility's "Notification of Resident change of Condition" policy and procedure dated 3/98 and 2/12 directed staff to notify the physician as soon as possible to participate in the decision-making process. Examples of change in condition included: New onset of abnormal vital signs Respiratory distress or cardiovascular changes including chest pain not relieved by [MEDICATION NAME] when ordered Changes in mental status and/or behavior changes Nursing progress noted dated 12/4/13 at 3:30 a.m., documented, in part, "sleeping now, had back pain now relieved by Tylenol, respirations regular and even, oxygen saturation 94% on room air, skin color gray, feet white, fleeting pedal pulses. " At 3:45 a.m., Resident #1 was found on the floor and while sitting up, the resident's breathing became striderous (a physical sign which is produced by narrowed or obstructed airway path) and the resident then became unresponsive. The resident did not have a pulse and did not have an apical heart rate. The licensed nurse (Staff C) performed 3 chest compressions and the resident became responsive. At 4:52 a.m., Staff C administered sublingual [MEDICATION NAME] for poor color perfusion. At 6:08 a.m., approximately 2 1/2 hours after being unresponsive and becoming responsive after chest compressions, the resident stated, "It seems like it's harder to get air," Staff C administered 2 puffs of an [MEDICATION NAME] inhaler. Staff C administered [MEDICATION NAME] for poor color perfusion although the medication was ordered to give as needed for chest pain. Staff C documented in a written statement, "I did give [MEDICATION NAME] as a preventative measure and should have only given it as ordered." On 12/18/13 at 6:20 a.m., during a phone interview, Staff C stated prior to the chest compressions, 911 was called, and when the resident became responsive she called and cancelled the 911 call. Staff C stated she cancelled the 911 call because the resident was talking, alert and oriented. According to Staff C she called the doctor at approximately 7 a.m. (three hours later) to inform him of the above events, when asked, Staff C stated she should have called the physician earlier. On 12/23/13 at 10:50 p.m., during and interview, a nursing assistant (Staff F) stated on 12/4/13 she was asked to get the lift and sling because Resident #1 was on the floor. Staff F stated she left the room while Staff C and the other licensed nurse (Staff G) worked on the Resident. According to Staff F, Staff G left out of the room to call 911. While staff G was on the phone, Staff C called out for Staff G to cancel the call. On 12/4/13 at 8:22 a.m., social service note documented, in part, resident is engaging and pleasant, though tired and has labored breathing. Resident indicates that he is very tired and has no energy, but does not feel depressed. On 12/16/13 at 11:00 a.m., during an interview, Social Services Staff (D) stated the resident called him in and asked if he needed to ask him questions. Staff D stated he noticed the resident was having difficulty breathing, but was not gasping for air and was no different from what he noticed before, and therefore did not notify the nurse. On 12/4/13 at 8:41 a.m., nursing note documented, in part, resident refused his breakfast did drink shake. Resident color is off from yesterday. Resident breathing is labored. Resident is on 4 liters of oxygen via nasal cannula placed on the previous shift. Heart rate irregular, has chest discomfort over the sternum. MD expected in, will leave resident in bed till he arrives. At 9:41 a.m., nursing note documented resident oxygen saturation of 80% on 4 liters of oxygen. Resident lethargic and not responding to verbal stimuli. Called 911, obtained large tank oxygen and placed on 10 liters of oxygen. Unable to get oxygen saturation. 911 arrived at 9:45 a.m., and worked on resident. Resident transferred to the stretcher at 10:05 a.m., left with paramedics to the hospital. According to the hospital records the resident arrived to the emergency department in active [MEDICAL CONDITION] with compressions started at 10:15 a.m., in route to the emergency department, and pronounced dead at 10:48 a.m. On 12/16/13 at 10:51 a.m., during an interview, licensed nurse Staff E stated she received in report from Staff C that Resident #1 became unresponsive and required 3 chest compressions and the 911 call was cancelled because he became responsive. Staff E reported when the resident was assessed at 8:41 a.m. and noted to have labored breathing and an irregular heart rate with color that was off from the day before, she did not notify the doctor because he was on the nebulizer at the time and was not different from the time she arrived on day shift. Staff E stated the night shift nurse had already informed the doctor of her findings, and received an order for [REDACTED].