Every finding on record at Heron's Key

Based on observation, interview, and record review, the facility failed to provide routine dental care for 1 of 2 sampled residents (Resident 3) when reviewed for dental needs. This failure placed the resident at risk for difficulty eating, dental pain, unintended weight loss, and diminished quality of life. Findings included.Review of the electronic health record (EHR) showed Resident 3 was admitted to the facility on [DATE] with diagnoses to include chronic kidney disease (loss of kidney functions), atrial fibrillation (irregular heart rhythm), and heart failure. Resident 3 was able to communicate their needs. During an interview on 02/10/2026 at 9:28 AM, Resident 3 stated they lost a tooth and needed to see a dentist, but their dentist did not see patients in wheelchairs. Review of the EHR showed no dental consultations. Review of the care plan, dated 07/07/2025, showed no dental needs addressed for Resident 3. During an interview on 02/12/2026 at 11:54 AM, Staff E, Registered Nurse/Minimum Data Set (RN/MDS), stated the facility did not automatically assign dentists for the residents, Resident 3 needed to be referred for dental services, and the care plan should accurately address dental needs. During a follow up interview on 02/13/2026 at 10:33 AM, Resident 3 stated they had five missing teeth, and a gold filling that fell out. During an interview on 02/13/2026 at 9:40 AM, Staff B, Director of Nursing Services, stated the facility would be working on the dental needs for Resident 3 and the records did not meet expectations. Reference WAC 399-97-1060(3)(j)(vii)

Based on observation, interview, and record review, the facility failed to provide quality care related to monitoring of resident skin injuries (bruises), bowel management, and orthostatic blood pressure (blood pressure taken while a person is laying, sitting and standing to monitor for sudden drop in pressure) for 2 of 9 sampled residents (Residents 8 and 11) when reviewed for quality of care. This failure placed residents at risk of injuries, untreated constipation, discomfort, and a diminished quality of life. Findings included.Resident 8Review of the electronic health record (EHR) showed Resident 8 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation (irregular heart rhythm), heart failure, chronic kidney disease (loss of kidney functions), and weakness. Resident 8 was able to communicate their needs. Observation and interview on 02/10/2026 at 11:08 AM, showed Resident 8 sat in the chair in their room and pointing towards two reddish colored bruises on their left forearm. During a follow up interview on 02/12/2026 at 11:50 AM, Resident 8 stated they did not know how the bruises were happening. Review of the EHR, showed Resident 8 had multiple progress notes related to bruises on different areas of their hands/arms. There was alert monitoring of the bruises, but it was not clear the size, color, or actual location. Progress notes on 01/17/2026 described a large bruise on the top of right hand. Progress notes on 01/31/2026 described a bruise to the left upper extremity (LUE, left upper portion of the arm) near the elbow sized 3x3 centimeters and almost fading. Progress notes on 02/01/2026 recorded a bruise on right hand and left upper arm. On 02/05/2026, progress notes described new bruising to the inner right forearm. Review of the weekly skin evaluation forms from January and February2026 showed Resident 8 had no new issues on a weekly basis. During an interview on 02/12/2026 at 1:27 PM, Staff D, Licensed Practical Nurse (LPN), stated the process for new bruises was to notify providers, obtain orders to monitor, initiate an investigation, and place the resident on alert status. During an interview on 02/13/2026 at 9:33 AM, Staff B, Director of Nursing Services (DNS), stated the nurses were expected to conduct weekly skin evaluations and have measurements and descriptions of the bruises. Staff B stated the records for Resident 8 did not meet expectations. Resident 11Review of the EHR showed Resident 11 was admitted to the facility on [DATE] with diagnoses to include delusions (false beliefs), hypertension (high blood pressure), diabetes (high blood sugar), and dementia (impaired memory, thinking and reasoning that interfere with daily life). Resident 11 could not communicate their needs. Review of EHR showed Resident 11 had a provider's order for monthly orthostatic blood pressure for 02/01/2026 that was not complete. Review of the documentation for bowel monitoring showed Resident 11 did not have bowel movements documented for four consecutive days in February 2026 (02/05/2026, 02/06/2026, 02/07/2026, and 02/08/2026). Review of the providers' orders showed Resident 11 had an order for milk of magnesia to be given for constipation, if there was not a bowel movement in three days. Review of the February 2026 medication administration record showed no milk of magnesia given to Resident 11. During an interview on 02/13/2026 at 9:52 AM, Staff B, DNS, stated the expectation was for license nurses to follow provider's orders and the bowel protocol. Staff B stated the records for Resident 11 did not meet expectations. Reference WAC 399-97-1060(1)-(3)

Based on observation, interview and record review, the facility failed to accurately assess dental status for 1 of 2 sampled residents (Resident 8) when reviewed for dental care. This failure placed the Resident at risk of pain, weight loss, and diminished quality of life. Findings included.Review of the electronic health record (EHR) showed Resident 8 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation (irregular heart rhythm), heart failure, chronic kidney disease (loss of kidney functions), and weakness. Resident 8 was able to communicate their needs. Observation and interview on 02/10/2026 at 11:02 AM showed Resident 8 sat in their chair and pointed to their mouth and stated, My teeth have fallen out, and No dentist comes here. Observation showed Resident 8 had missing teeth. Review of the EHR showed Resident 8 had a quarterly minimum data set (MDS, a required assessment), dated 11/16/2025, marked with no dental issues. Review of the care plan, dated 11/24/2025, showed Resident 8 had no dental focus area. During an interview on 02/11/2026 at 2:15 PM, Staff E, Registered Nurse (RN)/MDS, stated the MDS should have been marked accurately, and the care plan should reflect the status of teeth. During an interview on 02/13/2026 at 9:31 AM, Staff B, Director of Nursing Services, stated the expectation was for the MDS to correctively reflect residents' dental status, and Resident 8's MDS need to be corrected. Reference WAC 399-97-1000(1)(a)(b)(4)(a)

Based on observation and interview, the facility failed to sanitarily prepare food in the facility kitchen and failed to monitor resident refrigerators for 1 of 2 resident refrigerators (Front Refrigerator) when reviewed for kitchen. These failures placed residents at risk of consuming contaminated food, foodborne illness, and a diminished quality of life. Findings included . <Kitchen Observation> Observation on 11/13/2024 at 11:25 AM showed a peroxide cleaning spray hanging from food shelfing containing raw bananas and tortillas. Observation on 11/13/2024 at 11:28 AM showed Staff K, Cook, had an uncovered beard and was cutting pieces of pie at a preparation station. Observation on 11/13/2024 at 11:30 AM showed Staff L, Dietary Aide, wore a hairnet over the back portion of the head while leaving the bangs exposed. Observation on 11/13/2024 at 11:40 AM showed a personal cell phone on a shelf above a sandwich making station. A cell phone power cord was hanging over the edge of the shelving and dangling above the opened sandwich making station. Observation on 11/13/2024 at 11:45 AM showed Staff M, Dietary Aide, delivered trays to the main dining room and placed their hands on the legs and in their pockets while conversing with residents. Staff M then re-entered the kitchen and returned to tray service without performing hand hygiene. Observation showed Staff M move to the dining room and back into the kitchen without performing hand hygiene at 11:48 AM. During an interview on 11/13/2024 at 1:03 PM, Staff N, Dining Room Supervisor, stated cleaning supplies should not be stored near food items and the peroxide cleaner should not be hanging over the bananas and tortillas. Staff N stated that hair should be covered and Staff L having their bangs exposed did not meet expectation. Staff N stated beards should be covered once they were a certain length and Staff N was unsure whether Staff K's beard required a hair net. Staff N stated staff should wash their hands after returning from the dining room and Staff M's lack of hand hygiene after going to the dining room did not meet this expectation. Staff N stated staff personal items should be stored near the entrance to the kitchen and not be in the food preparation areas. Staff N stated the phone cord dangling over the sandwich making station did not meet expectation. During an interview on 11/13/2024 at 1:18 PM, Staff A, Administrator, stated cleaning products should not be stored near food items, hairnets should completely cover the hair or beard, personal items should not be in food preparation areas, and staff should perform hand hygiene whenever they returned to the kitchen from the dining area. Staff A stated the facility's kitchen had not met these expectations. <Resident Refrigerator> Observation on 11/13/2024 at 9:34 AM showed the front resident refrigerator contained: (1) A plastic container of noodle salad without labeling, (2) A cardboard container of half-consumed garden salad without labeling, (3) A squeeze style guacamole labeled with Staff O's, Dietary Manager, name and a use by date of 09/09/2024, (4) A squeeze style salsa verde with Staff O's name and no date labeling (Expiration date was worn off), (5) A cardboard cup with a dark brown unidentifiable substance without labeling, (6) A plastic bag with two Tupperware containers of food without labeling, and (7) A jar of blackberry preserve with a use by date of 01/20/2024. During an interview on 11/13/2024 at 1:03 PM, Staff N stated the resident refrigerators' contents were monitored by nursing staff who would ensure items were labeled with a resident's name and date when placed in the refrigerator. Staff N stated food items were thrown away after three days. Staff N reviewed the facility's front resident refrigerator and stated that there were multiple items that needed to be thrown away due to a lack of dating or being over three days old. Staff N stated staff food items should not be stored in resident refrigerators and was unsure why Staff O had stored items in the refrigerator. Staff N stated the refrigerator did not meet their expectation for sanitary food storage. During an interview on 11/13/2024 at 1:18 PM, Staff A stated the resident refrigerators' contents were monitored and thrown away by the dietary staff and they should not contain staff food items. Staff A stated the lack of labeling, food not being thrown out, and staff food items being in the resident refrigerator did not meet expectation. Reference WAC 388-97-1100 (3), -2980

Based on interview and record review, the facility failed to periodically inform residents of their rights after residents were admitted to the facility for 8 of 8 sampled residents (Residents 1, 3, 6, 9, 13, 14, 15 and 16) when reviewed for resident rights. This failure placed residents at risk of not being informed of their rights and a diminished quality of life. Findings included . During an interview on 11/12/2024 at 9:15 AM, Staff A, Administrator (ADM), stated they did not have a Resident Council President. Staff A stated they did not believe there were any residents that attended resident council for the past couple of months. During an interview on 11/15/2024 at 10:00 AM, Resident 3 stated they did not recall discussing or being provided information related to resident rights since they admitted to the facility. During an interview on 11/15/2024 at 9:19 AM, Resident 1 stated they were not aware of the Resident Council, and they were not aware of their resident rights. Review of Resident Council Minutes for August, September and October 2024 showed no residents attended the meetings. Review showed resident rights were not alternatively communicated to residents. During an interview on 11/15/2024 at 10:58 AM, Staff P, Life Enrichment Assistant, stated they did not periodically provide any information on resident rights to residents. During an interview on 11/15/2024 at 11:20 AM, Staff A, Administrator, stated the expectation was that residents were informed at admission and throughout their stay of the resident rights. Staff A stated communication should have been by other means since residents were not attending resident council. Reference WAC 388-97-0280(2), (3)(a-d)

Based on interview and record review, the facility failed to provide written bed hold notice at the time of transfer to the hospital for 1 of 1 sampled residents (Resident 1) reviewed for hospitalization . This failure placed the residents at risk for lacking knowledge regarding their right to hold their bed while in the hospital and diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 1 admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure) and heart failure. Resident 1 was able to make needs known. Review of Resident 1's EHR showed a hospitalization on [DATE], and readmission to the facility on [DATE]. There was no documentation regarding a bed hold being provided. During an interview on 11/14/2024 at 11:46 AM, Staff A, Administrator, stated they were not offering residents bed holds but should have been. Reference WAC 388-91-0120(4)

Based on interview and record review, the facility failed to provide written notification of the reason for transfer to the hospital to residents or responsible party for 1 of 1 sampled residents (Resident 1) reviewed for hospitalization . This failure placed the resident at risk for not knowing rights regarding transfer and discharge from the facility and diminished protection from being inappropriately discharged . Findings included . Review of the electronic health record (EHR) showed Resident 1 admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure) and heart failure. Resident 1 was able to make needs known. Review of Resident 1's EHR showed a hospitalization on [DATE], and readmission to the facility on [DATE]. There was no documentation regarding notice of transfer. During an interview on 11/14/2024 at 11:46 AM, Staff A, Administrator, stated they did not provide residents or resident representatives with written notice for reason of transfer to the hospital. Reference WAC 388-91-0120(2) (a-d)

Based on interview and record review, the facility failed to consistently implement the bowel program when needed for 1 of 5 sampled residents (Resident 15) reviewed for unnecessary medications. These failures placed the residents at risk for discomfort and a diminished quality of life. Findings included . Review of a document titled, Bowel Care Protocol-Standing House Orders dated 10/19/2022 showed a resident would be provided the following: (1) Milk of magnesia (MOM) suspension by mouth daily as needed for constipation. Give at bedtime or at resident preferred time if no bowel movement on 3rd day. (2) Dulcolax suppository as needed for constipation if no results from MOM after 12 hours. (3) Fleet enema every 24 hours as needed for constipation if no results from Dulcolax in four to six hours. (4) If no results from enema notify MD. Review of the electronic health record (EHR) showed Resident 15 admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure), diabetes and dementia. Resident 15 had impaired communication relating to making self-understood and understanding others. Review of Resident 15's care plan dated 10/21/2024 showed the resident received an antipsychotic medication, and that staff were to observe for any side effects to include constipation. Review of Resident 15's task section in the EHR for bowel movement showed no bowel movement (BM) on 11/06/2024, 11/07/2024, 11/08/2024 and 11/09/2024. The EHR showed documentation that the resident was administered a Dulcolax suppository on 11/09/2024. During an interview on 11/14/2024 at 12:11 PM, Staff B, Director of Nursing Services, stated the expectation was that the facility's bowel protocol should have been implemented within the stated time frame and documented whenever a resident had no BM for three days. Reference WAC 388-97-1060(1)

Based on interview and record review, the facility failed initiate non-pharmacological interventions prior to the administration of as needed pain medication for 1 of 5 sampled residents (Resident 14) reviewed for unnecessary medications. This failure placed residents at risk for receiving unnecessary medications and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 14 admitted to the facility on [DATE] with diagnoses that included left hip pain, muscle weakness and Guilian-Barre Syndrome (a condition in which the body's immune system attacks the nerves). Resident 14 was able to make needs known. Review of the EHR showed Resident 14 had orders for Tramadol 25 milligrams (MG) and acetaminophen 325 MG to be given as needed for pain. Review of the October 2024 medication administration record (MAR) showed that Resident 14 was provided Tramadol eighteen times and acetaminophen twice; however, there was no documentation that non-pharmacological interventions were provided prior to the administration of the medications. Review of the November 2024 MAR showed that Resident 14 was provided Tramadol six times; however, there was no documentation that non-pharmacological interventions were provided prior to the administration of the medications. During an interview on 11/14/2024 at 11:45 AM, Staff B, Director of Nursing Services, stated the expectation was for staff to provide and document non-pharmacological interventions to all residents who had as needed pain medications. Reference WAC 388-97-1060(3)(k)(i)

Based on observation, interview and record review, the facility failed to ensure a safe environment was maintained related to a reclining chair for 1 of 2 sampled residents (Resident 14) and common area appliances were safe from resident use for 2 of 2 common area ovens (East and West) when reviewed for accidents. These failures placed residents at risk for avoidable injuries and a diminished quality of life. Findings included . <Reclining Chair> Review of the electronic health record (EHR) showed Resident 14 admitted to the facility on [DATE] with diagnoses that included left hip pain, muscle weakness and Guilian-Barre Syndrome (a condition in which the body's immune system attacks the nerves). Resident 14 was able to make needs known. Observation on 11/13/2024 at 9:29 AM showed Resident 14 slumped down in a recliner chair located in the corner of their room. Review of Resident 14's EHR showed no safety assessment or informed consent with risks and benefits for the use of a recliner chair. Review of Resident 14's provider's orders showed no order for the use of a recliner chair. During an interview on 11/13/2024 at 11:56 AM, Staff B, Directo of Nursing Services, stated they did not have a process for assessing if the recliners were safe for residents. Staff B stated they would unplug recliners in some resident's room based on their diagnosis. Staff B stated the expectation was that residents with reclining chairs had a provider's order, an initial and quarterly assessment and that risk and benefits would be provided. <Common Area Ovens> Observation on 11/12/2024 at 11:55 AM showed a common area stove on the east side of the building with an out of order sign. The stove had push buttons and was easily accessible for residents to turn on. Observation showed the oven was able to be turned on. Observation on 11/12/2024 at 12:15 PM showed a common area stove on the west side of the building. The stove had push buttons and was easily accessible for residents to turn on. Observation showed the oven was able to be turned on. During an interview on 11/12/2024 at 2:15 PM, Staff A, Administrator, stated the stove units were disconnected and not able to be used. During an interview and observation on 11/12/2024 at 2:16 PM, Staff Q, Maintenance Supervisor, stated the electrical panel was distorted; therefore, the ovens did not work. Observation showed Staff Q was able to turn on the stoves in both the east and west common areas. Staff Q stated they were unaware the ovens continued to function and the ovens should have been disable but had not been. Observation on 11/12/2024 at 2:48 PM showed a Defective equipment, out of service sign on both the east and west common area stoves Reference WAC 388-97-1060 (3)(g)

Based on observation and interview, the facility failed to ensure a sanitary piece of equipment was available to 1 of 2 sampled residents (Resident 6) reviewed for safe and sanitary environment/equipment. This failure placed the resident at risk for infection and diminished quality of life. Findings included . Review of the electronic health record showed Resident 6 admitted to the facility on [DATE] with diagnoses that included Parkinson's (a degenerative brain condition that gets worse overtime), dementia (loss of memory, problem solving and thinking abilities) and end of life care. The change of condition minimum data set (MDS, an assessment tool), dated 10/17/2024, showed Resident 6 was not able to make needs known and was dependent on staff for activities of daily living. Observation on 11/12/2024 at lunch time showed Resident 6 visiting with their spouse and sitting in their wheelchair in the dining room. The armrests of the wheelchair were covered with multiple layers of black plastic tape and fabric tape and was showing frayed edges that were not a cleanable surface. During an interview on 11/15/2024 at 9:46 AM, Staff E, Central Supply, stated the process was for them to notify a company to come and repair the broken part. When asked about the condition of the armrest of Resident 6's wheelchair, Staff E stated they placed the tape on the armrest as Resident 6 had pulled out the cover from the armrests. Staff E stated the armrests were not a cleanable surface. During an interview on 11/15/2024 at 11:14 AM, Staff B, Director of Nursing Services, stated the expectation was to have wheelchairs in good condition and have cleanable surfaces. Reference WAC 388-97-3220(1)

Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan about post-traumatic stress disorder (PTSD, a mental health condition that can develop after someone experiences or witnesses a traumatic event) for 1 of 8 sampled residents (Resident 6) reviewed for care planning. This failure placed the resident at risk for unidentified and unmet care needs and diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 6 admitted to the facility on [DATE] with diagnoses that included PTSD, Parkinson's (a degenerative brain condition that gets worse overtime), dementia (loss of memory, problem solving and thinking abilities) and end of life care. The change of condition minimum data set (MDS, an assessment tool), dated 10/17/2024, showed Resident 6 was not able to make needs known and was dependent on staff for activities of daily living. Observation on 11/12/2024 at 9:45 AM showed Resident 6 with eyes closed, laying in a low bed. During an interview on 11/13/2024 at 2:11 PM, Collateral Contact 1 (CC1), stated Resident 6's behaviors had resolved and they were very weak. CC1 stated Resident 6 had PTSD and had specific triggers that affected them. CC1 stated being a previous [NAME] was Resident 6's identity. Review of Resident 6's EHR showed a care plan with no PTSD focus area, goals, or interventions. During an interview on 11/14/2024 at 2:16 PM, Staff C, Social Service Coordinator, stated they did the trauma assessment and then developed a care plan for each resident that had PTSD. Staff C was not able to locate a care plan that addressed PTSD for Resident 6 and stated it was not acceptable. During an interview on 11/14/2024 at 2:53 PM, Staff B, Director of Nursing Services, stated the expectation was for PTSD to be addressed in the residents' care plans. Reference WAC 388-97-1020(1), (2)(a)(b)

Based on interview and record review, the facility failed to determine if a resident had current advanced directives (AD), and if not, determine whether the resident wished to develop advanced directives for 1 of 4 sampled residents (Resident 9) when reviewed for AD. This failure potentially denied the resident the opportunity to direct their healthcare if they were to become unable to make decisions or communicate their health care preferences. Findings included . Review of a document titled, Advanced Directives, dated 08/18/2024, showed it was the policy of the facility to respect each resident's AD in accordance with state/federal law and facility policy. The facility's interdisciplinary team would review annually with the resident and/or representative their AD, upon the resident's request, when the residents condition warranted a review, and when there was a significant change in the resident's condition to ensure that such directives were still the wishes of the resident. Review of the admission minimum data set (MDS, a required assessment tool) dated 10/31/2024, showed Resident 9 admitted on [DATE] with multiple diagnoses to include cancer, anemia (a condition where the body does not produce enough red blood cells that can lead to a lack of oxygen in the body), dementia (a group of thinking and social symptoms that interferes with daily functioning), anxiety and depression. The MDS showed the resident was able to make needs known and had a change in condition to reflect being placed on hospice (care provided to people who are near the end of life and have stopped treatment to cure or control their disease). Review of Resident 9's electronic health record (EHR) showed they had no durable power of attorney (a legal document that gives someone the power to act on behalf of the resident if they ever became mentally incapacitated), which indicated the resident was responsible to make their own decisions. The resident's EHR showed an AD last dated for the month of March 2020; however, the residents change in condition on 10/31/2024 showed the MDS documented hospice care and no updated was documented to reflect this in the AD. During an interview on 11/13/2024 at 8:44 AM, Staff C, Social Services Coordinator, stated that the AD was in the chart; however, the form was last updated March 2020. During an interview on 11/13/2024 at 3:15 PM, Staff A, Administrator, stated the facility staff had conducted a recent audit to ensure all residents had a current AD; however, Resident 9 must not have had their records audited to ensure the AD was updated on a yearly basis and that their expectation would be that Resident 9 had a current AD in the EHR. Reference WAC 388-97-0300(3)(b)(c)

Based on observation, interview, and record review, the facility failed to ensure married residents were provided the right to share a room for 2 of 2 sampled residents (Residents 1 and 4) reviewed for room changes. This failure placed residents at risk for psychosocial stress and a diminished quality of life. Findings included . Resident 1 Review of the electronic health record (EHR) showed Resident 1 admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure) and heart failure. Resident 1 resided in room [ROOM NUMBER] and was able to make needs known. During an interview on 11/15/2024 at 9:55 AM, Resident 1 stated, I would prefer to share a room with my husband [Resident 212]. We assumed we would be able to, but they said we could not. Review of the care plan dated 09/05/2024 showed Resident 1 was at risk of decreased socialization due to cognitive decline. The care plan stated Resident 1 enjoyed spending time and eating meals with their spouse. Resident 1's recliner was relocated to their spouse's room to spend more time together. Resident 4 Review of the EHR showed Resident 4 admitted to the facility on [DATE] with diagnoses that included depression, dementia and heart failure. Resident 4 resided in room [ROOM NUMBER], required minimal assistance and was able to make needs known. During an interview on 11/15/2024 at 9:52 AM, Resident 4 stated they could not share a room with their spouse (Resident 1) because they were told it was one resident per room. During an interview on 11/15/2024 at 10:33 AM, Staff C, Social Services Coordinator (SSC), stated facility rooms were private and one resident per room. Staff C stated they did not know if two beds would fit in one room; however, they tried to accommodate Resident 1 by moving their recliner to Resident 4's room. During an interview on 11/15/2024 at 11:00 AM, Staff A, Administrator, stated the facility rooms were single occupancy. Staff A stated Resident 1 or Resident 4 never expressed they wanted to live together; however, they did express they wanted to spend more time together. Reference WAC 388-97-0580(1)(b)(i)(ii)

Based on interview and record review, the facility failed to post actual nurse staffing hours for 11 of 11 months reviewed (01/10/2024 through 11/14/2024) when reviewed for nurse staff posting. This failure placed residents and family at risk of not knowing the actual number of staff working within the facility. Findings included . Observation on 11/13/2024 at 11:11 AM showed a Daily Staffing sheet posted at the front of the facility which included a column for staff hours and a second column labeled Changes. Review of the nurse staff posting binder from 01/10/2024 through 11/14/2024 showed no daily staffing forms with any recorded changes in staffing. Review showed nurse staff postings were missing for 04/13/2024 through 04/15/2024 and 04/22/2024 through 04/23/2024. During an interview on 11/14/2024 at 2:31 PM, Staff F, Staffing Coordinator, stated they posted the daily staffing sheets. Staff F stated they did not update the posting with the actual hours worked by staff. During an interview on 11/14/2024 at 3:08 PM, Staff A, Administrator, stated Staff F was responsible for updating the nurse staff posting sheets with the actual hours worked by staff. Staff A stated the lack of actual hours worked by nursing staff on the nurse staff postings did not meet expectation. No Associated WAC

Based on observation, interview and record review the facility failed to ensure residents were served meals at appropriate temperatures. This failure placed the residents at risk for food bourne illness, decreased satisfaction with meals and diminished quality of life. Findings included . During an interview on 01/03/2024 Resident 4 said The food is ok but it is usually cold at the dinner. Observation of lunch tray service on 01/08/2024 between 11:00 AM and 12:30 PM showed the following; The Shepherd's Pie entree was not tempted prior to the beginning meal service. The mashed potatoes were observed on the steam table at 11:00AM and were not tempted prior to the beginning of meal service at noon. The Cream of Cauliflower soup was not tempted prior to being served at 11:56 AM to the first resident in the dining room. During an interview on 01/08/2024 at 12:07 PM Staff D, Cook, stated that they had taken the temperature of the soup at approximately 10:00 AM and that it was the dietary aide's responsibility to take the temperature again at the beginning of meal service. Staff D stated that other hot items were temped prior to being put on the steam table. During an observation on 01/08/2024 at 12:16 PM Staff E, Dietary Aide, was observed temping the soup. Review of the kitchen temperature logs at 12:30 PM showed no temperatures recorded for the 01/08/2024 lunch meal. The temperture log did not have an area to record the time the temperatures were taken. During an interview on 01/08/2024 at 12:55 PM, Staff C, Dietary Manger (DM), stated their expectation was that the temperature logs should have been completed after the temperature was taken for accuracy. Additionally, Staff C stated that they expected all other foods to be tempted before service and ideally in the middle of service. Reference WAC 388-97-1100 (1), (2)

Based on observation and interview, the facility failed to ensure drugs and biologicals were labeled, dated, or discarded in accordance with currently accepted professional standards for 2 of 2 medication carts (1200 and 1300 carts) reviewed for medication storage. This failure placed residents at risk of receiving compromised or expired medications. Findings included . Observation of the 1300 hall medication cart on 01/05/2024 at 9:33 AM, showed an opened bottle of latanoprast ophthalmic solution (a medication used to treat increased pressure inside the eye) for Resident 1, and an opened bottle of latanoprast ophthalmic solution for Resident 21. The bottles did not have the date that they were opened on the label. An opened bottle of unlabeled and undated GENTEAL tears eye drops (moisturizing eye drops) was on the medication cart. Observation of the 1200 hall medication cart on 01/05/2024 at 9:56 AM showed an opened tube of erythromycin (an antibiotic) eye ointment for Resident 18. The tube was not labeled with an opened date. During an interview on 01/05/2024 at 9:40 AM, Staff H, Registered Nurse, stated all multiuse vials such as eye drops should be labeled with the resident's name and the date it was opened. During an interview on 01/05/2024 at 9:59 AM, Staff J, Licensed Practical Nurse, stated that Resident 18 had completed treatment with the erythromycin eye ointment. Staff J stated the tube should have been dated when it was opened and discarded when completed. During an interview on 01/05/2024 at 11:14 AM, Staff B, Director of Nursing Services, stated that it was their expectation that all multiuse vials/tubes be dated and labeled when opened and the eye drops and ointments found undated did not meet expectations. Reference WAC 388-97--1300 (2)

Based on interview and record review the facility failed to adequately monitor for adverse side effects of anticoagulant (blood thinning) medications for 2 of 5 sampled residents (Residents 15 and 9) reviewed for unnecessary medications. This failure placed the residents at risk for unidentified adverse side effects and a decreased quality of life. Findings included . Review of Resident 15's electronic health record (EHR) showed the resident was receiving the blood thinning medication (Xerelto) for a diagnosis of atrial fibrillation (irregular heartbeat). The EHR did not show an order to monitor for adverse side effects. Review of Resident 9's EHR showed the resident was receiving the blood thinning medication (Xerelto) for a diagnosis of atrial fibrillation. The EHR did not show monitoring for adverse side effects. During an interview on 01/05/2024 at 10:26 AM, Staff F, Resident Care Manager, stated that it was their expectation that residents receiving blood thinning medications be monitored for signs of abnormal bleeding or bruising. Staff F stated that it should be in the medication administration record (MAR) or treatment administration record (TAR) but this was not done for Resident 15. During an interview on 01/05/2024 at 12:00 PM, Staff G, Minimum Data Set Registered Nurse, stated Resident 9 had an order in place to monitor for adverse effects of anticoagulant medication, but it was not showing for the nurses to complete. During an interview on 01/05/2024 at 11:20 AM, Staff B, Director of Nursing Services stated that it was their expectation that residents receiving anticoagulant medications be monitored for signs of abnormal bleeding/bruising, and that this was not being completed for Resident 15 and Resident 9, but should have been. Reference WAC 388-97--1060 (3)(k)(i) .

Based on interview and record review, the facility failed to implement the planned preventative measure of two person assist when using mechanical devices to ensure safety and prevent falls for 1 of 3 residents (Resident 1) reviewed for accident hazards. This failure resulted in harm to Resident 1 who experienced pain and sustained a left upper arm fracture when they were transferred with one person assist rather than two person assist as they were assessed to require. This failure also placed other residents at risk for falls, injury, and diminished quality of life. Findings included . Review of the facility's Safe Resident Handling Transfers Policy, dated 10/31/2021, it was the policy of the facility to ensure residents were handled and transferred safely to prevent or minimize risk for injury and provide and promote a safe, secure experience for the residents. Staff would be educated on safe handling transfer practices and use of mechanical lifts such as full body lifts (e.g., Hoyer lift) and sit-to-stand lifts (helps the patient to rise from the seated position but does not support the patient's entire body weight.)According to the policy Two staff members must be utilized when transferring residents with a mechanical lift and staff were expected to maintain compliance with these safe handling practices. Resident 1 Resident 1 admitted to the facility on [DATE]. According to the 05/15/2023 quarterly Minimum Data Set (MDS, an assessment tool), the resident was severely cognitively impaired, had a diagnoses of non-traumatic brain dysfunction, dementia, and required extensive two-person assistance with transfers. Review of Resident 1's electronic health record showed on 08/14/2023 an order was obtained for a left shoulder two view x-ray secondary to left arm pain with movement. Review of the 08/14/2023 x-ray results showed Resident 1 had a Recent fracture of the left humeral neck (upper arm) with modest displacement (end of the bones at the site of the break are not in alignment.) Review of the facility's incident log showed a 08/14/2023 incident was logged for an injury (fracture) during handling for Resident 1. Review of the Facility's 08/14/2023 investigation showed through staff interviews the facility was able to determine Resident 1 was injured sometime on 08/09/2023. Staff provided the following statements: a) According to Staff D, Licensed Practical Nurse (LPN), on 08/09/2023 at 8:00 AM, Staff D and Staff C, Certified Nursing Assistant (CNA) transferred Resident 1 utilizing a sit-to-stand lift without incident. b) According to Staff G, CNA, on the evening of 08/09/2023 (to 8/10/2023) when repositioning Resident 1 in bed, the resident called out in pain and placed their right hand on the wall to prevent Staff G from rolling them to their left side. Staff G indicated they immediately stopped and notified nursing. c) According to Staff F, LPN, on the evening of 08/09/2023 during movement toward either side Resident 1 voiced expressions of pain such as ow. e) According to Staff E, CNA, on the morning of 08/10/2023 they attempted to roll Resident 1 in bed, but the resident yelled out in pain. Staff E stated that they immediately stopped and informed the nurse. Review of the investigative documents showed on 08/10/2023 the provider was notified of Resident 1's new onset of pain, and an order for acetaminophen (a medication to control pain) was obtained. The provider stated the pain/soreness may be due to the resident's recent COVID (a highly contagious virus) positive test. When Resident 1's symptoms were not relieved by 08/14/2023, staff obtained an order for a left shoulder x-ray, which identified a left humerus fracture. On 08/14/2023 after Resident 1's fracture was identified, Staff C, the CNA assigned to care for Resident 1 on the day shift of 08/09/2023 was contacted for a statement as they had not prior provided one. Staff C explained that on 08/09/2023 just before lunch they attempted to transfer Resident 1 to the toilet by themself. According to Staff C the sit-to-stand sling was correctly placed, the resident grabbed the lift bar with their right hand and had the left hand across their chest. Per Staff C they began to lift Resident 1 in the sit-to-stand lift. While the lift was elevating Resident 1 was holding on with tightly had begun to slump. As the lift went higher, the resident let go and the sling slipped up under the resident's armpits causing the resident to hang freely from the sling. Staff C reported they supported the resident's buttocks while they lowered the resident back into the wheelchair. Staff C confirmed they attempted to transfer Resident 1 alone, despite being aware the resident required two-person assistance when being transferred. Staff C also confirmed they did not report the incident. During an interview on 09/31/2023 at 12:56 PM, Staff A, Administrator and Staff B, Director of Nursing Services, both confirmed the root cause of the incident was the failure to transfer Resident 1 with two people as the resident was assessed to require and as directed by facility policy when using mechanical lifts to ensure resident safety. Reference WAC 388-97-1060(3)(g)

Based on observation, interview and record review, the facility failed to ensure resident care plans (CPs) were reviewed, revised, and accurately reflected residents' care needs for nine of 12 sample residents (Residents 8, 73, 4, 9, 10, 11, 16, 19 and 21) whose care plans were reviewed. These failures placed residents at risk for unmet care needs and diminished quality of life. Findings included . RESIDENT 8 Review of Resident 8's Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 8's comprehensive CP showed a CP that addressed the resident's diuretic therapy and [CONDITION(S)] had not been developed, no goals were identified and no interventions were provided to staff about when/how to monitor and manage the resident's [CONDITION(S)]. During an interview on 09/19/2022 at 10:46 AM, Staff B, Director of Nursing Services (DNS), stated that the facility should have developed and implemented a CP addressing Resident 8's diuretic therapy and [CONDITION(S)] management, but failed to do so. Review of Resident 8's 06/02/2022 Falls CP showed staff were directed to ensure adaptive devices, Walker/Cane/Wheelchair, were within reach and in good repair. During an observation and interview on 09/19/2022 at 8:09 AM, Resident 8 stated that they did not have or use a cane and no cane was observed in the resident's room. During an interview on 09/19/2022 at 10:46 AM, Staff B, DNS, stated that she was not aware of Resident 8 ever using a cane and indicated the CP needed to be updated and personalized. Review of Resident 8's Nutrition CP, dated 06/20/2022, showed the following direction to staff: provide supplements and nourishment per recommendation as ordered by the doctor MD (The CP did not state what supplements or nourishments, if any, the resident was to receive); Honor food preferences. (The residents food preferences were not identified); Encourage fluid intake if not contraindicated with diagnosis. (The CP doesn't identify if encouraging fluids was contraindicated or identify what diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 09/19/2022 at 10:46 AM, Staff B, DNS, stated that Resident 8's Nutrition CP needed to be personalized to the resident's specific needs. Review of Resident 8's [CONDITION(S)] drugs CP, dated 06/20/2022, showed staff were directed to initiate a behavior management program; behavior monitoring and tracking; and monitor behaviors and document on behavior flowsheet. Staff were then directed to See Behavior care plan, however, further review showed a Behavior care plan had not been initiated. During an interview on 09/19/2022 at 10:46 AM, Staff B, DNS, acknowledged Resident 8 did not have a behavioral CP and stated that either the [CONDITION(S)] CP needed to be updated and the reference to the behavior CP removed, or a behavior CP needed to be developed and implemented. Review of Resident 8's therapy services CP, dated 06/20/2022, showed the resident was receiving Physical Therapy (PT), Occupational therapy (OT) and Speech therapy (SLP) services with an identified goal of meeting the resident's functional goals and improving to their prior level of function. The intervention listed was Therapy. Restorative. Review of Resident 8's electronic health record (EHR) showed the Resident was discharged from PT and OT services on 08/25/2022 and did not receive restorative nursing services. During an interview on 09/19/2022 at 10:46 AM, Staff B, DNS, stated that the CP needed to be revised. RESIDENT 73 Review of Resident 73's psychosocial CP, dated 08/21/2022, showed the problem was identified as Resident 73 having behaviors at others may find disruptive and socially inappropriate. The following was then listed: Behaviors exhibited; Other risk factors that may result in harm to the resident; Type of reprisal to guard against; Those who may seek reprisal; Resident specific information. The statements had not been personalized to include the resident's specific behaviors/information. During an interview on 09/19/2022 at 10:46 AM, Staff B, DNS, stated that the CP was incomplete and needed to be revised and personalized. RESIDENT 4 Review of Resident 4's [CONDITION(S)] drugs CP, dated 11/30/2021, showed the resident received the antipsychotic medication, [MEDICATION(S)]. Review of Resident 4's September 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 09/19/2022 at 10:46 AM, Staff B, DNS, stated that Resident 4's [MEDICATION(S)] had been discontinued and the CP needed to be revised and updated. RESIDENT 9 Review of Resident 9's September 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 9's [CONDITION(S)] drugs CP, dated 06/29/2022, showed staff were directed to initiate a behavior management program; behavior monitoring and tracking; and monitor behaviors and document on behavior flowsheet. Staff were then directed to See Behavior care plan, however, further review showed a behavior care plan had not been initiated. During an interview on 09/19/2022 at 10:46 AM, Staff B, DNS, acknowledged Resident 8 did not have a behavioral care plan and stated that either the [CONDITION(S)] CP needed to be revised or a behavior CP needed to be developed and implemented. RESIDENT 10 Review of Resident 19's September 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 10's [CONDITION(S)] drug CP, dated 03/30/2022, showed the following: Behaviors exhibited; Resident specific information. The spot provided to document Resident 10's target behaviors the antipsychotic medication was intended to treat and other resident specific information was left blank. During an interview on 09/19/2022 at 10:46 AM, Staff B, DNS, stated that the CP was incomplete and needed to be revised and personalized. RESIDENT 11 Resident 11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . >Eating< On 09/15/2022 at 1:00PM, Resident 11 was observed using a spoon and fork that were bent and had grips on the handles to eat lunch. On 09/16/2022 at 10:05 AM, Resident 11 stated when they had completed speech therapy the Speech Therapist was going to write suggestions to follow through with, but they did not know what happened to the suggestions. Review of Resident 11's Speech Therapy discharge summary, dated 04/27/2022, showed recommendations to include alternation of liquids and solids, slowing of rate, and size of bites. Review of Resident 11's Nutrition CP, dated 01/10/2022, showed Assess for need for adaptive equipment as needed and Resident denies swallow issues. Resident 11's CP showed no documentation of the adapted fork and spoon or the speech therapy recommendations. On 09/19/2022 at 11:19 AM, Staff B, DNS, reviewed Resident 11's CP and stated that the care plan had not been revised to include the adaptive fork and spoon and/or the Speech Therapy recommendations. >Catheter< Review of Resident 11's Minimum Data Set (MDS), an assessment tool, dated 01/14/2022, showed Resident 11 had a suprapubic catheter (a tube that is inserted into your bladder through your abdomen to drain urine). An observation on 09/12/2022 at 3:42 PM, showed Resident 11 with a urinary drainage bag (a bag that is connected to the suprapubic catheter with a tube to collect the urine) strapped to their leg. On 09/15/2022 at 12:20 PM, Staff H, Certified Nursing Assistant (NAC), stated that she changes Resident 11's nighttime urinary drainage bag to the leg bag in the morning. She stated that she cleaned the nighttime drainage bag out with a vinegar mixture that is in the bathroom and hung it up to dry. Staff H stated the licensed nurse told her how to clean it. On 09/15/2022 at 12:53 PM, Resident 11 stated that no one will listen to them about how to clean the drainage bags. Resident 11 stated that the old staff just tell the new staff and Resident 11's family buys the vinegar, and the nursing assistants mix it with water. On 09/16/2022 at 2:28 PM, Staff J, NAC, stated that she cleaned Resident 11's urinary drainage bags. Staff J stated that she used vinegar to wash them out and added a few drops of liquid soap to the mixture. Review of Resident 11's CP, dated 01/14/2022, showed catheter care per facility protocol, resident has own supplies in room and to change bag to leg bag during the day. On 09/19/2022 at 11:14 AM, Staff B, DNS, stated the CP had no instructions on how to clean the urinary drainage bags and the facility did not have a catheter protocol for cleaning the drainage bags for the nursing assistants to follow. Staff B stated the Care Plan had not been revised to include the instructions on caring for the drainage bags. RESIDENT 16 Resident 16 was admitted to the facility on [DATE]. Review of the Quarterly MDS, dated [DATE], showed the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/12/2022 at 2:27 PM, Resident 16, stated staff invited them to groups, but they did not like to go. On 09/15/2022 at 2:13 PM, Staff K, Certified Nursing Assistant, stated that Resident 16 occasionally liked to go outside and see the garden. Review of Resident 16's Activity CP, dated 05/20/2021, showed interventions; meet with resident one to one to determine specific concerns/interests; review past interests, advise resident of all the activities available. On 09/15/2022 at 12:45 PM, Staff M, Activity Director (AD), stated she is responsible for completing and revising the Activity CP for Resident 16. Staff M reviewed Resident 16's CP and stated that she had not updated and/or revised the CP and had not provided activity interventions specific to Resident 16's interests and activities. RESIDENT 19 Review of the Annual MDS, dated [DATE], showed Resident 19 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/12/2022 at 10:13 AM and 09/15/2022 at 11:47 AM, Resident 19 was observed sitting in her room alone looking at the ground. Review of Resident 19's Activity CP, dated 07/21/2022, showed interventions of; advise resident of all the activities available, ask family/significant other for suggestions about activities that the resident may enjoy, make positive comments about, and reinforce activities in which the resident is still independent. On 09/15/2022 at 12:38 PM, Staff M, AD, stated that she is responsible for completing and revising the Activity CP for Resident 19. Staff M reviewed Resident 19's CP and stated it was generic and was not reflective of Resident 19's current activity interests or activities for the staff to assist the resident with. RESIDENT 21 Resident 21 was admitted to the facility on [DATE]. Review of the Annual MDS, dated [DATE], showed the resident was cognitively intact. On 09/12/2022 at 11:45 AM, Resident 21 stated that their biggest concern is that they had pain when getting up in the morning and going to bed. Resident 21 stated that they discussed with the head nurse that they had assigned nursing assistants to them that did not know how to care for them, and it caused them discomfort. Resident 21 stated they were at the mercy of their communication and when they didn't communicate with each other on how to care for them it is uncomfortable. On 09/15/2022 at 2:07 PM, Staff K, Certified Nursing Assistant, stated that he knew the resident well and cared for him often. Staff K stated that Resident 21 was sensitive with movement, and you could decrease his pain if you knew how to set up the transfer correctly. Review of Resident 21's Activities of Daily Living CP, dated 11/18/2021, showed Resident 21 was an extensive assist with transfer pole. The CP showed no documentation to instruct the nursing staff on specific transfer techniques and/or interventions to reduce Resident 21's pain with transfer. On 09/15/2022 at 3:59 PM, Staff B, DNS, reviewed Resident 21's CP and stated that the CP did not give instructions for the nursing staff that were specific to Resident 21's transfer and care needs. Review of Resident 21's incident report, dated 08/02/2022, showed that Resident 21 sustained a fall related to the resident's knee buckling and therapy recommended the right knee brace be evaluated for proper fit. On 09/16/2022 at 11:00 AM, Staff L, Physical Therapist, stated that Resident 21 was on therapy caseload and evaluated for an adjustment to Resident 21's right knee brace. Review of Resident 21's CP, dated 11/18/2021, showed no documentation of a right knee brace. On 09/19/2022 at 11:23 AM, Staff B, DNS, reviewed Resident 21's Care Plan and stated that Resident 21's CP did not include their right knee brace. Reference WAC 388-97-1020 (5)(b)

Based on observation, interview and record review, the facility failed to prevent and immediately assess and treat a burn injury when one of four residents (Resident 1) reviewed for accidents spilled hot soup at lunch time. This failure resulted in harm to Resident 1 when assistance during mealtime was not provided per assessment, the resident sustained a blistering burn injury, and the nurse was not notified immediately so that the resident could be assessed for injury and provided with first aid and pain management in a timely manner. Findings included . Resident 1 was admitted [DATE] with diagnosis of Alzheimer's Disease. The Quarterly Minimum Data Set (MDS), an assessment, dated 11/18/2021, documented Resident 1's cognitive skills for decision-making were severely impaired. The MDS, dated [DATE], documented Resident 1 needed limited physical assistance from one person to guide maneuvering of limbs during eating. The Admission MDS, dated [DATE], documented Resident 1 needed only supervision, encouragement, and cueing to eat. Resident 1's Care Plan, dated 08/13/2021, was not revised with new interventions to reflect the 11/18/2021 Quarterly MDS assessment when the resident's need for increased assistance at mealtime was determined. Progress note, dated 11/28/2021, documented Resident 1's family alerted a nurse at 1:00 PM there was redness on the resident's right thigh where the resident reported having spilled hot soup at lunchtime. The progress note documented the right thigh had a 9 cm by 12 cm (3.5 inches by 4.7 inches) reddened area with blistering and the resident was given Tylenol for discomfort. Pain Assessment, dated 11/28/2021 at 1:30 PM, documented Resident 1 experienced pain on the right thigh as 6 on a scale of 0-10 with 10 being most painful. The Pain Assessment showed Resident 1 had vocal complaints and facial expressions of pain. Facility Incident Report, dated 11/29/2021, documented Staff C, Certified Nursing Assistant (NAC), stated the kitchen brought Resident 1 a bowl of soup and Staff C provided silverware and went to help feed another resident. Staff C documented that after two minutes she turned around and saw Resident 1 wiping the table and saw there was soup on the resident's pants. Staff C documented, I wiped [Resident 1's] pants with a cloth. Staff C documented she called the kitchen to report the spilled soup and to get Resident 1 another bowl of soup. Staff C documented the kitchen brought another bowl of soup and afterwards the family arrived and took the resident away. The Incident Report, dated 11/29/2021, documented the family stated they thought the resident spilled the soup prior to 1:00 PM when they arrived to visit with the resident. On 11/30/2021 at 4:00 PM, Staff D, Dietary Manager, indicated Resident 1 was served the hot soup in a mug without a lid. Staff D stated the resident's tray card containing instructions to dietary staff did not include the requirement for lids on all mugs, however, Staff D explained that after this burn incident, a text message went out to all staff to make sure there were lids on mugs and bowls containing hot liquids. On 11/30/2021 at 5:15 PM, Resident 1 was observed in the dining room where staff were observed cueing him and encouraging him to eat but not providing physical assistance. On 12/17/2021 at 11:30 AM, Staff E, NAC, stated if hot soup was spilled on the resident's body, it should be reported to the nurse immediately. At 11:37 AM, Staff F, Licensed Practical Nurse, stated the NAC should have reported the spill of hot soup to the nurse immediately. Staff F indicated the longer the hot soup stayed on the skin, the more serious would be the burn and described necessary first aid. On 01/04/2021 at 11:56 AM, Staff B, Director of Nursing Services, stated Staff C should have reported to the nurse immediately when it was apparent that Resident 1 spilled hot soup on the right thigh so that assessment and first aid could be implemented. Staff B said serving residents hot soup in lidded mugs might decrease the risk of injury related to spilling. Reference WAC 388-97 -1060 (3)(g)