Every finding on record at Garden Terrace Healthcare Center of Federal Way

Based on observation, interview, and record review, the facility failed to ensure grievances were initiated, logged, investigated, resolved, and responded to in accordance with facility policy for 2 of 15 sampled residents (Residents 11 & 69) and 5 supplemental residents (Resident 6, 28, 46, 62, & 108) reviewed for grievances. These failures placed residents at risk for unresolved concerns, frustration, unmet care needs, and diminished quality of life.Findings included .FACILITY POLICYReview of the facility's Grievance Program (Concern and Comment) policy, reviewed 09/26/2025, showed the facility would inform residents upon admission of their right to file grievances either verbally or in writing, and would post a contact name and telephone number for the designated Grievance Officer (GO-person responsible for overseeing intake, investigations, issuance of written decisions, and tracking) in a prominent location. The GO would ensure concerned individuals felt some type of resolution was achieved and communicated in a timely and appropriate manner. The policy showed any staff member could assist a resident in the completion of the grievance form and immediately report alleged violations involving abuse or neglect to the GO. Observation on 08/13/2026 at 8:13 AM showed a framed information sign near the grievance forms and submission box. The instructions included directions regarding how to submit a concern or comment and described the GO name as Our Grievance Official and their telephone number. The name listed was not the current GO and the telephone number listed was disconnected. In an interview and record review on 08/13/2026 at 10:30 AM, Staff A (Administrator) stated they were the GO, and the sign should have been updated when they became the GO in March 2026, but it was not. Staff A stated not having updated information placed residents at risk for not having access to the GO to discuss concerns or file grievances. RESIDENT 11 In an interview and observation on 08/10/2026 at 1:59 PM, Resident 11 told Staff G (Housekeeping Assistant) they were missing clothing. Staff G searched the laundry room and returned to tell Resident 11 they did not locate the items described but would continue to watch for them. Staff G did not complete a grievance form for Resident 11 at that time. In an interview 08/10/2026 at 2:15 PM, Staff G stated they were not aware they should complete a grievance form for Resident 11's concern related to missing clothing. RESIDENTS 6, 28, 46, 62 In an interview on 08/12/2026 at 1:06 PM, Resident 6's representative stated Resident 6 was discharged on 07/31/2026 without one of their hearing aids or a white sweater. Resident 6's representative stated they immediately called the facility to report the concern to Staff I (LPN Unit Care Coordinator). Resident 6's representative stated they returned to the facility on [DATE], and Staff I told them they had not found the hearing aid. Resident 6's representative stated they were escorted to the facility's laundry room by Staff H (Housekeeping Director), and Staff H wrote down a description of the sweater on a blank piece of paper and stated they would continue searching for the sweater. In an interview and record review on 08/14/2026 at 9:50 AM, Staff I stated they did not complete a grievance form to document Resident 6's missing hearing aid and sweater but should have. In an observation and record review on 08/14/2026 at 8:32 AM, Staff H removed three purple grievance forms and a white piece of paper from their desk drawer. Review of the items showed: A blank piece of paper with Resident 6's representative's name and telephone number and a description of Resident 6's missing sweater. No other information was written on the paper. An original purple grievance card, completed by Resident 28 on 08/10/2026, showed they were missing 2 pairs of pants and a shirt. Resident 28 indicated they had reported the concern to a staff member, but no staff name was listed or information indicating the facility had investigated or communicated a resolution with Resident 28. An original purple grievance card, completed by Resident 46 on 08/06/2026, showed they were missing a black back brace. The form showed the concern was received by a staff member on 08/09/2026 but no information was documented to indicate the facility had investigated or communicated a resolution with Resident 46. An original purple grievance card, completed by Resident 62 on 08/02/2026, showed they were missing a pair of pants and a shirt. The form showed the concern was received by a staff member on 08/02/2026 but was not signed by staff and no information was documented to indicate the facility had investigated or communicated a resolution with Resident 62. In an interview on 08/14/2026 at 8:32 AM, Staff H stated they did not complete a grievance form for Resident 6, because only residents completed grievance forms. Staff H stated they received the grievance cards directly from Resident 28, 46 and 62. Staff H stated they did not provide copies of the grievance cards to Staff A for tracking purposes, they instead placed the forms in their desk drawer when unable to locate the missing items. Staff H stated that both sides of the grievance cards would be completed and returned to Staff A only after the concerns were fully investigated. Staff H stated they were unaware of a specific timeframe within which resident grievances must be addressed. RESIDENT 69 In an interview and record review on 08/11/2026 at 12:28 PM, Resident 69's representative stated they emailed the Social Services Director (SSD) on 07/28/2026 regarding allegations of neglect involving direct care staff, resulting in frustration and anxiety by Resident 69. Resident 69's representative stated the SSD replied immediately stating they would forward the original concerns to Staff B (Director of Nursing Services) to investigate and respond. Resident 69's representative stated they did not receive a response from Staff B. In an interview and record review on 08/14/2026 at 12:52 PM, Staff B provided notes regarding an investigation that was conducted on 07/29/2026, showing the staff involved with Resident 69 were interviewed and re-educated regarding the facility's customer service expectations. The investigation showed Resident 69 was assessed for skin impairments and Resident 69 agreed to continue to work with the staff member involved. Staff B stated they did not respond to specific questions asked by Resident 69's representative, but they should have. Staff B stated they did not complete a grievance form or report the allegation of neglect to Staff A but should have. RESIDENT 108 According to the 07/26/2026 admission MDS, Resident 108 had diagnoses including a recent surgery to repair fracture, depression and pain. The MDS showed Resident 108 could be understood, was able to understand others and needed set up and cleaning assistance with eating. Review of the 07/23/2026 At risk for change in mood care plan showed staff were to consult with Resident 108 on preferences regarding customary routine. Review of the 07/23/2026 Pain care plan, showed the goals were for Resident 108 to express pain relief and staff were to evaluate the effectiveness of pain interventions. In an interview on 08/18/2026 at 3:30 PM, Resident 108 stated that when they were a resident at the facility on 07/25/2026, they completed a grievance report and told facility staff about an incident when Staff K (Certified Nursing Assistant) was arranging Resident 108's bedside table, a juice container was knocked over and spilled into Resident 108's clothes drawer. Resident 108 stated they told Staff K to slow down while providing care to avoid accidents from happening and Staff K, stated they were Mexican and that's the way they do things. Resident 108 also stated they told Staff K they were in pain and Staff K told Resident 108, if you don't have any pain, you would not get any better. Resident 108 reported they did not feel Staff K was professional and did not care about their needs. Resident 108 stated they reported the incident as a grievance to the facility's nursing staff, and a physical therapist gave them a grievance form to complete. Resident 108 stated they gave the completed grievance form to the physical therapist because there was no one else they could give the grievance form to on the weekend. Resident 108 stated they did not think the grievance process worked because they did not hear back from the facility regarding their grievance. Review of the facility's July 2026 and August 2026 Grievance Logs showed no grievance concerns were logged for Residents 11, 6, 28, 46, 62, 69, or 108. In an interview and record review on 08/14/2026 at 12:43 PM, Staff A stated they expected staff to assist residents to complete grievance forms when needed. Staff A stated they did not receive grievance forms for Residents 11, 6, 28, 46, 62, 69, or 108 but should have to effectively log and track the investigation process. Staff A stated they expected department leadership to complete grievance investigations within five days and return the completed forms to them. Staff A stated they would then contact the residents involved to ensure they were satisfied with the facility's resolution. Staff A stated they expected allegations of abuse or neglect to be reported to them immediately. Staff A stated an effective grievance process was important to ensure residents were free from frustration, unmet care needs, and diminished quality of life. Refer to F584 Safe/Clean/Comfortable/Homelike Environment REFERENCE: WAC 388-97-0460 (1)(2).

Based on observation, interview, and record review, the facility failed to maintain sink faucets in good repair for 1 supplemental resident (Resident 38) and 2 of 15 sampled residents (Residents 95 & 3); failed to ensure building repairs were completed in a timely manner for 1 of 15 sampled residents (Residents 97) reviewed for environment, failed to ensure common area carpeting was clean for 1 of 2 common areas (Lower-level main hallway); and failed to ensure residents' personal property was protected from loss for 1 of 15 sampled resident (Residents 11) and 1 supplemental resident (Resident 6) reviewed for missing property. These failures to ensure timely repairs and an effective personal property system placed residents at risk of frustration and a decreased quality of life.Findings included .Facility PolicyReview of the facility's Resident Belongings and Home Like Environment policy, reviewed 04/01/2026, showed the facility would provide a safe, clean, comfortable and homelike environment. The policy showed staff would treat residents' possessions with respect.Review of the facility's Inventory of Personal Belongings (IPB) policy, reviewed 04/01/2026, showed staff would account for each of residents' items on an inventory sheet with a description upon admission and whenever new clothing was brought into the facility.SINK FAUCETS RESIDENT 38 In an observation and interview on 08/10/2026 at 1:31 PM, observation showed the faucet in the sink in Resident 38's bedroom, within view of Resident 38's bed, was continuously dripping water. Resident 38 stated the dripping faucet was their biggest concern with the facility; staff didn't turn the water all the way off because it was difficult, and they left the water dripping. Resident 38 stated they reported the problem to staff many times. Observation showed the dripping stopped after pushing very hard on the hot water faucet handle. In an observation and interview on 08/14/2026 at 8:37 AM, Resident 38 stated that their faucet was dripping again, and had been dripping for two days. Observation showed the faucet was continuously dripping. In an observation and interview with Staff D (Maintenance Director) on 08/14/2026 at 10:13 AM, observation showed Resident 38's faucet was continuously dripping. Resident 38 stated the faucet dripped all the time, and there were a lot of other sinks on the unit with the same problem. Staff D confirmed the findings and stated the faucet handle needed a cartridge replacement. RESIDENT 95 In an observation and interview on 08/12/2026 at 12:40 PM, observation showed Resident 95's faucet in the sink in their bedroom, within view of Resident 95's bed, was continuously dripping water. Resident 95's family member attempted to turn the water off and stated the faucet was very hard to turn off, was always dripping, and the room across the hall had the same problem. RESIDENT 3 Observation on 08/12/2026 at 1:34 PM showed the faucet for the sink in Resident 3's bedroom, within view of Resident 3's bed, continued to drip after the water was turned off, and required several forceful pushes on the handle to stop the dripping. In an interview on 08/14/2026 at 10:16 AM, Staff D stated that faucets should not be left dripping and should be turned off easily. Staff D stated they would replace the faucet handle cartridges in the affected sinks and start monitoring all sinks for dripping issues. STAINED CEILING TILES RESIDENT 97 According to the 08/06/2026 admission Minimum Data Set (MDS - an assessment tool), Resident 97 had neurological conditions including functional limitations on at least one side of both upper and lower areas of their body. The MDS showed Resident 69 admitted on [DATE] and was completely dependent on staff for assistance with sitting, standing, toileting, upper and lower dressing, and personal hygiene. In an observation and interview on 08/12/2026 at 9:05 AM, Resident #97 stated they disliked the stained ceiling tiles above her bed, which they noticed most of the time since they were bed bound. Resident 97 stated the stains had been present since their admission. She stated their spouse would have replaced them promptly after a leak at home and they preferred the tiles be replaced. In an observation, interview and record review on 08/12/2026 at 11:05 AM, Staff A (Administrator) observed several stained ceiling tiles in the residents' main dining room located in the [NAME] Garden, as well as the stained ceiling tiles in Resident 97's room. Staff A stated the areas had been previously identified as needing repair due to past roof leaks. Staff A stated that these repairs were recognized but would need to be prioritized alongside other ongoing maintenance and improvement projects within the facility. Staff A stated resident rooms and common areas should be an important level of priority due to the residents' right to a homelike environment. LOWER-LEVEL SOILED CARPETS Observation on 08/13/2026 at 9:14 AM showed the main area carpeting had staining in high-traffic zones including a large stain directly outside the elevator and heavily soiled areas outside the kitchen, laundry and Tea Garden entrances. In an observation, interview and record review on 08/14/2026 at 11:35 AM, Staff D (Maintenance Director) toured the facility and confirmed the stained carpeting in the Lower level. Review of the Physical Plant Improvement Plan, dated 08/14/2026, showed an entry on 03/10/2026 for carpet cleaning in the Lower-level corridor and to clean the carpet regularly. Staff D stated they were currently training staff on how to operate the carpet cleaning equipment but had not gotten to the Lower-level area yet. Staff D stated the stained ceiling tiles should have been identified by nursing staff and logged into the maintenance binder on the [NAME] nursing station desk at the time of the leak, but it was not. Staff D reviewed the facility's maintenance reporting system (TELS) to determine whether entries had been made for ceiling tile repairs or carpet cleaning, but they were not. Staff D stated completing the repairs in a timely manner was important to ensure residents a safe and homelike environment. In an interview on 08/14/2026 at 11:35 AM, Staff B (Director of Nursing Services) stated they expected nursing staff to identify repair concerns on the units and immediately log them into the maintenance binders on each nursing station desk. INVENTORY OF PERSONAL EFFECTS/MISSING ITEMS RESIDENT 11 According to the 08/06/2026 5-day Minimum Data Set (MDS - an assessment tool), Resident 11 had medically complex conditions, including impaired memory. Resident 11 was admitted to the facility on [DATE]. In an interview and observation on 08/10/2026 at 1:59 PM, Resident 11 sat in their wheelchair near the elevator and requested directions to the laundry department. Resident 11 stated they were missing clothing, including their only bra, two black T-shirts, and a pair of black shorts. Resident 11 stated staff had placed the clothing in a labeled, sealed bag approximately two weeks prior and told them laundry staff would label and return the items. Resident 11 stated the clothing had not been returned. Resident 11 stated housekeeping staff told them to come to the laundry room to potentially identify their clothing. In the meantime, housekeeping staff had brought Resident 11 clothing from the community racks containing unclaimed clothing from other residents to ensure they had something to wear. Resident 11 stated they were not happy wearing someone else's bra and clothing, and wanted their own clothing returned. Resident 11 arrived at the Lower-Level laundry door labeled Staff Only and waited outside until they recognized Staff G (Housekeeping Assistant) walking by. Resident 11 asked about their missing clothing. Staff G went to the laundry room to search and returned to tell Resident 11 they did not locate the items described but would continue to watch for them. Staff G stated, We're doing the best that we can. Staff G did not complete a grievance form for Resident 11 at that time. In an interview and observation on 08/10/2026 at 2:15 PM, Staff G stated laundry staff did not label clothing received in sealed bags, even when the bag had a label with the resident's information. Staff G stated they did not know who was responsible for labeling residents' clothing. Staff G stated when clothing was laundered without a label and the owner could not be identified, staff placed the item on a hanger, attached a paper with the date it was laundered, and stored it in a cabinet in case a resident later reported the item missing. Staff G was not aware of a process to return unlabeled clothing to residents. Staff G stated they were not aware they needed to complete a grievance form for Resident 11's concern of missing clothing. Review of Resident 11's undated IPE showed they were admitted with 1 blanket, 4 shirts, 1 fan, and 1 pair of shoes with no additional description of the items. The inventory did not identify whether laundry was to be completed by the facility or family and lacked the resident/responsible party's admission signature acknowledging the accuracy of the inventory. In an interview on 08/11/2026 at 8:13 AM, Staff H (Housekeeping Director) stated they recognized ongoing issues regarding missing laundry items. Staff H stated nursing staff completed the IPE process and laundry staff would then collect residents' clothing (excluding what the resident was wearing) and label the items with the resident's last name. Staff H stated nursing staff were responsible for labelling the clothing residents wore during admission and ensuring only items designated for facility laundering were sent to the laundry department. Staff H stated they were unsure where to locate the completed IPE binders on each unit and did not know whether they were allowed to review them due to privacy concerns. Staff H stated they were not aware that the form included laundry preferences or identifying information about each item. Staff H stated they kept a list of complaints of missing items verbalized by residents in their pocket and frequently chaperoned residents or their representatives to the clean laundry room to assist in identifying missing items. Staff H stated they did not use the IPE to confirm items given to residents belonged to them. Staff H stated there was a cabinet containing labeled items from discharged residents, but there was no established process to ensure these items were returned to their owners. Staff H stated they frequently received verbal complaints from residents about missing laundry but did not complete grievance cards and submit them to Staff A (Administrator/Grievance Officer) when items were not immediately found. In an observation and interview of the facility's clean laundry room on 08/11/2026 at 9:30 AM, two wall cabinets showed numerous unlabeled and unidentifiable clothing items and 1 cabinet containing multiple hangers with labelled and identified clothing for discharged residents. Staff H stated the clothing would be retained by the facility for 90 days after the day it was laundered and, if not claimed, would become community property for any resident to take. Staff H stated they were unaware of a process to ensure the labelled items in the discharged residents cabinet would be returned to the owners. RESIDENT 6 According to the 07/15/2026 admission MDS, Resident 6 admitted with moderate hearing loss and hearing aids on 07/11/2026. In an interview on 08/12/2026 at 1:06 PM, Resident 6's representative stated Resident 6 was discharged on 07/31/2026 without one of their hearing aids, a white sweater and a pillowcase. Resident 6's representative stated they immediately called the facility to report the concern and spoke to Staff I (LPN Unit Care Coordinator). Resident 6's representative stated they washed Resident 6's laundry at home and the sweater and pillowcase should not have been sent to the facility's laundry room. On 07/31/2026, Resident 6's representative returned to the facility and was escorted to the facility's clean laundry room by Staff H. The pillowcase was found but not the sweater. Resident 6's representative stated Staff H wrote down a description of the sweater and Staff I told them they would continue searching for the missing hearing aid, but no one had contacted them again. In an interview and record review on 08/14/2026 at 9:45 AM, Staff J (Certified Nursing Assistant) stated they completed the IPE process for Resident 6 and signed the form acknowledging the inventory was accurate on 07/15/2026, four days after admission. Review of Resident 6's IPE showed Staff J did not document where Resident 6's clothing would be laundered and did not have Resident 6's representative sign to acknowledge the accuracy of the inventory. Staff J stated the IPE should have been completed thoroughly upon admission and signed by Resident 6's representative but it was not. In an interview and record review on 08/14/2026 at 9:50 AM, Staff I stated they signed the IB for Resident 11 upon admission; however, the inventory was not dated, and the resident did not sign to acknowledge that the items listed represented a complete inventory of their personal belongings. Staff I stated Resident 11 was unable to sign for the items upon admission due to their medical condition. Staff I stated the items listed on the IPE lacked sufficient descriptive information to assist staff in identifying the items if they became lost or separated during laundering. Staff I stated they signed the IPE for Resident 6, upon discharge, but did not notice the hearing aids were not listed. Staff I recalled receiving a telephone call from Resident 6's representative regarding the missing items, but was unable to immediately locate the items and did not complete a grievance card to submit to Staff A. In an interview and record review on 08/14/2026 at 12:43 PM, Staff A stated they expected staff to complete the IPE thoroughly upon admission and include enough descriptive information as to assist in identifying lost items. Staff A stated they expected staff to label all residents' clothing items prior to being laundered and make every effort to return labelled items to the owner. Staff A stated that when a resident was unable to sign the IPE, two staff members were expected to sign on the resident's behalf to verify accuracy. Staff A stated they expected staff to follow facility policies and training, as well as state and federal regulations. Staff A stated it was important to protect the residents' right to have personal property treated with respect by maintaining an accurate inventory and properly managing complaints of missing items. Refer to F585 Grievances. REFERENCE: WAC 388-97-0880.

Based on observation, interview, and record review, the facility failed to ensure residents who were dependent on staff for daily cares received the assistance they required for 2 of 3 sample residents (Residents 3 & 21) reviewed for Activities of Daily Living (ADLs) and 2 supplemental residents (Residents 41 & 87). The failure to provide feeding assistance, nail care, and/or bathing assistance put residents at risk for poor nutrition, weight loss, embarrassment, poor personal hygiene and other negative health outcomes.Findings included.FACILITY POLICYAccording to the facility's Activities of Daily Living (ADLs) policy, revised 09/04/2025, residents would receive assistance as needed to complete ADLs. Any change in ability to perform ADLs would be reported to the nurse.According to the facility's Feeding a Resident policy, reviewed 09/10/2024, staff would assist residents as needed with meals and snacks and feed residents who were unable to feed themselves. FEEDING ASSISTANCE AND NAIL CARE RESIDENT 3 According to the 07/20/2026 Modified admission Minimum Data Set (MDS – an assessment tool), Resident 3 admitted to the facility on [DATE] with multiple diagnoses including a broken hip and cognitive issues. The MDS showed Resident 3 rarely made themselves understood and rarely understood others, required supervision or touching assistance with eating, including verbal cues and/or touching or steadying assistance, and required substantial/maximal assistance with personal hygiene. Review of Resident 3's CP, dated 07/16/2026, showed staff were to provide assistance with ADL's and assistance with meals as needed. Observations on 08/10/2026 at 3:55 PM and 08/12/2026 at 1:30 PM showed Resident 3 lying in their bed. Resident 3's fingernails on both hands were observed to be long, extending past their fingertips, with brown debris under each fingernail. Review of the facility's Meal Times, provided on 08/10/2026, showed breakfast was scheduled to be served daily at 7:50 AM on Resident 3's unit. Observation on 08/13/2026 at 8:51 AM showed Resident 3's hallway door was kept closed. Resident 3 was observed lying in bed on their back with the head of the bed elevated, with their breakfast tray on the overbed table in front of them. Resident 3 appeared to be resting and was not attempting to eat their meal. Continuous observations on 08/13/2026 from 08:51 AM to 10:10 AM showed no staff attempted to provide feeding assistance for Resident 3. In an interview and observation on 08/13/2026 at 10:50 AM, observation showed Resident 3 lying in bed with their breakfast tray on the overbed table in front of them. The food and drinks appeared to be untouched, utensils were wrapped tightly in a napkin, and condiment packets were unopened. Resident 3 stated they would like to eat but needed some help. Resident 3 was observed chewing on one of their long, dirty fingernails. In an interview and observation on 08/13/2026 at 10:53 AM, three hours after the scheduled breakfast time, Staff O (RN Unit Nurse) confirmed that Resident 3's breakfast tray appeared untouched and stated that a Certified Nursing Assistant (CNA) was coming to feed them. Staff O confirmed that Resident 3's fingernails were long and dirty and needed to be trimmed. Observation with Staff O of Resident 3's toenails showed they were long, and Staff O confirmed they should be trimmed. In an interview on 08/13/2026 at 11:24 AM, Staff P (CNA) stated that they did not usually work on that unit, and they were not aware that Resident 3 needed feeding assistance. In an interview on 08/13/2026 at 1:47 PM, Staff M (RN Unit Coordinator) confirmed that staff should have provided feeding assistance for Resident 3 in a timely manner per their CP but they did not. Staff M stated that because of the delay and food safety concerns, Resident 3 was unable to eat their breakfast and instead had an early lunch. In an interview on 08/14/2026 at 1:15 PM, Staff B (Director of Nursing) stated that they expected staff to provide feeding assistance for Resident 3 while their food was still hot, but they did not. Staff B stated they expected staff to keep residents' nails clean and short as residents allow, and they should not have long, dirty fingernails. SHOWERS AND BATHING RESIDENT 41 According to the 07/31/2026 admission MDS, Resident 41 admitted to the facility on [DATE] with diagnoses that included hip fracture and multiple trauma, mild cognitive impairment, and anxiety disorder. The MDS showed Resident 41 was incontinent of bowel and bladder, and was dependent on staff for toileting hygiene, shower and bathing, and personal hygiene. In an observation and interview on 08/10/2026 at 9:17 AM, observation showed Resident 41 lying in bed. Resident 41 stated they had not had a shower since their admission to the facility, 13 days earlier. Resident 41 stated staff had not offered them a shower or a bed bath and stated they would like to shower if the shower was warm. Review of Resident 41's Activity of Daily Living (ADLs) assistance care plan (CP), revised 07/30/2026, showed one staff was to assist Resident 41 with a bed bath. Review of Resident 41's July and August 2026 shower task record showed no documented shower or bathing assistance had been provided since the resident's admission and no documented refusal of showering or bathing. Review of Resident 41's progress notes showed no documentation that the resident had refused a shower or bed bath since their admission. In an interview and record review on 08/14/2026 at 09:30 AM, Staff E (Unit Care Coordinator-Licensed Practical Nurse-LPN) stated residents were supposed to receive showers or baths at least twice weekly or according to their preferences if they desired more frequent bathing. Staff E stated residents shower preferences were assessed upon admission, and staff were expected to provide shower or bathing assistance according to the resident's scheduled bathing days or preferences. Staff E reviewed Resident 41's records and confirmed there was no documentation that shower or bathing assistance had been offered or provided since their admission on [DATE]. RESIDENT 21 According to the 08/03/2026 MDS, Resident 21 admitted to the facility on [DATE] with diagnoses including a urinary tract infection, cognitive deficits, and memory impairment. The MDS showed Resident 21 was occasionally incontinent of bowel and bladder and was dependent on staff for toileting hygiene, shower and bathing, and personal hygiene. Observation on 08/10/2026 at 1:24 PM showed Resident 21 sitting in a wheelchair in the dining room area. Resident 21 was observed to have facial hair present on the chin and around the mouth area. Review of Resident 21's shower task record showed Resident 21 received a shower 07/30/2026, 11 days earlier, with no other documentation of shower or bath assistance and no documented refusals of bathing care. In an interview and record review on 08/14/2026 at 09:30 AM, Staff E reviewed Resident 21's records and confirmed there was no documentation that shower or bathing assistance had been offered or provided since 07/30/2026. RESIDENT 87 According to a 07/23/2026 admission MDS, Resident 87 admitted to the facility with multiple diagnoses, including stroke, paralysis of one side of their body, and mild cognitive deficit. The MDS showed Resident 87 was always incontinent of bowel and bladder, was dependent on staff for shower and bathing, required substantial/maximal assistance for toileting hygiene, and required partial/moderate assistance with personal hygiene. The MDS showed Resident 87 had no refusals of care during the assessment period. Observation on 08/10/2026 at 9:53 AM showed Resident 87 lying in bed. Black debris was observed underneath the fingernails of both of Resident 87's hands Review of Resident 87's shower task record showed the last documented shower assistance was provided on 07/30/2026, 11 days prior. Review of Resident 87's records showed no documentation the resident had refused care related to showering or bathing. Review of a revised 07/22/2026 ADL Assistance CP directed one staff to provide bed bath assistance for Resident 87. In an interview and record review on 08/14/2026 at 09:30 AM, Staff E reviewed Resident 87's records and confirmed there was no documentation that shower or bathing assistance had been offered or provided to Resident 87 since 07/30/2026. In an interview on 08/14/2026 at 12:14 PM, Staff B stated staff were expected to provide ADL care to all residents, including showering and bathing, according to the residents schedules and preferences, but they did not. Staff B stated showering and bathing helped prevent health complications including skin breakdown. REFER to F656 – Develop/Implement Comprehensive Care Plan. REFERENCE: WAC 388-97-1060(2)(c).

Based on interview and record review, the facility failed to ensure residents received care and treatment in accordance with their assessed needs and professional standards of practice for 1 of 5 residents (Resident 1) reviewed for bowel care. The failure to assess a resident's change in condition, address identified signs and symptoms of distress, and notify the physician when residents present with diarrhea (multiple episodes of loose bowel movement) placed residents at risk for nutrition and hydration problems and a decreased quality of life.Findings included.<Resident 1>According to the 07/22/2025 admission Minimum Data Set (MDS- an assessment tool), Resident 1 was alert, oriented, and able to verbalize their needs. The MDS showed Resident 1 had medical conditions including kidney and heart diseases, unstable blood sugar levels in the body, bone infection, and amputation of their right toe. The MDS showed Resident 1 was given antibiotic medication during the assessment period. A 08/29/2025 Discharge MDS showed Resident 1 was discharged to a hospital.Review of Resident 1's 08/11/2025 Care Plan (CP) showed the resident was at risk for rehospitalization due to their complex medical condition. A 08/11/2025 CP intervention showed staff would provide timely communication to the physician and/or nurse practitioner regarding any change in Resident 1's condition.Review of Resident 1's August 2025 Bowel Monitor log showed staff documented Resident 1 started having loose bowel movements from 08/20/2025 until 08/29/2025. On 08/27/2025, Resident 1 had four documented episodes of diarrhea in one day.A 08/27/2025 Physical Therapy (PT) treatment encounter noted showed Resident 1 verbalized they had a terrible night sleep related to frequent brief changes because of their ongoing diarrhea.A 08/29/2025 PT treatment encounter note showed Resident 1 verbalized feeling very fatigued and did not have any energy because of their ongoing diarrhea. The note showed Resident 1 exhibited distress during therapy session due to their weakness. The note showed, .the Occupational Therapist reported [Resident 1's] anxiety to the nurse.On 09/02/2025 at 12:48 PM, Resident 1's representative stated the resident had several diarrheal episodes and the facility staff did not realize Resident 1 was in distress. The representative stated it was Resident 1 themself who told the nursing staff to send them to the hospital on [DATE].Review of Resident 1's medical records showed there was no indication the nursing staff assessed Resident 1's ongoing diarrhea, addressed the resident's identified distress, or informed the physician of the resident's condition as indicated in Resident 1's CP.In an interview on 09/12/2025 at 1:38 PM with Staff B (Director of Nursing), documentation of assessment, interventions, or physician notification regarding Resident 1's ongoing diarrhea was requested but none was provided. Staff B stated there was no documentation to provide. Staff B stated they expected the nursing staff to assess Resident 1's diarrhea, provide interventions accordingly, and to notify the physician within 24 hours, but the staff did not do them as expected. When Staff B was asked for the facility policy regarding standards of care for a resident with diarrhea, Staff B stated, We don't have a policy for that.REFERENCE: WAC 388-97-1060 (1)

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a sanitary environment to help prevent the transmission of communicable diseases. The facility: failed to follow Contact Precautions signs for 3 of 5 residents (Residents 167, 265, & 270) and 2 supplemental residents (Resident 47, & 44) reviewed for Transmission-Based Precautions (TBP - airborne, contact, and droplet precautions used to prevent the spread of transmissible diseases); failed to follow Enhanced Barrier Precautions (EBP) for 1 of 1 residents (Resident 44) reviewed for EBP; failed to ensure the ice scoop was only used by staff on 1 of 4 units (Lily Garden). The failure to wear PPE (Personal Protective Equipment - gowns, gloves etc.) when required for residents with TBP or EBP orders and prevent potential cross contamination from an ice scoop placed residents at risk for facility-acquired/healthcare-associated infections and related complications. Findings included . <Facility Policy> Review of the facility's revised 09/24/2024 Transmission Based Precautions and Isolation Procedures policy showed the facility would implement TBP to prevent or control infections when necessary. Review of the facility's 06/13/2024 Contact Precautions policy showed when contact precautions were implemented, the use of PPE was required and resident risk factors that increased the likelihood of transmission would be identified, including incontinence. The policy showed the facility should ensure healthcare personnel were educated and trained regarding the appropriate use of PPE prior to caring for a resident. The policy showed when a resident was transported outside of their room for medically necessary purposes, the transporter would discard contaminated PPE before transport and wear clean PPE to work with the resident at the destination. The Policy showed the facility would clean high touch areas, patient bathrooms, and areas close to the resident daily, and showed housekeeping should wear a gown and gloves before cleaning and disinfecting a Contact Precautions resident's room. <Contact Precautions> <Resident 167> According to the 06/09/2025 admission 5 Day Minimum Data Set (MDS - an assessment tool), Resident 167 admitted to the facility with respiratory issues and a bladder infection. The MDS showed Resident received intravenous antibiotic medications every day during the assessment period. The MDS showed Resident 167 had an indwelling catheter (a flexible tube inserted into the bladder to drain urine) and was assessed to require maximal assistance from staff for their toileting hygiene. Observations on 06/09/2025 at 10:23 AM, on 06/10/2025 at 9:12 AM, and on 06/11/2025 at 8:00 AM showed a Contact Precautions sign was posted outside Resident 167's room that instructed all staff to perform hand hygiene and to wear PPE before entering the room. An isolation cart with PPE was placed outside Resident 167's room. In an interview on 06/09/2025 at 11:02 AM, Staff N (Registered Nurse) stated Resident 167 required contact precautions because the resident had a urinary infection. Staff N stated staff had to wear PPE before they entered the room and needed to remove PPE inside the room before they exited the resident's room. Staff N stated staff had to sanitize their hands before they entered the room and before they left the resident's room. Observation on 06/11/2025 at 8:57 AM showed Staff W (Certified Occupational Therapy Assistant) enter Resident 167's room without any PPE while Resident 167 ate breakfast. Staff W talked to the resident for a few minutes, then left the room and talked to the floor nurse in the hallway and left the unit. In an interview on 06/11/2025 at 12:10 PM, Staff W stated they had to follow the instructions on the sign posted outside Resident 167's room for Contact Precautions. Staff W read the directions on the posted sign and stated they should have put on PPE before they entered the room, but they did not. <Resident 47> Observation of lunch service on the [NAME] Garden unit on 06/09/2025 at 11:55 AM showed Staff T (Certified Nurse's Assistant) enter room [ROOM NUMBER] to deliver Resident 47 a lunch tray. The Contact Precautions sign outside the door showed anyone entering the room should perform hand hygiene and put on a gown and gloves prior to entering the room. Staff T was observed to enter the room without performing hand hygiene or putting on a gown and gloves as directed on the sign. In an interview on 06/13/2025 at 10:31 AM, Staff S (Infection Preventionist) stated all staff should follow the directions on the signs posted outside residents' rooms to prevent the spread of infections. Staff S stated staff should wear PPE before they enter Contact Precautions rooms. When asked if the therapist should wear PPE as directed by the sign posted on the resident's door, Staff S stated the therapist should wear PPE before entering the room, but they did not. <Resident 265> According to the 06/02/2025 admission MDS, Resident 265 had a diagnosis of a bone infection in their back and was being treated with an intravenous antibiotic. Review of 05/28/2025 physician's orders showed Resident 265 required Enhanced EBP related to their PICC line (Peripheral Inserted Center Catheter - tubing used to administer medications directly into the bloodstream). Observation on 06/09/2025 at 8:43 AM showed Resident 265 had a Contact Precautions sign (rather than the EBP ordered) outside their door that directed all staff to use gloves, a gown, and a mask whenever they entered Resident 265's room. In an interview on 06/10/2025 at 9:58 AM Resident 265 stated they walked around the unit often and worked on puzzles in the dining room without using a gown or mask. Observation on 06/12/2025 at 9:00 AM showed Resident 265 standing at the nurses' station and then entering the dining room without a mask or gown. Observation on 06/12/2025 at 9:11 AM showed Staff U (Housekeeping Assistant) cleaning Resident 265's room without a gown on. Staff U stated they were unsure if the Contact Precautions posted on Resident 265's room applied to housekeeping tasks. Staff U stated they were confused because Resident 265 sat everywhere on the unit and was in the dining room now without gown or gloves, so they did not understand why Resident 265 was still on contact precautions. <Resident 270> According to the 05/27/2025 admission MDS, Resident 270 had muscle weakness and a history of urinary tract and pneumonia infections. Review of the 06/04/2025 Infection CP showed Resident 270 required Contact Precautions due to the presence of bacteria in their urine. Review of the 05/21/2025 Activities of Daily Living (ADLs - washing, grooming, dressing, showering, oral hygiene etc.) and Therapy Services CP showed Resident 270 received therapy services to maintain their level of function. Record review showed a 05/21/2025 physician's order for Resident 270 for Contact Precautions due to the presence of a multi-drug-resistant bacteria in their urine. Observation on 06/12/2025 at 1:54 PM showed Staff V (Physical Therapy Assistant) escorting Resident 270 from the therapy room to the dining room after therapy. Staff V did not have a mask, gown, or gloves on. Observation on 06/13/2025 at 9:01 AM showed Staff V transferring Resident 270 from their room to the activity room while Staff V did not wear a gown. Observation on 06/13/2025 at 9:25 AM showed Resident 270 in the therapy room with no gown, gloves, or mask on while they worked with Staff V who only wore a mask and was seated next to Resident 270. At that time, Staff V stated they should wear a gown, gloves, and a mask when working with residents who required contact precautions. Staff V stated they used a gown when transferring Resident 270 today but no longer used one during therapy. <EBP/Urostomy Care> <Resident 44> According to the 05/30/2025 admission MDS, Resident 44 had diagnoses that included cancer of the urinary system and an artificial opening of their urinary tract. The MDS showed Resident 44 was dependent on staff for their ADLs including showers and lower body dressing. Review of the 06/03/2025 Risk for Rehospitalization CP showed Resident 44 had a recent surgery of their urinary system and was at risk for a break in their skin integrity. The CP showed staff were to clean and dry the resident's skin after each incontinent episode. Review of a 05/29/2025 physician's order showed Resident 44 required Enhanced Barrier Precautions related to their urostomy bag. Observation on 06/09/2025 at 8:42 AM showed a Contact Precautions sign posted outside Resident 44's room. In an interview on 06/12/2025 at 9:48 AM Resident 44's family member stated Resident 44's urostomy bag was changed but continued to leak. Observation at that time showed Resident 44's urostomy bag leaking. There was a puddle of urine on Resident 44's abdomen and their bedding and gown were soiled with urine. In an interview on 06/13/2025 at 9:09 AM Resident 44's family member reported Resident 44's urostomy bag continued to leak. The family member stated staff changed Resident 44's urostomy bag the prior night and left the soiled linen on the resident's table in their room. Resident 44's family member pointed out the soiled laundry observed in Resident 44's closet. <Tea Garden> On 06/10/2025 at 9:55 AM Resident 32's family member were observed exiting Resident 32's room and entering the unit dining room for a cup of water. Resident 32's family member reached into an unlabeled ice cooler left on a dining table and scooped ice into a cup without hand hygiene or wearing gloves. The sign outside Resident 32's door showed Resident 32 required EBP. In an interview on 06/13/2025 at 8:52 AM Staff S stated every staff member including housekeeping and therapy should know about EBP and contact precautions and when to use them. Staff S stated residents' precaution status was documented in their medical record, so all staff were aware. Staff S verified the sign outside Resident 265's door and stated the sign was incorrect and Resident 265 should be on EBP precautions and not Contact Precautions. Staff S stated some signs outside rooms on the unit were incorrect and someone had placed signs on for Contact Precautions instead of EBP. Staff S stated visitors should not use the ice scoop. In an interview on 06/16/2025 at 9:59 AM Staff E (Unit Care Coordinator) stated Resident 44's linens and personal laundry should be bagged and brought to the laundry room, cleaned and should not be left in Resident 44's room due to infection control concerns. In an interview on 06/16/2025 at 10:32 AM Staff B (Director of Nursing) stated staff should keep Resident 44's urostomy area clean and dry, and all linen and laundry should be removed and laundered promptly rather than keeping it in Resident 44's room for hygiene and infection control reasons. REFERENCE: WAC 388-97-1320 (1)(a), (2)(b). .

Based on observation, interview, and record review the facility failed to prepare food under sanitary conditions for 1 of 1 facility kitchens. The failure to ensure cooking surface sanitizer was available at a suitable concentration and ensure exhaust fans were clean placed residents at risk for contaminated food and food-borne illness. Findings included . <Facility Policy> According to the facility's 05/01/2025 Prevention of Cross Contamination policy, the facility must store, prepare, distribute and serve food in accordance with professional standards for food service safety. The policy showed all equipment, utensils, counters, workstations, and cutting boards should be cleaned and sanitized per department guidelines. <Initial Kitchen Observations> Observation of the facility kitchen on 06/09/2025 at 8:40 AM (a Monday morning) showed the facility kitchen had two red buckets of surface sanitizer prepared. Testing of both buckets showed neither bucket had an effective concentration of sanitizer. The test strip remained orange rather than turning green, indicating the sanitizer was not strong enough. At that time, Staff I (Food Service Manager - Dietary Manager) entered the kitchen and announced to the other dietary staff that they had no sanitizer concentrate and they needed to go to a sister facility to get some. Staff I stated the weekend staff did not let them know they ran out. Observation on 06/12/20025 at 11:05 AM showed there were four square exhaust fans placed in the ceiling of the steam table area of kitchen where resident meals were assembled for distribution after cooking. The four fans had an accumulation of dirt/dust/grime forming the same pattern on each fan due to the airflow caused by the shape of the fans. One of the fans was located directly above the steam table, increasing the potential of contaminants falling from the fan into a resident's meal. In an interview on 06/12/2025 at 1:03 PM, Staff I stated weekend staff did not tell them they ran of sanitizer concentrate but they should so they could maintain a clean kitchen. Staff I observed the exhaust fans and stated they saw the debris build up on the fans, including a hanging piece of dust. Staff I stated the facility's maintenance department was responsible for cleaning fans. Staff I stated they felt the surface of the fans allowed dust to accumulate too easily. REFERENCE: WAC 388-97-1100 (3), -2980. .

Based observation, interview, and record review, the facility failed to ensure the provision of skin care for residents with skin impairments for 1 of 4 residents (Residents 113) reviewed for non-pressure skin; provide bowel/constipation care for 2 of 4 residents (Residents 3 & 166) reviewed for constipation. These failures placed residents at risk for avoidable discomfort, skin breakdown, pain, and infection. Findings included . <Facility Policy> According to the facility's 07/09/2024 Skin Integrity . policy, a comprehensive skin inspection/assessment would be completed on admission to the facility. The policy showed skin assessments should be completed weekly and any changes reported to the nurse. According to the facility's 09/12/2023 Bowel Protocol policy, the facility would provide effective interventions for constipation consistent with current standards of practice. The policy showed nursing staff would document in the record each time a resident had a Bowel Movement (BM), and the physician would implement standing orders to address any lack of BM. <Skin Care> <Resident 113> According to the 06/06/2025 admission MDS, Resident 113 had diagnoses including cancer, and fractures to their pelvic area and left upper arm. The MDS showed Resident 113 had no skin impairments. Review of the 06/03/2025 Nursing Admission/readmission Collection Tool showed Resident 113 was identified with redness to the skin of their pelvic area, and some edema (swelling) in their left arm. No other skin impairments were identified on this assessment. In an interview and observation on 06/10/2025 at 8:47 AM Resident 113 stated they had a skin impairment on their elbow that hurt. Resident 113 rolled up their sleeve to show their right elbow had a dark brown/black scab-like skin impairment on the inside of their right elbow that was half an inch in diameter. Review of the 06/10/2025 weekly skin assessment Resident 113 had redness in their lower back area and upper vertebrae and edema on their left arm. The skin impairment on Resident 113's right elbow was not noted on this weekly skin check. The weekly skin check showed it had an effective date of 06/10/2025, 9:42 AM. In an interview on 06/16/2025 at 10:22 AM Staff M went to Resident 113's room and examined the resident's elbow. Staff M noted the skin impairment and stated it looked like a scab. Staff M stated it looked like it was present for some time and should have been noted on the weekly skin check and identified by CNAs during care. Staff M stated the skin impairment should be assessed and treated. <Bowel Care> <Resident 3> According to the 04/22/2025 Quarterly Minimum Data MDS, Resident 3 had intact memory, and had multiple Gastrointestinal (GI - stomach/bowel) diagnoses. The MDS showed Resident 3 was always incontinent of bowel and depended on staff for toileting assistance. Record review showed the following orders: a 03/26/2025 physician's order to provide 30 Milliliters (ML) of Milk of Magnesia (MOM) if no bowel movement (BM) in three days; a 03/26/2025 for a suppository bowel medication to be given as needed if no results after eight hours from MOM; a 03/26/2025 order for an enema to given as needed if no results after eight hours after the suppository. In an interview on 06/10/2025 at 11:15 AM Resident 3 stated they often were constipated due to their diagnoses. Resident 3 stated I am not like other people when it comes to my bowels. I have a condition, and they just work different for me. Review of the May 2025 bowel documentation showed Resident 3 was documented to not have a bowel movement between 05/18/2026 at 2:12 PM through 05/26/2025 at 5:11 AM, over seven days later. Review of the May 2025 Medication Administration Record (MAR) showed Resident 3 was given MOM on 05/22/2025 at 2:27 PM. The MAR showed Resident 3 was not provided a suppository 8 hours after a nurse gave them MOM even though Resident 3 did not have a BM for three and a half more days. In an interview on 06/16/2025 at 10:17 AM Staff M (Unit Care Coordinator) stated Resident 3 experience constipation frequently related to their GI diagnoses. Staff M stated it was important to treat Resident 3's constipation when present but the resident was self-directive with their care and sometimes refused treatment. Record review showed no documentation Resident 3 refused bowel care between 05/18/2026 at 2:12 PM through 05/26/2025 at 5:11 AM. <Resident 166> According to the 06/03/2025 admission MDS, Resident 166 had no memory impairment, and had multiple medical conditions including cancer, kidney disease, and respiratory issues. The MDS showed Resident 166 was always continent of bowel and required moderate assistance from staff with transferring and toileting needs. The MDS showed Resident 166 had no rejection of care during assessment period. Record review showed the following physician's orders for Resident 166: a 05/30/2025 order for 30 ML of MOM if no BM in three days; a 05/30/2025 for a suppository bowel medication as needed if no results after eight hours from MOM; a 05/30/2025 order for an enema as needed if no results eight hours after the suppository. In an interview on 06/10/2025 at 8:59 AM, Resident 166 stated they last had a BM more than a week ago and they were constipated. Review of June 2025 bowel records showed Resident 166 last had a BM on 06/03/2025. The documentation showed Resident 166 had no BM between 06/04/2025 through 06/10/2025, a total of seven days. Review of the June 2025 MAR on 06/10/2025 at 8:39 AM showed Resident 166 did not receive bowel medications as ordered per the facility bowel protocol. In an interview on 06/13/2025 at 9:14 AM, Staff N (Registered Nurse) stated if residents did not have a BM for three days, staff must follow the BM protocol. Staff N reviewed Resident 166's bowel record and stated Resident 166 did not have BM for seven days from 06/04/2025 through 06/10/2025 and staff did not provide Resident 166 their bowel medications as ordered. In an interview on 06/13/2025 at 9:21 AM Staff O (Unit Care Coordinator) reviewed Resident 166's bowel record and MAR, and stated Resident 166 did not have a BM for seven days and staff did not administer the BM medications as ordered. Staff O stated staff should follow the facility's BM protocol, but they did not. REFERENCE: WAC 388-97-1060 (1). .

Based on observation, interview, and record review the facility failed to ensure residents received timely specialized rehabilitative services for 1 of 4 residents reviewed for therapy services (Resident 113). The failure to timely complete a Speech Language Pathologist (SLP - a speech therapist) evaluation placed Resident 113 at risk for unnecessary diet restrictions, weight loss, and a diminished quality of life. Findings included . <Resident 113> According to the 06/06/2025 admission Minimum Data Set (MDS - an assessment tool) Resident 113 had a moderate memory impairment and no signs and symptoms of a possible swallowing disorder. The MDS showed Resident 113 admitted to the facility on [DATE], received a mechanically altered diet on admission and while a resident at the facility, and received no SLP services during the MDS's lookback period. Record review showed Resident 113 had a 06/03/2025 dietary order for a regular diet with an easy to chew texture and chopped meats. According to the 06/03/2025 Nursing Admission/readmission Collection Tool, Resident 113 was noted with no chewing or swallowing issues at that time but did require swallowing precautions. According to the 06/06/2025 Nutritional Assessment Resident 113 disliked the food they were served. The assessment showed Resident 113 told the registered dietician they did not like their meat to be ground up. In an interview on 06/10/2025 at 8:42 AM Resident 113 stated they did not like the food they were served. They chop everything up. It looks like it has been chewed. Resident 113 stated no one explained why their food was the texture it was. Observation of Resident 113's breakfast tray showed the sausage served was ground, not served with a gravy, and was untouched by the resident. In an interview on 06/12/2025 at 9:17 AM Staff F (SLP) stated they completed an SLP evaluation and would provide the documentation. Staff F stated she assessed Resident 113 with a mild swallowing impairment and stated they would provide clinical records related to Resident 113's SLP therapy. Review of the documentation Staff F provided showed on 06/11/2025 Staff F assessed Resident 113 with a mild swallowing impairment and agreed to upgrade Resident 113's diet from chopped meats to cut meats with extra sauce. There was no prior SLP documentation. In an interview on 06/13/2025 at 1:16 PM Staff J (Director of Rehabilitation) stated all admitting residents had standing orders for evaluation and treatment for physical and occupational therapy. Staff J stated they looked at the records of newly admitted residents and referred them as needed to the SLP for evaluation and treatment if they had needs such as orders for a modified diet or a memory impairment. Staff J stated the gold standard for the timeline to be seen by the SLP once a need was identified was a day or two. In an interview on 06/13/2025 at 1:20 PM Staff I (Food Service Manager - Dietary Manager) stated both the registered dietician and SLP could change dietary orders but only the SLP had the scope of practice to upgrade dietary orders. In an interview on 06/16/2025 at 12:35 PM Staff J confirmed Resident 113 had hospital orders for an altered texture diet. Staff J stated Staff I was on vacation when Resident 113 admitted but they could have used an outside SLP if the need was identified. Staff J stated they were unaware of Resident 113's complaints to the RD on 06/06/2025. Staff J stated a lack of notification from the dietary department prevented them from providing Resident 113 with SLP services and an upgraded diet until 06/11/2025, eight days after admission. Staff J stated it was a shame. REFERENCE: WAC 388-97-1280 (1)(a-b), (3)(a-b). .

Observation of the the freezer in the Tea Garden Unit's nourishment pantry on 06/13/2025 at 10:41 AM showed an opened package of glycerine swabs. The packaging stated it contained three swabs and two remained in the packet. The packaging stated it was sterile. There was no date on the swab packet indicating when it was opened or for how long the swabs could safely be used. REFERENCE: WAC 388-97-1300(2), -2340. Based on observation, interview, and record review, the facility failed to ensure proper storage and labeling of medications in 1 of 4 unit nutrition pantry fridges (Tea Garden) and 1 of 4 medication carts ([NAME] Unit) and failed to account for missing signatures in the narcotic book for 1 of 4 medication carts ([NAME] Unit) reviewed for medication storage. These failures placed residents at risk of receiving expired medications, ineffective treatment, missing medications and a diminished quality of life. Findings included . <Policy> According to the facility's revised 08/01/2024 Storage and Expiration Dating of Medications policy, the facility would record the date opened on the primary medication container (i.e vial, bottle, inhaler). When the medication had a shortened expiration date once opened, suspension medications or eye drops use would use a date opened and the expired date on the container. Medication for each resident would be stored in the containers in which they were originally received. The policy showed controlled medications must be counted with another designated staff member when there was an exchange of keys to the medication cart, such as at the time nursing staff changed shifts. <[NAME] Medication Cart> On 06/11/2025 at 11:06 AM, observation showed one steroid inhaler on the top drawer of medication cart, without a box, unlabeled with no resident name. The medication counter (doses administered and/or remaining) was set at dose 28 which showed the medication was used. Another steroid as needed inhaler was observed inside a box and opened with no open and discard date on the container. In an interview on 06/11/2025 at 11:28 AM, Staff L (Registered Nurse) stated, even if the facility knew for which resident the steroid inhaler was intended, the medication container should have had a resident name on it and dated when it was first opened and a date of when to discard the medication for resident safety. In an interview on 06/11/2025 at 11:35 AM Staff M (Unit Care Coordinator) stated they expected the nurses to ensure medications were labeled and dated to prevent medication errors and to ensure resident safety. <Narcotic Book> Observation on 06/11/2025 at 10:59 AM, showed narcotic logbook on the medication cart ([NAME] Unit) had five times in May 2025: on 05/10/2025, 05/17/2025, 05/21/2025, 05/22/2025, and 05/27/2025 where nurses did not sign the logbook to show they counted medications to ensure the correct count of narcotic medications. In an interview on 06/11/2025 at 11:06 AM, Staff L stated the signatures were missing and nurses should sign the book during shift change to show the narcotic count was correct, but they did not. In an interview on 06/11/2025 at 11:35 AM, Staff M stated they expected the nurses to reconcile the narcotic count and sign the narcotic log books to ensure they attest to its accuracy at shift change. Staff M stated it was important to maintain this practice consistently to prevent drug diversion and to avoid the dangers involved in missing narcotics.

<Resident 115> According to the 04/24/2025 admission MDS, Resident 115 had medical conditions including brain cancer. The MDS showed Resident 115 developed brain abscess (accumulation of pus within the tissues) while recovering from the surgical resection (the process of cutting out tissue or part of an organ) of their brain tumor. The 04/21/2025 pain CP showed Resident 115 expressed discomfort/pain related to their recent brain surgery, back pain, bilateral leg pain from having blood clots, and generalized deconditioning. The CP outlined interventions directing the nursing staff to administer pain medications to Resident 115 as ordered by the physician and to notify the physician if interventions were unsuccessful or if there was a significant change from the resident's past experience of pain. A 04/21/2025 physician's order instructed staff to administer an over-the-counter pain reliever every six hours as needed for a pain level of one-to-three on the zero-to-ten pain scale. An additional 04/21/2025 order instructed staff to administer a narcotic pain reliever every eight hours as needed for severe pain. This order did not have pain level parameters. A 05/04/2025 progress note showed Resident 115 was in distress and requesting more pain relief related to the pain on their back and bilateral legs that was not relieved by either the over-the-counter or the narcotic pain medications administered by the nurse. In an interview on 05/16/2025 at 10:20 AM, Resident 115's representative stated the resident's pain was not effectively managed, particularly the pain on the resident's legs. In an interview on 06/11/2025 at 9:38 AM. Staff M (Unit Care Coordinator) stated the nursing staff used the zero-to-ten pain scale when assessing a resident's pain level. Staff M stated the over-the-counter pain medication would not be effective for the higher pain level, .that is why it [the over-the-counter medication] was ordered for a pain level of 1-3 only. In an interview on 06/11/2025 at 9:56 AM, Staff B (Director of Nursing) stated pain management was important because it enhanced a resident's quality of life. Staff B reviewed the administration of Resident 115's over-the-counter pain medication and stated the nurses should not have administered when the resident rated their pain at four or higher. REFERENCE: WAC 388-97-1060 (1). .Based on interview and record review, the facility failed to ensure effective pain management was provided to residents, consistent with professional standards of practice. The failure to offer non-pharmacological interventions to residents experiencing pain and use sufficient parameters for administration of as needed (PRN) pain medications for 1 of 3 sampled residents (Residents 265) and one closed record (Residents 115) reviewed for pain management placed residents at risk for untreated pain, unnecessary discomfort, and a decreased quality of life. Findings included . <Facility Policy> Review of the facility's revised 04/22/2025 Pain Assessment and Management policy showed the facility must ensure residents received the treatment and care they needed in accordance with professional standards of practice, the comprehensive Care Plan (CP), and the resident's choices to manage their pain. The policy showed the facility would collaborate with the attending physician, other health care professionals, and the resident and/or their representative to prevent or manage each individual resident's pain. The policy showed the facility would address and treat the underlying causes of the pain to the extent possible by developing and implementing both non-pharmacological (not involving the use of drug/medication) and pharmacological interventions and approaches to pain management. <Resident 265> According to the 06/02/2025 admission Minimum Data Set (MDS - an assessment tool) Resident 265 was admitted to the facility on [DATE] and had a bone infection in their back that caused them to have back pain. Review of the 05/28/2025 Pain/Discomfort CP showed Resident 265 had pain related to their medical conditions. The CP showed staff were to anticipate Resident 265's need for pain relief and respond immediately to any complaints of pain. Review of a 05/28/2025 physician order showed staff were to assess pain and attempt non-pharmacological interventions prior to administering pain medications. Record review showed a 06/05/2025 physician order to give two tablets of pain medication every six hours as needed for pain if their pain level was seven or higher on a zero-to-ten pain scale and to give one tablet of pain medication if their pain level was between four and six on the pain scale. Review of the June 2025 Medication Administration Record (MAR) showed Resident 265's pain level was at an eight on 06/07/2025 and at a seven on 06/09/2025. The MAR showed Resident 265 received one tablet of the pain medication on 06/07/2025 and on 06/09/2025 instead of the two tablets ordered for that pain level. Non-pharmacological interventions were not provided prior to pain medication administration as ordered on 06/07/2025, 06/08/2025, and 06/09/2025. In an interview on 06/09/2025 at 12:01 PM, Resident 265 stated they had a biopsy (a procedure where a tissue sample is collected) on their back and two infections, and because of this they had back pain. In an interview and observation on 06/10/2025 at 9:59 AM Resident 265 stated on Friday, they were supposed to receive their pain medication that was ordered by their provider, but did not receive the correct dose until Monday morning. Resident 265 stated they told the nurses about their pain and were told they did not have the proper dose of the medication available. Resident 265 stated the nurses did not offer the correct medication for the pain they experienced and instead offered an over-the-counter pain medication instead which the resident refused because the over-the-counter pain medication did not help. Resident 265 became frustrated as they described the situation. In an interview on 06/16/2025 at 9:52 AM Staff E (Unit Care Coordinator) stated staff should have called the pharmacy and received the pain mediation immediately so Resident 265's pain could be effectively managed. In an interview on 06/16/2025 at 10:41 AM Staff B (Director of Nursing) stated staff should have called the provider right away to obtain the orders so Resident 265 could have their pain medication as ordered.

Based on observation, interview, and record review the facility failed to ensure activity programs met the needs of each resident for 3 of 3 residents (Resident 264, 265 & 270) reviewed for activities. The failure to provide meaningful activities left residents at risk of boredom and a diminished quality of life. Findings included . <Facility Policy> According to the facility's 09/2024 Activities policy, the facility would implement an ongoing activities program that incorporated residents' interests and created opportunities for each resident to have a meaningful life by supporting their wellness. The policy showed all residents who are unable or unwilling to participate in group programs would have consistent, goal oriented and individualized recreation opportunities. <Resident 264> According to the 06/02/2025 admission Minimum Data Set (MDS - an assessment tool) Resident 264 had intact memory and had symptoms of feeling down or depressed. The MDS showed it was very important for Resident 264 to do their favorite activities. Review of the 06/02/2025 Activity Care Plan (CP), showed Resident 264's goal was to express satisfaction in pursuing self-directed activities and to accept regular check-in visits and invitations to group programs. Review of Resident 264's record did not show where activity participation was tracked. In an interview on 06/09/2025 at 9:18 AM Resident 264 stated they were concerned the facility did not provide them with any activities to do. Resident 264 stated they should have a more personalized activity plan because they were younger than most of the residents on their unit. In an observation and interview on 06/09/2025 at 2:34 PM, Resident 264 stated there was not much to do, they were bored and stated all activities were meant for older residents. Resident 264 was observed ambulating around the unit in their wheelchair looking for things to do. Observation on 06/12/2025 at 12:50 PM showed Staff H (Activity Assistant) entering Resident 264's room and offer to paint their fingernails. Resident 264 stated they did not want their nails painted. Staff H offered no other activity. Observation on 06/12/2025 at 1:55 PM showed an activity calendar posted on the bulletin board near the nurses' station showing nail painting was scheduled twice that week and bingo on Sundays in the Tea Garden (Resident 264's unit). No other activities were scheduled for the unit. The same activities were scheduled the week prior. <Resident 265> According to the 06/02/2025 admission MDS, Resident 265 was admitted to the facility on [DATE] and had a bone infection in their back, back pain and used a walker. The MDS showed it was very important for Resident 265 to listen to music, keep up with news, do things with groups of people, do their favorite activities, and attend religious services. Review of the 06/02/2025 Activities CP, showed Resident 265 had a bone infection in their back with a goal that Resident 265 would accept regular check-in visits and invitations to out-of-room activities. The CP directed staff to regularly offer invitations and escorts to scheduled activities. Review of Resident 265's medical record did not show where activity participation was tracked. In an interview on 06/10/2025 at 9:49 AM Resident 265 stated they did puzzles in the dining room but that was all there was to do. Resident 265 stated it looked like other places in the building had activities going on but not on this unit. In an interview on 06/11/2025 at 12:43 PM Resident 265 stated no activities were scheduled that day and they planned to work on a puzzle today because they had nothing else to do. <Resident 270> According to the 05/27/2025 admission MDS, Resident 270 was admitted on [DATE] and had a memory impairment disorder. The MDS showed it was very important for Resident 270 to read books/newspapers, listen to music, and do their favorite things. Review of the 05/24/2025 Activities CP showed Resident 270 enjoyed all the activities at their assisted living facility before admission and enjoyed listening to their favorite radio station and having educational programs. Goals on the CP showed Resident 265 would express satisfaction in pursuing self-directed activities and accept regular check-in visits. Review of Resident 270's medical record did not show where activity participation was tracked. In an interview on 06/10/2025 at 10:15 AM, Resident 270 stated there was nothing to do so they just laid in bed all day. Resident 270 stated staff offered to paint their nails, but they already did this last week. In an observation and interview on 06/11/2025 at 12:51 PM Resident 270 was observed watching TV with the volume down and said there was no other activity to participate in. In an observation and interview on 06/13/2025 at 12:25 PM Staff G (Activities Director) stated they and their assistant conducted one-on-one activities for residents, especially those who could not leave their room and they tried to touch base with every resident every day. Staff G stated for younger residents they were still trying to learn what activities to offer them and knew they had to find activities to meet their needs. Staff G stated group activities rotated to different locations within the building but were primarily held in units with larger common areas. Staff G stated less activities were scheduled in the Tea Garden unit because they had a smaller dining room. Staff G observed the June 2025 activity calendar and stated there were not many activities scheduled in the Tea Garden Unit and there should be more. Staff G stated they did not currently document activities provided but knew they should, so they kept daily census sheets and checked off daily one-on-one visits being provided. Staff G provided 11 facility census lists used by the activities team to show when one-on-one visits occurred. The 11 censuses showed Resident 264 did not have any one-on-one visits, and Resident 270 had four, one-on-one visits since they admitted to the facility, three weeks ago. REFERENCE: WAC 388-97-0940 (1). .

Based on observation, interview, and record review, the facility failed to ensure residents who were dependent on facility staff for assistance with Activities of Daily Living (ADLs - personal hygiene, grooming, and bathing) received the assistance they were assessed to require for 4 of 9 residents (Residents 36, 45, 166, & 167) reviewed for ADLs. The failure to provide ADL assistance to dependent residents as required left residents at risk for poor hygiene, diminished feelings of self-worth, and other negative health outcomes. Findings included . <Facility Policy> Review of the facility's 02/12/2024 Activities of Daily Living policy showed the facility would provide all treatment and care based on the comprehensive assessment of the resident, person-centered Care Plan, and resident's choices. The policy showed residents who were unable to carry out their own ADLs would receive the necessary services to maintain good nutrition and personal hygiene including bathing, dressing, grooming, and oral care. The policy showed the facility would ensure residents' fingernails were clean and trimmed to avoid injury and infection. <Resident 36> According to the 05/05/2025 admission 5 Day Minimum Data Set (MDS - an assessment tool) Resident 36 admitted to the facility on [DATE] with respiratory issues. The MDS showed Resident 36 required assistance from staff for toileting, transferring, personal hygiene including shaving, oral care and bathing. The MDS showed Resident 36 did not refuse care during the assessment period. According to the 04/30/2025 ADL Care Plan (CP) Resident 36 needed ADL assistance and therapy services to maintain or attain their highest level of function. The CP showed Resident 36 required one-person assistance for showers/bathing, personal hygiene, and transfers. Observations on 06/09/2025 at 1:34 PM and on 06/11/2025 at 10:16 AM showed Resident 36 lying in their bed, not shaved with long dirty fingernails. In an observation and interview on 06/13/2025 at 11:27 AM, Resident 36 again had long, dirty fingernails, and was not shaved. Resident 36 stated staff were supposed to trim their fingernails and shave them, but no one did. Resident 36 stated they would ask their family to bring a razor to shave them. In an interview on 06/13/2025 at 8:37 AM, Staff N (Registered Nurse) stated Resident 36 needed assistance with all ADLs including personal hygiene. Staff N stated they did not get a report from staff that Resident 36 refused care. In an interview on 06/13/2025 at 9:42 AM, Staff O (Unit Care Coordinator) stated they expected staff to provide morning care to every resident including oral care, shaving, dressing, and trimming fingernails on shower days and as needed, but they did not. <Resident 45> According to the 04/21/2025 admission MDS, Resident 45 was admitted to the facility on [DATE] with lower body impairment after a stroke. The MDS showed Resident 45 was dependent on staff for transferring and toileting needs and required one person assistance with personal hygiene including shaving, oral care, clip fingernails, and bathing. The MDS showed Resident 45 did not refuse care during the assessment period. According to the 04/17/2025 ADL CP Resident 45 needed ADL assistance and therapy services to maintain or attain the highest level of function. The CP showed Resident 45 required one-to-two-person assistance with showers, personal hygiene, toileting, and transfers. Observations on 06/09/2025 at 11:59 AM and on 06/10/2025 at 9:09 AM showed Resident 45 in their bed with long, dirty fingernails. In an observation and interview on 06/12/2025 at 10:55 AM, Resident 45 again had long, dirty fingernails. Resident 45 stated they needed assistance from staff to clip their fingernails, but no one helped. In an interview on 06/13/2025 at 9:29 AM, Staff N stated Resident 45 needed assistance with showers, shaving, toileting and clip their fingernails. Staff N confirmed Resident 45 had dirty long fingernails and stated if residents refused care, staff should document in resident's record and report to the supervisor. In an interview on 06/13/2025 at 10:22 AM, Staff O stated their expectation from staff was to provide morning care to every resident in the morning as they allow to. Staff should offer and assist residents with oral care, shaving, and dressing every day. Staff O stated staff should provide showers to residents as scheduled and clip fingernails on shower days and as needed, but they did not. <Resident 166> According to the 06/03/2025 admission MDS, Resident 166 was admitted to the facility on [DATE] with anxiety disorder and respiratory issues. The MDS showed Resident 166 required moderate assistance with upper and lower body dressing, transferring, toileting, showers, and personal hygiene including shaving and nail care. The MDS showed Resident 166 had no behavior of rejecting care during the assessment period. According to 05/30/2025 ADL CP, Resident 166 needed ADL assistance and therapy services to maintain or attain the highest level of function. The CP showed Resident 166 required one person assistance with showers, personal hygiene, toileting, and transferring needs. Observations on 06/09/2025 at 10:24 AM showed Resident 166 in a wheelchair in their room. Resident 166 had long broken fingernails with black debris under them. In an observation and interview on 06/10/2025 at 10:42 AM, Resident 166 had long dirty fingernails. Resident 166's teeth were not brushed, their hair was greasy, and they were not shaved. Resident 166 stated they needed assistance from staff with all ADLs, but no one offered help. In an interview on 06/13/2025 at 10:22 AM, Staff O stated their expectation from staff was to provide morning care to every resident. Staff should offer and assist residents with oral care, shaving, and dressing every day. Staff O stated staff should provide showers to residents as scheduled and clip fingernails on shower days and as needed, but they did not. <Resident 167> According to the 04/09/2025 admission MDS, Resident 167 was admitted to the facility on [DATE] with respiratory issues and vision issues. The MDS showed Resident 167 was dependent on staff with upper and lower body dressing, transferring, toileting, showers, and oral care. The MDS showed Resident 167 required one person assistance with personal hygiene including shaving and nail care. The MDS showed Resident 167 did not reject care during the assessment period. The 06/06/2025 ADL Self Care Deficit CP showed Resident 167 required two person-assistance with showers, toileting, and transferring, and one-person assistance with oral care and personal hygiene including shaving and nail care. Observations on 06/09/2025 at 1:58 PM showed Resident 167 with long, dirty fingernails and greasy hair. Resident 167 was not shaved. Observation on 06/12/2025 at 8:53 AM showed Resident 167 receiving medications in bed from Staff N. Resident 167 had long, dirty fingernails, greasy hair, and was not shaved. In an interview on 06/12/2025 at 8:56 AM, Staff N confirmed Resident 167 had long, dirty fingernails and was not shaved. Staff N stated staff should shave the resident every day during morning care, provide showers as scheduled and clip fingernails weekly and as needed, but they did not. In an interview on 06/13/2025 at 10:22 AM, Staff O stated their expectation from staff was to provide morning care to every resident. Staff should offer and assist residents with oral care, shaving, and dressing every day. Staff O stated staff should provide showers to residents as scheduled and clip fingernails on shower days and as needed, but they did not. REFERENCE: WAC 388-97-1060(2)(c). .

Based on observation, interview, and record review the facility: failed to ensure physician ordered parameters for medications were followed for 3 of 17 (Resident 114 & 264) sampled residents; failed to ensure orders were clarified as needed for 2 of 5 residents (residents 18 & 166) whose medication regimens were reviewed; failed to ensure weights were monitored as ordered for 1 of 4 residents (Resident 115) reviewed for nutrition. These failures placed residents at risk for unmet needs, and ineffective and/or delayed treatments. Findings included . <Following Orders> <Resident 114> According to the 06/03/2025 admission Minimum Data Set (MDS - an assessment tool) Resident 114 had diagnoses including a stroke history and arthritis. The MDS showed Resident 114 frequently experienced pain during the lookback period. The MDS showed Resident 114's pain frequently made sleeping, participating in therapy, and day-to-day activities more difficult, and reached a severity of seven on a zero-to-ten scale. Observation on 06/10/25 10:55 AM showed Resident 114 in bed with familiy members present. Resident 114 stated they had left shoulder pain and pointed to their left shoulder and frowned. Review of the June 2025 Medication Administration Record (MAR) showed a 06/12/2025 physician's order for an as-needed pain medication. The order showed this medication should be given every four hours as needed for a pain six out of ten or more. The June 2025 MAR showed on 06/13/2025 Resident 114 was given this medication for a pain of five out of ten, outside the parameters of the order. In an interview on 06/16/2025 at 8:44 AM, Staff B (Director of Nursing) stated it was important for physician's orders to be followed and for medications to be given within the prescribed parameters. In an interview on 06/16/2025 at 12:49 PM, Staff B stated Resident 144's pain of 06/13/2025 did not meet the parameters of the pain medication. <Clarifying Orders> <Resident 18> According to the 06/06/2025 admission MDS, Resident 18 was admitted to the facility on [DATE] with clear speech, intact memory, and medical conditions including an anxiety disorder, heart failure, and trouble falling asleep. Observation on 06/09/2025 at 11:23 AM and on 06/11/2025 at 12:43 PM showed Resident 18 was lying in their bed and both feet were swollen. Record review showed a 06/03/2025 physician's order directing staff to give Resident 18 one tablet of an antianxiety medication every 24 hours as needed for severe anxiety and two tablets every 24 hours as needed for severe anxiety. Record review showed a 06/03/2025 physician's order directing staff to monitor Resident 18's edema every shift and document a score 0, 1+, 2+, 3+ (larger numbers indicate more severe swelling). This order did not indicate on what part(s) of Resident 18's body needed edema monitoring or if action was necessary for edema of a particular severity. Review of the June 2025 MAR showed staff documented Resident 18's edema was 0 every day. In an interview on 06/13/2025 at 8:19 AM, Staff N (Registered Nurse) stated the antianxiety medication order needed to be clarified with the provider to include parameters for when to give one tablet and when to give two tablets. Staff N stated staff should have clarified the edema monitoring order with the provider as well about which body part the edema should monitor and what to do if Resident 18 had 3+ edema but did not. In an interview on 06/13/2025 at 9:14 AM, Staff O (Unit Care Coordinator) reviewed the physician orders and stated the orders for antianxiety medication and to monitor edema were not clear. Staff O stated staff should clarify the orders with the provider to provide care, but they did not. <Resident 166> According to the 06/03/2025 admission MDS, Resident 166 was admitted to the facility with medically complex conditions including anxiety and difficulty falling asleep. The MDS showed Resident 166 received an antidepressant medication every day during the assessment period. Observation on 06/11/2025 at 8:49 AM showed Resident 166 awake but in bed with their breakfast to the side. Resident 166 was well rested. Record review showed: a 05/30/2025 physician's order directing staff to give Resident 166 one tablet of their antidepressant medication at bedtime for insomnia; a 05/30/2025 physician's order directing staff to give Resident 166 four tablets of a supplement every 24 hours as needed for insomnia. The order did not include parameters for staff to know when to administer the supplement 4 tablets for sleeping. In an interview on 06/13/2025 at 8:22 AM, Staff N stated the order PO was not clear about when to give as-needed sleep supplement to Resident 166. Staff N stated staff should have clarified the order with the provider, but they did not. In an interview on 06/13/2025 at 9:20 AM, Staff O reviewed Resident 166's physician's orders and stated the as needed order for sleeping medication was incomplete. Staff O stated staff should have clarified the order with the provider, but they did not.<Weight Monitoring> <Facility Policy> Review of the facility's revised 07/17/2021 Weights and Heights policy showed all residents were weighed within 24 hours of admission and then weekly for four weeks and as needed thereafter. The policy indicated the facility used the Lippincott procedures reference (a supplemental nursing care resource guide) for weight monitoring in Long-Term Care and showed malnutrition in residents could result from various conditions including cancer, heart failure, and decreased ability to participate in activities of daily living. The guidelines showed residents should be weighed on the same scale and at the same time of the day, typically in the morning before eating or drinking and after urinating, especially for high-risk residents, for consistency, to aid in eliminating variables, and to ensure an accurate weight. <Resident 115> According to the 04/24/2025 admission MDS, Resident 115 was admitted on [DATE], had medical conditions including cancer, heart disease, weakness on the left side of their body, and was unsteady on their feet. The MDS showed Resident 115 was assessed to require staff assistance with their daily cares for safety. A 05/13/2025 Discharge MDS showed Resident 115 was sent to the hospital. The 04/21/2025 nutrition CP showed Resident 115 was at risk for malnutrition and weight fluctuation related to the resident's current health status. A CP intervention instructed the nursing staff to weigh Resident 115 weekly for four weeks. On 05/16/2025 at 10:20 AM, Resident 115's representative stated they felt the facility was not taking good care of the resident, . [Resident 115] appeared to have severely declined and looked very dehydrated . The representative stated they asked the facility to send the resident out to the hospital for evaluation. Review of Resident 115's weight monitoring log showed, on 04/28/2025, the resident weighed 186.6 pounds (lbs.) while in the wheelchair, and on 05/05/2025, the resident weighed 161.8 lbs. while standing up. The log showed a total of 24.8 lbs. weight difference in one week and the manner how the staff obtained Resident 115's weight was not consistent. Review of Resident 115's medical records did not show the facility was able to re-weigh Resident 115 between 05/06/2025 and the next weekly weight scheduled on 05/12/2025 to confirm the significant weight loss or that the physician was notified. A 05/09/2025 Nutrition/Dietary progress note showed, .pending re-weigh related to likely erroneous 25 lbs. loss x 1 week. A 05/12/2025 Nursing progress note showed Resident 115 refused to be weighed at that time. In an interview on 06/11/2025 at 9:38 AM, Staff M (Unit Care Coordinator) stated the facility's protocol was to re-weigh a resident if there was a weight difference of over or less than 3 lbs in one week as soon as possible to determine if it was a true weight loss or gain. Staff M reviewed Resident 115's medical records and stated there was no re-weigh completed, or physician notification documented regarding the resident's significant weight loss. In an interview on 06/11/2025 at 9:56 AM, Staff B stated weight monitoring was important, especially among residents with a terminal illness and heart disease, to ensure the resident maintained their weight and safety. Staff B stated they expected the nursing staff to follow the facility's re-weigh protocol for validation, and to notify the physician if it was deemed a true weight loss/gain for proper treatment and interventions. REFERENCE: WAC 388-97-1620(2)(b)(i)(ii), (6)(b)(i). <Resident 264> According to the 06/02/2025 admission MDS, Resident 264 had a pain disorder and muscle weakness. Observation on 06/10/2025 at 9:59 AM showed Resident 265 getting up from their bed and stated they were on their way out to walk around the unit to exercise. At this time, Resident 265 stated they had concerns about their pain management. Review of an 05/29/2025 Pain/Discomfort CP showed staff were to provide pain medication as ordered. Record review showed a 05/29/2025 physician's order for a pain medication, give one tablet every three hours as needed for a pain level of seven to ten on a pain scale of zero-to-ten. Review of the June 2025 MAR showed staff gave one tablet of the pain medication for a pain of six to ten, outside the order's parameters. Record review showed a 06/03/2025 physician's order for a pain medication and to give one tablet every three hours as needed for a pain level of six or greater on the pain scale. Review of the June 2025 MAR showed staff gave Resident 264 one tablet of pain medication on 06/03/2025 and 06/05/2025 for a pain level of five instead of six or higher, outside of the order's parameters. In an interview on 06/16/2025 at 10:48 AM Staff B stated staff should follow physician orders for pain parameters as it was important for residents' safety, but did not. <Resident 265> According to the 06/02/2025 admission MDS, Resident 265 was admitted to the facility on [DATE] with diagnoses of congestive heart failure and high blood pressure. The MDS showed Resident 265 took a diuretic (water pill) for edema (swelling). Record review showed a physician's order 05/28/2025 directing staff to monitor Resident 265's edema every shift and to document using the edema scale. Review of the 06/09/2025 At Risk for Weight Fluctuation CP, showed staff were to monitor Resident 265's edema every shift and document the condition of the edema using an edema scale of 0 to 4+. Review of June 2025 MAR showed no documentation of edema on day, evening, or night shifts from 06/03/2025 through 06/16/2025. Review of Resident 265's progress notes did not show staff observed any edema from 06/06/2025 through 06/13/2025. In an interview on 06/10/2025 at 10:04 AM, Resident 265 stated they had swelling on both legs. At this time Resident 265 was observed with swelling on their left leg and ankle which was bigger than the right leg and ankle. In an interview on 06/11/2025 at 12:35 PM, Resident 265 stated they gain water weight. At this time, Resident 265's left leg and ankle were observed to be larger than their right leg and ankle. Observation on 06/12/2025 at 1:31 PM showed Resident 265 stated their legs were hurting today due to the swelling. At that time Resident 265's left leg was observed to be larger than the right leg. In an interview on 06/16/2025 at 9:52 AM Staff E (Unit Care Coordinator) stated staff should check edema on every shift and document their findings per the physician's order. In an interview on 06/16/2025 at 10:41 AM Staff B stated the nurses should have monitored Resident 265 for edema per the order and notified the provider about the increase in weight to determine what interventions were needed but did not.

Based on interview, observation, and record review the facility failed to develop and/or implement comprehensive Care Plans (CPs) for 3 (Residents 15, 36, & 167) of 17 sample residents whose CPs were reviewed. The failure to develop comprehensive, individualized CPs to address residents' care needs placed residents at risk for unmet care needs, frustration, and other negative health outcomes. Findings included . <Facility Policies> According to the facility's 09/05/2024 Comprehensive CPs and Conferences policy, the facility would develop a comprehensive CP for each resident within seven days of completion of an admission Minimum Data Set (MDS - an assessment tool). The facility's 09/11/2024 Comprehensive CPs and Revisions policy showed the facility would ensure CPs continued to meet residents' needs including addressing short-term problems, adding new interventions to existing CPs, and updating goals as needed. <Resident 15> According to the 05/07/2025 admission MDS, Resident 15 had diagnoses including pneumonia, asthma, and respiratory failure. The MDS showed Resident 15 needed supplemental oxygen while a resident. Record review showed no CP developed to address Resident 15's respiratory conditions or supplemental oxygen needs. Observation on 06/09/2025 at 10:35 AM and on 06/10/2025 at 9:22 AM showed Resident 15 in bed using a nasal cannula (tubing that delivers oxygen to the nostrils) to receive oxygen from an oxygen concentrator set at 2 liters per minute. In an interview on 06/16/2025 at 11:03 AM Staff P (MDS Nurse) stated respiratory needs identified in the MDS process did not automatically trigger CP development. Staff P stated nurses needed to identify the need for a CP and initiate the CP. In an interview on 06/16/2025 at 10:09 AM Staff M (Unit Care Coordinator) reviewed Resident 15's CP and stated there was no respiratory CP developed. Staff M stated there should be a CP to address Resident 15's oxygen and respiratory care needs. In an interview on 06/16/2025 at 12:43 PM Staff B (Director of Nursing) reviewed Resident 15's CP and stated they did not see a respiratory/oxygen CP. Staff B stated because Resident 15 needed supplemental oxygen, there should be a CP to address it. <Resident 36> According to the 05/05/2025 Admission/5-Day MDS, Resident 36 admitted to the facility on [DATE] with respiratory issues and kidney disease. The MDS showed Resident 36 did not reject care during the assessment period. Observation on 06/09/2025 at 1:39 PM showed Resident 36 sitting on the edge of their bed and both of the resident's feet were swollen. Resident 36 did not wear any socks or shoes. Review of Resident 36's record showed no CP developed to direct staff to address the swelling in both Resident 36's feet. In an interview on 06/12/2025 at 9:19 AM, Staff O (Unit Care Coordinator) reviewed Resident 36's record and stated there were no clear directions for staff to address Resident 26's swollen feet. Staff O stated there should be physician's orders and CPs to direct staff when and how to monitor the swelling on Resident 36's feet, but there was no CP developed. <Resident 167> According to the 04/09/2025 admission MDS, Resident 167 was admitted to the facility on [DATE] with respiratory issues and was blind in one eye. The MDS showed Resident 167 was dependent on staff for oral hygiene, showers, and toileting needs and did not reject care during the assessment period. Observations on 06/09/2025 at 2:00 PM and on 06/10/2025 at 10:24 AM showed Resident 167 had multiple purple-colored bruises on both arms and on the right side of their neck. Record review showed Resident 167 was readmitted to the facility from hospital on [DATE] with multiple bruises on both arms, neck, and upper medial chest areas. Review of Resident 167's physician's orders and CP showed no direction for staff to monitor for any changes on the bruises on both arms, neck, and chest areas. In an interview on 06/12/2025 at 8:58 AM, Staff N (Registered Nurse) confirmed Resident 167 had multiple bruises on their arms, neck, and chest areas. Staff N stated they did not know if the bruises were new or old. Staff N reviewed Resident 167's record and stated there was no physician order or CP for staff to address these bruises. In an interview on 06/12/2025 at 9:13 AM, Staff O stated the facility staff should notify the provider and receive physician's orders to monitor the bruises for any change or infections. Staff O stated staff should develop a CP to direct staff to monitor the bruises for any changes and for new bruises and document the results in Resident 167's record but they did not. REFERENCE: WAC 388-97-1020(1), (2)(a)(b). .

Based on interview and record review, the facility failed to ensure an allegation of drug diversion was thoroughly investigated for 1 of 1 supplemental resident (Resident 55) reviewed for grievances. This failure placed residents at risk for uncontrolled pain and a diminished quality of life. Findings included . <Facility Policy> According to the facility's 05/07/2025 Abuse - Conducting an Investigation policy, when a resident made a complaint or grievance to the facility would be investigated. The policy showed if there was a finding involving neglect, abuse, and/or misappropriation the facility would report the incident, as required by state law. The policy showed the written summary of the investigation should include, but was not limited to: an interview with the person reporting the incident, interviews with any witnesses, an interview with the resident, an interview with the employee as needed, a review of the employee's file, interviews with staff members on all shifts having contact with the resident at the time of the incident, and interviews other residents who received care or services from the alleged perpetrator. <Resident 55> According to the 05/15/2025 admission Minimum Data Set (MDS - an assessment tool) Resident 55 had adequate vision and used glasses. The MDS showed Resident 55 had intact memory and demonstrated no behavior. The MDS showed Resident 55 received scheduled and as needed pain medications. The MDS showed Resident 55 had frequent pain that occasionally affected their sleep and frequently interfered with therapy and day-to-day activities, and could be as severe as seven on a one-to-ten scale. Review of the facility's May 2025 Grievance Log showed a 05/24/2025 grievance logged for Resident 55 showing the resident felt the nurse swapped their pain pill for a different pill. The log showed Staff A (Administrator) approved the grievance process for Resident 55's grievance. Review of the 05/24/2025 Concern and Comment Form showed the form was completed by Resident 55. Resident 55 wrote that on 05/23/2025 at 3 PM and 10 PM the nurse exchanged their pain pill for another pill. Resident 55 wrote that they knew what their pain pill looked like because they took it when at home. Resident 55 wrote that a facility nurse was stealing residents' pain pills. Review of the facility's investigation into Resident 55's 05/24/2025 grievance showed the facility showed Resident 55 was given their as-needed pain medication at 8:20 AM and 3:20 PM on 05/23/2025, and clarified Resident 55 did not receive their as-needed pain medication at 10 PM. The investigation's summary showed: Staff B (Director of Nursing) explained to Resident 55 that the same medication could look different depending on the manufacturer; Resident 55's Medication Administration Record (MAR) and narcotic sheet (a document tracking the use of narcotic pain medications to ensure narcotics are accounted for) were reviewed and were consistent with the orders; progress notes showed the as-needed pain medication was effective. The investigation did not include clear determination of what happened. The 05/24/2025 grievance investigation did not include an interview with Resident 55 to ask whether they thought the pain medication was effective, did not identify which nurse was alleged to divert the as-needed pain medication, did not include an interview with the nurse Resident 55 alleged to divert the as-needed pain medication, did not include a review of the nurse's file, did not include interviews with other residents who could be witnesses or who received pain medication on the unit, and did not include interviews with staff on the unit. The summary did not indicate who wrote the summary. In an interview on 06/16/2025 at 8:44 AM, Staff B stated the process to determine if a resident concern was a grievance or rose to the level of a reportable allegation was for Staff B and Staff A to discuss the matter and make a determination. Staff B stated because the grievance log showed Resident 55 felt like the nurse swapped their as-needed pain medication, it was a concern and not an allegation. (While the grievance log stated Resident 55 felt the nurse diverted their medication, Resident 55 only wrote that the nurse exchanged their pain pill.) Staff B reviewed the grievance investigation and stated it did not show which nurse was alleged to divert the medication. Staff B stated they did not know which nurse was alleged by Resident 55 to divert the as-needed pain medication. Staff B stated the summary did not indicate who wrote it. In an interview on 06/16/2025 at 9:42 AM Staff A stated after they spoke with Staff B they determined quickly the situation was a one off, an accident, did not happen. Staff A stated because the as-needed pain medication was signed as administered by the nurse and corresponded with the narcotic sheet, and progress notes showed the medication was effective, the nurse did not divert the medication. Staff A stated there was no documentation to show that Resident 55, other residents, the nurse Resident 55 who allegedly diverted the medication, or other staff were interviewed. Staff A stated they did not ask Resident 55 if the medication was effective. Staff A stated the investigation did not identify the staff in question but was able to state which staff was named by Resident 55. Staff A stated they did not think Resident 55's concern needed to be included on the facility's state reporting log. REFERENCE: WAC 388-97-0640 (6)(c). .

Based on observation, interview, and record review, the facility failed to initiate, investigate, and resolve grievances for 2 of 17 sampled residents (Resident 44 & 45) reviewed for grievances and 1 supplementary resident (Resident 55). This failure placed residents at risk for emotional distress, unresolved frustration, and a diminished quality of life. Findings included . <Facility Policy> According to the facility's revised 01/07/2025 Grievance Program (Concern and Comment) policy, Residents and families would receive information on the facility's grievance procedure upon admission, including their right to file a complaint orally or in writing without fear of reprisal. The policy showed if a resident/representative expressed a concern or comment, any staff member could assist them to complete a concern and comment form and resolve the concern. If resolution was not possible at that time, staff would explain to the resident that another staff would be assigned to investigate the concern and contact the resident/representative in a timely manner. The policy showed the Executive Director would ensure all grievances were reviewed and addressed in a timely manner and that residents felt that some type of resolution was communicated, achieved, and maintained. <Resident 44> According to a 05/30/2025 admission Minimum Data Set Assessment (MDS - an assessment tool) Resident 44 had a memory impairment and was dependent on staff for activities of daily living (hygiene, feeding, dressing etc.) Review of 05/30/2025 ADL performance deficit Care Plan (CP) showed staff were to provide Resident 44 with assistance to dress and undress. In an interview on 06/10/2025 at 11:30 AM, Resident 44's family member stated Resident 44's clothes did not always come back from the laundry. Resident 44's family member stated they asked staff about the missing laundry and had not heard back. The family member stated Resident 44 was missing a pair of pants and four shirts since last week. The family stated they labeled all of Resident 44's clothing with their name when they were admitted to the facility. In an interview on 06/12/2025 at 9:16 AM Resident 44's family member stated staff still did not find the missing clothing they reported to staff. The family member stated they told the nurse at the nurse's station every day about the missing clothing and so far, nothing was returned. Observation on 06/12/2025 at 10:06 AM showed Staff D (Licensed Practical Nurse) tell Resident 44's family they found one shirt in the laundry room but were not able to find the other missing clothing. In an interview on 06/13/2025 at 8:47 AM, Resident 44's family member stated the clothes were still missing, and stated five pieces of clothing did not come back. The family member stated they frequently asked staff about the missing laundry but so far nothing was returned. In an interview on 06/16/2025 at 9:59 AM Staff E (Unit Care Coordinator) stated staff should have taken the family to the laundry room to identify the missing clothing and staff should have completed a concern and comment form so missing items would be reported and actions taken to resolve the issue. In an interview on 06/16/2025 at 10:32 AM Staff B (Director of Nursing) stated a concern form should have been completed but was not. Staff B stated if staff could not find the items, the facility would replace the clothing. Staff B stated it was their expectation that staff looked for the missing items and completed a concern form to begin the investigation of the missing items. Staff B stated they did not receive a complaint form regarding Resident 44's missing items but should have. <Resident 45> According to the 04/21/2025 admission MDS, Resident 45 admitted to the facility on [DATE] with lower body impairment after a stroke. The MDS showed Resident 45 had no cognitive impairment, clear speech, and was able to make themselves understood. The MDS showed Resident 45 had no natural teeth and had difficulty chewing. Observation and interview on 06/09/2027 at 11:59 AM showed Resident 45 lying in bed, and had no teeth. Resident 45 stated they lost their dentures in the facility a month ago. Resident 45 stated they told staff, and they could not find their dentures. Review of the 04/17/2025 admission assessment showed Resident 45 had dentures and no chewing or swallowing issue at that time. Review of the 04/28/2025 Oral/Dental health problem CP showed Resident 45 had no teeth and had chewing difficulty. The CP included interventions directing staff to provide oral and denture care to Resident 45 daily and to report loose dentures as needed. Review of the facility's grievance and investigation log for April, May, and June 2025 showed no documentation of Resident 45's missing dentures. Review of Resident 45's record showed no documentation Resident 45 lost their dentures. In an interview on 06/12/2025 at 11:00 AM, Resident 45 stated they lost their dentures around second week of May 2025 and told staff that same day. Resident 45 stated they talked to Staff O (Unit Care Coordinator) and another staff member whom they did not recall, filled out a concern and comment form, and gave it to a staff member. Resident 45 stated they did not hear anything back from staff since that time. In an interview on 06/12/2025 at 11:59 AM, Staff O stated they knew Resident 45 lost their dentures more than three weeks ago and completed a concern and comment form. Staff O stated the form went to Staff A (Administrator) and they did not hear anything back yet. Staff O stated they should have followed up with the grievance process, but they did not. In an interview on 06/13/2025 at 12:54 PM, Staff A stated they heard about Resident 45's missing dentures but did not remember if they received a concern and comment from the resident or staff. Staff A reviewed the grievance log and stated there was not a grievance logged for Resident 45 missing dentures but there should be. <Resident 55> According to the 05/15/2025 admission MDS, Resident 55 had adequate vision and used glasses. The MDS showed Resident 55 had intact memory and demonstrated no behavior. The MDS showed Resident 55 received scheduled and as needed pain medications. The MDS showed Resident 55 had frequent pain that occasionally affected their sleep and frequently interfered with therapy and day-to-day activities, and could be as severe as seven on a one-to-ten scale. Review of the facility's May 2025 Grievance Log showed a 05/24/2025 grievance logged for Resident 55 showing the resident felt the nurse swapped their pain pill for a different pill. The log showed Staff A (Administrator) approved the grievance process for Resident 55's grievance. Review of the 05/24/2025 concern and comment form showed the form was completed by Resident 55. Resident 55 wrote that on 05/23/2025 at 3 PM and 10 PM the nurse exchanged their pain pill for another pill. Resident 55 wrote that they knew what their pain pill looked like because they took it when at home. Resident 55 wrote that a facility nurse was stealing residents' pain pills. This form showed the resident reported their concern to a staff member who could not resolve the issue at the time it was reported. The form included a space for the associate receiving the concern to add their name, date, and time of the concern. This space was left blank. The concern and comment form came with a 05/27/2025 typed summary showing Staff B told the resident that the same medicine could look different depending on the manufacturer. This summary did not indicate if Resident 55 was satisfied with the outcome of this grievance process or who wrote the summary. In an interview on 06/16/2025 at 8:44 AM Staff B stated the concern and comment form was not signed or dated but should be. Staff B stated the summary did not indicate who wrote it but stated it was not them. In an interview on 06/16/2025 at 9:42 AM Staff A stated they worked on the grievance with Staff B and If I had it to do again, I would document the response. Staff A stated the form was not signed and dated by staff but should be. REFERENCE: WAC 388-97-0460 .

Based on observation, interview and record review, the facility failed to ensure walls and baseboard in resident rooms were maintained in a homelike condition for 5 of 17 rooms sampled (Rooms 111, 112, 113, 116 & 120) and failed to ensure a privacy curtain was maintained in a clean sanitary condition (room [ROOM NUMBER]). These failures left residents at risk for a less than homelike environment and a diminished quality of life. Findings included . <Facility Policy> According to the facility's 06/12/2024 Resident Belongings and Home Like Environment policy, the facility must provide a safe, clean, comfortable and homelike environment. The policy stated it was the responsibility of all facility staff to create a homelike environment and promptly address any cleaning needs. <room [ROOM NUMBER]> Observation on 06/10/2025 at 8:30 AM areas of white paint splotches were on the wall behind the headboard of resident's bed and was not painted to blend with the rest of the wall color. <room [ROOM NUMBER]> Observation on 06/10/2025 at 10:29 AM white paint splotches were on the wall behind the headboard of resident's bed. <room [ROOM NUMBER]> Observation and interview on 06/12/2025 at 12:43 PM, Resident 264 stated their room looked dirty and pointed to the privacy curtain in the middle of the room and said it was soiled with dark brown and dark red spots and brown liquid stains. Observed the baseboard along the wall was not painted and appeared chipped and soiled with brown debris. <room [ROOM NUMBER]> Observation on 06/09/2025 at 8:48 AM several scratches were observed on the wall behind the head of resident's bed. <room [ROOM NUMBER]> Observation on 06/09/2025 at 9:10 AM, wall scratches were observed behind the head of resident's bed. In an observation and interview on 06/16/2025 at 1:13 PM Staff C (Maintenance Assistant) observed all the repairs that needed to be repaired in rooms 111,112,113,116 & 120. Staff C stated some rooms had areas where the white paint was used to patch the paint but the area was not fully painted to match the walls. Staff C stated all areas should be painted for a homelike setting and the privacy curtain in room [ROOM NUMBER] should be replaced for cleanliness and for a homelike setting but was not. REFERENCE: WAC 388-97-0880. .

Based on interview and record review, the facility failed to provide required liability notices for 1 of 3 residents (Resident 117) reviewed for liability notices. Failure of the facility to issue a Notification of Medicare Non-Coverage (NOMNC - a document informing Medicare beneficiaries that their covered services will be terminated and providing information on their appeal rights) before discharge from the facility placed Resident 117 at risk for not fully understanding their Medicare benefits and appeal rights. Findings included . <Resident 117> Record review showed Resident 117 was readmitted to the facility on [DATE] and discharged home on [DATE]. Resident 117's record showed the facility did not document they provided a NOMNC letter to Resident 117. Resident 117's record showed the facility provided a Nursing Home Transfer or Discharge notice to the resident on 05/22/2025. This notice showed the reason for the discharge was Resident 117's health had improved, and they no longer needed the services provided by the facility. According to a 05/19/2025 Social Services note, the facility sent a discharge notice to the local Long Term Care Ombuds (a mandated resident care advocacy group) regarding Resident 117's discharge home on [DATE]. This note showed Resident 117 had met their goals and completed antibiotic treatment. A 05/22/2025 nursing note showed the facility provided medications and discharge papers to Resident 117 to discharge with. The facility did not document they provided a NOMNC letter to Resident 117. In an interview on 06/13/2025 at 12:07 PM, Staff K (Social Services Director) reviewed Resident 117's record and stated the facility should have provided a NOMNC letter to Resident 117 before they discharged home, but did not. Reference: WAC 388-97-0300(1)(e),(5),(6).

Based on observation, interview, and record review, the facility failed to provide behavioral health services for 1 of 3 (Resident 264) residents reviewed for behavioral-emotional health. The failure to provide interventions to Resident 264 behavioral health concerns placed Resident 264 and other residents at risk for not receiving the services necessary to meet their mental health needs and a diminished quality of life. Findings included . <Resident 264> According to the 06/02/2025 admission Minimum Data Set (MDS- an assessment tool) Resident 264 had diagnoses including anxiety and depression. The MDS showed Resident 264 took medication for anxiety and had several days when they were feeling down or depressed. Review of 06/10/2025 Mood Care Plan (CP), showed Resident 264 was at risk for changes in their mood or behavior due to their medical conditions. The CP included interventions for staff to provide a psychological (psych) evaluation consult as indicated. Record review showed a 06/03/2025 progress note that showed Resident 264 requested to be referred to psych and the status was pending with no follow up documented. In an interview and observation on 06/09/2025 at 9:18 AM, Resident 264 was tearful when talking about their medical condition and needing to stay at the facility. Resident 264 stated they were frustrated at the staff for not attending to their mental health needs and because they noticed they were younger than most of the residents at the facility. Resident 264 stated the facility did not know how to take care of a younger residents' needs. In an interview on 06/09/2025 at 2:39 PM Resident 264 stated they were very sad about the health conditions that caused them to be admitted to the facility and was very tearful when discussing their past. Resident 264 stated they were upset that the facility did not attend to their needs. In an interview on 06/12/2025 at 12:50 PM Resident 264 was tearful and stated they were very upset about having to stay at the facility. Resident 264 stated they did not have an appetite lately. Resident 264 stated they asked the facility about getting a psychological evaluation, but it did not happen. In an interview on 06/16/2025 at 9:41 AM Staff E (Unit Care Coordinator) stated they could not find documentation that a referral for a psych evaluation was made, but a referral should have been made. In an interview on 06/16/2025 at 10:48 AM Staff B (Director of Nursing) stated Resident 264's record showed a request for a psych evaluation was made on 06/02/2025 but the order showed as pending in their records. Staff B stated they were not sure why the referral was not made but it should have been. REFERENCE WAC: 388-97-1060(1)(3)( e). .

Based on interview and record review, the facility failed to ensure 1 of 3 residents (Resident 1) reviewed for Pressure Ulcer/Pressure Injury (PU/PI) was provided the necessary treatment and services consistent with professional standards of practice to promote wound healing. This failure placed residents at risk for worsening skin conditions, skin breakdown, and a diminished quality of life. Findings included . <Facility Policy> The facility policy titled, Skin Integrity & PU/PI Prevention and Management, revised 07/09/2024, showed the facility would provide the necessary treatment and services, consistent with professional standards of practice, to a resident with PU/PI to promote healing, prevent infection, and prevent new ulcers from developing. The policy showed preventative measures identified to maintain and improve the resident's skin condition were implemented in the Care Plan (CP). The policy showed when skin breakdown occurred, it required attention and a change in the plan of care could be indicated to treat the resident. <Resident 1> According to the 01/21/2025 Facility Nursing Admission/Readmission Collection Tool, Resident 1 had medical conditions including memory impairment, unstable blood sugar levels, heart and kidney disease, malnutrition, and a surgically repaired hip fracture sustained from a fall. The assessment tool showed Resident 1 had altered skin integrity during the assessment and a Deep Tissue Injury (DTI - a damage to the soft tissue beneath the skin caused by pressure or shear forces) to their buttocks was identified. Review of the 01/22/2025 Baseline CP showed Resident 1 had a break in skin integrity. An intervention listed in the CP instructed the nursing staff to provide treatment as ordered. Review of the 01/24/2025 wound care provider report showed the skin covering Resident 1's DTI on their buttocks opened and measured 2.5 centimeters (cm) x 2.5 cm x 0 cm. The wound care provider recommended a treatment using a medical-grade honey-based dressing. Review of Resident 1's January 2025 Treatment Administration Record (TAR) showed no treatment was scheduled and/or carried out by the nursing staff regarding the initiation of the medicated honey-based treatment as ordered by the wound care provider. A 01/27/2025 progress note showed Resident 1's representative wanted the resident transferred to the hospital for further evaluation of the buttocks wound. The facility census showed Resident 1 was transferred to the hospital on the same day. The 01/27/2025 facility investigation report showed, Due to receiving the [wound care team] orders for [honey-based treatment] late Friday night [01/24/2025], it was not processed until Monday [01/27/2025] morning . and led to the delay in the application of the treatment. In an interview on 02/07/2025 at 2:23 PM, Staff D (Certified Nursing Assistant) stated Resident 1 was able to use the bathroom when cued and assisted, and as the resident would allow. In an interview on 02/07/2025 at 2:46 PM, Staff C (Licensed Practical Nurse) stated they did not know Resident 1's buttocks wound was a PU and thought it was moisture-associated skin damage because of the resident's incontinence. Staff C stated they were not aware a medicated honey-based treatment was ordered for Resident 1 on 01/24/2025 because the order was not in the TAR, .[treatment order] was not shown in my computer. In an interview on 02/07/2025 at 3:23 PM, Staff B (Interim Director of Nursing) reviewed Resident 1's January 2025 TAR and confirmed the medicated honey-based treatment for the resident's buttocks wound was not carried out and/or provided by the nursing staff as ordered. Staff B stated it was important to implement and follow provider treatment orders for effective management of wounds and to facilitate PU/wound healing. Staff B stated they expected the nursing staff to implement and follow wound care treatments as ordered. REFERENCE: WAC 388-97-1060(3)(b).

Based on interview and record review, the facility failed to provide adequate supervision to dissuade one of two residents (Resident #1) from self-ambulation and a fall, resulting in substantial injury and subsequent death. The failure to supervise Resident #1 allowed Resident #1 to self-ambulate five to eight feet, experiencing a fall that caused Resident #1 to strike his head on a wooden/wicker cabinet resulting in a subdural hematoma and ultimately death. Findings included: Resident #1, reviewed as a closed record and not available for interview or observation, was admitted to the facility on [DATE], according to the 11/03/17 Minimum Data Set (MDS, a comprehensive assessment), with [DIAGNOSES REDACTED]. Staff documented on this assessment, Resident #1 experienced at least one fall during the seven day assessment period between admission and the assessment, and was taking anticoagulant medication to thin the blood. Staff assessed Resident #1 to be at risk for falls on the facility's 10/27/17 Fall Risk Evaluation form, with a score of 24. Instruction to staff on this form was, A resident who scores a 10 or higher is at risk (for falls). The facility reassessed Resident #1 after each subsequent fall so that on 11/13/17 Resident #1's score was 28. Review of the initial 10/27/17 and revised care plans/directives revealed undated and hand written notes on the Care Directives instructing, .Resident requires close supervision (secondary ) to impulsivity and poor safety awareness .encourage resident to remain in social areas when up in (wheelchair). Review of the facility's incident recording log revealed Resident #1 experienced four falls; 1. A non-injury fall on 11/03/17 out of a wheelchair. The facility assessed the cause of the fall to be the wheelchair cushion and replaced it with Dycem. 2. A non-injury fall on 11/10/17 out of a wheelchair. The cause was established when the resident attempted to ambulate and the wheelchair moved, because the brakes were not engaged. The facility provided a wheelchair with an anti-roll back brake system. 3. A non-injury fall on 11/13/17 off of the couch in the day room when Resident #1 fell asleep and rolled off the couch. The facility responded by ensuring Resident #1 napped in their own bed. According to Staff C the Director of Nursing and Staff D the Residential Care Manger, interviewed on 12/13/17 at 10:45 a.m., Resident #1 experienced the fourth and egregiously injurious fall requiring hospitalization on [DATE] at 2:00 a.m. from which Resident #1 did not recover. According to the facility's evidence of investigation two Certified Nursing Assistants (CNA) Staff F and G, were present with the resident in the main dining/activity room prior to the fall. According to Staff D interviewed on 12/16/17 at 12:10 p.m., Staff F was assigned to be with Resident #1 because of Resident #1's restless state and propensity to fall. Staff F left the dining room to answer a call light, but did not inform Staff G she was leaving the dining room or, to watch Resident #1. According to Staff D, Staff G was in the dining room on her break, not watching Resident #1. Resident #1 fell after attempting self-ambulation of five to eight feet, striking his head on the wicker/wooden cabinet. Staff G, interviewed on 12/19/17 at 6:00 a.m. said, I didn't see what happened, I was on my break. I was sitting in a chair way (in the) back not in the front (where Resident #1 was sitting in his wheelchair) .Staff F left (Resident #1). I heard the fall and I called the nurse (Staff E). He didn't have a bump at that time .(Staff F) was supposed to be watching him because he was a fall risk. She left to answer a call light. Staff E said, in an interview on 12/19/17 at 6:30 a.m., one (Staff F) of two CNA staff in the room with Resident #1 left Resident #1 to answer a call light. Staff E said the other CNA, Staff G, was on a break in the same room but was not watching Resident #1 when he fell striking his head. Staff E said of her assessment after Resident #1 fell , Resident #1 had a bandage on his head from the fall that occurred on 12/13/17. Staff E said there was also a scratch on Resident #1's head. Staff E said after the 11/13/17 fall from the sofa, the facility determined Resident #1 needed to remain, .within line of (staff) sight . to prevent further falls and injury. Staff E said, of Resident #1, Usually we had him with us at the nurses' station because one of use was at the station. He was on close monitoring. If I'm gone the (certified nursing assistants) will watch (Resident #1). According to 11/15/17 hospital emergency room and diagnostic testing records, Resident #1 suffered a hematoma to the forehead, an abrasion to the left shin and a laceration to the left hand. The emergency room staff added; On [MEDICATION NAME], ([MEDICATION NAME] is used to thin the blood causing excessive bleeding in some patients). The 11/15/17 diagnostic scan report said, Acute subdural hematoma (brain bleed). This report indicated the condition was the result of trauma. The facility failed to provide assessed and care planned supervision to prevent falls and/or injury to cognitively impaired Resident #1, placing the resident in a position to self-ambulate, fall, striking his head and causing a subdural hematoma, contributing to Resident #1's death. Refer to WAC 388-97-1060(3)(g)

Based on observation, interview and record review, the facility failed to ensure pharmaceutical service policies regarding the dispensing of prescribed medication to one of eight sampled residents (#1) reviewed for medication errors, was implemented. This failure contributed to staff repeatedly administering the wrong dose of Digoxin to Resident #1, contributing to Resident #1's hospitalization for Digoxin toxicity. Findings include: FACILITY'S Pharmacy Services Policy and Procedure stated "Inspect the package(s) for damage or errors and notify Pharmacy as soon as possible but within twenty-four (24) hours of any damage or other discrepancies". According to the facility's 02/06/2011 admission documents and 2/13/11 Minimum Data Set, Resident # 1 was admitted with a [DIAGNOSES REDACTED]. Staff E stated in an interview on 03/09/2011 at 4:35 p.m. "Orders are received by a Pharmacist ..., the Pharmacist misread the order and dispensed the wrong dose..this is clearly a human error. After (the) Pharmacist check(s) it (prescription) the next opportunity to check the appropriateness of (the) medication will be the nurse who administer the medication." "It was a transcription error. Review of the 02/22/2011 Physician order [REDACTED]. (micrograms) every day. According to the facility's 02/22/2011 MAR indicated Digoxin 75mcg. po (by mouth) daily." The pharmacy provided a 02/25/2011 medication card labeled "Digoxin 250mcg tablet. Give 3 tablets (0.75mg) by mouth once a day". Review of the 02/2011 MAR indicated [REDACTED]. According to facility's 02/27/2011, 02/28/2011, 03/01/2011 and 03/02/11 Nurses Notes staff documented Resident #1 repeatedly complained of nausea, vomiting and refused meals, medications and fluids. Review of 03/03/2011 hospital records revealed Resident # 1 was hospitalized from [DATE] to 03/05/2011 due to Digoxin toxicity. Refer to related CFR 483.20(d)(k) F-279 Comprehensive Plan Of Care, and CFR 483.25(m)(2) F-333 Residents are free of any significant medication errors.

Based on interview and record review, the facility failed to prevent a significant medication error to one of eight sampled residents (#1) reviewed for medication error. This failure resulted in Resident #1 being exposed to critically high doses of [MEDICATION NAME], experienced nausea and vomiting that required three days of hospitalization . Findings include: According to facility's Medication Administration Policy, it is the responsibility of the nursing professional to be aware of the "classification, action, correct dosage, and side effects of a medication before administration". Additionally, the facility's Medication Administration Policy stated "If there is any discrepancy between the MAR (Medication Administration Record) and the label, check physician orders [REDACTED]. According to facility's 02/06/2011 [DIAGNOSES REDACTED]. Interview on 03/08/2011 the Resident stated " (the facility) Gave me wrong med". Review of the 02/22/2011 Physician order [REDACTED]. (micrograms) every day. According to the facility's 02/22/2011 MAR indicated [MEDICATION NAME] 75mcg. po (by mouth) daily." According to facility's 3/02/2011 at 11:30 a.m. Nurses Notes noted medication card was labeled [MEDICATION NAME] 250mcg tablet. Give 3 tablets (0.75mg) by mouth once a day. Review of the 02/2011 MAR indicated [REDACTED]. Staff A stated in an interview on 03/08/2011 at 11:00 a.m. "I'm the nurse who didn't pay attention (giving the wrong dose of medication)....It's the pharmacy, they know what they are doing. I didn't second guess it." Review of the facility's 3/3/11 investigation revealed Staff A stated "I did not clearly look at (the)dose written by (the) pharmacy on (the) Bingo card (medication card). I saw that it was to give 3 tab to = 75. So that is what I did." In addition, Staff C said in an interview on 03/07/2011 at 1:45 p.m. that Staff A withheld the [MEDICATION NAME] on 02/28/2011 but was unable to explain why. Only after Staff F reviewed the medication card on 03/02/2011 was staff made aware a medication error occurred. Review of facility's 2/27/2011 at 6:30 a.m. Nurses Notes indicated Resident #1 stated "I'm not feeling good, I feel like if I move I'm going to throw up." The facility's 2/27/2011 at 11:15 a.m. Nurses Notes indicated the resident refused medication due to "feeling (of) GI (Gastro Intestinal) upset." The facility's 2/27/2011 at 9:40 p.m. Nurses Notes indicated that Resident #1 refused the medications, vomited few minutes after dinner, refused any fluids offered and repeatedly verbalized of feeling very ill. On 02/28/2011 at 5:50 a.m. Nurses Notes indicated the resident continued to refuse medications, fluids, complained for nausea and vomited. On 2/28/2011 at 24:15 Nurses Notes indicated resident refused to get up for dinner, refused medications, complained of not feeling well and nauseated. A call was placed to Physician with an order of [MEDICATION NAME] (a drug that helps control nausea). On 03/01/2011 at 14:30 p.m. Nurses Notes indicated that Resident #1 was experiencing an increase of "lethargy (low level of consciousness, lack of energy)." It also noted that Resident #1 refused two meals and continued to experience nausea. Review of 03/02/2011 at 13:16 p.m. laboratory result for [MEDICATION NAME] level revealed "critical high." Review of 03/03/2011 hospital records revealed Resident # 1 was hosptalized on [DATE], 03/03/2011, 03/04/2011 and 03/05/2011 due to [MEDICATION NAME] toxicity. Refer to related CFR 483.20(d)(k) F 279 Comprehensive Plan Of Care