Every finding on record at Kin on Health Care Center

Based on observation, interview, and record review, the facility failed to ensure Activities of Daily Living (ADL) assistance were consistently provided for 5 of 9 residents (Residents 12, 15, 35, 37 & 81), reviewed for dining. The failure to provide residents who were dependent on staff for assistance with meals placed the residents at risk for unmet care needs, poor nutrition, and a diminished quality of life.Findings included. Review of the facility's policy titled, Activities of Daily Living (ADLs), revised on 03/20/2026 showed, Care and services will be provided for the following activities of daily living .eating to include meals . The policy further showed, A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition . RESIDENT 12Review of the quarterly Minimum Data Set (MDS-an assessment tool) dated 05/07/2026 showed Resident 12 had impaired cognition and was dependent with eating. Review of the ADL/self-care deficit care plan printed on 05/22/2026 showed Resident 12 required 1[one]-person dependent assistance in feeding (1:1 [one-to-one] feeding). RESIDENT 15Review of the quarterly MDS dated [DATE] showed Resident 15 had impaired cognition and was dependent with eating. Review of the self-care deficit care plan printed on 05/22/2026 showed Resident 15 required 1-person dependent assistance in feeding. RESIDENT 35Review of the quarterly MDS dated [DATE] showed Resident 35 had impaired cognition and was dependent with eating. Review of the self-care deficit care plan printed on 05/22/2026 showed Resident 35 required 1-person dependent assistance in feeding. RESIDENT 37Review of the annual MDS dated [DATE] showed Resident 37 had impaired cognition and was dependent with eating. Review of the self-care deficit plan printed on 05/22/2026 showed Resident 37 required 1-person dependent assistance in feeding. RESIDENT 81Review of the quarterly MDS dated [DATE] showed Resident 81 had impaired cognition and was dependent with eating. Review of the self-care deficit care plan printed on 05/22/2026 showed Resident 81 required 1-person dependent assistance in feeding. Observation on 05/19/2026 at 12:11 PM, showed Residents 12, 15, 37 and 81 were seated together and were waiting to be assisted with their meals. Observation showed Residents 12, 15, 37 and 81 had their eyes closed and they responded to voice and touch. Further observation showed that no staff were providing them assistance with their meals. A concurrent observation showed Resident 35 was seated in another table with three unknown residents who were assisted by staff with their meals. Observation showed Resident 35 had their meal tray and staff were not seen assisting them. Observations on 05/21/2026 at 12:28 PM, showed Residents 12, 15, 35, 37 and 81 had their meal trays on the table and staff were not seen assisting them with their meals. At 12:42 PM, a resident representative came and assisted Resident 37 with their meals. From 12:43 PM to 12:58 PM, four unknown staff approached and assisted Residents 12, 15, 35 and 81 approached and assisted the residents with their meals. There was a delay in assisting the residents with their meals. In an interview on 05/22/2026 at 1:15 PM, Staff H, Certified Nursing Assistant (CNA), stated that there were many residents that need assistance with their meals and that they had a seating arrangement for residents that were dependent with their meals. Staff H stated, that sometimes some nurses help but it depends when they are busy [they were not able to help]. Staff H stated that they had to wait for the resident they were helping with eating to finish their meal before they would start assisting another dependent resident with their meals. In an interview on 05/22/2026 at 1:35 PM, Staff U, CNA, stated that they used to have nurses who would help with dining. Staff U stated, there are staff available, but we had to ask for their help. Once we are done [finished with dining assistance] with a resident, we go to the other resident to help them [with their meals]. Staff U stated that residents who were dependent with eating had to wait for staff assistance. In an interview on 05/26/2026 at 1:13 PM, Staff V, Licensed Practical Nurse, stated that they were aware that Residents 12, 15, 35, 37 and 81 needed assistance with their meals. Staff V stated that they too had observed Residents 12, 15, 35, 37 and 81 and other dependent residents waited to be assisted with their meals and that they expected dependent residents to be assisted with their meals timely. In an interview on 05/26/2026 at 2:29 PM, Staff D, Resident Care Manager, stated that residents in the dining room were seated according to their planned seating arrangement. When asked, Staff D stated that Residents 12, 15, 35, 37 and 81 were all dependent with eating and required assistance with their meals. Staff D stated that they expected staff to assist dependent residents with eating in a timely manner. In an interview on 05/27/2026 at 1:19 PM, Staff B, Interim Director of Nursing Services, stated that they expected staff to provide meal assistance for dependent residents and that dependent residents did not have to wait for assistance after their meals were served. Reference: (WAC) 388-97-1060 (1)(2)(c).

Based on observation, interview, and record review, the facility failed to maintain the sanitizing solution concentration within the manufacturer recommended parts per million (ppm) for 1 of 2 kitchen's sanitizing buckets (Red Bucket for the Three Compartment Sink), reviewed for food services. This failure placed residents at risk for foodborne illness (caused by the ingestion of contaminated food or beverages), cross contamination, and a diminished quality of life.Findings included.Review of the facility's policy titled, Manual Warewashing-3 [three] Compartment Sink, revised on 12/15/2025, showed, To prevent the spread of bacteria [tiny germs] that may cause food borne illness, this facility washes, rinses and sanitizes pots, pans and other utensils using a 3 compartment sink in accordance with current standards for food safety. The policy further showed, Sanitizing solutions shall be tested by a test kit or other device that accurately measures the concentration in MG/L [milligrams per liter [unit of measurement].Review of the facility's policy titled, Dishwasher Temperature, revised on 12/22/2025, showed, Chemical solutions shall be maintained at the correct concentration, based on periodic testing at least once per shift and for the effective contact time according to manufacturer's guidelines.Review of the undated facility's kitchen signage titled, Sanitizing Bucket Procedures, showed instructions for preparing a sanitizing bucket, including testing the solution with test strips for proper ppm and maintaining a required concentration of 200 to 400 ppm.Review of the facility's provided document titled, Service Report, dated 05/26/2026 at 2:19 PM, showed, Customer [facility] called due to Barrier II [the second layer of protection used to stop germs from spreading] not testing properly.In a joint observation and interview on 05/26/2026 at 11:09 AM, Staff J, Dietary Coordinator, used a Hydrion (a brand name) test strip to check the sanitizer concentration in the sanitizing bucket (red bucket for the three-compartment sink). Staff J dipped the test strip into the solution for 10 seconds. A joint observation of the test strip showed, 0 ppm (no color change from the strip's original color). Staff J repeated the process with a second test strip, which again showed 0 ppm. Staff J stated, It was working this morning, and it was logged. In a follow up interview on 05/26/2026 at 11:59 AM, Staff J stated that they had been using the sanitizing bucket for the three-compartment sink. Staff J stated that the three compartment sink sanitizing solution was okay when I checked it this morning. Staff J stated, The correct ppm is 200 to 400, but this is not in that range. If the concentration is right, the color should have been changed to green. In an interview on 05/26/2026 at 1:45 PM, Staff A, Administrator, stated it was their expectation that kitchen staff would test the concentration of the sanitizing solution according to facility's policy. Staff A stated that if the sanitizing solution testing did not work, they would expect the staff to contact the service provider to fix it. Staff A further stated that Staff J informed them the sanitizing solution testing was not working and that the service provider had been called to address the issue.Reference: (WAC) 388-97-1100 (3).

Based on observation, interview, and record review, the facility failed to ensure wheelchairs were cleaned for 13 of 16 residents (Residents 81, 73, 71, 70, 12, 37, 45, 47, 41, 22, 9, 76 & 27), reviewed for comfortable/safe equipment use. This failure placed the residents at risk for unsafe equipment and a diminished quality of life.Findings included . Review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Equipment, reviewed on 02/20/2026, showed, Resident care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with current CDC [Centers for Disease Control and Prevention] recommendations in order to break the chain of infection . Direct staff are responsible for cleaning single-resident equipment when visibly soiled, and according to routine schedule (where applicable) . most equipment may be cleaned/disinfected in the areas in which the equipment is used . RESIDENT 81Observations on 05/21/2026 at 12:51 PM and on 05/22/2026 at 12:29 PM, showed Resident 81's wheelchair had multiple drop-like/patches of white dry matter on the footrests, right and left armrests, right and left frames of the front wheels, and on the right headrest and right backrest cushioned area. In an interview on 05/22/2026 at 3:05 PM, Staff D, Resident Care Manager (RCM), stated that residents' wheelchairs would be cleaned when filthy. Staff D further stated that nursing staff would clean wheelchairs with sanitizing wipes and that if soiled material was not removed, the facility would ask maintenance staff to clean wheelchairs by using pressure water. A joint observation and interview on 05/22/2026 at 3:38 PM with Staff D, showed Resident 81 had multiple drop-like/patches of white dry matter on the footrests, right and left armrests, right and left frames of the front wheels, and on the right headrest area and right backrest cushioned area. Staff D stated, it is dry milk. RESIDENT 73Multiple observations on 05/19/2026 at 2:38 PM, on 05/21/2026 at 12:30 PM, and on 05/22/2026 at 12:29 PM, showed Resident 73's left side wheelchair seat had a piece of white-yellowish dry matter. A joint observation and interview on 05/22/2026 at 3:22 PM with Staff D showed Resident 73's wheelchair had a white/yellowish dry matter on the left front seat. Staff D stated, it is probably dry food. RESIDENT 71Observations on 05/21/2026 at 1:10 PM and on 05/22/2026 at 12:30 PM, showed Resident 71's wheelchair had multiple spots/patches of yellowish white dry matter on the right and left armrests and on the right side of the wheelchair cushion seat. A joint observation and interview on 05/22/2026 at 3:31 PM with Staff D showed Resident 71's wheelchair had multiple spots/patches of yellowish white dry matter on the right armrest, left armrest, and on the right side of the wheelchair cushion seat. Staff D stated, it is probably dry food. RESIDENT 70Observation on 05/22/2026 at 12:49 PM, showed Resident 70's wheelchair had multiple spots/patches of white dry matter on the left armrest and two round spots/patches of dry red matter on the wheelchair cushion seat. A joint observation and interview on 05/22/2026 at 3:32 PM with Staff D showed multiple spots/patches of white dry matter on the left armrest and two round spots/patches of dry red matter on the wheelchair cushion seat. Staff D stated, it is dry food. RESIDENT 12Observations on 05/21/2026 at 1:21 PM and on 05/22/2026 at 12:21 PM, showed Resident 12's wheelchair had multiple spots/patches of dry white matter on the right armrest, and two linear streaks of white matter on the left armrest. A joint observation and interview on 05/22/2026 at 3:35 PM with Staff D showed Resident 12's wheelchair had multiple two linear streaks of white dry matter on the left armrest area and spots/patches of white dry matter on the right armrest. Staff D stated, it is probably dry milk or dry food. RESIDENT 37Observation on 05/22/2026 at 12:41 PM, showed Resident 37's wheelchair had multiple spots/patches of white dry matter on the left armrest. A joint observation and interview on 05/22/2026 at 3:42 PM with Staff D, showed Resident 37's wheelchair had multiple spots/patches of white dry matter on the left armrest. Staff D stated, it is dry food. RESIDENT 45Observations on 05/21/2026 at 1:24 PM and on 05/22/2026 at 12:18 PM, showed Resident 45's wheelchair had multiple spots/patches of white/yellowish dry matter on the right and left armrest, left backrest, and left headrest cushion. A joint observation and interview on 05/22/2026 at 3:16 PM with Staff D showed Resident 45's wheelchair had multiple spots/patches of yellowish white dry matter on the right and left armrest, left backrest, and left headrest. Staff D stated, it is dry milk. In a follow up interview on 05/22/2026 at 3:47 PM, Staff D stated that the wheelchairs for Residents 81, 73, 71, 70, 12, 37 and 45 were dirty and should have been cleaned. Staff D further stated that the wheelchair cushions should have been washed. RESIDENT 47Observation on 05/22/2026 at 12:57 PM showed Resident 47's wheelchair had multiple spots/patches of white dry matter on the right and left armrest, and on the right and left wheelchair cushion seat. RESIDENT 41Observation on 05/22/2026 at 2:59 PM showed Resident 41's wheelchair had multiple spots/patches of white dry matter on the left armrest. In an interview and joint observation on 05/22/2026 at 3:54 PM, Staff E, RCM, stated that residents' wheelchairs were supposed to have a [cleaning] schedule and that wheelchairs were cleaned by maintenance staff. A joint observation showed that Resident 47's wheelchair had multiple spots/patches of white matter on the right and left armrest, and the right and left wheelchair cushion seat. Staff E stated, it [the wheelchair] needs to be cleaned. A joint observation showed Resident 41's wheelchair had multiple spots/patches of white dry matter on the left armrest. Staff E stated that the wheelchairs for Residents 47 and 41 should have been cleaned. RESIDENT 22 Observations on 05/21/2026 at 1:13 PM and on 05/22/2026 at 2:57 PM showed Resident 22's wheelchair had multiple dried circular whitish matter over the metal frame that holds the two small front wheels, on the wheelchair frame, hand rims (ring metal attached to the rear wheels), and the front and side of the seat cushion. RESIDENT 9 Observations on 05/21/2026 at 1:53 PM and on 05/22/2026 at 9:31 AM, showed Resident 9's wheelchair had dust-like particles all over its metal frame underneath the seat and multiple visible dried, circular whitish matter all over the wheelchair's frame. RESIDENT 76 Observations on 05/21/2026 at 8:39 AM and on 05/22/2026 at 9:36 AM, showed Resident 76 had multiple dried circular whitish matter over the seat cushion and on the left armrest, and had dust-like particles all over the wheelchair frame. RESIDENT 27 Observations on 05/21/2026 at 1:55 PM and on 05/22/2026 at 12:58 PM showed Resident 27's wheelchair had multiple dried whitish and brownish matter all over its left and right hand rims. In an interview on 05/22/2026 at 3:05 PM, Staff D stated that staff were responsible to clean and sanitize the residents' wheelchairs using sanitizing wipes. Staff D stated that if staff could not remove the dirt then they would inform maintenance about it. Staff D stated, there is no regular schedule to clean-we just let them [maintenance] know. Staff D further stated that they would consider a wheelchair filthy as anything that can't [cannot] be removed using a sanitizing wipe and there is a need to wash them down with water. In a joint observation and interview on 05/22/2026 at 3:25 PM with Staff D showed Resident 22's wheelchair had multiple visible dried, circular whitish matter over the seat cushion, caster fork and metal frames. When asked to describe, Staff D stated, Very dirty, those are food particles, dried milk. Staff D stated, it should be cleaned by staff. A joint observation at 3:26 PM with Staff D, showed Resident 27's wheelchair and was asked to describe what they had observed. Staff D stated, .dried milk over the seat cushion.wheel handle [hand rims] had dried food particles, those brownish spot, dried particles. I really don't know what it is, but they need to be cleaned. A joint observation at 3:28 PM with Staff D, showed Resident 76's wheelchair. Staff D stated, Those are dried milk [on] the seat cushion and [on] the left armrest. There are also dust on the railings [metal frames]. I expect them to have been cleaned. I will tell maintenance. A joint observation at 3:31 PM with Staff D showed Resident 9's wheelchair parked in the bathroom. When asked to describe what they were seeing, Staff D stated, Looks like dried milk and food particles on the seat cushion and dust on the wheelchair frames. Staff D further stated that they expected Resident 9's wheelchair to have been cleaned. In a follow up interview on 05/22/2026 at 3:49 PM, Staff D stated that they expected staff to have cleaned Residents 22, 9, 76 and 27 wheelchairs and that they informed maintenance to pressure wash the wheelchairs. On 05/27/2026 at 1:45 PM, Staff B, Interim Director of Nursing Services, stated that they expected residents' wheelchairs to be cleaned when visibly soiled. Staff B further stated that the wheelchairs for Residents 81, 73, 71, 70, 12, 37, 45, 47, 41, 22, 9, 76 and 27 should have been cleaned. On 05/27/2026 at 2:04 PM, Staff A, Administrator, stated that the soiled wheelchairs for Residents 81, 73, 71, 70, 12, 37, 45, 47, 41, 22, 9, 76 and 27 should have been cleaned. Reference: (WAC) 388-97-0880 (1) .

Based on observation, interview, and record review, the facility failed to ensure medications were secured for 1 of 4 medication carts (Station 2 Medication Cart 1), reviewed for medication administration. This failure placed residents at risk for unintended access to medications and biologicals, and negative outcomes.Findings included.Review of the facility's policy titled, Medication Storage, revised on 02/26/2026, showed, All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. The policy showed, Only authorized personnel will have access to the keys to locked compartments. The policy further showed, During medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.Observation on 05/21/2026 at 8:27 AM showed Staff I, Registered Nurse, opened Station 2 Medication Cart 1 without a key. An additional observation at 8:43 AM showed Staff I opened Station 2 Medication Cart 1 without a key. The medication cart was not locked all the way and/or secured.In an interview and joint observation on 05/21/2026 at 8:45 AM, Staff I stated that they were not supervising Station 2 Medication Cart 1 while they were in a resident room. A joint observation showed the Station 2 Medication Cart 1 was able to be opened without a key. Staff I stated that the medication cart was not secured and that they would have expected it to have been locked completely.On 05/21/2026 at 8:48 AM, Staff E, Resident Care Manager, stated that they would expect nursing staff to secure the medication cart by locking the cart and using the keys to open it.On 05/21/2026 at 8:51 AM, Staff B, Interim Director of Nursing Services, stated that staff should lock the medication cart. Staff B further stated that staff [Staff I] should have locked the medication cart completely to secure medications.Reference: (WAC) 388-97-1300 (2).

Based on interview and record review, the facility failed to complete a new Level I PASARR (or PASRR-an assessment used to identify people [residents] with Serious Mental Illness [SMI], intellectual disabilities, or related conditions) after a significant change in status and failed to notify the PASARR Coordinator for 3 of 6 residents (Residents 10, 47 & 8), reviewed for PASARR. These failures placed the residents at risk for unmet care needs and a diminished quality of life. Findings included. Review of the Level I PASRR form revised in June 2025 showed, In the event the resident experiences a significant change in condition.the NF [Nursing Facility] must complete a new PASRR Level 1 and make referrals to the appropriate entities. RESIDENT 10 Review of the Minimum Data Set (MDS-an assessment tool) look up page showed Resident 10 had a Significant Change Assessment (SCSA) dated 04/02/2026. Review of the Hospice Notification of admission dated 03/26/2026 showed Resident 10 had metastatic (spread to other parts of the body) bladder (body organ that stores urine) cancer (abnormal cells growth) and was admitted to hospice. Review of the Electronic Health Record (EHR-miscellaneous) showed no new PASARR Level I completed related to Resident 10's significant change for hospice care. In an interview on 05/22/2026 at 2:13 PM, Staff L, Director of Social Services , stated, If there is a significant change, we are expected to complete a new Level I PASARR. When asked if a new Level I PASARR was completed for Resident 10 who had a significant change related to hospice admission, Staff L stated that they would need to review Resident 10's EHR. In a follow-up interview on 05/22/2026 at 3:38 PM, Staff L stated, Definitely, we don't [do not] have anything sent for [Resident 10]. When asked to clarify, Staff L stated that they had not completed a new Level I PASARR and had not notified the PASARR Coordinator about Resident 10's significant change. RESIDENT 47Review of the admission record printed on 05/27/2026 showed that Resident 47 was admitted to the facility on [DATE]. Review of a SCSA MDS dated [DATE] showed that Resident 47's MDS was completed due to a decline in activities of daily living and a fall that occurred on 05/18/2025. Review of Resident 47's EHR showed no documentation of a completed Level I PASARR evaluation following their significant change in status and/or documentation that the PASARR Coordinator had been notified of Resident 47's significant change. RESIDENT 8Review of the admission record printed on 05/19/2026 showed that Resident 8 was admitted to the facility on [DATE]. Review of a SCSA MDS dated [DATE] showed Resident 8's MDS was completed due to exhibiting behavioral symptoms and having severely impaired decision making abilities. Review of Resident 8's EHR showed no documentation of a completed Level I PASARR evaluation following their significant change in status and/or documentation that the PASARR Coordinator had been notified of Resident 8's significant change. A joint record review and interview on 05/22/2026 at 2:13 PM with Staff L showed that Resident 47 had a SCSA completed on 05/29/2025 and Resident 8 had a SCSA completed on 04/24/2026. A joint record review further showed that no documentation of a completed Level I PASARR evaluation or the PASARR Coordinator had been notified of Resident 47's and Resident 8's significant change in status. Staff L stated that residents who had a significant change in status were required to have an updated Level I PASARR completed, and a Level II evaluation referral as needed. In a follow up interview on 05/22/2026 at 3:38 PM, Staff L stated that Level I PASARR evaluations for Resident 47 and Resident 8 were not completed, and the PASARR Coordinator had not been notified of their significant changes in status. In an interview on 05/27/2026 at 11:34 AM, Staff A, Administrator, stated that they expected a new Level I PASARR to be completed for Residents 10, 47 and 8 and that the PASARR Coordinator should have been notified of their significant change in status. Reference: (WAC) 388-97-1975 (7) .

Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan for 2 of 7 residents (Residents 47 & 10), reviewed for comprehensive care plans. The failure to develop a care plan for diabetes mellitus (a disease where the body cannot properly regulate blood sugar levels), use of insulin (a hormone that helps regulate blood sugar levels) and hospice care (comfort care for individuals with terminal illness or with six months or less life expectancy) placed residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility's policy titled, Comprehensive Care Plans, revised on 04/24/2026, showed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. The policy further showed, The comprehensive care plan will be developed within 7 [seven] days after the completion of the comprehensive MDS [Minimum Data Set, assessment tool] assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. RESIDENT 47 Review of the admission record printed on 05/27/2026 showed that Resident 47 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus. Review of the comprehensive care plan, printed on 05/21/2026, showed no care plan had been developed to address Resident 47's diagnosis of diabetes mellitus or use of insulin. In an interview and joint record review on 05/22/2026 at 8:44 AM, Staff E, Resident Care Manager (RCM), stated that Resident 47 had been receiving insulin for diabetes mellitus since 05/29/2025. A joint record review showed that Resident 47 did not have a care plan addressing insulin use or diabetes mellitus. Staff E stated that they would expect a care plan to be developed for Resident 47's insulin use. Staff E further stated that no care plan had been developed for Resident 47's insulin use and that there should have been one. In an interview on 05/27/2026 at 10:16 AM, Staff B, Interim Director of Nursing Services, stated they would expect a care plan to be developed for residents with diabetes mellitus or who use insulin. Staff B further stated that a care plan addressing Resident 47's diabetes mellitus and insulin use should have been developed. RESIDENT 10 Review of the Hospice Notification of admission dated 03/26/2026 showed Resident 10 had metastatic (spread to other parts of the body) bladder (serves as a storage of urine) cancer (abnormal cell growth) and was admitted to hospice. Review of the comprehensive care plan, printed on 05/21/2026 showed no hospice care plan was developed for Resident 10. In an interview and joint record review on 05/22/2026 at 10:12 AM, Staff F, Registered Nurse, stated that Resident 10 was admitted to hospice due to metastatic bladder cancer and continued to receive hospice services in the facility. A joint record review of the comprehensive care plan showed no hospice care plan was developed for Resident 10. When asked if Resident 10's comprehensive care plan showed their end-of-life status, contact or coordination with hospice and/or hospice services being received, Staff F stated, No. A joint record review and interview on 05/22/2026 at 11:14 AM with Staff D, RCM, showed Resident 10's hospice notification of admission dated 03/26/2026 was due to metastatic bladder cancer. Staff D stated that they communicated and coordinated with the hospice team regarding Resident 10's care. Staff D stated that Resident 10's comprehensive care plan did not include Resident 10's prognosis, hospice care and/or coordination with hospice services. In an interview on 05/27/2026 at 1:19 PM, Staff B stated that they expected a hospice care plan to have been developed for Resident 10 when they were admitted to hospice. Reference: (WAC) 388-97-1020(1) .

Based on interview and record review, the facility failed to review and revise comprehensive care plans for 2 of 6 residents (Residents 61 & 10), reviewed for care planning. The failure to review and revise care plans for nutrition and discontinuation of psychotropic (mind-altering) medications placed the residents at risk for unmet care needs and a diminished quality of life. Findings included. Review of the facility's policy titled, Comprehensive Care Plans, revised on 04/24/2026, showed, The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS [Minimum Data Set-an assessment tool]. RESIDENT 61Review of Resident 61's nutrition care plan, revised on 01/15/2025, showed interventions for dysphagia (difficulty swallowing)-aspiration (something entering the airway or lungs) precautions, which included sit in upright position during eating; feed in small sips/bite; Stop for awhile and report to LN [Licensed Nurse] if cough during eating; use small spoon. Sit up for at least 30 min [minutes] before lying down. Review of the Speech Therapy Evaluation and Plan of Treatment, dated 10/27/2025, showed that Resident 61 required 1:1 (one to one) feeding assistance. Further review of the Speech Therapy Discharge summary, dated [DATE], showed that the requirement for 1:1 was no longer recommended. In an interview on 05/22/2026 at 12:52 PM, Staff M, Certified Nursing Assistant (CNA) stated that they looked at the care plans/Kardex (a care guide for CNAs) for residents every day. Staff M stated that Resident 61 required set-up help with eating. A joint record review and interview on 05/26/2026 at 12:35 PM with Staff N, CNA, showed that Resident 61's Kardex had interventions, which included sit in upright position during eating; feed in small sips/bite; Stop for awhile and report to LN if cough during eating; use small spoon. Sit up for at least 30 min before lying down. Staff N stated, she [Resident 61] doesn't [does not] want to have help and stated that the Kardex showed to feed in small bites, but she doesn't want [that]. A joint record review and interview on 05/26/2026 at 12:39 PM with Staff P, Registered Nurse (RN), showed Resident 61's nutrition care plan had interventions for dysphagia-aspiration precautions, which included sit in upright position during eating; feed in small sips/bite; Stop for awhile and report to LN if cough during eating; use small spoon. Sit up for at least 30 min before lying down. When asked if Resident 61 should be assisted during their meals, Staff P stated, I think we need to clarify with the RCM [Resident Care Mangager]. In an interview and joint record review on 05/26/2026 at 12:49 PM, Staff E, RCM, stated that they updated care plans depending on needs of the residents. Staff E stated that Resident 61 was able to eat by herself. A joint record review of Resident 61's nutrition care plan, revised on 01/15/2025, showed interventions for dysphagia-aspiration precautions, which included sit in upright position during eating; feed in small sips/bite; Stop for awhile and report to LN if cough during eating; use small spoon. Sit up for at least 30 min before lying down. Staff E stated that Resident 61's care plan needs to be updated. In an interview and joint record review on 05/26/2026 at 1:04 PM, Staff Q, Speech Language Pathologist, stated that Resident 61 was discharged from speech therapy in December 2025. Staff Q stated that Resident 61 was able to feed herself. A joint record review of the Speech Therapy Discharge summary, dated [DATE], showed that the requirement for 1:1 feeding assistance was no longer recommended for Resident 61. A joint record review of Resident 61's nutrition care plan showed that it was revised on 01/15/2025 and included the interventions to feed in small sips/bite; Stop for awhile and report to LN if cough during eating; use small spoon. Staff Q stated that Resident 61's nutrition care plan was not updated with the December 2025 [Speech Therapy] recommendations. In a follow-up interview on 05/27/2026 at 11:57 AM, Staff E stated that they had clarified with therapy [Speech therapy] and that Resident 61 did not need assistance with eating and needed set up assistance with meals. Staff E stated that Resident 61's nutrition care plan needed to be revised due to the therapy recommendations from December 2025 and that she's [she is] able to feed herself. In an interview on 05/27/2026 at 12:49 PM, Staff B, Interim Director of Nursing Services, stated that comprehensive care plans should be updated/revised when there were new orders or a new focus [area of concern/problem] for a resident. Staff B further stated that if speech therapy made recommendations, they expected that a resident's care plan to be updated/revised within twenty-four hours. RESIDENT 10 Review of the order summary report printed on 05/21/2026 did not show Resident 10 had orders for Lorazepam (a psychotropic medication for anxiety [persistent worry]) and Mirtazapine (a psychotropic medication for depression [persistent sadness and loss of interest] and for poor appetite when given on low dose). Review of Resident 10's March 2026 Medication Administration Record (MAR) printed on 05/21/2026 showed Lorazepam was discontinued on 03/26/2026. Review of Resident 10's April 2026 MAR printed on 05/21/2026 showed Mirtazapine was discontinued on 04/28/2026. Review of Resident 10's comprehensive care plan printed on 05/21/2026 showed, [Resident 10] is on Mirtazapine for poor appetite.on PRN [as needed] Lorazepam for anxiety. In an interview and joint record review on 05/22/2026 at 10:12 AM, Staff F, RN, stated that they would revise or update a resident's care plan when there is a change in condition or medications. A joint record review of Resident 10's active physician order showed they were not taking Lorazepam and Mirtazapine. Staff F stated that those medications were discontinued. A joint record review of the comprehensive care plan showed Resident 10 was on Mirtazapine for poor appetite.on PRN Lorazepam for anxiety. Staff F stated that Resident 10's comprehensive care plan was not updated. In an interview and joint record review on 05/22/2026 at 11:14 AM, Staff D, RCM, stated that they would revise or update a resident's comprehensive care plan quarterly, annually, [when there is a] significant change or as needed. A joint record review of Resident 10's active physician order showed they were not taking Lorazepam and Mirtazapine. Staff D stated that Resident 10 was not anymore on psychotropic medications and that they were aware that Resident 10's comprehensive care plan was not updated. In an interview on 05/27/2026 at 1:19 PM, Staff B stated that they expected residents' care plan to be revised or updated if there is a new focus, [change in] order . Staff B further stated that they expected Resident 10's comprehensive care plan to have been updated when their psychotropic medications were discontinued. Reference:(WAC) 388-97-1020(5)(b)

Based on observation, interview, and record review, the facility failed to provide adequate supervision for 1 of 4 residents (Resident 61), reviewed for accident/hazards. The failure to ensure aspiration precautions (safety measures designed to prevent food, liquids, or saliva from entering the airway and lungs) were implemented, placed the resident at risk for accidents, injury, and other negative outcomes.Findings included.Review of the facility's policy titled, Accidents and Supervision, revised on 03/20/2026, showed, Each resident will receive adequate supervision and assistive devices to prevent accidents, which includes Implementing interventions to reduce hazard(s) and risk(s).Review of Resident 61's quarterly Minimum Data Set (an assessment tool), dated 04/16/2026, showed that Resident 61 had a diagnosis of dysphagia (difficulty swallowing).Review of Resident 61's nutrition care plan, revised on 01/15/2025, showed interventions for dysphagia aspiration (something entering the airway or lungs) precautions, which included sit in upright position during eating; feed in small sips/bite; Stop for awhile and report to LN [Licensed Nurse] if cough during eating; use small spoon. Sit up for at least 30 min [minutes] before lying down.Review of the physician orders printed on 05/22/2026, showed Resident 61 had an order for Aspiration precautions-bolt upright positioning, assist with meals, small sips with fluids for safety.Observation on 05/22/2026 at 8:56 AM, showed Resident 61 independently eating breakfast in their bed. It showed the head of the bed at less than 90 degrees and Resident 61 was slouched and not sitting upright in bed. An additional observation at 12:38 PM showed Resident 61 independently eating lunch in their bed. It showed the head of the bed at less than 90 degrees and Resident 61 was slouched and not sitting upright in bed.In a joint record review and interview on 05/22/2026 at 1:02 PM with Staff R, Certified Nursing Assistant, showed Resident 61's nutrition care plan revealed interventions for Dysphagia-Aspiration precautions, which included sit in upright position during eating; feed in small sips/bite; Stop for awhile and report to LN if cough during eating; use small spoon. Sit up for at least 30 min before lying down. Staff R stated that Resident 61 was on aspiration precautions and needs to sit straight up while eating. A joint observation showed Resident 61 with their head of the bed at less than 90 degrees, and the resident was slouched and not sitting upright in bed. Staff R stated that the head of the bed was not upright and it should be straight up.A joint record review and interview on 05/26/2026 at 12:39 PM with Staff P, Registered Nurse, showed that Resident 61 had an order for Aspiration precautions-bolt upright positioning, assist with meals, small sips with fluids for safety. Staff P stated that they followed physician orders and that if a resident was on aspiration precautions, they would not expect the head of bed to be less than upright while eating.In an interview and joint record review on 05/26/2026 at 12:49 PM, Staff E, Resident Care Manager, stated that they expected staff to follow physician orders. A joint record review of Resident 61's diagnoses showed that Resident 61 had dysphagia. A joint record review of the physician orders printed on 05/22/2026 showed that Resident 61 had an order for Aspiration precautions-bolt upright positioning, assist with meals, small sips with fluids for safety. Staff E stated that Resident 61 should be sitting upright while eating. When asked if they expected Resident 61 to be slouched down in their bed with the head of the bed less than 90 degrees during two meals, Staff E stated, I expect her to be safe.In an interview and joint record review on 05/27/2026 at 12:49 PM, Staff B, Interim Director of Nursing Services, stated that if a physician order showed that a resident should be sitting upright during meals, then the head of the bed should be at 90 degrees. Staff B stated that if a resident was on aspiration precautions and was not sitting upright, the resident would be at risk for choking. A joint record review of the physician orders printed on 05/22/2026 showed that Resident 61 had an order for Aspiration precautions-bolt upright positioning, assist with meals, small sips with fluids for safety. Staff B stated that they expected staff to follow the physician orders and would not expect Resident 61 to be slouching in bed with the head of the bed at less than 90 degrees. Staff B stated that the sitting position was important for preventing aspiration. Staff B further stated that Resident 61's bed shouldn't [should not] have been at less than 90 degrees while eating.Reference: (WAC) 388-97-1060(3)(g).

Based on interview and record review, the facility failed to ensure controlled medications had a record of receipt with sufficient detail to allow for reconciliation and/or have disposal methods that involved a secure and safe method for 1 of 3 medication carts (Station 1 Medication Cart 3), reviewed for medication storage. This failure placed the facility at risk for potential loss/misappropriation, drug diversion, and negative outcomes.Findings included.Review of the facility's policy titled, Controlled Substance Administration & Accountability, revised on 02/26/2026, showed Two licensed staff must witness any disposal or destruction of a controlled substance and document on the Drug Disposition Record, Controlled Drug Record, or via the automated dispensing system.Review of a narcotic book page showed an area to be filled out when a controlled medication was transferred, the quantity remaining at the time of transfer, the book, page, staff initials, and date the transfer occurred. The page showed another area for Disposition [removal or transfer] of Unused Medication, and an area for the nurse/authorized staff receiving medication to sign, an area to write where the medication was transferred from if applicable and the quantity received.Record review of Station 1's Medication Cart 3 Narcotic Book page 9 showed, an order for Pregabalin (controlled substance- used to treat nerve pain) 50 milligrams (mg- unit of measurement) for Resident 100. Further review showed a quantity of 30 capsules remained, the page did not show where the medication was transferred to or disposed of, and the medication was no longer in the narcotic drawer. The narcotic book further showed page 12 had an order for Pregabalin 50 mg capsule, dated 12/29/2025 with the first entry having a quantity of 29 capsules remaining. The narcotic book showed it was transferred from Page #9, however, it did not show that staff filled out where the medication was transferred to, what narcotic book, page, initials, and date sections on page 9.Further review of Station 1's Medication Cart 3 Narcotic Book page 24 showed an order for oxycodone (controlled substance- used to treat pain) 5 mg tablet to take one to two tablets for Resident 101. The page showed an entry, dated 03/13/2026 and 03/15/2026 where a 7.5 mg dose was given and 1/2 tab [tablet]=2.5 mg wasted was wasted on each day (with 20 tablets remaining). The documentation did not show a second witness nurse signature. The page further showed no documentation to indicate what happened to the remaining 20 tablets. Review of page 28 showed an order for oxycodone 5 mg for Resident 101 and an entry, dated 03/16/2026 [at 1:42 PM] where a 7.5 mg dose was given and 1/2 tab [2.5 mg] tablet was wasted. There was no documentation to show a second nurse witness signature.In a joint record review and interview on 05/19/2026 at 12:14 PM, with Staff K, Registered Nurse, showed Station 1's Medication Cart 3 Narcotic Book page 9 and page 12 had the same order for Resident 100. The pages did not show sufficient detail was filled out when the medication was transferred from page 9 to page 12. In addition, the narcotic book page 24 and page 28 showed entries of oxycodone 1/2 tablet was wasted and had no second nurse witness signature. Staff K stated that when destroying a controlled substance, they needed a second nurse witness and document with their signature. Staff K stated that there was no documentation to show a second nurse witness signature when the oxycodone 1/2 tablet was destroyed on page 24 and page 28. Staff K further stated that they should have filled out the appropriate information in detail when transferring the controlled substance from page 9 to page 12.On 05/19/2026 at 1:49 PM, Staff D, Resident Care Manager, stated that when destroying controlled substances, two licensed nurses would need to be present and document in the narcotic book with their signatures. Staff D stated when transferring a controlled substance from one page to another or other narcotic book, staff would have to completely fill out the information on the page to show where the medication came from and where it was transferring to. Staff D stated there was no documentation to show a second nurse witness on the oxycodone that was destroyed on page 24 and page 28. Staff D further stated that staff did not completely fill out the information section when transferring medication from page 9 to page 12.On 05/19/2026 at 2:20 PM, Staff B, Interim Director of Nursing Services, stated that they expected two nurse witnesses to destroy controlled substances and document their signatures in the narcotic book.Reference: (WAC) 388-97-1300 (b)(ii).

Based on interview and record review, the facility failed to ensure adverse side effects of an antidepressant (medication to treat depression [persistent feeling of sadness and loss of interest]) were monitored for 1 of 5 residents (Resident 63), reviewed for unnecessary medications. This failure placed the resident at risk for negative outcomes, related complications, and a diminished quality of life.Findings included. Review of the facility's policy titled, High Risk Medications, revised on 04/09/2026, showed, .high risk medications can include.psychotropics [mind-altering medications].that can bear a heightened risk. The policy further showed, The resident's plan of care shall alert staff to monitor for adverse consequences of any high-risk medications given.Residents and/or representatives will be educated on the use and risks/benefits of high-risk medications, including adverse effects. Review of the facility's policy titled, Use of Psychotropic Medication(s), revised on 04/21/2026, showed, Psychotropic medications are to be used only.to treat a resident's specific, diagnosed and documented condition and the medication(s) is beneficial to the resident,.by monitoring and documentation of the resident's response to the medication(s). Review of the physician order summary printed on 05/20/2026 showed Resident 63 had been prescribed sertraline (antidepressant). Further review of the physician order summary did not show monitoring for adverse side effects related to antidepressant use. Review of the May 2026 Medication Administration Record (MAR) printed on 05/27/2026 showed Resident 63 had been on antidepressant and was not monitored for potential adverse side effects. In an interview and joint record review on 05/27/2026 at 10:30 AM, Staff S, Registered Nurse, stated that they monitored residents for psychotropic's adverse side effects. Staff S stated that they would monitor every day and that there is an order and. shows what side effects to monitor. A joint record review of Resident 63's MAR showed they were taking sertraline. When asked if Resident 63 was being monitored for the antidepressant's adverse side effects, Staff S stated, Not in the record [or] in the MAR at this time. I will have to ask my supervisor. In an interview and joint record review on 05/27/2026 at 11:06 AM, Staff E, Resident Care Manager, stated that residents on psychotropics were monitored for adverse side effects and that they would put it [monitor of adverse side effects] on the MAR. Staff E stated that Resident 63 had been prescribed with an antidepressant and that there was no monitoring for its adverse side effects. In an interview on 05/27/2026 at 1:19 PM, Staff B, Interim Director of Nursing Services, stated that residents on psychotropics should have had an order to monitor for adverse side effects and that they expected staff to monitor Resident 63's use of antidepressant. Reference: (WAC) 388-97-1060(4).

Based on observation, interview, and record review, the facility failed to ensure Transmission Based Precautions (TBP- measures put in place to prevent spread of infection by staff wearing Personal Protective Equipment [PPE-use of gown, gloves, mask and/or face shield/goggles] before entering a resident's room or environment) practices were followed for 1 of 1 resident (Resident 99), and failed to follow Enhanced Barrier Precautions (EBP- protocols to protect residents from multidrug-resistant organisms [a germ that is resistant to medications that treat infections]) practices were followed by 1 of 3 staff (Staff T), reviewed for infection control. These failures placed the residents, visitors, and staff at an increased risk for infection, related complications and a diminished quality of life. Findings included. Review of the facility's policy titled, Transmission-Based (Isolation) Precautions, revised on 02/20/2026, showed, The facility will use standard approaches, as defined by the CDC [Centers for Disease Control and Prevention], for transmission-based precautions: airborne [wear N95 mask/respirator, gown, gloves and eye protection (goggles/face shield)], contact [wear gown and gloves], and droplet precautions [wear face mask and eye protection]. The category of transmission-based precautions will determine the type of personal protective equipment (PPE) to be used. Review of the undated CDC signage titled, Droplet Precautions, showed that everyone entering the room must make sure their eyes, nose and mouth are fully covered before room entry and showed that eye protection included a face shield or goggles. TBPRESIDENT 99Review of the physician orders printed on 05/22/2026, showed that Resident 99 was on Contact and Droplet Precautions every shift for HMPV [Human Metapneumovirus-a respiratory illness]. Observation on 05/21/2026 at 10:24 AM, showed signage at Resident 99's door for Contact and Droplet Precautions. Further observation at 12:22 PM, showed Staff O, Certified Nursing Assistant, entered Resident 99's room wearing a gown, gloves and surgical mask to deliver Resident 99's meal tray and was not wearing a face shield or goggles. In an interview and joint observation on 05/21/2026 at 12:30 PM, Staff O, stated that they followed the sign by the room if a resident was on isolation precautions. A joint observation of the signage showed that Resident 99 was on Droplet and Contact Precautions. Staff O stated that droplet precautions included wearing a face shield or goggles prior to entering Resident 99's room. Staff O further stated that they did not use a face shield or goggles when they entered Resident 99's room. In an interview on 05/27/2026 at 10:12 AM, Staff C, Infection Preventionist, stated that they expected staff to read and follow the signage by residents' doors to know what PPE they needed to use. Staff C stated that they expected staff to use a face shield or goggles prior to entering a droplet precautions room. Staff C further stated that Staff O should have worn a face shield or googles prior to entering Resident 99's room. In an interview on 05/27/2026 at 12:49 PM, Staff B, Interim Director of Nursing Services, stated that they expected staff to wear appropriate PPE when a resident was on droplet precautions. Staff B further stated that Staff O should have worn a face shield or googles prior to entering Resident 99's room. EBP STAFF T Review of the facility's policy titled, Enhanced Barrier Precautions, revised on 02/20/2026, showed, Therapists should use gown and gloves when working with resident on EBP in the therapy gym or in the resident's room if they anticipate prolonged close physical contact where MDRO transmission is possible. Review of an undated CDC signage titled, Enhanced Barrier Precautions, showed, Staff must wear gloves and a gown for high-contact resident care activities that included care or use of feeding tube (a flexible tubing used to deliver nourishment through an opening on the abdomen [stomach]). Observation on 05/22/2026 at 9:00 AM, showed Staff T, Physical Therapist, inside Resident 19's room. Resident 19 was on EBP due to their feeding tube. Further observation showed Staff T was not using PPE (gown) while providing physical therapy to Resident 19. In an interview on 05/22/2026 at 9:22 AM, Staff T stated that they provided physical therapy to Resident 19, helping [them] with mobility. I got [Resident 19] up. Staff T stated that they were in direct contact with Resident 19 who required moderate assistance with bed mobility. When asked if they were aware that Resident 19 was on EBP, Staff T stated, I was not. Now I know and I was told to wear a gown. I did not wear a gown the first time I went in [Resident 19's room]. In an interview on 05/27/2026 at 9:24 AM, Staff C stated that they expected staff to wear their PPE when in direct contact with residents on EBP and follow EBP guidelines. Staff C stated that they considered providing bed mobility and transfers to Resident 19 as direct contact activities and would expect staff to have worn their gown. In an interview on 05/27/2026 at 1:19 PM, Staff B stated that they expected staff to follow precautions in front of the door, should wear PPE, everything that should be done for EBP patients [residents]. [Staff] should follow the EBP protocols. Reference: (WAC) 388-97-1320(1)(a) .

Based on interview and record review, the facility failed to follow the plan of care to use a gait belt (a safety device used to assist residents with mobility issues) for 1 of 1 resident (Resident 1), reviewed for accident hazards. Resident 1 experienced harm when they fractured their left clavicle (a break in the bone that connects the breastbone to the shoulder blade) and experienced pain when staff members transferred the resident without the use of a gait belt. The failure to follow plan of care when assisting with transfers placed residents at risk for avoidable injury, unsafe transfers, and a diminished quality of life.Findings included.Review the facility's policy, titled Use of Gait Belt, revised on 05/30/2024 showed it was the facility's policy to use gait belts with residents that cannot independently ambulate or transfer for the purpose of safety. The policy showed that each employee would be given a gait belt during orientation, receive education on the proper use of gait belts, and that each employee was expected to always have it available for use when at work.Review of the facility's policy titled, Safe Resident Handling/Transfer, revised on 03/27/2025, showed the facility would ensure that residents were handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines.Review of Resident 1's face sheet showed they were admitted to the facility on [DATE] with multiple diagnoses including dementia (decline in mental ability), difficulty walking, and Osteoporosis (a disease that weakens your bones).Review of Resident 1's care plan, initiated on 08/22/2016, showed an intervention to use a gait belt when the resident needed more help due to weakness.Review of the hospital notes dated 06/09/2025, showed that Resident 1 was in the Emergency Department (ED) on 06/09/2025. Resident 1 reported they had a shoulder injury after staff members at the facility transferred them from the wheelchair into the bed. The note further showed Resident 1 stated a yank [a sudden, forceful pull or tug] was involved during this transfer. The x-ray done at the ED showed Resident 1 had sustained a left clavicle fracture.Review of the investigation report dated 06/13/2025, showed Resident 1 was too weak to bear weight when Staff C, Certified Nursing Assistant (CNA) and Staff D, Licensed Practical Nurse (LPN) tried to assist Resident 1 from the floor and into bed without using a gait belt. Staff C and Staff D were not able to transfer Resident 1 and Staff E, CNA, was called to help, then all three staff members transferred Resident 1 to bed without the use of a gait belt.In a phone interview on 08/08/2025 at 11:32 AM, Staff D stated that on the night of the 06/08/2025 incident, they went to the room after hearing Staff C calling for help, then saw Resident 1 on the floor with Staff C behind them. Staff D stated they did an assessment and Resident 1 denied they were in any pain. Staff D stated that they called another staff member to help Resident 1 off the floor since Resident 1 did not have the strength to bear weight. They then transferred Resident 1 to the wheelchair. Staff D stated that a gait belt was not used with either one of these transfers. Staff D further stated that they felt Resident 1 may be in pain and gave Resident 1 pain medication and applied a pain-relieving cream on Resident 1's shoulders, neck, and arm after the transfer.In an interview on 08/11/2025 at 11:02 PM, Staff C, stated that on the night of the fall incident (06/08/2025) they found Resident 1 attempting to transfer themselves into the wheelchair. Staff C stated that they ran to Resident 1 and assisted them onto the floor as Resident1's legs started buckling. Staff C stated that as they guided Resident 1 down to the floor, Resident 1 grabbed onto the wheelchair brakes causing the chair to unlock, which then caused the wheelchair to roll back as they held onto it. Staff C stated that Staff D came into the room after hearing Staff C call for help. Staff C stated that Staff D and Staff E were on each side of the resident, lifting Resident 1 up as Staff C was behind the resident lifting her bottom and guiding the resident onto the bed. Staff C stated that they usually use a gait belt but did not have a chance to get one since they had to act fast. Staff C stated that Resident 1 grimaced during the transfer. Staff C further stated that Resident 1 was quieter than usual the next day, which indicated to Staff C that Resident 1 was in pain.In an interview on 07/08/2025 at 1:30 PM, Staff B, Director of Nursing, stated that they expected the care staff to follow the residents' care plan on how to transfer residents. Staff B further stated that staff should have used a gait belt with Resident 1 to help minimize injury.In an interview on 07/08/2025 at 3:19 PM, Staff A, Administrator, stated that they expected the care staff to follow the care plan and use the gait belt.Reference: (WAC) 388-97-1060 (3)(g).

Based on observation, interview, and record review, the facility failed to provide safe water temperatures and ensure adequate supervision and/or assistance to prevent accidents for 2 of 5 residents (Residents 1 & 2), reviewed for accident hazards. Resident 1 experienced serious injury when unsafe hot water temperature was provided to them sustaining second-degree burns (damage to both the outer and inner layers of the skin) requiring treatment. Resident 2 was at risk of harm when they were observed accessing unsafe hot water temperatures in the nurse's lounge. These failures placed the residents at risk of further injuries, related complications, and a diminished quality of life. An Immediate Jeopardy (IJ) was identified, and the facility was notified of the noncompliance on 05/14/2025. The IJ was determined to have begun on 05/11/2025, when the facility failed to provide Resident 1 with safe water temperatures resulting in second degree burns and failed to provide supervision for ambulatory residents (Resident 2) as hot water was accessible at the nurse's lounge on 05/14/2025. The IJ was removed on 05/15/2025 when an on-site inspection confirmed the facility implemented their removal plan by removing the hot water auxiliary spout in the nurse's lounge, locking door to the nurse's lounge and requiring key access to nourishment rooms, training provided to staff, hot liquids evaluations completed for all residents and revision of their hot liquids safety policy. Findings included . Review of the facility's policy titled, Hot Liquids Safety, implemented on 11/06/2024, showed, Hot liquids are to be served at proper (safe and appetizing) temperatures using appropriate safety precautions. It further showed that hot liquids can cause scalding and burns, and that the degree of injury depends on the temperature, the amount of skin exposed and the duration of exposure. Additionally, it showed that five minutes time required for a third degree burn to occur for a water temperature of 120 degrees Fahrenheit (F- scale of temperature). RESIDENT 1 Review of the face sheet printed on 05/19/2025, showed Resident 1 readmitted to the facility on [DATE] with diagnosis that included hemiplegia (weakness on one side of the body) affecting the left nondominant side and unspecified dementia (memory loss). Review of the quarterly Minimum Data Set (MDS- an assessment tool) dated 04/23/2025, showed Resident 1 had cognitive impairments, functional limitation in range of motion on one side of their upper and lower extremity. Review of the nursing progress note dated 05/11/2025 showed, Per NAC [Nursing Assistant Certified] report at approximate 1830 [6:30 PM], she was checking room [ROOM NUMBER] when [they] heard the resident, calling for help from [the] resident's [Resident 1] room. NAC checked and found the resident lying in bed while [their] left hand is holding his water bottle. Resident's shirt and bed sheet arewet [are wet]. It showed Resident 1 had intermittent confusion at baseline and that they stated, I was trying to drink water. But it spills on my shirt. It further showed that Resident 1's skin was noted with redness to their neck, chest, abdomen and the left side of their trunk. Review of Resident 1's progress note dated 05/12/2025 showed, Light skin redness remains over right/middle upper chest down to sternal [chest] area and left upper abdomen. Noted few cluster of yellowish blisters scattered from mid-sternum down. Observation on 05/14/2025 at 3:01 PM showed the Station 2 nurse's lounge hot water auxiliary spout showed the following water temperature: -At 3:01 PM it was 145.7 F. -At 3:13 PM it was 149.0 F. -At 3:52 PM it was 164.7 F. In an interview on 05/14/2025 at 2:34 PM, Staff E, Dietary Manager, stated that the kitchen provided the water in the nourishment rooms and that water temperatures were taken prior to delivery. Staff E stated that the water temperature should be 120 F or below. Staff E further stated that they checked the temperature of the water prior to delivery but that they did not keep a log of it. In an interview on 05/14/2025 at 3:23 PM, Staff D, Certified Nursing Assistant, stated that Resident 1 always ask for hot water and if they did not give them what they wanted, Resident 1 would yell at them. Staff D stated that every night Resident 1 would ask for hot water and that they would give them hot water from the hot water auxiliary spout at Station 2 nurse's lounge. Staff D stated that they would fill Resident 1's water bottle and place it on top of a chair next to their bed. Staff D stated that they did not know what happened on 05/11/2025 and that they gave Resident 1 hot water, left the room and they heard Resident 1 shouting shortly after. Staff D stated that they were not the only ones that would get hot water from the nurse's lounge and that everybody gets the water from there [hot water auxiliary spout]. When asked if they knew what the temperature should be, Staff D stated, No, I don't know. Staff D stated that they did not mix it with water and that they would give Resident 1 water straight from the hot water auxiliary spout. A joint observation of the nurse's lounge hot water auxiliary spout water temperature showed 137 F. Staff D further stated that they knew the nurse's lounge had hot water but, that they did not know that the hot water temperature was over 120 F. In an interview on 05/14/2025 at 5:27 PM, Staff B, Interim Director of Nursing, stated that they received a call on 05/11/2025 and was informed that Resident 1 was drinking water and that their hand was shaky and had spilled water on themselves. Staff B stated that Staff H, Registered Nurse (RN), stated that Staff D had given Resident 1 hot water and that they did not want to drink it at that moment and placed it at the bedside table for them to drink later. Resident 1 tried to drink it themselves and spilled it on their neck and chest area. When asked where Staff D got the hot water that they provided to Resident 1, Staff B stated they were still investigating and that they had not spoken to Staff D. Staff B further stated that staff were in-serviced that water provided to residents should come from the dietary department, and they should check the water temperature and that it should be 120 F. Review of Resident 1's physician note dated 05/16/2025 showed Resident 1 had a patch of second degree burn that was approximately 12 by 12 centimeters (cm - unit of measurement) that started on the upper left to middle chest, with a streak of burn that extended from the mid-sternum (breastbone) that was approximately 12 by 4 cm down from the burn then curves to the right upper abdomen. In an interview on 05/20/2025 at 3:09 PM, Staff H stated that they were assigned to Resident 1 on 05/11/2025 when the incident occurred. Staff H stated that Staff D reported that Resident 1 yelled out and when Staff D went to their room, Resident 1 had spilled water on themselves. Staff H stated that when they assessed Resident 1, they had redness on their neck, chest, abdomen and torso. Staff H stated at that time, they did not know how hot the water was, and that Resident 1 was not able to get water on their own. When asked if they were aware that staff were getting hot water from the nurse's lounge, Staff H stated that they did not know. Staff H stated that staff should have been getting water from the nourishment room or from the kitchen. RESIDENT 2 Review of the quarterly MDS dated [DATE] showed Resident 2 admitted to the facility on [DATE]. It further showed that Resident 1 had cognitive impairment and had a diagnosis of Alzheimer's Disease (brain disorder that affects memory, thinking and behavior). Review of Resident 2's behavior problem care plan dated 03/08/2023, showed a behavior problem with a goal that resident will have less episodes of going into nourishment room to microwave drink or to get hot water by review date. It further showed, Behavior: resident tend to go into nourishment room to warm up coffee for herself .Resident agreed however she sill [still] often go to the nourishment room without staff supervision when she does not see staffs around. Observation on 05/14/2025 at 3:07 PM, showed Resident 2 entered Station 2 nurse's lounge and filled a metal container with hot water from the hot water auxiliary spout. Staff C, RN, entered, saw Resident 2 and attempted to stop them. Resident 2 was resistive and did not want to give Staff C the container of hot water. Resident 2 held on to the metal container of hot water and walked out of the nurse's lounge towards the hallway followed by Staff C. In an interview and observation on 05/14/2025 at 3:15 PM, Staff C stated that if staff were not at the nurse's station, Resident 2 would sneak in and get hot water. If staff were there, they would stop Resident 2. Staff C stated that residents were not allowed in the nurse's lounge. Staff C stated that if they were to use the hot water from the hot water auxiliary spout, they would mix it with cold water. A joint observation of Station 2 nurse's lounge hot water auxiliary spout water temperature showed 150 F. Staff C stated if the nourishment room water thermos was empty, they would use the hot water from Station 2 nurse's lounge. In a follow-up interview on 05/19/2025 at 3:18 PM, Staff C stated that they were not aware of the hot water temperature in the nurse's lounge but that they knew that it was hot water. When asked if they took the temperature prior to using the hot water, Staff C stated that they did not have a thermometer to check the temperature of the hot water. In an interview on 05/20/2025 at 1:46 PM, Staff F, Resident Care Manager, stated that their process for hot liquids was that nursing staff would need to get warm water from the kitchen or nourishment rooms where it was allocated and if they ran out of water, they would call the kitchen to replenish it. Staff F stated that they were not aware that staff were getting hot water from the nurse's lounge hot water axillary spout until the incident with Resident 1 was investigated. Staff F stated that based on what they were told, Resident 2 goes to the nurse's lounge and the nourishment room to get hot water. Staff F stated that Staff C informed them that they saw Resident 2 enter the nurse's lounge to get hot water and that they tried to stop them. Staff F stated that they needed to ensure the safety of the residents and expected staff to follow the precautions that they had put in place. Staff F further stated that they did not expect Staff D to provide Resident 1 hot water from the nurse's lounge and that they expected that they would get the water from the nourishment room provided by the kitchen. In an interview on 05/20/2025 at 3:33 PM, Staff G, Assistant Director of Nursing, stated that the hot liquids safety policy was updated and that we double check, be more careful and have the kitchen deliver warm water every shift. Staff G stated that the water temperature should not be over 120 F. Staff G stated that the nurse's lounge was locked, and the nourishment room doors were changed to require key access to enter. When asked if they were aware that staff were getting hot water from the nurse's lounge to provide to residents, Staff G stated it happens sometimes and that if they ran out of water late at night, they tried their best to provide warm water to residents who request it but, that they would mix it with cold water and feel the temperature if it was safe. Staff G further stated that they expected staff to provide water to residents that was provided by the kitchen, and that staff should be locking the doors to the nurse's lounge and nourishment rooms to prevent residents from entering. In an interview on 05/20/2025 at 3:35 PM, Staff A, Interim Administrator, stated that they expected staff to follow their policy and procedure for hot liquid safety. Staff A stated that they updated their policy to change the water temperature to 120 F and that it was to be provided by dietary staff. Staff A stated that they were not aware Staff D was getting hot water from the hot water auxiliary spout and that they thought they were getting it from the faucet. Staff A further stated that they knew after the fact that Staff D was getting water from the auxiliary spout and that there was an auxiliary spout in addition to the faucet when they were informed about it on 05/14/2025. Reference: (WAC) 388-97-1060 (3)(g)

Based on interview and record review, the facility failed to ensure the attending physician reviewed the total program of care including treatment and medications and completed progress notes timely for 38 of 38 residents (Residents 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41 & 42), reviewed for physician progress notes. This failure had the potential to place the residents at risk for a delay in treatment, unmet medical care needs, and lack of physician oversight. Findings included . Review of the complaint hotline form dated 03/05/2025, showed the facility submitted to the state agency that there are concerns in regard to the Medical Director [Staff D] and his medical duties. Review of the incident investigation dated 03/04/2025, showed that Staff D saw around 40 residents [Residents 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41 & 42] here at the facility and was also the Medical Director. In an interview on 04/04/2025 at 1:01 PM, Staff E, Registered Nurse/Resident Care Manager, stated that Staff D came to the facility on ce a week at least to see residents. Staff E further stated that Staff D was not putting progress notes in right away after seeing residents. In an interview on 04/04/2025 at 1:10 PM, Staff F, Physician Assistant, stated that it was their process that every time they saw residents they review medications, treatments, and program of care and will write a progress note that reflected those things within 48 hours. In an interview on 04/04/2025 at 9:58 AM, Staff G, Medical Records, stated that Staff D doesn't tell anyone which residents he visits, he just comes every Monday. Staff D stated that other providers will upload their progress notes within 24 hours, he [Staff D] doesn't do that. When asked to provide any progress notes uploaded from 02/26/2025 until 04/04/2025, Staff G provided undated blank documentation [and printed their Electronic Health Record] that no progress notes written by Staff D had been uploaded during those dates. In a follow-up interview at 10:03 AM, Staff G stated that no progress notes were uploaded from [02/26/2025] until now from [Staff D]. In an interview and joint record review on 04/04/2025 at 1:45 PM, Staff C, Chief Executive Officer, stated that they expected physicians to see residents usually once a week. Staff C stated that they expected physicians to document clinical metrics, treatment plans, observations and they should document any changes, treatment changes, medications. Staff C stated that they expected physicians progress notes to be completed within days and I would think the progress notes should be in the system [electronic health records], it's important, so we know if something happened or if a doctor on call needs to look at it. Staff C stated that Staff D was slow in putting in progress notes. Staff C stated that they would expect progress notes from Staff D from 02/26/2025 until now and by now yes there should be. Joint record review of the documentation showing no progress notes written by Staff D uploaded from 02/26/2025 until 04/04/2025. Staff C stated, he has not uploaded anything, that's not good. In an interview on 04/04/2025 at 2:03 PM, Staff D stated the last day they saw a resident was on 03/05/2025 and usually saw residents every Monday and sometimes every day. Staff D stated it was their process to provide handwritten documentation after seeing the patient [resident] and would upload a progress note every four to six weeks. When asked if the handwritten documentation included documentation of the resident's care program, a review of medications and treatments, Staff D stated, no that's impossible. In an interview and joint record review on 04/04/2025 at 4:12 PM, Staff B, Interim Director of Nursing, stated that they expected physician progress notes to be written for all residents and all visits. Staff B stated that if it had been longer than seven days, they would expect medical records to reach out to the physician. Staff B further stated that they expected the physician progress notes to include a summary of what's going on with the resident, medications and any complaints. Joint record review of the documentation showing no progress notes written by Staff D uploaded from 02/26/2025 until 04/04/2025, Staff B stated, I would expect there to be progress notes for the residents he saw. In an interview on 04/04/2025 at 4:17 PM, Staff A, Interim Administrator stated, I expect there to be progress notes for the residents he [Staff D] saw. Reference: (WAC) 388-97-1260 (4)(a)

Based on interview and record review, the facility failed to ensure injuries of unknown source and abuse allegations were thoroughly investigated for 4 of 5 residents (Residents 1, 2, 3 & 4), reviewed for abuse investigations. This failure placed the residents at risk for repeated incidents, unidentified abuse, and a diminished quality of life. Findings included . Review of the Nursing Home Guidelines, The Purple Book, Sixth Edition, dated October 2015, showed that injuries of unknown source meant any injury sustained by a resident where the source of the injury was Not observed directly by a staff person . The resident is not able to report/inform how the injury occurred .Injuries of unknown source may be either superficial or substantial in nature. It showed, Substantial injuries require more than first aid and may require close assessment and monitoring by nursing or medical staff. They also include injuries occurring in areas not generally vulnerable to trauma .Substantial injuries of unknown source, even if they do not appear to be due to abuse or neglect, must be reported to the Department, because the injuries may have resulted from the failure to take preventative measures. ALL substantial injuries of unknown source must be thoroughly investigated. ALL injuries (regardless of the extent) occurring in nonvulnerable areas of the body will be considered substantial injuries. The abuse guidelines further showed, EXAMPLES of SUBSTANTIAL INJURIES may include, but are not limited to the following: Abrasions, burns, deep lacerations, bruises of deep color and depth, or those occurring in areas not generally vulnerable to trauma, such as the back, face, head, neck chest, breasts . It further showed that showed that all alleged incidents of abuse, neglect, abandonment, mistreatment, injuries of unknown source, personal and/or financial exploitation, or misappropriation of resident property must be thoroughly investigated. Review of the facility's policy titled, Abuse, Neglect and Exploitation, dated 09/07/2023, showed physical marks such as bruises or physical injury of a resident of unknown source were possible indicators of abuse. The policy also showed that an immediate investigation would be warranted when suspicion of abuse occurred. The policy further showed an investigation would be completed and have thorough documentation. RESIDENT 1 Review of the facility's March 2025 incident log showed an incident logged for Resident 1 on 03/14/2025. Review of the complaint hotline form dated 03/11/2025, showed Staff I, Social Worker, submitted to the state agency that Resident 1 reported that a staff member was rougher than usual and stated, she hurt me. In an interview and joint record review on 04/03/2025 at 1:15 PM, Staff A, Interim Administrator, provided a folder of what was done for Resident 1's incident and did not include an investigation report for Resident 1's allegation on 03/11/2025. When asked if there was written documentation that an investigation was conducted, Staff A stated they would look and see if there's any documentation about the investigation. In a follow-up interview at 2:21 PM, Staff A provided a written report of the investigation and stated, I just wrote what we did. When asked if this was completed today, Staff A stated, yes. In another interview on 04/04/2025 at 2:56 PM, Staff A stated they stated they had five days to complete an abuse investigation. Staff A further stated there should be written documentation of investigations conducted for abuse. When asked if the investigation for Resident 2's allegation was completed within five days, Staff A stated that there was no documentation that it had been completed in five days. RESIDENT 2 Review of the complaint hotline form dated 03/10/2025, showed Staff B, Interim Director of Nursing, submitted to the state agency that a Certified Nursing Assistant (CNA) noticed that Resident 2 had bruising on their left ankle with tenderness when touched. Review of Resident 2's incident investigation dated 03/10/2025, showed a Xray was completed, and that Resident 2 had a fracture [broken ankle-the joint that connects the bones in the lower leg to the foot bones]. It further showed the facility did not thoroughly collect evidence related to other possible witnesses or other residents related to the investigation. The investigation did not show the conclusion of the investigation to rule out abuse was documented. In an interview and joint record review on 04/04/2025 at 3:45 PM, Staff B stated that the process for investigating an injury of unknown origin included, reporting, investigating, asking questions, and interviews with staff and residents in the area. Joint record review of Resident 2's incident investigation dated 03/10/2025, showed Resident 2 had discoloration and swelling of their ankle and Staff B stated, it was reported because it was an injury of unknown origin. When asked if the investigation included other resident interviews, Staff B stated no. Staff B further stated that they didn't put in the conclusion that [abuse] was ruled out. In an interview on 04/04/2025 at 3:45 PM, Staff A stated that when investigating an injury of unknown origin, the goal is to rule out abuse. Staff A stated that the conclusion will say unfounded if abuse was ruled out. When asked if it was a thorough investigation if they did not interview other residents, Staff A stated it was a case by case basis for when they interviewed other residents. When the example was provided that interviewing a roommate might show if they heard or saw anything related to the investigation, Staff A stated, yes, it could be helpful. When asked if abuse was ruled out for Resident 2, Staff A stated, it was not written. RESIDENT 3 Review of the facility's March 2025 incident log showed that an incident for Resident 3 was logged on 03/03/2025 and had not been reported to the state agency. Review of the investigation report dated 03/05/2025, showed that a Certified Nursing Assistant reported to the Registered Nurse (RN) that Resident 3 had bruising on her upper torso. The RN noted one large green-yellow color bruising on resident chest between two breast[s] .and RN noted another purple color bruising on Resident 3's left side torso next to the left breast. It further showed, Resident did not know what happened, resident [sic] showed signs of discomfort and c/o [complained of] pain during movement and touch. Additionally, it showed, Investigation started, writer tried to talk to resident, resident doesn't know where it comes from. The investigation report did not show that minimum staff and resident interviews were conducted and/or the conclusion of the investigation to rule out abuse was documented. In an interview and joint record review on 04/04/2025 at 2:56 PM, Staff B stated that the process for investigating an injury of unknown origin would be the same process as investigating abuse and neglect and would be to report and investigate. A joint record review of the investigation report dated 03/05/2025, showed that Resident 4 was found to have two bruises on their upper torso and left side torso. When asked if there were any resident interviews conducted, Staff B stated, none noted. Staff B further stated it was inconclusive if there was a thorough investigation done for Resident 3's injury of unknown origin. In an interview on 04/04/2025 at 3:55 PM, Staff A stated that according to the purple book it should have been reported to the state agency when Resident 3 was found to have bruising on their torso. When asked if abuse had been ruled out, Staff A stated it was undetermined by the evidence presented. RESIDENT 4 Review of the complaint hotline form dated 03/14/2025, showed Staff A submitted to the state agency that Resident 4 was found to have discoloration to the right upper arm with swelling and pain to touch. Review of the undated investigation report showed Resident 4 had cognitive deficits and that on 03/10/2025, Resident 4 was found to have pain in their arm. During an assessment, it was found that Resident 4 had some discoloration and swelling to her forearm and it was painful and warm to touch. The investigation did not show that minimum resident interviews were conducted and/or the conclusion of the investigation to rule out abuse was documented. Review of the Radiology Results Report, dated 03/14/2025, showed that Resident 4 had a dislocated shoulder and a fracture [broken and/or dislocated arm bone]. In an interview on 04/04/2025 at 2:56 PM, Staff B stated that the facility reported Resident 4's incident because it was an injury of unknown origin. Staff B further stated they were looking at possible abuse. In an interview and joint record review on 04/04/2025 at 3:05 PM, Staff A stated that we didn't interview any other residents, no documentation that I did. Reference: (WAC) 388-97-0640 (6)(a)

Based on interview and record review, the facility failed to report significant injury of unknown origin for 1 of 5 residents (Resident 3) reviewed for abuse investigations. The facility's failure to report large bruises of unknown origin on the resident's chest and torso, placed the residents at risk for repeated incidents and unidentified abuse and/or neglect. Findings included . Review of the Nursing Home Guidelines, The Purple Book, dated October 2015 (sixth edition) showed, The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source .are reported to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). It showed that Injuries of unknown source means any injury sustained by a resident where the source of the injury was .not observed by a staff person .the resident is not able to report/inform how the injury occurred. It further showed that substantial injuries (including bruises occurring in areas not generally vulnerable to trauma such as the back, face, head, neck, chest, breasts, groin, inner thigh, buttock, genital, or anal area) even if they do not appear to be due to abuse or neglect, must be reported to the Department. Review of the facility's policy titled, Abuse, Neglect and Exploitation, dated 09/07/2023, showed, Possible indicators of abuse include, but are not limited to .physical marks such as bruises .physical injury of a resident, of unknown source. It showed that The facility will have written procedures that include .reporting of alleged violations to the Administrator, state agency . within specified timeframes. Review of the investigation report dated 03/05/2025, showed that a Certified Nursing Assistant reported to the Registered Nurse (RN) that Resident 3 had bruising on her upper torso. The RN noted one large green-yellow color bruising on resident chest between two breast[s] . and RN noted another purple color bruising on Resident 3's left side torso next to the left breast. It further showed, Resident did not know what happened, resident [sic] showed signs of discomfort and c/o [complained of] pain during movement and touch. Review of the facility's March 2025 incident log showed that an incident for Resident 3 was logged on 03/03/2025 and had not been reported to the state agency. In an interview and joint record review on 04/04/2025 at 2:56 PM, Staff B, Interim Director of Nursing, stated that the process for investigating an injury of unknown origin was the same process as investigating abuse and neglect and would report and investigate. Joint record review of the investigation report dated 03/05/2025, showed that Resident 3 was found to have two bruises on their chest between two breast [s] and their left side torso. Staff B stated that yes the incident was reportable to the state agency, and it was not reported. In an interview on 04/04/2025 at 3:55 PM, Staff A, Interim Administrator, stated that according to the purple book it should have been reported to the state agency, when Resident 3 was found to have injuries of unknown source. Reference: (WAC) 388-97-0640 (5)(a)

Based on observation, interview, and record review, the facility failed to revise comprehensive care plans for 4 of 18 residents (Residents 76, 1, 492 & 58), reviewed for care plan revision. The failure to revise care plans for residents with diagnosis of dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), missing/broken denture and discharge planning placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility's policy titled, Comprehensive Care Plans, revised on 02/17/2025, showed, The comprehensive care plan will be reviewed and revised by the interdisciplinary team [IDT-therapy, nursing, social services] after each comprehensive and quarterly MDS [Minimum Data Set- an assessment tool] assessment. Review of the facility's policy titled, Discharge Planning Process, revised on 02/17/2025, showed that subsequent assessment information and discharge goals would be included in the resident's comprehensive plan of care. The policy further showed, The ongoing process of developing the discharge plan will include a regular re-evaluation of the resident to identify changes that require modification of the discharge plan, and updating of the discharge plan, as needed, to reflect the modifications. RESIDENT 76 Review of the annual MDS dated [DATE] showed Resident 76 admitted to the facility on [DATE] and was severely impaired with daily decision making. It further showed that Resident 76 was marked in Section I (Active Diagnosis) for non-alzheimer's dementia (cognitive disorders that cause memory loss, confusion, and other cognitive impairments). Review of Resident 76's comprehensive care plan printed on 02/25/2025 showed a care plan for Alt. [alteration] in thought process/psychosocial [aspects relating to social and emotional state] wellbeing r/t [related to] strokes [damage to the brain from interruption of blood supply], encephalopathy [disturbance of brain function], low energy and weakness, adjusting new environment. Further review of the comprehensive care plan did not show a care plan to address Resident 76's dementia. Review of Resident 76's Diagnosis Report printed on 02/25/2025, showed a diagnosis of encephalopathy with an onset date of 07/17/2023 and classified as history. In an interview on 02/25/2025 at 10:28 AM, Staff Q, Certified Nursing Assistant, stated that they would review the care plan when caring for Resident 76. Staff Q further stated that Resident 76 had dementia and required total assist with their care. In an interview and joint record review on 02/25/2025 at 10:46 AM, Staff D, Resident Care Manager (RCM), stated that dementia should be care planned. Joint record review of Resident 76's diagnosis list showed a diagnosis of dementia. Staff D stated Resident 76 had dementia. Joint record review of Resident 76's comprehensive care plan showed a care plan for altered thought process related to encephalopathy and did not show that it was related to dementia. Joint record review of Resident 76's diagnosis list showed that encephalopathy was classified as a history. Staff D stated that Resident 76's care plan should have been revised to address Resident 76's dementia. In an interview on 02/25/2025 at 12:57 PM, Staff B, Director of Nursing, stated that they expected residents' who had a diagnosis of dementia to have had a care plan, and that Staff D could have revised it [Resident 76's care plan]. 45146 RESIDENT 1 Review of the quarterly MDS dated [DATE], showed Resident 1 was cognitively intact. Observations on 02/18/2025 at 2:00 PM, on 02/21/2025 at 7:58 PM, and on 02/24/2025 at 8:08 AM, showed Resident 1 was wearing their broken upper denture with two teeth missing. Resident 1 stated that their bottom denture was missing at the facility a year ago and that they did not have replacement yet. Review of the dental consult note dated 06/21/2024 showed that the resident had a loose or ill-fitting upper denture with teeth that were worn down. Review of the dental care plan, revised on 07/06/2021 showed that Resident 1, .has upper and lower full dentures. During an interview and a joint record review on 02/24/2025 at 1:16 PM, Staff E, RCM, stated that Resident 1's lower denture was missing a couple months ago. Joint record review of the dental care plan last revised on 07/06/2021 showed that Resident 1 had full upper and lower dentures. Staff E stated that Resident 1's dental care plan should have been updated. In an interview on 02/25/2025 at 12:30 PM, Staff B stated that they expected Resident 1's dental care plan was reviewed and revised with changes in the resident's dental status. 48298 RESIDENT 492 Review of the Resident 492's admission MDS dated [DATE], showed a Section Q0310 (Resident's Overall Goal) was coded 1 [one], indicating a discharge plan to the community (home). Review of Resident 492's Medicare (national health insurance program) weekly management reviews by the IDT dated 02/04/2025, 02/11/2025 and 02/18/2025 showed Resident 492's discharge goal was to return home after completion of their rehabilitation. Review of Resident 492's discharge planning care plan printed on 02/19/2025 showed that it was initiated on 01/31/2025. Further review of the discharge planning care plan did not show Resident 492's discharge goal to return home and did not show goals or interventions were revised or updated. In an interview and a joint record review on 02/25/2025 at 10:10 AM, Staff Z, Social Worker (SW), stated that Resident 492's discharge goal was to return home after their rehabilitation. Joint record review of discharge planning care plan with Staff Z did not show Resident 492's goal to return home. Staff Z stated that Resident 492's care plan had not been revised or updated to reflect their discharge goal. In an interview on 02/25/2025 at 12:20 PM, Staff G, Social Services Director, stated that Resident 492's discharge goal to return home had been determined at the IDT meeting and should have had been reflected in Resident 492's discharge planning care plan. In an interview on 02/26/2025 at 10:37 AM, Staff B stated that it was their expectation that residents' care plans were reviewed, revised or updated with any change on focus, goals, [and] interventions. Staff B further stated that Resident 492's discharge planning care plan was updated yesterday [02/25/2025] as they had discussed the concerns of not revising the care plan. In an interview on 02/26/2025 at 11:38 AM, Staff A, Administrator, stated that they expected social services staff to have updated or revised the discharge care plans to reflect residents' specific goals and interventions. 49619 RESIDENT 58 Resident 58 admitted to the facility on [DATE]. Review of the admission MDS dated [DATE], showed under Section Q0310. Resident 58's Overall Goal would like to discharge to the community per representative interview. Review of Resident 58's care plan initiated on 01/01/2025, showed a discharge care plan goal of STG [short term goal]: Discharge determination in 3 [three] months, and an intervention for Multidisciplinary evaluation in 3 months. The discharge care plan did not reflect the resident and/or representative's goals for discharge. On 02/18/2025 at 11:34 AM, Collateral Contact 1 stated that Resident 65's goal was to discharge back home. On 02/25/2025 at 10:30 AM, Staff X, SW, stated they determined the resident's goals for discharge upon their admission and in care plan meetings. Staff X stated they would document the resident's goals under Section Q of the MDS. Joint record review and interview on 02/25/2025 at 10:43 AM with Staff X, did not show that Resident 58's care plan as to where the resident would like to be discharged to. Staff X stated that Resident 58's representative would like them to go back to the community where they originally lived. Staff X stated that there was no specific goal for the resident in their care plan that reflected this. Staff X further stated that the care plan was a framework for how they cared for the residents and that the social services department was responsible for the discharge planning part of the care plan. On 02/25/2025 at 12:22 PM, Staff G stated that their expectation would be to see the resident's goal coded in section Q of the MDS reflected in the resident's care plan. On 02/26/2025 at 10:37 AM, Staff B stated their expectation was for the care plan to include the resident's goals and they had 21 days to complete the care plan after admission. Staff B further stated if a resident's goals had changed, they would expect staff to update/revise the care plan to reflect the changes. On 02/26/2025 at 11:29 AM, Staff A stated that they would expect the resident's discharge goal to be in their care plan. Reference: (WAC) 388-97-1020 (2)(f) (4)(b) (5)(b)

Based on observation, interview, and record review, the facility failed to develop and/or implement care plans for 7 of 8 residents (Residents 43, 78, 1, 9, 80, 3 & 85), reviewed for care planning. The failure to develop person-centered care plans for use of bed rails placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility's policy titled, Comprehensive Care Plans, revised on 02/17/2025, showed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .that includes measurable objectives and timeframes to meet a resident's medical, nursing .and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality. The policy further showed that comprehensive care plan will be developed within seven days after the completion of the comprehensive Minimum Data Set (MDS-an assessment tool) assessment. Review of the facility's policy titled, Proper Use of Bed Rails, revised on 02/24/2025, showed, The facility will continue to provide necessary treatment and care to the resident who has bed rails .This should be evidenced in the resident's records, including their care plan .Examples of bed rails include, but are not limited to side rails, bed side rails, safety rails, grab bars and assist bars [enabler]. RESIDENT 43 Review of the February 2025 physician order summary report, showed Resident 43 had an order for a left bed enabler bars for transfer and activities of daily living (ADLs), dated 01/15/2025. Review of Resident 43's comprehensive care plan printed on 02/21/2025 did not show a person-centered care plan for use of left bed rail/enabler. Observation and interview on 02/21/2025 at 9:05 AM, showed Resident 43 had a left side rail attached to their bed frame in the raised position. Resident 43 stated that they used the left side rail to reposition and transfer themselves out of their bed. In an interview on 02/24/2025 at 12:15 PM, Staff V, Certified Nursing Assistant (CNA), stated that Resident 43 had a left side rail that they used to reposition in bed and helped [Resident 43] to stand up. In an interview on 02/24/2025 at 12:37 PM, Staff E, Resident Care Manager (RCM), stated that Resident 43 had a left bed enabler or side rail that they used for transfer or repositioning. Staff E stated that Resident 43 did not have a care plan related to the use of bed rails. Staff E stated they did an audit of all residents in their unit that used bed rails and that they added the left bed enabler on 2/20 [02/20/2025] in one of [Resident 43's] care plans. RESIDENT 78 Review of the February 2025 physician order summary report, showed Resident 78 had an order for both half side rails, dated 10/13/2023, Review of Resident 78's comprehensive care plans printed on 02/21/2025 did not show a person-centered care plan for the use of half side rails. Observation and interview on 02/21/2025 at 8:58 AM, showed Resident 78 had a left side rail attached to their bed frame in the raised position. Resident 78 stated that they used the left side rail to reposition and transfer themselves out of their bed. In an interview on 02/24/2025 at 12:18 PM, Staff V stated that Resident 78 had a left side rail that they used to reposition in bed and helped [Resident 78] to get up from bed. In an interview on 02/24/2025 at 12:51 PM, Staff E stated that Resident 78 did not have bed rails on both sides of their bed. Staff E stated that Resident 78 had a left side bed rail to help with transfer and repositioning. Staff E stated that Resident 78 did not have a care plan for bed rail use. Staff E stated they did an audit of all residents in their unit that used bed rails and that they added the left side enabler bar on 2/20 [02/20/2025] in one of [Resident 78's] care plans. In an interview on 02/25/2025 at 1:04 PM, Staff B, Director of Nursing, stated that they expected for Resident 43 and Resident 78 to have a person-centered care plan related to their use of bed rails. 45146 RESIDENT 1 Observations on 02/19/2025 at 10:41 AM, on 02/20/2025 at 1:51 PM, on 02/21/2025 at 7:55 AM, and on 02/24/2025 at 8:05 AM, showed Resident 1's bed had a bed rail/enabler attached to both sides of their bed. Review of the February 2025 physician order summary report, active as of 02/18/2025, showed Resident 1 had an order for Both 1/2 [half] side rails up for enabler, with an order date of 05/07/2021. Review of the comprehensive care plan printed on 02/20/2025 showed there was no comprehensive person-centered care plan initiated for Resident 1's bed rail/enabler use. A joint observation and record review on 02/24/2025 at 1:08 PM with Staff E, showed Resident 1 had a bed rail attached to both sides of their bed. A joint record review of Resident 1's comprehensive care plan showed there was no care plan for bed rail use. Staff E stated Resident 1 had bed enabler and there was no care plan for it. RESIDENT 9 Review of the quarterly MDS dated [DATE], showed Resident 9 was moderately impaired with cognition. Observations on 02/19/2025 at 10:22 AM, on 02/20/2025 at 9:57 AM and at 1:47 PM, on 02/21/2025 at 7:45 AM, and on 02/25/2025 at 9:09 AM, showed Resident 9 was lying in bed with half bed rails attached to both sides of their bed in the raised position. Review of the February 2025 physician order summary report, active as of 02/19/2025, showed Resident 9 had an order for Both 1/2 side rails up for enabler, with an order date of 09/20/2023. Review of the comprehensive care plan printed on 02/20/2025 showed there was no comprehensive person-centered care plan initiated for Resident 9's bed rails use. A joint observation and record review on 02/24/2025 at 12:59 PM with Staff E, showed Resident 9 was lying in bed with half bed rails attached to both sides of their bed in the raised position. A joint record review of Resident 9's comprehensive care plan showed there was no care plan for bed rail use. Staff E stated that Resident 9 had half bed rail on both sides of their bed and there was no care plan initiated for it. RESIDENT 80 Review of the quarterly MDS dated [DATE], showed Resident 80 was severely impaired with cognition. Observations on 02/19/2025 at 10:33 AM, on 02/20/2025 at 9:54 AM and at 1:49 PM, and on 02/24/2025 at 9:31 AM, showed Resident 80 was lying in bed with quarter bed rails attached to both sides of their bed in the raised position. Review of the February 2025 physician order summary report, active as of 02/19/2025, showed Resident 80 had an order for Bilateral [both sides] bed enabler bars for enabler/promote transfer and ADLs [activities of daily living], with an order date of 08/18/2024. Review of the comprehensive care plan printed on 02/20/2025 showed there was no comprehensive person-centered care plan initiated for Resident 80's bed rails use. A joint observation and record review on 02/24/2025 at 1:06 PM with Staff E, showed Resident 80 was lying in bed with quarter bed rails attached to both sides of their bed in the raised position. A joint record review of Resident 80's comprehensive care plan showed there was no care plan for bed rail use. Staff E stated that Resident 80 had bed enabler on both sides of their bed and there was no care plan initiated for it. In an interview on 02/25/2025 at 12:25 PM, Staff B stated that bed enablers were considered as grab bar, or an assist bar and it was their expectation that a care plan was initiated prior to using it. 47680 RESIDENT 3 Review of the quarterly MDS dated [DATE] showed that Resident 3 admitted to the facility on [DATE] and was cognitively intact. Review of Resident 3's February 2025 physician order summary report showed, Left bed enabler bars to promote transfers and ADLs dated 09/23/2024. Review of the comprehensive care plan printed on 02/19/2025 did not show a comprehensive person-centered care plan to address Resident 3's bed rail use. Observation and interview on 02/18/2025 at 10:45 AM, showed Resident 3 lying in bed with a bed rail on the left side of their bed in the raised position. Resident 3 stated that they used their bed rail to get up from bed. Observations on 02/20/2025 at 1:20 PM and on 02/24/2025 at 10:15 AM, showed Resident 3's left bed rail in the raised position. In an interview on 02/24/2025 at 2:17 PM, Staff P, CNA, stated that Resident 3 used the bed rail during transfers and that they would look at the care plan on how to care for Resident 3. In an interview and joint record review on 02/24/2025 at 2:26 PM, Staff D, RCM, stated that they care planned use of bed rails. Joint record review of Resident 3's care plan did not show a care plan for bed rails. Staff D stated that it should have been care planned. In an interview on 02/25/2025 at 12:50 PM, Staff B stated that they expected Resident 3's bed rails/enablers to have been care planned. 52133 RESIDENT 85 Review of the quarterly MDS dated on 12/19/2024, showed Resident 85 was moderately impaired with cognition. Review of Resident 85's February 2025 physician order summary report showed, right bed enabler bar for enabler/promote transfer and ADLs, with an order date on 10/03/2024. Review of Resident 85's comprehensive care plan printed on 02/19/2025 did not show a person-centered care plan for use of right bed rail. Observations on 02/18/2025 at 9:56 AM and on 02/19/2025 at 9:20 AM, showed Resident 85 had a bed rail attached to the right side of their bed in the raised position. Observation on 02/20/2025 at 1:40 PM, showed Resident 85 used the bed rail to turn while in bed. Observation and interview on 02/24/2025 at 7:30 AM, Staff Q, CNA, stated that Resident 85 had one enabler bar on the right side of the bed and that it helped Resident 85 to get up and move in bed. Staff Q further stated that if a resident had a bed rail/enabler bar on their bed, it would be in the care plan in the electronic health record. In an interview on 02/25/2025 at 10:55 AM, Staff D stated that for the enabler bars we do [obtain] an order, inform family, and care plan it. In an interview on 02/25/2025 at 12:25 PM, Staff B, stated that the bed enablers were considered as grab bar, or an assist bar and it was their expectation that a care plan was initiated prior to using it. Reference: (WAC) 388-97-1020 (1)(2)(a)

Based on observation, interview, and record review, the facility failed to ensure the survey result binder included the recertification and complaint survey results that resulted in citations for 2 of 3 years (2022 & 2024), reviewed for availability of survey reports. In addition, the facility failed to post notice of the availability of survey reports in areas of the facility that are prominent and accessible to the public. These failures prevented residents, residents' representatives and visitors from exercising their right to review past survey results and the facility's plan of corrections. Findings included . Review of the facility's policy titled, Availability of Survey Results, revised on 02/25/2025, showed, The facility will maintain reports of any surveys, certifications, and complaint investigations made respecting the facility during the 3 preceding years, and any plan of correction in effect with respect to the facility. This information will be available for any individual to review upon request. The policy further showed, Signs identifying the availability and location of our survey binder and availability of previous survey results are posted throughout the building and public bulletin boards. Review of the State Survey/Inspection Report binder on 02/21/2025 at 9:06 AM, showed that the binder did not contain recertification and complaint surveys that resulted in citations during the three preceding years. Further review showed recertification survey results and associated plan of corrections dated 09/28/2022 and complaint survey results, and associated plans of corrections dated 08/01/2024 and 12/23/2024 were missing. In an interview and joint record review on 02/21/2025 at 2:37 PM, Staff A, Administrator, stated that they were in charge in maintaining the State Survey/Inspection Report binder and that it included recertification and complaint surveys. Staff A stated that they had been in the facility for two years and had been keeping the records in the binder since January 2023. Joint record review of the State Survey/Inspection Report binder did not show recertification survey results and associated plan of corrections dated 09/28/2022 and complaint survey results, and associated plans of corrections dated 08/01/2024 and 12/23/2024. Staff A stated that they should have been included in the binder. Observation on 02/21/2025 at 3:10 PM, showed that the facility did not have a posting of the availability of state survey results in areas of the facility that were prominent and accessible to the public (facility entrance, lobby, hallway by the main dining room, and bulletin board by the Social Services office). In a follow up interview on 02/21/2025 at 3:14 PM, Staff A stated that they had a posting of the availability of the state survey reports in areas of the facility that were prominent and accessible to the public and that it was located next to the State Survey/Inspection Report binder (by the bulletin board by the Social Services office). Joint observation of the bulletin board by the Social Services office did not show a posting of the availability of the state survey reports. Staff A stated that they did not have a posting of the availability of the state survey reports and that they should have. Reference: (WAC) 388-97-0480(1)(a)(b)(c)(2)(b)

Based on observation, interview, and record review, the facility staff failed to provide care and services in a manner that maintained and promoted dignity before entering resident rooms for 4 of 11 rooms (Rooms 121, 122, 126 & 119), reviewed for dignity. This failure placed the residents at risk for a diminished self-worth and over-all well-being. Findings included . Review of the facility's policy titled, Resident Rights, revised on 10/17/2024, showed the resident has a right to be treated with respect and dignity. room [ROOM NUMBER] Multiple observations on 02/20/2025 at 8:55 AM, at 9:01 AM, at 9:11 AM, and at 9:20 AM, showed Staff R, Licensed Practical Nurse, entered room [ROOM NUMBER] without knocking or identifying themselves to the residents prior to entering. room [ROOM NUMBER] Multiple observations on 02/20/2025 at 8:56 AM, at 12:22 PM, and at 12:46 PM, showed Staff R entered room [ROOM NUMBER] without knocking or identifying themselves to the residents prior to entering. room [ROOM NUMBER] Observations on 02/20/2025 at 12:08 PM and at 12:48 PM, showed Staff R entered room [ROOM NUMBER] without knocking or identifying themselves to the residents prior to entering. room [ROOM NUMBER] Observation on 02/20/2025 at 12:54 PM, showed Staff R entered room [ROOM NUMBER] without knocking prior to entering the resident's room. On 02/20/2025 at 1:09 PM, Staff R stated that before they entered a resident's room they would knock on the door and introduce themselves. Staff R stated that they did not knock or introduce themselves prior to entering because some of the residents were sleeping, but that they should have. On 02/25/2025 at 1:10 PM, Staff D, Resident Care Manager, stated that the resident's room was considered their personal private space. Staff D further stated that prior to entering a resident's room, staff should knock on the door and introduce themselves. On 02/26/2025 at 11:08 AM, Staff B, Director of Nursing, stated it was their expectation for staff to knock and introduce themselves prior to entering a resident room. On 02/26/2025 at 11:30 AM, Staff A, Administrator, stated it was their expectation for staff to knock on the door, call the resident by their name, and introduce themselves prior to entering a resident room. Reference: (WAC) 388-97-0180 (1-2)

Based on observation, interview and record review, the facility failed to ensure 1 of 5 residents sampled for abuse (Resident #1) remained free from physical restraints imposed for purposes of staff convenience. This failure led to Resident #1's diminished right to be treated with dignity, respect, and led to the resident's inability to move both her arms in bed for hours. Findings include: --also see F609, F610-- Review of facility medical records revealed, Resident #1 resided in the facility since (YEAR) for long term care. Review of the facility Minimum Data Set (MDS) assessment dated [DATE] revealed, Resident #1 had severe cognitive impairment and needed assistance of two staff for bed transfers, dressing, and toileting needs, as well as at least 1 staff for all activities of daily living. Resident #1 used a wheelchair for mobility. In addition, the MDS assessment revealed, Resident #1 had constant behaviors of inattention and sometimes rejects care. The facility record also revealed, Resident #1 had dementia with behaviors, resisted care and plays with her feces. Further review revealed, Resident #1 had no limited motion with her upper extremities. Review of the facility care plan dated 09/03/18 for Resident #1 revealed, Resident #1 needed good pericare after each incontinence, call light within reach at all times, check every two hours and as needed when in bed especially at night to be sure she is clean and dry, resident digs and plays in bowel movements, sometimes refuses care so approach later if refuses and provide reassurance. In an interview on 09/24/18 at 12:45 p.m., Staff L stated Resident #1 could move her arms and use her arms and hands with no limitations, and was strong. In an interview on 09/24/18 at 12:50 p.m., Staff C stated Resident #1 can be combative and uses both hands and arms to swat at staff and was strong. Staff C also stated Resident #1 could sit up in bed on her own by grabbing the quarter side rails. Observation on 08/29/18 at 12:30 a.m. revealed, Resident #1 could move both arms and used her hands to hold onto the blanket on the bed during the observation. The facility medical record had no physician's order for the use of [REDACTED]. RESTRAINT/ABUSE ALLEGATION According to the State Hotline, on 08/12/18, there was an anonymous allegation of abuse with a physical restraint used on Resident #1 reported to the hotline and a perpetrator was named (Staff K). In an interview on 09/26/18 at 5:30 p.m., Staff K stated she used wrist restraints on both arms on Resident #1 one time. Staff K stated she was passing Resident #1's room early in the morning around 6:00 a.m., and smelled feces, so she entered the room and Resident #1 had messy hands with feces on them. Staff K further stated, she attempted to clean Resident #1, but the resident was fighting and tried to hit Staff K. In addition, Staff K stated Resident #1 continued to fight with her as she applied the two wrist restraints, one on each arm and tied them to the bed frame below the (quarter) side rails. Staff K stated Resident #1 did not hit her but got some feces on Staff K's uniform. Staff K stated after she tied the restraints on Resident #1's wrists the resident could no longer move her arms and became quiet. Staff K stated Resident #1 was alert and confused. Furthermore, Staff K stated she left the room to provide care for another resident and forgot to remove the restraints from Resident #1 when she went home at the end of her shift. WITNESSES In an interview on at 11:30 a.m., Staff H stated she found the wrist restraints on Resident #1 around 10:00 a.m., about 4 or more hours after Staff K stated she applied the restraints. Staff H stated Resident #1 could not move her hands or arms in the bed when she saw her restrained. In an interview on 09/24/18 at 11:35 p.m., Staff I stated she saw the wrist restraints on Resident #1 in bed in the morning and was shocked. Resident #1 was not moving in the bed. In an interview on 09/24/18 at 1:10 p.m., Staff F stated, Resident #1 could normally move her hands and arms. Staff F stated she saw the wrist restraints on Resident #1 in the morning as alleged above. Review of a written witness statement dated 09/20/18, Staff J stated he saw wrist restraints on Resident #1 in the morning as alleged above. Staff J stated he reviewed the medical record and there was no physician's order for a restraint for Resident #1. Reference (WAC) 388-97-0620(1)

Based on observation, interview and record review, the facility failed to provide timely urinary continence needs, that led to avoidable incontinence at night, and resulted in humiliation, pain from a pressure ulcer, and the wish of euthanasia for 1 of 19 residents reviewed (Resident #4) when the facility did not provide the care planned need for toileting. In addition, the facility failed to ensure call lights were in reach for 17 of 50 residents (Residents #2 through #18) who were able to use call lights, and had care plans to have their call lights in reach. This failure led to neglect for Resident #4, and placed other residents at risk for neglect and unmet needs. Findings include: --also see F609, F610-- Review of the facility policy for Call Lights, received from the Administrator on 09/07/18 revealed, staff are to: make sure the call lights are within the reach of the residents while they are in bed, answer the call lights and respond in a timely manner, and the charge nurse and supervisor will monitor the call light responding times. Resident #4 Review of the facility Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #4 was alert and oriented, and needed assistance from staff for all activities of daily living including toileting. Resident #4 had no limitations in any range of motion of extremities but was not steady while standing, so he used a wheelchair for mobility. Review of the facility Admission assessment dated [DATE], revealed Resident #4 was continent of urine. Review of the facility Bladder assessment dated [DATE], revealed Resident #4 was not a candidate for a toileting program because he was alert, oriented, communicated his needs when asked, was able to sense his need for urination, and was continent with assistance. Review of the facility Treatment Record revealed, Resident #4 was also admitted with a Stage 2 pressure ulcer on his bottom 1 centimeter by 1.2 centimeters in size, that had not changed in size since admission (12 days prior). In an interview on 09/07/18 at 11:00 a.m., Staff F, a charge nurse, stated Resident #4 can sense when he needs to urinate and can ask for assistance, he knows what is going on and can use his call light. Staff F stated he uses the bedside commode with the help of two staff for bowel movements, and used a urinal for urination when he is in bed with staff assistance. In an interview on 09/06/18 at 1:15 p.m., Resident #4, a resident who was interviewable (and observed without call light in reach as noted below) stated through a phone interpreter service for the Mandarin language, I feel very frustrated, humiliated, angry and helpless because I lose control of my bladder because I cannot wait too long when I need to urinate. Many times at night I put my call light on and there is no response for over 20 minutes or more. I hold my urine as long as I can but sometimes I have to urinate in my brief, because I cannot wait any longer for them to come, which is sad and humiliating. One time they came over an hour later. Resident #4 also stated, through the phone interpreter service for the Mandarin lnguage, when I put my call light on at night, it gets answered timely maybe 20 percent of the time, it really is just a decoration. I prefer to have euthanasia. Observation of Resident #4 during the above interview revealed, a very sad grimaced face, and a helpless look as he was lying in bed, with a urinal and a bedside commode next to him. In an interview on 09/07/18 at 10:45 a.m., Staff G, an MDS assessment nurse, stated Resident #4 had some incontinence due to his weakness and he is too weak for a toileting program, because he cannot use the toilet on time without assistance. In an interview on 09/07/18 at 11:05 a.m., Staff B, a caregiver, stated Resident #4 puts his call light on frequently to urinate, sometimes 10 times per shift, and the staff must get there promptly for him to be continent of urine using the urinal as he needs assistance. In an interview on 09/07/18 at 11:50 a.m., Staff C, a licensed nurse supervisor stated, Resident #4 can use his call light and can feel the need to urinate but he is weak. Staff C stated incontinence for Resident #4 could be resolved if the staff stay close by to meet his needs. Staff C did not know why Resident #4 was not on a toileting program. In an interview on 09/06/18 at 3:18 p.m., Staff D, a caregiver, stated Resident #4 is able to use the call light and is mostly continent during the day and evening shifts. In an interview on 09/06/18 at 3:22 p.m., Staff E, a caregiver, stated Resident #4 was continent because he is able to communicate when he needs the bathroom. In an additional interview on 09/07/18, the day after the initial interview, Resdient #4 stated, through Staff F, a licensed nurse speaking the Mandarin Chinese language, he waited over 20 minutes for the call light to be answered last night and he had to urinate in his brief. Resident #4 stated he is bothered by having to urinate in a brief. He also stated his stage 2 pressure ulcer on his bottom hurts. Review of the facility Progress Notes revealed: 08/27/18, Needed extensive assistance from 2 people to use the commode, and could sense when he needed to urinate or have a bowel movement. Uses call light often for needs, uses urinal and bedside commode. Frequent urination. Continent of bowel and bladder (evening shift). The facility night shift notes revealed, incontinent of large amount of urine and bowel on 08/27/18 and 08/28/18. The day shift progress notes dated 08/28/18 noted, Resident #4 was continent and used the commode for urine and bowel with assistance and request. Night shift 08/29/18 incontinent of urine and stool. Further review of the facility notes revealed Resident #4 was incontinent of a large amount of urine at night 08/30/18, 08/31/18, but continent when assisted with the urinal during the day and evening. On 09/03/18, a progress note by a licensed nurse noted, Resident #4's urinary incontinence was due to low energy and weakness. Additional review of the progress notes revealed, Resident #4 continued to have large amount of incontinent urine most nights and some evenings. Review of caregiver urinary output charting was not complete for every shift for Resident #4 from admission 08/27/18 to 09/07/18. Review of the Care Plan for Resident #4 revealed, call light within reach at all times-response to call light promptly - anticipate resident needs e.g. toileting, uses urinal and bedside commode, assist to use urinal per request, keep skin clean and dry. In an interview on 09/24/18 at 10:40 a.m., the facility Administrator stated he investigated the call lights one night recently and found two not in reach; in addition, the Administrator stated he checked call light response times for Resident #4 and the wait times were long. The facility failed to provide timely and adequate care and services to Resident #4 to prevent avoidable incontinent episodes at night, and caused the resident to feel frustrated, and humiliated when he urinated in his brief. This failure also placed the resident at risk for the worsening of a pressure ulcer due to large amounts of urinary incontinence at night. CALL LIGHTS NOT IN REACH AT NIGHT Observations of residents who were reported by the charge nurses as able to use their call lights on 08/29/18 at approximately 12:05 a.m. (night shift), revealed 17 residents had call lights out of reach as listed below (Care Plans also listed): Resident #2: The call light was not in reach but was clipped on the light cord on the wall, behind and above bed (Care Plan: call light within reach at all times-respond to call light promptly; history of falls and impulsive) Resident #3: The call light was out of reach and was on floor, behind the headboard of the bed (Care Plan: call light within reach at all times-response to call light promptly; history of falls, forgetful) Resident #4: The call light was clipped to the light cord, behind the bed, and was not in reach (Care Plan: call light within reach at all times-response to call light promptly - anticipate resident needs e.g. toileting). Resident #5: The call light was out of reach, clipped to cord on wall behind bed (Care Plan: call light within reach at all times-response to call light promptly-toileting) Resident #6: The call light was out of reach and was on the floor behind the headboard (Care Plan: call light within reach at all times-history of falls) Resident #7: The call light was out of reach, clipped to cord on wall behind the bed (Care Plan: call light within reach at all times-response to call light promptly-toileting-on diuretic) Resident #8: The call light was out of reach and was on the floor behind headboard (Care Plan: call light within reach at all times-history of falls, [MEDICAL CONDITION]) Resident #9: The call light was on the floor and not in reach (Care Plan: call light within reach at all times-history of falls-impulsive and will not wait for assistance) Resident #10: The call light was not visible or in reach next to the resident (Care Plan: call light within reach at all times-impaired vision, history of falls, easily agitated) Resident #11: The call light was not within reach (Care Plan: call light within reach at all times-history of falls, impaired mobility) Resident #12: The call light was behind the headboard and not in reach (Care Plan: call light within reach-history of falls, unsteady gait) Resident #13: The call light was not seen next to the resident (Care Plan: call light within reach at all times, history of falls, dizziness) Resident #14: The call light was not visible next to the resident (Care Plan: call light within reach at all times-history of fracture and pain) Resident #15: The call light was not visible next to the resident (Care Plan: call light within reach at all times-weakness) Resident #16: The call light was not visible next to the resident (Care Plan: call light within reach at all times-weakness, [MEDICAL CONDITION], anxiety) Resident #17: The call light was not visible next to the resident (Care Plan: call light within reach at all times-weakness, history of falls) Resident #18: The call light was not visible next to the resident Care Plan: call light within reach at all times-impaired mobility, communication problem) The facility failed to ensure 17 call lights were in reach of the residents, to allow residents to communicate their needs for care during the night shift on 08/28/18. Reference (WAC) 388-97-0640(1)

Based on interview and record review, it was determined, the Administrator failed to effectively and efficiently manage resources to ensure established policies and procedures to protect residents from physical abuse were implemented as required by the federal and state regulations. This resulted in harm for one of four residents sampled (#1) and placed all other residents at risk of harm related to actual abuse and lack of prevention of recurring abuse. Findings include: Failed practice found during an abbreviated survey ending on 03/01/17 was as follows: F 223 - 483.13(b) &(C) Free from abuse The administration failed to ensure residents were free from abuse F 226 - 483.13 (b) & (c) (3) -Develop/implement abuse/neglect, etc. policies The administration failed to thoroughly investigate an incident of physical abuse by a staff member to resident. F 309 - 483.25 Provide care/services for highest well being The administration failed to ensure facility staff provided individualized care and services to attain or maintain the highest practicable physical and mental and psychological well - being in accordance with comprehensive assessment and plan of care for individualized approach to the resident related to dementia care and behavior.

Based on observation, interview, and record review, the facility failed to ensure one ( Resident #1) of three current residents reviewed received the necessary care and services to attain or maintain their highest practicable level of well-being related to individualized approach to dementia and behaviors consistent with the resident's dementia and behavior care plan. Failure to ensure Resident #1 received individualized care and services consistent with his behavior care needs, resulted in actual harm when a caregiver managed the resident's combative behavior with using a shoe to strike the resident. Findings include: RESIDENT #1 Resident #1 admitted to the facility on [DATE] with care needs related to stroke with right sided weakness, depression, and dementia. According to the 11/09/16 Minimum Data Set (MDS) assessement, the resident required two person extensive assistance with bed mobility/transfers, and depended on staff for most activities of daily living. This MDS revealed Resident #1 had combative behavior, angry outbursts, hitting others, and refusal to go to bed after meals. Review of the Care Plan (CP) last revised on 10/01/16 instructed Staff to give short and concise explanation when the resident starts hitting people. This CP also instructed staff to have familiar speaking staff talk to him with a soothing voice in order to get the resident to comply with care. Review of the witness statement dated 02/17/17, completed by staff F, certified nursing assistant, (CNA) revealed that on 01/03/17 approximately 3:00 p.m., Resident #1 was exhibiting combative bahavior ( hitting and kicking) as Staff E was attempting to change the resident's briefs. Resident #1 hit Staff E in the chest area. Staff E, CNA, lost balance and fell on the floor. When Staff E got up from the floor, she started hitting Resident #1 with a shoe, contrary to the individualized plan of care for Resident #1 which instructed staff to approach the resident calmly and to reapproach him when he was more receptive of care. Staff E, failed to approach the resident as indicated in the resident's individualized plan of care. On 02/23/17, approximately 3:30 p.m., in an interview, Staff F confirmed that she had observed Staff E hitting Resident #1 with a shoe. Staff F continued and stated that a family member of Resident # 2 was also in the room at the time of incident. Attempts to interview Staff F failed as her employment was terminated related to substantiated physical abuse. The failure to ensure Resident #1 reviewed the necessary care and services to attain or maintain his highest practicable level of well-being, placed the resident resulted in psychological harm and fearfulness, according to the reasonable person rule.

Based on interview, and record review, the facility failed to implement written policies and procedures for protecting residents from physical abuse for 1 of 4 sampled residents (Resident #1), by failing to thoroughly investigate allegations of physical abuse when they were made aware of allegations of abuse by a staff member, failed to notify local law enforcement (LLE) to report actual abuse, and failed to suspend staff who allegedly abused a resident. These failures resulted in harm toward Resident #1, and placed other residents at risk for continued physical abuse and psychological harm. Findings include: Refer to F 223. The August 2015 facility Abuse Policy and Procedure indicated it was the policy of the facility to protect residents from abuse. The policy further indicated facility staff, including nurses and administration, were responsible for following the care plan, and administrative staff were responsible for supervision of facility staff (to ensure this was being done). Resident #1 was initially admitted to the facility 11/14/03, with [DIAGNOSES REDACTED]. A quarterly assessment, dated 11/09/16, documented the resident was cognitively impaired, had combative behavior during care, and required extensive assistance of 2 staff for most activities of daily living. Review of a facility investigation (IIR), dated 01/04/17, revealed on 01/03/17, Staff F, a Certified Nurse's Aide (CNA) had observed another staff member Staff E, CNA, hitting Resident #1 with a shoe. This IR revealed Staff F, had reported her observations to Staff C, RCM, resident care manager (RCM). Record review of the witness statements completed by Staff F, did not reflect the actual observations of Staff F, CNA. The witness statement did not include documentation Staff E, CNA had been observed hitting the resident with a shoe. On 01/06/17, Staff C, RCM had completed the investigation of allegations of physical abuse of Resident #1, and indicated that there was no evidence of physical abuse. On 02/03/17, in an interview when Staff C,RCM, was asked if she had followed up with Staff F, to verify the discrepancy in what Staff F, CNA had reported and what she had written in the witness statement, Staff C, RCM stated No. When asked why, she stated I trusted what Staff E, CNA and F, CNA had written. When Staff C, RCM was asked how she made a determination physical abuse did not occur, she stated that in addition to collecting statements from Staff E, CNA and F, CNA she also interviewed Resident #1 and Resident #2 to find if they had experienced any physical abuse by a staff member. Review of Resident #1's and Resident #2's medical records revealed both residents had impaired cognition and were forgetful. Staff C was again asked if she had interviewed other residents with intact cognition and/or other staff members other that Staff E and F, she stated No. Staff C, acknowledged, and stated: I should have interviewed other residents with intact cognition and other staff members. On 03/01/17 approximately 11:00 a.m., Staff A (Administrator) was notified that Staff C RCM had not completed a thorough investigation. Staff A, also acknowledged and stated we could have done a better job. On 02/23/17, approximately 4:00 p.m., Staff A, stated that he had terminated the employment of Staff E, on 02/20/17. When asked why Staff F's (CNA) employment was terminated, Staff A stated that the facility had made a determination physical abuse had occurred based on the new witness statement completed by Staff F on 02/17/17, 4.00 p.m. Review of the new witness statement completed by Staff F, revealed she had observed Staff E hitting Resident #1 with a shoe on the afternoon of 01/03/17. Staff A also added that an unidentified family member who was visiting Resident #2, had left a message on the facility's phone reporting the allegations of physical abuse by a staff member to Resident #1. Staff A acknowledged the facility did not notify LLE at any time during this investigation related to Staff E striking/hitting a resident with a shoe. Review of the employee electronic time card for Staff E, revealed Staff E reported for work on the 02/17/17 and on 02/18/17 night shifts and worked a full 8 hour shifts. In an interview on 02/23/17 approximately 4:30 p.m., when Staff A was asked what he had done to protect Resident # 1 and other resident from possible physical abuse, he stated that he had not implemented any interventions as he was still gathering more details about the incident. The failure to protect and thoroughly investigate allegations of physical abuse resulted in Resident #1 not being protected from abuse, and placed other residents at risk for continued physical abuse, psychological harm and diminished quality of life.

Based on interview and record review, it was determined the facility failed to ensure 1 of 4 sampled residents (#1) was free from physical abuse. The failure to protect Resident #1 from physical abuse, caused Resident #1 to experience psychological harm and diminished quality of life, according to the reasonable person rule, when a caregiver hit Resident #1 with a shoe, and the resident was not able to verbalize his feelings. In addition, the incident occurred in the presence of Resident #1's roommate and family member. Findings include: Resident #1 was initially admitted to the facility 11/14/03 with multiple health conditions which included stroke with right sided weakness, depression and dementia. Resident #1's Minimum Data Set (MDS), a comprehensive assessment tool dated 01/01/17, indicated the resident had an impaired cognition with a Brief Interval for Mental Status (BIMs) of (11/15) and required extensive Physical assistance of 2 persons or more for transfers and activities of daily living. Review of an Incident Report dated 01/04/17, revealed, on the afternoon of 01/03/17 approximately 3:00 p.m., Staff # F, a Certified Nurse's Aide (CNA) had observed Staff E, another CNA, hitting Resident #1 with a shoe as she was assisting him to change his soiled briefs. Staff F, advised Staff E to calm down. Staff E did not take the advice, and instructed Staff F to leave the resident's room. The family member of Resident #1's roommate was in the room visiting Resident #2, and both the roommate and the family member witnessed the abuse. On 01/03/17 approximately 4:00 p.m., Staff F, reported her observations of Staff E, hitting the resident with a shoe to Staff C. Review of the Incident Investigation Report (IIR) dated 01/03/17 revealed Staff C requested Staff E and F to completed written statements of the incident. Statements written by Staff E and F did not reflect what Staff E had observed and reported to Staff C, the residential care manager (RCM). On 01/25/17 in an interview, when Staff C was asked (In the presence of Staff E) what she did to protect Resident #1 and other residents from abuse after Staff E reported allegations of physical abuse, Staff C stated I can't remember if Staff E reported the incident to me .if she did, I may have spaced out, because I was just coming out of the meeting. On 01/03/17, approximately 4:00 p.m., an unidentified family member left a voice mail on the Director of Nursing's (DNS) phone, reporting concerns with her observations of physical abuse by a care giver on the afternoon of 01/03/17 (consistent with Staff F's report to Staff C). Review of the Investigation Summary of the incident report dated 01/03/17, revealed Staff C an RCM, who completed the investigation had interviewed Resident #1 and his roommate (both residents had impaired cognition), to find if the residents had experienced any physical abuse by Staff E, CNA. When Staff C asked Resident # 1 if he liked to be in the facility? He stated No, I like to go to Florida. Review of the IIR could not find documentation, the facility followed up with Resident #1 to find out why he did not like being in the facility and wanted to go to Florida. Staff C, did not interview any other residents or other staff members in order to rule out abuse. Review of the IIR could not find documentation the facility made a reasonable effort to identify the family member who had left the voice message on the phone to find out the details of the incident. On 01/06/17, Staff E reported for work after a two days suspension pending investigation, and continued to work normally as a full time employee. On 02/17/17, Staff F, presented a written statement (different from the statement she presented on 01/03/17) to Staff A. Review of the statement revealed Staff F, had observed with a family member visiting Resident #1's roommate, Staff E hitting Resident #1 with a shoe. Review of the staff electronic time card for the month of February 2017, revealed Staff E (alleged perpetrator) continued to report to work as scheduled. The facility did not remove Staff E from direct resident care to protect Resident #1 and other residents from possible continued physical abuse. Staff E, reported to work on 02/17/17 and 02/18/17 and worked 8 hour shifts. On 02/25/17 approximately 11:00 a.m., when Staff A was asked how he protected Resident #1 and other residents from possible physical abuse, he stated The case is still under investigation. It is still not clear what had happened. Once we find out the details, then we will take action. When Staff A, the facility's administrator was asked why Staff E was not removed from direct resident care when he received a written statement by Staff F who witnessed Staff E, hitting the resident with the shoe, he stated that he wanted to give instructions to Staff E to be removed from resident care in person, however, Staff E reported to work at night and got off work very early in the morning (6 a.m.), so was unable to deliver the information in person. The failure to protect Resident #1 from physical abuse caused Resident #1 to experience physical harm and potential psychological harm and diminished quality of life.

Based on interviews, record review and observations the facility failed to address the emotional and psychosocial needs of Resident #33, one of 11 residents interviews of 35 sampled residents.. Resident #33 expressed feeling of distress related to the actions and behaviors of the roommate. Although multiple staff members were aware of issues, Resident #33 remained in a distressing environment for a period of time which contributed to emotional harm for this resident. Findings include: Resident #33 was admitted to the facility on [DATE] with multiple medical [DIAGNOSES REDACTED]. In an interview on 11/19/13 at 1:30 p.m. the resident stated through an interpreter he had repeatedly requested the facility provide a room/roommate change for more than a month. The resident explained, in his primary language, of three separate actions and behaviors of his roommate which contributed to feeling mentally miserable in his present room assignment. The resident stated he was frequently woken in the middle of the night when the roommate pulled back the privacy curtain and stared steadily with "wolf-like eyes". The resident described this as torture. The interpreter confirmed the resident was very upset about the issue based on his vocal inflection and the amount of details he used to describe the situation. Resident #33 also stated his roommate had a habit of spitting on himself, the floor and at times on clothing laid out by staff for Resident #33. The resident stated the roommate might have dementia, nevertheless described this behavior as foul and unsanitary especially since it involved his personal belongings. Lastly Resident #33 explained his dresser was between the two beds and the roommate reached inside the top drawer and took small items such as a comb and pens. Staff moved the dresser to the other side of the bed instead of moving the resident to another room as he had requested. On 11/19/13 at 8:30 a.m. an observation confirmed the dresser was located between the bed of Resident #33 and the closet. The resident stated his DPOA was aware of his desire for a change in roommate and has spoken to the facility on his behalf, yet the facility had taken no action. The resident also said he propelled himself by wheelchair and was very distress to find empty beds the facility. The facility told Resident #33 there was no suitable room change options available. On 11/17/13 at 12:16 p.m. an observation revealed the roommate of Resident #33 was sitting in his wheelchair in his room. The roommate had a large amount of mucous he slowly spewed from his mouth on to his clothing and the floor. On 11/20/13, a record review revealed a roommate change form dated 11/04/13 was partially filled out. No documentation was found in the social services notes or nursing progress notes regarding the reason behind the request or action taken. In an interview on 11/20/13 at 2:08 p.m. Staff S, Social Service staff, stated she knew about the change of room/roommate request but did not document her conversations with residents. Upon review of daily Staff Stand Up meetings notes, Staff S found the roommate change request for Resident #33 had been mentioned on 10/23/13 and 10/28/13. In an interview on 11/21/13 at 9:20 a.m. with Staff D, director of Social Services confirmed the resident and his DPOA had requested a roommate change. Staff D stated he normally attempted to resolve the issue between roommates; however this would not be possible due to the cognitive impairment of the roommate. Staff D repeatedly stated the facility had delayed the request only because no suitable roommate had been available. Record review of the new admissions information the facility provided revealed 7 male residents had been admitted to the facility since 10/23/13. Three of these residents were assessed to be of the same cognitive level as Resident #33 and were placed in rooms suitable for them. In an interview on 11/21/13 at 10:41 a.m. Staff G, the Nursing Station Coordinator, stated she did not speak the resident's primary language and did not use an interpreter. Staff G described her conversations with the resident as simple yes and no questions which she felt were adequate. She also stated stated she knew Resident #33 was disturbed by the roommate pulling the curtain as well as the coughing and spitting. She was unable to discern in their conversations the roommate had spit on the personal belongings of Resident #33. Staff G acknowledged she had moved the dresser because of the roommate's behavior. She was aware the resident was roommate opened the dresser drawer, but was not able to discern from their conversation this roommate removed items from the dresser of Resident #33. .