Every finding on record at Lake Ridge Center

Based on observation, interview, and record review, the facility failed to protect the residents' right to be free of abuse for 1 of 4 residents (Resident 2) reviewed for abuse and neglect. This deficient practice resulted in Resident 2 being subjected to physical abuse and put other residents at risk of further abuse and potential injury.Findings included .Review of the facility policy titled Abuse Prohibition, revised on 11/14/2025, showed facility staff would be trained to identify, correct, and intervene in situations where abuse, neglect, or exploitation were likely to occur.Resident 1Review of the medical record showed Resident 1 admitted to the facility, on 02/03/2025, with diagnoses of dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) with behavioral disturbance (acting out in a way that is disruptive, harmful, or highly unusual for a given situation), epilepsy (a common brain disorder that causes a person to have repeated, unexpected seizures [a sudden, uncontrolled burst of electrical activity in the brain that temporarily disrupts how a person moves, thinks, or feels], and anxiety (feeling of worry, nervousness, or unease about something that might happen in the future). Review of the comprehensive assessment, dated 07/14/2026, showed Resident 1 had severe cognitive impairment, required set up for eating, and was independent with walking. Further review showed Resident 1 exhibited physical (hitting, kicking, pushing, scratching, grabbing) and verbal (threatening, screaming and/or cursing at others) one to three days out of the previous seven day look back period (07/08/2026 to 07/14/2026).Review of the care plan, initiated on 02/03/2025, showed Resident 1 had a history of exhibiting physical behaviors after experiencing seizure activity and due to cognitive impairment from dementia. The care plan showed identified triggers of loud noises and conversations for Resident 1's agitated/angry times, and interventions, dated 03/26/2026, included the provision of a quiet, calm environment, to redirect Resident 1 away from loud areas, and to use plastic plates with meals due to behaviors of throwing coffee mugs and plates when angry.Resident 2Review of the medical record showed Resident 2 admitted to the facility, on 06/11/2026, with diagnoses of Alzheimer's Disease (a progressive brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple daily tasks) and dementia without behavioral disturbance. Review of the comprehensive assessment, dated 06/16/2026, showed Resident 2 had severe cognitive impairment, required the assistance of one person for dressing, toileting, transfers, and used a manual wheelchair for mobility.Review of the facility's incident report log showed on 08/16/2026 at 10:35 AM in a resident-to-resident altercation occurred between Resident 1 and Resident 2.Review of nursing progress note, dated 08/16/2026 at 5:49 PM, showed staff witnessed a verbal altercation between Resident 1 and Resident 2 in the dining room, attempted to redirect Resident 2 away from the situation when Resident 1 stood from the table and suddenly turned and threw their coffee on (Resident 2). Staff intervened immediately, separated the residents and checked them for injuries.During a concurrent observation and interview, on 08/19/2026 at 3:15 PM, Staff C, Nursing Assistant (NA), was sitting in the hallway outside of Resident 1's room while Resident 1 was sleeping in their bed. Staff C stated they were aware of the incident between Resident 1 and Resident 2, and their assignment was to maintain an increased level of supervision on Resident 1 for safety. Staff C stated Resident 1's action of throwing their coffee was likely in response to being agitated.During an interview, on 08/19/2026 at 3:30 PM, Staff B, Director of Nursing, stated Resident 1 did not tolerate loud environments, and Resident 2 had been talking loudly at Resident 1 which set (them) off. Staff B stated staff was present and attempted to redirect, but Resident 1 responded by throwing their coffee, thankfully it was cold. Staff B stated they understood the actions of Resident 1 were considered abuse, and it was not okay.Reference: WAC 388-97-0640 (1)

Based on interview and record review, the facility failed to ensure a resident's authority by extending the resident's representative the right to make decisions on behalf of the resident beyond those which were previously delegated by the residents, within the resident's advance directives (AD, a legal document in which a individual person specifies what actions should be taken for their health care and/or finances in the event they were no longer are able to make decisions for themselves because of illness or incapacity), for 1 of 3 residents (Resident 49) reviewed for resident rights with acceptance of a binding arbitration agreement (an alternative means of settling disputes without a jury by trial). This failure placed the resident at risk for violation of their rights as a resident who had made their health care and financial wishes known.Findings included .Review of the medical record showed Resident 49 was admitted to the facility on [DATE] with diagnosis including moderate dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities) with agitation, hearing loss, depression and anxiety. The 12/02/2025comprehensive assessment showed the resident had a severely impaired cognition, was unable to speak clearly, sometimes able to make their needs known.Review of Resident 49's Power of Attorney (POA) for Health Care (an AD document delegating a person that is authorized to make health care decision for you) document, dated 07/22/2022 showed Resident 49 delegated their Resident Representative (RR) to make health care decisions on behalf of the resident. The document showed the RR was not given the power to agree or enter into a facility's binding arbitration agreement.Record review of Resident 49's arbitration agreement showed the agreement was offered/signed by the RR on 12/04/2023. Staff O, Admissions Coordinator, signed the arbitration agreement on 12/06/2023 as a witness.During an interview on 04/15/2026 at 8:31 AM, Staff O stated the arbitration agreement was discussed with resident and/or the RR's upon admission to the facility. Staff O stated the process for residents with a severely impaired cognition, would be to have the RR, who was delegated as the POA, sign the arbitration agreement. Staff O stated they reviewed and obtained a copy of AD's that designated a RR as the residents POA in order to ensure the RR had the authority to make decisions on behalf of the resident.During an interview on 04/16/2026 at 8:17 AM, Staff P, Business Office Manager, stated they reviewed POA paperwork within the facility. Staff P stated they reviewed Resident 49's POA documentation submitted by RR to ensure the authenticity of the document and that the RR was the correct individual that had been extending a RR the right to make decisions on behalf of Resident 49.During an interview on 04/16/2026 at 8:33 AM, Staff E, Social Services Specialist, stated they reviewed the AD paperwork submitted for residents. Staff E stated the AD paperwork was a legal document that extended a RR the right to make decisions on behalf of a resident within the guidelines specified in the document. Upon reviewing Resident 49's POA document, Staff E stated the RR was not extended the right to sign an arbitration agreement with the facility on behalf of the resident.During an interview on 04/16/2026 at 8:48 AM, Staff A, Administrator, stated the facility's process was to ensure a resident's wishes specified in their AD/POA paperwork were followed, and for Resident 9 that would mean the resident did not want a binding arbitration agreement signed by the RR. Staff A stated the facility should not have asked the RR POA to enter into or sign a binding arbitration agreement on behalf of Resident 49.Reference: WAC 388-97-0240(1)(c)(7)

Based on observation, interview, and record review, the facility failed to ensure staff implemented interventions to prevent resident to resident altercations involving 4 of 7 Residents (12, 24, 40 and 39) reviewed for abuse. This failed practice placed residents at risk for physical harm, mental anguish, and a diminished quality of life.Findings included . Resident 12Review of the resident's medical record showed they were admitted with diagnoses which included dementia (a decline in mental ability), stroke (blood flow is cut-off from the brain causing tissue damage) and enchalomalcia (a softening or loss of brain tissue following a stroke). Review of the comprehensive assessment dated [DATE] showed the resident had severe cognitive impairment and required substantial assistance for daily activities such as dressing, showering, personal hygiene and using the bathroom. The residents were independent with walking and mobility requiring no assistance from staff. Resident 24Review of the resident's medical record showed they were admitted with diagnoses which included dementia and diabetes (high blood sugar levels). Review of the comprehensive assessment dated [DATE] showed the resident was severely cognitively impaired and required moderate assistance for showering and using the bathroom. Supervision for dressing and was independent with transfers and mobility. Review of a nursing progress note (PN) dated 04/03/2026 at 10:54 AM, Staff J, Licensed Practical Nurse (LPN), documented that Resident 12 and Resident 24 were both in the hallway, and as Resident 24 walked by Resident 12 pushed Resident 24 into the wall. The PN further showed the incident was not provoked and was difficult to anticipate or prevent at the time of the occurrence. During an interview on 04/14/2026 at 11:03 AM, Staff B, Director of Nursing Services (DNS), stated that Resident 12 gets aggressive at times and acknowledged the incident involving Residents 12 and 24 did fit the definition of abuse. Resident 40Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses of dementia (a group of symptoms that affect memory, thinking and social abilities, severely enough to interfere with daily life), depression and difficulty sleeping. Review of the 03/04/2026 care plan showed the resident was rarely (verbally) understood but could reply yes or no. The resident did experience short and long-term memory loss. Resident 40 was dependent on staff for transfers to and from their bed to the resident's tilt in space wheelchair (a wheelchair designed to tilt the seat, the back of the wheelchair and leg rests as a single unit to redistribute weight and improve positioning). Resident 39Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses of dementia with agitation and restlessness and seizures (a sudden surge of abnormal electrical activity in the brain which causes changes in awareness and muscle control). Review of the 04/06/2026 care plan showed Resident 39 was cognitively impaired, verbal, independent with walking and had poor impulse control. Resident 39 had a history of getting into other residents spaces which staff were to redirect Resident 39 and provide constant oversight when these behaviors occurred. Review of the 03/31/2026 incident investigation showed Resident 40 was up in of the in their tilt in space wheelchair in the C hallway when Resident 39 came up behind Resident 40's wheelchair when Resident 39 (another resident) pushed Resident 40's wheelchair and forced the resident forward where Resident 40 slid to the floor from their wheelchair and landed on their bottom. There were no injuries sustained for Resident 40. Resident 39, who was also demented staff stated Resident 39 was trying to push Resident 40 in their wheelchair into the Hall C dining room. The nursing staff were to redirect Resident 39 when they wheel residents' wheelchairs. Residents 39 and 40 could not recall the 03/31/2026 incident. During an interview on 04/16/2026 at 2:00 PM, Staff B, DNS, stated Resident 40's incident was an isolated event. Staff B stated Resident 39 was confused and demented and tried to help staff at times and had in the past assisted by wheeling other residents in wheelchairs. The interventions were to redirect the resident to another area or activity. Resident 40 did not sustain any injury from the incident. Staff B stated Resident 39 was observed and had walked quickly and grabbed Resident 40's wheelchair and started walking quickly pushing Resident 40's tilted wheelchair when the incident occurred. Reference: WAC 388-97-0640(1)

Based on interview and record review the facility failed to ensure residents Preadmission Screening and Resident Reviews ([PASARR], an assessment to ensure individuals with serious mental illness [SMI] or intellectual/developmental disabilities [ID/DD] were not inappropriately placed in nursing homes for long term care) were accurately completed for 3 of 5 residents (Resident's 24, 2, and 47) reviewed for accuracy of PASARR assessments. Additionally, no referrals had been requested for a PASARR Level II (a comprehensive evaluation by the appropriate state-designated authority) which is required if the PASARR Level l has indicators of mental illness. This failure placed the residents at risk of not receiving the mental health care and services appropriate for their needs.Findings Included .Record review of a facility policy titled Pre-admission Screening for Mental Disorder and/or Intellectual Disability Patients dated 02/16/2024 showed, Center Social Worker or designee will ensure individuals with mental disorders or intellectual disability are appropriately evaluated and receive care and services to meet their needs. Social Services will review PASARR and refer to the appropriate state designated authority when a patient is identified as having mental illness or intellectual disability.Resident 24Review of the resident's medical record showed the resident was admitted with diagnoses which included dementia (a decline in mental function) with agitation, and diabetes (too much sugar in the blood). Review of the comprehensive assessment dated [DATE] showed the resident was severely cognitively impaired and required substantial assistance for daily care activities including dressing, toileting, personal hygiene and bathing. The resident was independent with transfers and ambulation.Review of a Psychiatric note dated 01/09/2026 showed the resident exhibited persistent behaviors of severe aggression and agitation which were difficult to re-direct.Review of Resident 24's PASARR Level l assessment dated [DATE] showed that no indications of mental illness were present even though the record showed the resident had documented behaviors which reflected mental illness. No PASRR Level 2 was requested related to incorrect data on the PASARR Level 1 assessment.Resident 2Review of the resident's medical record showed the resident was admitted with diagnoses which included dementia with agitation and anxiety. Review of the comprehensive assessment dated [DATE] showed the resident was severely cognitively impaired and required substantial assistance for daily care activities including dressing, and personal hygiene. The resident was dependent on staff for showering and toileting needs.Review of a Psychiatric Review note dated 03/26/2026 showed the resident frequently exhibited behaviors of aggression and paranoia (intense irrational distrust or suspicion).Review of Resident 2's PASARR level l assessment dated [DATE] did not show indications of mental illness even though the record showed the resident had documented behaviors of paranoia, therefore there was no PASARR Level 2 assessment referral related to the incorrect data on the PASARR Level l.Resident 47Review of the resident's medical record showed the resident admitted with diagnoses which included dementia with agitation and atrial fibrillation (a rapid irregular heart rate). Review of the comprehensive assessment dated [DATE] showed the resident was severely cognitively impaired and was dependent on staff for daily activities which included showers and personal hygiene. The resident was independent with transfers and ambulation.Review of a Psychiatric Review note dated 03/26/2026 showed Resident 47 consistently exhibited behaviors of agitation, aggression and paranoia with hallucinations (hearing, seeing, smelling or tasting things that are not present).Review of Resident 47's PASARR Level l dated 09/10/2025 showed no indications of mental illness even though the resident had documented behaviors of agitation, aggression, paranoia and hallucinations. Further review showed no referral for a PASARR Level 2 had been requested related to incorrect data on the resident's PASARR Level l.During an interview on 04/16/2026n at 11:05 AM, Staff E, Social Service Specialist, stated they understood that resident behaviors which indicated mental illness were required to be reflected on the PASARR Level l therefore Resident 24, 2 and 47 should have had referrals for PASARR Level 2 assessments.During an interview on 04/16/2026 at 11:30 AM, Staff B, Director of Nursing Services, stated the PASARR Level l's had not been filled out correctly which was why PASARR Level 2's had not been requested.Reference: WAC 388-97-1915(1)(2)(a)-(c)

Based on observation, interview, and record review, the facility failed to ensure identification and evaluation of accident (any unexpected or unintentional incident, which results or may result in injury or illness to a resident) risk/hazards (elements of a residents environment that have the potential to cause injury or illness) regarding residents spilling hot liquids on themselves, nor implementation of an individualized, resident-centered care plan to reduce the risk/hazards related to the spilling of hot liquids for 2 of 3 residents (Resident 48 and 51) reviewed for accident/hazards. This failure placed residents at an increased risk for avoidable accidents, significant injury, and unmet care needs.Findings included.Review of the facility's guidelines titled, Food and Nutrition Services Guideline for Hot Beverages, dated 07/15/2025, showed that hot beverages such as coffee, tea and hot chocolate, held at high temperatures and posed a risk of injury/burns to residents. The guidelines showed that hot liquids would be held at a temperature between 120 to 150 degrees Fahrenheit (F, a unit of measure) before leaving the kitchen to be delivered to residents. The guidelines showed that in order to limit the risk of burns resident's .who may be at greater risk of spilling hot beverages on themselves ., would be identified, which may include, but were not limited to; residents with tremors (an involuntary rhythmic shaking movement of one or more body parts), residents with poor hand control from a stroke (a complication when blood supply to the brain is blocked or reduced which can lead to brain damage and loss of muscle movement of affected arms/legs) or weakness, residents not seated or walking with a hot beverage and resident in a wheelchair traveling with a hot beverage .even a few feet.Review of facility's guidelines presented on survey titled, Hot food and Beverages Can Burn, dated April 2016, showed that hot beverages spilling was a frequent source for scald (an injury that occurs when a portion of skin is exposed to a hot liquid and can damage several layers of skin) injury's. The guidelines showed that vulnerable residents with limited mobility, carrying hot liquids while seated in a wheelchair, were at an increased risk for scalding injuries and that hot liquid temperatures of 155 degrees F, at one second (a unit of measure) or 140 degrees F, at five seconds could cause a serious burn injury.<Resident 48>Review of the medical record showed they were admitted to the facility on [DATE] with diagnosis including stroke, severe dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities) with behavioral disturbances (a pattern of disruptive behaviors that can significantly impact an individual's daily life and social interactions), agitation, exit-seeking behavior (a form of wandering where an individual attempts to leave a safe environment, common with dementia residents and can be driven by confusion, distress/anxiety) and generalized muscle weakness. The 04/06/2026 comprehensive assessment showed the resident had a severely impaired cognition, was wheelchair dependent, required substantial/maximal assistance from nursing staff with transfers, had no skin/wound or open sores noted, and had been receiving psychotropic medications (drugs that affect brain activities associated with mental processes, emotions and behavior).Record review of the resident-centered care plan, last revised 04/10/2026, showed Resident 48 did not have an individualized care plan that identified/assessed the residents risks for hazards or accidents regarding the spilling of hot beverages nor specific interventions or assistive devices that might be utilized to mitigate (to make something less severe or harmful) Resident 48's risk for an avoidable accident/injury from the spilling of a hot beverage on themselves. Observations of the A- Hall dining room on 04/13/2026 from 11:50 AM to 12:42 PM showed Resident 48 sitting in their wheelchair, at a table with other residents, drinking hot tea in a mug/cup with a plastic lid. Resident 48 self-propelled in/out of the dining room multiple times, using their feet in conjunction with grabbing at tables/chairs and handrails to maneuver themselves around, waiting for lunch to be served. Confused, Resident 48 maneuvered up to the door that led from the A-hall dining room to outside the facility and proceeded to grab/bang their hands on the door stating, you can't get out of here (exit-seeking behaviors).Record review of an initial incident report/investigation on 04/14/2026 at 2:30 PM, showed Staff I, Licensed Practical Nurse (LPN), was informed that Resident 48 had spilled hot tea on themselves during a group activity. Resident 48 removed the lid from their hot beverage and lost their grip, spilling the beverage into their own lap. The hot water used for the resident's beverage was temped at 146 degrees F, after the resident had the spill incident and per the facility's policy the temperature of hot liquids used for beverages were to be at most 150 degrees F. Additionally, Resident 48 had a history of spilling a hot tea/beverage on themselves.Record review of a progress note, summary to provider, documented by Staff I on 04/14/2026 at 2:30 PM, showed that Resident 48 was very confused and disoriented (a state of mental confusion where a resident is unsure on the time, place, identity or situation). Staff I stated the resident had spilled tea on themselves and when assessing the skin at the site where the resident had spilled, .redness noted with some peel skin to right inner thigh .Record review of the facility's kitchen temperature guidelines and daily logs for hot beverages served out to residents from 03/22/2026 through 04/14/2026, showed when preparing hot beverage like tea or coffee, .hold hot beverage until temperature is in range from 120 degrees F to 150 degrees F before delivering . The temperature logs from 03/22/2026 through 04/14/2026 showed that everyday hot beverages were initially temped at 170 degrees F, then delivered at 150 degrees F, with the 04/14/2026 hot beverages being delivered at 1:40 PM that day.During a concurrent observation and interview on 04/14/2026 at 5:01 PM, Resident 48 was making their way down the hallway in their wheelchair. When asked, the resident could not remember spilling hot tea on themselves earlier in the day and kept looking at the double doors that exited the hallway. Resident 48 was confused by questions about the accident but stated no when asked if they had any pain from spilling the hot tea and was redirected by nursing staff as the resident got closer to the hallways exit doors.During an interview on 04/14/2026 at 5:04 PM, Staff I stated the resident was in the dining room for activities when they spilled their hot tea on themselves. Staff I stated that Resident 48 normally dropped things like their drinks and food. Staff I stated they had notified the provider who assessed the resident after the hot tea spilling incident and that it was common for Resident 48 to take the lid off their hot tea beverage.During an interview on 04/14/2026 at 5:29 PM, Staff B, Director of Nursing Services, stated they had just started an investigation into Resident 48's accident involving the spilling of hot tea on themselves and was not aware of the resident having an accidental spill of their hot beverages prior to the incident on 04/14/2026 at 2:30 PM. Staff B stated that Resident 48 would now have to be supervised when drinking their hot tea, that hot beverages from the kitchen should be at a lower temperature than 150 degrees F, and an assisted device cup with a screw top lid.During an interview on 04/14/2026 at 5:40 PM, Staff Q, Activities Director, stated that Resident 48 did have a previous accident where they had spilled their hot tea beverage before, but remembered the resident's tea had been sitting out and that it was at a cooler temperature at that time the resident spilled the beverage. Staff Q stated they conveyed the accidental spill to the nursing staff but were unsure of the date the accident happened, maybe three months ago and did not complete any documentation nor present documentation of it in the resident's record.During an interview on 04/15/2026 at 11:16 AM, Staff J, LPN, stated that within the past couple of months Resident 48 had been more anxious, exit-seeking and just a lot more movement (referring to the residents anxiousness and inability to sit still in one place for too long). Staff J stated they had not completed an evaluation, nor did they know of an assessment regarding Resident 48's risk for spilling their hot beverages or care plan interventions implemented. Additionally, if the resident was at risk of spilling hot beverages, that information would be conveyed to the Resident Care Manager (RCM).During a concurrent interview with facility staff on 04/15/2026 at 11:32 AM, Staff G, RCM, stated they oversaw Resident 48's care. Staff G stated that residents who had tremors, impaired cognition or the inability to understand safe practices regarding handling of hot liquids/drinks would be at an increased risk for accidents/hazards around the spilling of hot beverages. Staff G stated they were not aware of Resident 48 spilling their hot tea before. Staff G stated they did not know of a facility process for identifying/assessing residents that were at an increased risk for the spilling of hot beverages and did not identify or complete an evaluation or a resident-centered care plan regarding Resident 48's accidents/hazards with spilling of hot liquids/beverages. Staff L, Physician's Assistant, stated the facility's resident population was at risk for accidents/hazards with the spilling of hot beverages and Resident 48 would be at an increased risk. Staff L stated they were not aware of the resident having an incident with spilling their hot beverages before. Staff L stated that if a resident had a prior incident of spilling their hot liquids, it would be a safety concern and Staff L would expect care plan intervention to be implemented. Staff L stated they were not aware of the facility hot beverage temperature guidelines process or parameters, or that the daily kitchen temperature logs showed resident hot beverage temperatures of 150 degrees F were being served out. Staff L stated that hot beverage temperatures of 150 degrees F placed residents at an increased risk for scalding and would expect the temperature to be 140 degrees F or lower. Staff F stated that if residents, like Resident 48, with an increased risk for accidents/hazards around spilling hot beverages were identified, assessed and interventions care planned/implemented it would mitigate or prevent accidents/injury from the spilling of hot beverages.During an interview on 04/15/2026 at 12:53 PM, Staff B stated the facility did not have a process for identifying or assessing residents at risk for the spilling of hot beverages. Staff B stated residents that walked around with a hot beverage or self-propelled themselves around in a wheelchair with a hot beverage, residents with a diagnosis that may cause tremors and have an impaired cognition would have an increased risk for accidents/hazards of hot beverages spills. Staff B stated that Resident 48 was not at an increased risk of spilling their hot beverages before the incident on 04/14/2026. During an interview on 04/15/2026 at 12:59 PM, Staff S, Activities Assistant, stated they were familiar with Resident 48. Staff S stated they were in the A-hall dining room on 04/14/2026 when they heard Resident 48 state, Ow, it burns and noted the resident had accidentally spilled hot tea on themselves. Staff S stated the resident normally drank the hot tea beverage before activities in the dining area. Staff S stated that Resident 48 was normally confused and would take off the lid to their hot beverages most times, after a few sips. Additionally, Staff S stated that Resident 48 had been known to take their hot beverage with them into the hallways while self-propelling/shuffling in their wheelchair. During a concurrent observation and interview on 04/15/2026 at 3:16 PM, showed A-hall residents gathering in the dining room for tea and coffee before activities started. Staff R, Activities Assistant, stated they were familiar with Resident 48 and worked with the resident during activities in the A-hall dining room area. Staff R stated they had not been informed of any residents having complications with the spilling of their hot beverages or that needed increased supervision during the afternoon hot tea/coffee time before activities. Staff R stated that residents had spilled their hot coffee/tea before but not on themselves. Staff R stated that Resident 48 was a risk for spilling their hot beverage. Staff R stated they had to take the hot tea beverage from the resident sometimes because the resident would fall asleep with the hot beverage in their hands. Staff R stated that sometimes Resident 48 would be in their wheelchair, take their hot beverage, with the lid already off, and attempt to self-propel in the hallway. Staff R stated it was not safe. Staff R stated it was the residents right to take off the hot beverage lid, and the staff member would remind the resident to be careful.During a follow-up interview on 04/15/2026 at 3:36 PM, Staff I stated that residents with tremors, had dementia with confusion or were cognitively impaired, or had behaviors where the resident could not sit still or moved around constantly, were at an increased risk for spilling beverages. Staff I stated that some residents were at a higher risk for spilling their hot beverages and Resident 48 was one of them. Staff I stated there was no formal process for identifying or assessing residents at high risk for spilling hot liquids/beverages. Staff I stated that measure or intervention for Resident 48 should have been put in place to help prevent or mitigate accidents/hazards for spilling of hot beverages.<Resident 51>Review of the medical record showed they were admitted to the facility on [DATE] with diagnosis including stroke, Alzheimer's disease (a progressive disease that destroys memory and cognitive functioning, thinking, remembering, and reasoning) with other behavioral disturbances, anxiety, depression and generalized muscle weakness. The 02/06/2026 comprehensive assessment showed the resident had a severely impaired cognition and had active diagnosis of a cognitive communication deficit (a condition where cognitive impairments disrupt an individual's ability to communicate effectively, despite intact language and speech abilities).Record review of a Licensed Nurse (LN) progress note dated 05/12/2025 at 10:21 AM, showed that Resident 51, .spilled hot coffee on (Resident 51's) right thigh during today's activity . The LN documented that Resident 51 refused an assessment, but the resident pushed up their pant leg and the LN observed a light pink discoloration.Record review of the resident-centered care plan, last revised 02/23/2026, showed Resident 51 did not have an individualized care plan that identified/assessed the residents risks for hazards or accidents regarding the spilling of hot beverages nor specific interventions or assistive devices that might be utilized to mitigate risk for an avoidable accident/injury from the spilling of hot beverage on themselves.During a concurrent observation and interview on 04/16/2026 at 11:06 AM, showed activities staff finishing tea and coffee time with the residents in the dining room along with Resident 51. Staff T, Medication Assistant Certified/Nursing Assistant, stated they knew all the residents and had been working with Resident 51 for many years. Staff T stated the resident did like to have coffee during activities. Staff T stated Resident 51 was confused at times, with short term memory loss and would have behaviors of expressed frustration when confused or if Resident 51 did not understand what another resident was saying. Staff T stated that due to Resident 51 and other residents with impaired cogitation and behaviors, many of the residents within the C-hall dining area were at a higher risk for spilling their hot beverages. Staff T stated they were not aware of Resident 51 ever spilling their hot beverage on themselves. Staff T stated, we have had accidents with spilling of hot liquids but nothing that has caused injury.During an interview on 04/16/2026 at 11:31 PM, Staff B stated they had not been informed of an incident where Resident 51 had spilled hot coffee on themselves. Staff B stated they had not completed an investigation into the accident. When surveyor inquired on identifying the resident risk/hazards of spilling hot beverages, Staff B stated, I do not think (Resident 51) is a risk if (the resident) only spilled the hot coffee that one time. Staff B stated that no care plan intervention or changes were completed regarding the Resident 51's spilling of hot coffee on themselves.During an interview on 04/16/2026 at 11:45 AM, Staff U, Regional Clinical Resource Nurse Manager, stated they were unaware of Resident 51's accident regarding spilling hot coffee on themselves. Staff U stated that residents should have been identified/assessed on the risk/hazards regarding the spilling of hot beverages and that none of the facility residents had a resident-centered care plan implemented to reduce the risk/hazards towards the spilling of hot beverages.Reference: WAC 388-97-1060(3)(g)

Based on interview and record review the facility failed to obtain registry verification to ensure staff met competency evaluation requirements for 2 of 3 Nursing Assistants (NA, Staff M and N) reviewed for staff qualifications. This failure placed residents at risk for abuse/neglect and unmet care needs. Findings included.Review of the policy titled, Abuse Prohibition, revised 11/14/2025, showed the facility would screen potential employees for a history of abuse, neglect, and mistreatment of residents by obtaining information from past employees and checking with the appropriate licensing boards and registries. Review of the Washington State Board of Nursing guidance titled, OBRA [(Omnibus Budget Reconciliation Act) a database that includes the names of individuals who met the federal requirements to provide caregiving to residents in skilled nursing facilities or nursing homes in Washington State] Registry, undated, showed a NA must be active on the OBRA Registry in order to work in skilled nursing facilities or nursing homes. The OBRA Registry also informs skilled nursing facilities of people that are ineligible to work in a skilled nursing facility or nursing home due to findings of abuse, neglect or misappropriation of property. Review of Staff M, NA, personnel record showed Staff M was hired on 12/10/2025, and the first day of work was 01/11/2026. The personnel record showed no documentation for OBRA registry verification. Review of Staff N, NA, personnel record showed Staff N was hired on 10/29/2025, and the first day of work was 12/14/2025. The personnel record showed no documentation for OBRA registry verification. During an interview on 04/15/2026 at 2:09 PM, Staff D, Human Resources, stated they were required to complete OBRA verification prior to any NA being hired. Staff D stated they did not follow the process for OBRA verifications and had not completed the OBRA's for Staff M and Staff N. During an interview on 04/16/2026 at 2:42 PM, Staff A, Administrator, stated OBRA's were to be completed to follow regulatory compliance and the facility abuse prohibition policy. Staff A stated OBRA's were completed to ensure NAs were verified to exclude anyone with past harm and that could potentially place residents at risk of abuse/neglect. Staff A stated the process of OBRA verification was not followed. Reference WAC: 388-97-1660(3)(c)

Based on interview and record review the facility failed to ensure 1 of 5 residents (Resident 16) had documentation in their record to indicate the resident or their representative was provided education on the influenza vaccine reviewed for vaccinations. This failure placed residents and their representatives at risk for not having the knowledge to make an informed decision on whether to receive an influenza vaccination or to decline it. Findings included. Resident 16Review of the resident's medical record showed they were admitted with diagnoses which included dementia (a decline in mental ability), depression and hypertension. Review of the comprehensive assessment dated [DATE], showed the resident was severely cognitively impaired and required substantial assistance for daily activities such as dressing, personal hygiene and using the bathroom. The resident was independent with transfers and mobility.Review of Resident 16'srecord showed no documentation regarding the influenza vaccine they received on 10/22/2025.During an interview on 04/16/2026 at 2:49 PM, Staff C, Infection Preventionist/Licensed Practical Nurse, stated they were unable to find paperwork in the resident's record to show the resident's representative had been given education to include risks and benefits for the influenza vaccine or signed a consent to administer the vaccine to the resident.Reference: WAC 388-97-1340(1)(2)(3)

Based on interview and record review, the facility failed to ensure orders given by a urologist [a doctor who specializes in the urinary system (the body's drainage system for filtering waste and excess fluid to produce and expel urine) and male reproductive system] were completed and reviewed, in a manner that met professional standards of practice, for 1 of 3 residents (Resident 1) reviewed for change in condition related to the urinary system. Resident 1 experienced harm when they were hospitalized for sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection causing widespread inflammation and injury to organs) related to an untreated urinary tract infection [(UTI) an infection in any part of the urinary system--the kidneys, ureters, bladder and urethra].Findings included .Review of Lippincott Manual of Nursing Practice, 11th edition, showed a cystoscopy [procedure where the physician inserts a thin tube with a camera into the urethra (tube that carries urine out of the body) and bladder] was not recommended for patients with a known UTI. Nursing considerations for cystoscopy aftercare included monitoring for burning with urination, frequency (frequent sensation to urinate) due to trauma to the lining of the urethra and signs of infection in the bladder.Review of the facility policy, Physician/Advanced Practice Provider (APP) Notification, revised on [DATE], showed the nurse must promptly notify the provider of laboratory or diagnostic test results that fall outside of clinical reference ranges and will compare them with the previous results.Resident 1Review of the medical record showed Resident 1 admitted to the facility on [DATE] with diagnoses of diabetes (a disease that impacts how the body process sugar), obstructive uropathy (a condition where a blockage prevents urine from flowing out of the body, causing it to back up and potentially damage the kidneys), and dementia (a group of conditions that cause a decline in cognitive abilities, such as memory, thinking, reasoning, and problem-solving). Review of the comprehensive assessment, dated [DATE], showed Resident 1 had severe cognitive impairment, was frequently incontinent of urine and bowel, and required the assistance of one person for personal hygiene, dressing, toileting, transfers, and incontinent care.Review of the medical record showed a Situation, Background, Assessment, and Recommendation [(SBAR) a tool used to communicate a change in condition], dated [DATE] at 6:53 PM, documenting Resident 1 experiencing painful urination and blood in urine. The SBAR showed new orders from the medical provider to obtain a urinalysis (UA) with culture and sensitivity [(C & S) a laboratory test to show the specific bacteria present and which antibiotics work to treat it], Comprehensive Metabolic Panel [(CMP) laboratory blood test to show electrolyte levels and kidney function], and Complete Blood Count [(CBC) a laboratory blood test to show the levels of white and red blood cells in the body].Review of the medical record showed a urine sample for Resident 1 was obtained on [DATE] at 7:50 PM, and the UA laboratory test results were reported to the facility by fax on [DATE] at 10:01 PM.Review of the nursing Progress Note (PN), dated [DATE] at 5:20 PM, showed Resident 1 was sent to the local hospital for evaluation and treatment for the continued hematuria (blood in the urine) per the family's request.Review of the hospital emergency room documents, dated [DATE] at 12:37 AM, showed Resident 1's UA did not show indications of infection. Resident 1 had their bladder irrigated (a process of inserting a catheter through urethra and into the bladder and flushing with sterile solution), removing multiple blood clots. The urinary catheter was left in place to monitor for continued bleeding, and a follow-up appointment was scheduled with the urologist for [DATE].Review of the urologist visit note, dated [DATE] at 10:52 AM, showed Resident 1 had no further hematuria, the catheter was removed, cystoscopy was scheduled for [DATE], and a UA was to be completed prior to the procedure.Review of Resident 1's Medication Administration Record (MAR) for [DATE], showed an order, dated [DATE], to obtain a UA with C & S and the results to be faxed to the urologist's office. Further review of the MAR showed no documentation indicating the UA was completed.Review of the urologist visit note, dated [DATE] at 1:09 PM, showed Resident 1 had a cystoscopy completed with no worrisome findings, and a UA was needed as Resident 1 was unable to provide a urine sample prior to leaving the office.Review of Resident 1's MARs for [DATE], showed an order, dated [DATE], to obtain a UA.Review of the medical record showed a urine sample was obtained from Resident 1 on [DATE] at 2:08 PM. The UA laboratory results were reviewed by the facility's medical provider on [DATE] with the notation no symptoms (sx). Await C & S.Review of the nursing PN, dated [DATE] at 1:24 PM, showed Resident 1 had increased behaviors this shift, hitting, kicking, punching staff. Attempts to bite staff.Review of the medical provider note, dated [DATE], showed Resident 1 was evaluated for follow-up regarding behaviors, functional decline, cognition decline, nutrition, blood sugar management, falls, and antithrombotic therapy (medications used to slow the formation of blood clots). The provider note showed no recent laboratory values reviewed and no mention of the UA with C & S obtained on [DATE] (seven days prior).Review of the nursing PN, dated [DATE] at 9:27 PM, showed Resident 1 was unable to be redirected after displaying verbally and physically aggressive behaviors toward staff and other residents.Review of the nursing PN, dated [DATE] at 12:32 PM, showed the Interdisciplinary Team (IDT) reviewed Resident 1's medication management for behaviors. The PN stated Resident 1 has had an increase in physical and verbal aggression. (Resident 1) needs an extensive med/chart review. The medical record did not reference the pending UA with C & S obtained on [DATE] (10 days prior).Review of the medical provider note, dated [DATE], showed Resident 1 was evaluated for asymptomatic (no symptoms) bacteriuria (bacteria in the urine) as a follow-up for the UA with C & S obtained on [DATE] (14 days prior). The provider note showed the UA and culture were positive for bacteria and other infection indicating markers, but due to no documented UTI symptoms (discomfort with urinating or frequency) or change in behavior, the plan was to not treat Resident 1 with antibiotics (medications used to treat infections by killing bacteria).Review of the provider PN, dated [DATE], showed a communication exchange between the medical provider and facility Licensed Nurses (LNs), from 3:17 PM to 3:58 PM, regarding a change in condition for Resident 1. The PN showed an LN reported Resident 1 had been lethargic and had back pain, inquired about the UA obtained on [DATE], and asked the provider if they had the C & S results because (the facility) can't find the culture results.Further review of the above PN showed the communication exchange included the medical provider stating Resident 1's C & S showed a bacteria that was Multi-Drug Resistant [(MDR) bacteria that have become resistant to certain antibiotics] and would require intravenous [(IV) a method of administering fluids or medicines directly into a person's bloodstream through a needle or tube inserted into a vein] antibiotics with close monitoring-which would be done at the hospital. The communication exchange showed the LN responded Perfect!! Push fluids, no treatment.Review of the nursing PN, dated [DATE] at 6:10 PM, showed Resident 1 was transferred to the local hospital for evaluation and treatment due to altered mental status (being slightly confused, sleepy or completely disoriented), low blood sugar and complaints of chest pain.Review of the hospital History and Physical (H & P) document, dated [DATE] at 12:03 AM, showed Resident 1 was admitted to the hospital for septic shock (a life-threatening condition that occurs when an infection spreads throughout the body, causing a severe drop in blood pressure and organ failure) from urosepsis (a life-threatening condition where a UTI spreads from the urinary system to the bloodstream, causing the body's response to harm its own organs).During an interview, on [DATE] at 4:26 PM, a Resident Representative (RR) stated they did not feel the facility was responding timely or thoroughly to Resident 1's change in condition. The RR stated they had to request Resident 1 to be evaluated at the local hospital on [DATE] for the hematuria and on [DATE] for Resident 1's altered mental status. The RR stated, I really feel (Resident 1) would have died if I had not come in and demanded they send them to the hospital.During an interview, on [DATE] at 2:20PM, Staff C, Physician's Assistant Certified (PA-C) stated Resident 1's facility medical record did not show the C & S results for the UA obtained on [DATE], and when they were contacted on [DATE] (14 days after collection) regarding the results, Staff C had to extensively look for the lab report in the hospital laboratory database. Staff C stated C & S reports were completed and ready for review after a few days, and the LNs notified the medical provider once the results were received. Staff C confirmed Resident 1's C & S results should have been received and reviewed sooner than 14 days after collection.During an interview, on [DATE] at 3:26 PM, Staff D, Resident Care Manager (RCM), stated they received the telephone order for Resident 1's UA with C & S from the urologist on [DATE]. Staff D stated the purpose of the test was to rule out infection due to Resident 1's recent bladder irrigation, catheter placement and cystoscopy (procedures that increased the risk of introducing bacteria into the bladder). Staff D stated the facility process was for the floor LNs to follow up on lab results-ensuring the results were received, reviewed, and documented.During an interview, on [DATE] at 4:00 PM, Staff E, Licensed Practical Nurse (LPN), stated they were aware a UA had been collected for Resident 1 but did not recall receiving the C & S results. Staff E stated they assumed someone else had received and addressed the results.During an interview, on [DATE] at 4:27 PM, Staff B, Director of Nursing Services (DNS), stated they were unaware Resident 1 had a pending UA with C & S from [DATE] until a RR contacted them, on [DATE], asking about the treatment plan. Staff B stated the RR was contacted by the urology office and was informed that Resident 1 had a UTI. Staff B stated they discussed the results with Staff C, and no antibiotic treatment was ordered due to Resident 1 having no symptoms or change in behavior. Staff B stated they were unsure why it took 14 days for the C & S results to be reviewed.Reference: WAC 388-97-1060(3)(c)

Based on interview and record review, the facility failed to ensure the Resident Representative (RR) and physician were notified of multiple medication refusals that resulted in a change in condition for 1 of 2 residents (Resident 1) reviewed for change in condition. This deficient practice placed residents at risk of a potential delay in medical treatment.Findings included.<Resident 1>Review of the medical record showed Resident 1 admitted to the facility on [DATE] with diagnoses of dementia (a decline in mental ability, impacting memory, thinking, and social abilities enough to interfere with daily life) with agitation (feeling restless, uneasy, or disturbed), heart failure (condition where the heart muscle is weakened or stiffened, making it less effective at pumping blood), and diabetes mellitus (a condition where your body has trouble regulating blood sugar levels). Review of the comprehensive assessment dated [DATE] showed Resident 1 had severely impaired cognition and required the assistance of one person for dressing, personal hygiene, toileting, and bathing.Review of the physician's orders for June 2025 showed Resident 1 was prescribed the following medications to treat diabetes mellitus:Glipizide (a medication used to treat high blood sugar levels) 5 milligrams (mg)--take by mouth in the morning.Humalog (fast-acting-within 15-60 minutes) Insulin (man-made form of the hormone needed to manage blood sugar levels) 100 units/milliliter (mL)--inject subcutaneously [SQ (under the skin)] per sliding scale based on blood sugar (BS) value with meals and at bedtime. If BS 150-200=inject zero units; 201-250=inject one unit; 251-300=inject two units; 301-350=inject three units; 351-400=inject four units; 401-500=inject five units and call provider.Lantus (long-acting-works over 24-hours) Insulin 100 units/mL-Inject 30 units SQ in the evening.Review of the Medication Administration Record (MAR) for June 2025 showed Resident 1 had the following documented refusals:Glipizide was refused two out of 25 opportunities.Humalog Insulin was refused two out of 24 opportunities with breakfast, two out of 23 opportunities with lunch, 18 out of 24 opportunities with dinner, and 22 out of 24 opportunities at bedtime.Lantus Insulin was refused 20 out of 25 opportunities.Review of the nursing progress notes from 06/05/2025 to 06/30/2025 showed no documented notifications to Resident 1's Representative or the medical provider regarding their medication refusals.Review of the medical record showed Resident 1 was admitted to the local hospital on [DATE] for hyperglycemia (a condition where there's too much sugar in the blood) and altered mental status.During an interview, on 07/09/2025 at 10:10 AM, a Resident Representative (RR) stated they were unaware of the number of medication refusals by Resident 1 and felt this was the cause of Resident 1's change in condition and hospitalization.During an interview, on 07/09/2025 at 2:40 PM, Staff C, Advanced Registered Nurse Practitioner (ARNP), stated they expected facility nursing staff to notify a medical provider (either in-person while they were at the facility or by phone) within 24 hours of a resident refusing vital medications such as insulin, antibiotics (medicines that fight bacterial infections), blood thinners (medications that prevent blood clots from forming), or antiseizure medications [used to prevent or stop seizures (a sudden, temporary surge of abnormal electrical activity in the brain that can cause changes in behavior, sensations, muscle control, and awareness)]. Staff C stated patterns of overall medication refusals or missed doses should be brought to the medical provider's attention regardless of the type of medication within a week's time. Staff C stated they were not aware of the number of medication refusals Resident 1 had since admission.During an interview, on 07/16/2025 at 2:15 PM, Staff D, Licensed Practical Nurse (LPN), stated they were aware Resident 1 refused their medications frequently, especially in the evening. Staff D stated their practice was to notify nursing management and the medical provider when residents refuse their medications on more than one occasion. Staff D stated they were usually successful with medication administration for Resident 1 and did not recall a time when notification was warranted.During an interview, on 07/16/2025 at 2:35 PM, Staff E, LPN, stated Resident 1 was very difficult to administer medications to, and they were usually not successful. Staff E stated their practice was to verbally notify the Director of Nursing Services (DNS), medical provider, and/or the RR of medication refusals when they saw them in person. Staff E stated they try (to remember) to document (the notification) in the medical record.During an interview, on 07/16/2025 at 3:45 PM, Staff B, DNS, stated the expectation was for the nursing staff to notify the nursing managers, medical provider, and the RR when a resident refused to take medication, especially medications that can had negative impacts if missed. Staff B stated notifications for Resident 1's medication refusals should have been made and were not.Reference: WAC 388-97-0320(1)(c)

Based on observation, interview, and record review the facility failed to 1) thoroughly evaluate and monitor the significant changes in a resident's respiratory condition and increased sedation from medications given for 1 of 3 residents (Resident 1) reviewed for change of condition; 2) accurately assess and notify the provider timely of wound changes for prompt medical evaluation for 1 of 3 residents (Resident 11) reviewed for skin conditions; 3) follow through with specialized services for 2 of 2 residents (Resident 34 and 57) reviewed for quality of care. This failed practice placed residents at risk of not receiving the care and services they needed to prevent a decline in their health and/or mobility. Additionally, Resident 1 experienced actual harm due to a delay in obtaining prompt medical treatment that resulted in hospital intervention and treatment for over sedation and aspiration pneumonia (a lung infection that occurs when stomach contents or mouth secretions are inhaled into the lungs). Resident 11 experienced harm when there was a delay in notification to the provider that a wound had worsened and caused severe pain. Findings included . <Resident 1> The medical record showed the resident was admitted on [DATE] with diagnoses including a left thigh bone fracture with surgical repair, Rheumatoid arthritis (a chronic autoimmune disease that attacks healthy cells and tissues located in the joints of both sides of the body), heart disease, chronic oxygen use and chronic pain. The 03/13/2025 admission assessment showed Resident 1 was alert and oriented and made their needs known. During an interview and concurrent observation on 05/05/2025 at 2:45 PM, Resident 1 stated they were in pain and hurt all over and felt they could not breathe and felt that they were not receiving their oxygen. The resident was lying in bed with oxygen cannula (a medical device that delivers through two prongs that fit into the nostrils) connected to the oxygen concentrator. Resident 1's face showed their skin was gray, ashen (white) in color, pale and flakey. The residents' lips were dry with gummy/sticky substances at the corners of their mouth. Resident 1 was slow to respond to questions and closed their eyes and opened them between answering questions and spoke in a low soft voice. During an interview on 05/05/2025 at 2:50 PM, Staff I, Licensed Practical Nurse (LPN), stated that they informed staff of Resident 1's concerns with pain and shortness of breath. During an observation on 05/05/2025 at 3:00 PM, Staff C was in the resident's room and stated the resident's blood pressure and oxygen level were good at 93% (normal levels are 92% and above). During an interview on 05/05/2025 at 3:05 PM, Staff U, Advanced Registered Nurse Practitioner (ARNP), stated they thought the resident was experiencing some symptoms. Staff U stated Resident 1 might be having a stroke, had been responding slowly to their questions, and drowsy. Resident 1's oxygen level was at 94%. Review of the 05/05/2025 progress notes, documented at 3:20 PM, showed Staff U wrote an order for an additional Oxycodone (narcotic pain medication) dose for Resident 1's increased pain. Review of a progress note on 05/05/2025 at 3:38 PM showed new orders from Staff U for laboratory orders, a chest x-ray and an electrocardiogram (EKG-process of recording of heart beating). Review of a 05/05/2025 at 9:52 PM progress note showed no respiratory lung assessment documented and oxygen levels were at 94%. During an observation and concurrent interview on 05/06/2025 at 8:17 AM, Resident 1 was in their bed with the head of the bed at a 35-degree angle in which the resident had to partially lean forward to reach their over bed table to pick up items such as food on their tray then they had to lay their head back on the bed to swallow their food. Resident 1 was confused as to where they were and the day and season of the year. The resident had their oxygen nasal cannula connected to the oxygen concentrator. Resident 1's skin was pale white to their face with dry lips and oral mucus membranes. The resident complained of pain, shortness of breath and being weak. When the Surveyor immediately notified Staff EE, LPN, they stated it was their second day on that particular assignment at the facility and they were unfamiliar with resident conditions and would get information from the computer. Review of the 05/06/2025 at 8:41 AM progress note showed Resident 1 was in no distress and their oxygen level was 92%. Review of the 05/06/2025 at 1:00 PM progress note showed Resident 1 was observed to be lethargic (drowsy). Resident 1's blood pressure was 88/46 (normal blood pressure 120/80), oxygen level 61% (normal is 92% and above) oxygen. Resident 1 was sent to the hospital. The progress notes also stated the chest x-ray, EKG and laboratory request were not completed on 05/05/2025 from Staff U. Review of the 05/06/2025 Hospital emergency room (ER) physician's report showed the resident was confused and had been weaker than usual. According to the Emergency Medical Services (EMS) ER report the resident was unresponsive when they arrived at the facility. The ER physician's review of Resident 1's medications showed high risk medications to include Seroquel (an anti-psychotic medication), Gabapentin (an anti-convulsant medication used for pain) and Oxycodone (opioid [class of drugs used to reduce pain] narcotic pain reliever). The 05/06/2025 report showed Resident 1 experienced an opioid overdose due to the medication given together in a close amount of time and the accumulation of side effects produced by the resident's medications. Resident 1 was given Narcan (medication that blocks opioid receptors in the brain to reverse the overdose). Additionally, the 05/06/2025 hospital ER report showed Resident 1 had developed a respiratory sepsis (infection) which was diagnosed as Aspiration Pneumonia. During an interview on 05/08/2025 at 9:58 AM, Staff T, Registered Nurse (RN), stated they realized the nursing staff did not immediately act upon changes in Resident 1's condition. Additionally, the facility failed to monitor side effects of the multiple medications given to Resident 1 and would recommend changes. <Resident 11> Review of Resident 11's medical record showed they admitted on [DATE] with diagnoses to include end stage renal disease (your kidneys have failed and can no longer effectively filter waste and excess fluid from your blood) and osteomyelitis (a bone infection). The 02/12/2025 comprehensive assessment showed the residents 'cognition was moderately impaired and required substantial to maximum staff assistance with bed mobility and transfers. The assessment also showed Resident 11 was at risk for developing pressure injuries ( PIs- areas of skin and tissue damage caused by prolonged pressure, friciton, or sliding). Record review of a progress note titled Situation, Background, Assessment, and Recommendation (SBAR- a form used to communicate changes to the provider) dated 03/29/2025 showed Resident 11 acquired a PI to their coccyx (tailbone) measuring 1.0 centimeter (cm, a unit of measure) by 1.0 cm. The SBAR further showed the provider responded with new intervention orders. The March 2025 provider orders showed no new orders since 02/10/2025 had been initiated. Record review of the outside wound care consultant 04/14/2025 wound assessment showed the left coccyx wound was closed but remained high risk with new orders to use house emollient (softens and smooths dry, rough, or flaky skin) cream during perineal (the area between the genitals and the rectum) care and as needed. Record review of the April 2025 orders showed no new or updated orders were initiated for the coccyx wound on 04/14/2025. Record review of a communication form (a form used by nursing staff to communicate changes to the interdisciplinary team) dated 05/04/2025 showed Staff L, Licensed Practical Nurse, (LPN), stated Resident 11's coccyx wound was worsening and presented with eschar (a thick, dead tissue that forms over a wound, espicially after an injury). Staff L requested Resident 11 be seen by the outside wound consultant when they were in the facility for wound rounds on 05/05/2025. Further review of the record showed no evaluation or assessment of the worsening of the coccyx wound and no notification to the provider. During an interview on 05/07/2025 at 1:57 PM, Staff L stated the wound on Resident 11's coccyx was an unstageable PI related to the eschar covering the wound bed and they were unable to see what the wound looked like underneath the eschar. Staff L stated they were not sure why the communication form did not get addressed. During an interview on 05/07/2025 at 3:06 PM, Staff D, Resident Case Manager (RCM), stated they were unaware the area to Resident 11 's coccyx was opened, I thought it was all healed. An observation and concurrent interview on 05/07/2025 at 3:38 PM, with Staff C, RCM and Staff D, showed Staff D removed the foam dressing from Resident 11 's coccyx. The coccyx had a wound with eschar, full thickness skin loss, and surrounding the wound bed was red and moist tissue. Staff D and Staff C both stated they were not sure what stage the wound was but if they had to say they would stage it as an unstageable PI related to not being able to see the wound bed. Measurements of the wound were measured as: area 7.73 cm, length 3.28.cm, width 2.65 cm. An observation and concurrent interview on 05/07/2025 at 3:45 PM, showed Resident 11 lying in bed on their back. Resident 11 stated it is so painful to sit and lay on my bottom. The resident stated the medication helped but the wound still hurt them during the changing of their wound dressing. Record review of the May 2025 treatment medication record (TAR) showed Staff C had documented they completed the wound treatment for Resident 11's coccyx wound on 05/05/2025. During an interview on 05/07/2025 at 4:28PM, Staff C stated they signed that they completed the wound care on Resident 11 on 05/05/2025. Staff C stated they did not actually see the wound or do the wound care. Staff C stated they assumed the wound care consultant would be doing the wound care as Mondays were the days they came into the facility. Staff C looked at the outside wound consultant's notes from 05/05/2025 and stated, it does not look like she addressed the coccyx wound. Record review of the outside wound consultant 05/05/2025 wound assessment notes for Resident 11 showed no assessment of the coccyx wound. During an interview on 05/08/2025 at 8:09 AM, Staff L stated they could not remember exactly when the wound started changing. Staff L stated the process for an existing wound that worsened would be to notify the wound consultant and place a note in the binder for the doctor to review. Staff L stated they had asked the RCMs what to do and they stated to put it on the communications form and that they had done that on maybe Friday, Saturday or Sunday they would have to look they could not remember. Staff C stated they only did a visual on the wound and did not do an assessment or obtain measurements. Staff C stated they should have done a better assessment, measured the wound and called the provider for further orders on 05/04/2025. During an interview on 05/08/2025 at 8:24 AM, Staff A, Administrator, stated the process for communication forms from the nursing staff was they addressed all communication forms each morning in the morning meeting. Staff C stated Staff L's communication of Resident 11's coccyx wound worsening should have been addressed in the morning meeting on 05/05/2025. Staff A stated the expectation for Staff L was to do a complete assessment of Resident 11's coccyx wound including measurements and to notify the provider. Staff A stated the RCMs were responsible for doing an immediate follow-up on 05/05/2025 and the process was not followed. An observation and concurrent interview on 05/08/2025 at 8:39 AM showed Resident 11 lying in their bed on their back moaning oh it hurts, oh it hurts. Resident 11 stated their pain to their bottom was so painful and they just could not stand it. During an interview on 05/08/2025 at 8:58 AM, Staff V, Nursing Assistant (NA), stated they had seen the wound on Resident 11's coccyx on 05/05/2025 and it had looked the same as last week, it had looked the same for about three weeks. Staff V stated their process was to notify the nurse for any skin issues or changes and with Resident 11 they must notify the nurse every time the dressing comes off which is often, so the nurses were aware of the changes to the wound. During an interview on 05/08/2025 at 3:13 PM, Staff W, NA, stated they had seen the wound on Resident 11's coccyx the evening before (05/07/2025) and it had black areas and was open. Staff W stated they had also seen it the Friday before and the wound had been like that for about three weeks. Staff W stated the nurses were aware of the change in the wound because they had to go and get the nurse to place a new dressing when it came off. Staff W stated their process for any wound that was new or had changes was to immediately tell the nurse on the floor and all the nurses were aware of how Resident 11's wound looked. Staff W stated Resident 11 has had an increase in pain and they have had to reposition Resident 11 a lot more recently because it helped with the pain they had on their bottom. During an interview on 05/08/2025 at 3:18 PM, Staff Y, LPN, stated they had seen the wound to Resident 11's coccyx on Tuesday (05/06/2025) and they were unable to see the wound bed because there was a white, soft scab covering it. Staff Y stated they did not know how to stage a PI and they did not notify the provider because it was just a scab. During an interview on 05/08/2025 at 3:22 PM, Staff D stated they were responsible for entering new orders from the 04/14/2025 outside wound consultant visit. Staff D stated the order was missed. Staff D stated they became aware of Resident 11's coccyx wound on 05/07/2025 (3 days after the communication form was written). Staff D stated they and Staff C were responsible for reviewing communication forms from nursing staff during morning meetings. Staff C stated they missed the communication about Resident 11's coccyx wound on 05/05/2025 because they had worked the night before and arrived late. Staff C stated Staff D was on the floor that morning, and since the RCMs were not at the meeting, the communication for Resident 11's wound just got missed. Record review on 05/08/2025 of a Skin and wound evaluation opened by Staff C on 05/07/2025 showed the assessment was blank (four days after communication from Staff L on the worsening of Resident 11's coccyx wound.) During an interview on 05/08/2025 at 3:51 PM with Staff D and Staff C, Staff C stated they did not know how to assess the wound on Resident 11's coccyx. Staff C stated they waited for the outside wound consultant to call and complete their tele health (using technology like phone or video calls to deliver healthcare services remotely) assessment of the wound before they finished their assessment or changed any orders. Both Staff C and Staff D stated they were unaware identifying the stage of a wound was within their scope of practice as a nurse and should get some training. During an interview on 05/09/2025 at 9:23 AM, Staff U, Advanced Registered Nurse Practitioner, stated the process for a significant change in wound was to call them or the on-call provider for further orders immediately. Staff U stated the four-day delay in notifying a provider or completing an assessment was a delay in treatment because a wound could change quickly. Staff U stated a complete assessment of the wound should have been done immediately, and the correct process was not followed for Resident 11. During an interview on 05/09/2025 at 11:18 AM, Staff A stated Staff L should have completed a change in condition and notified the provider for further orders. Staff A stated the inter disciplinary team was responsible for reviewing all communications from the prior day/eve in the morning meetings and they did not do that. Staff A stated they expect immediate action on any significant change with wounds. Staff A stated there was a delay in treatment for Resident 11 from 05/04/2025 to 05/09/2025 and the overall process was not followed correctly for Resident 11. <Resident 34> Review of the resident's medical records showed they admitted with diagnoses to include Alzheimer's disease (a brain disorder that slowly destroys a person's memory and thinking skills) and malnutrition (an imbalance between the nutrients your body needs to function and the nutrients it gets). The 03/10/2025 comprehensive assessment showed Resident 34's cognition was severely impaired and had not experienced behaviors during the assessment period. The assessment showed Resident 34 was independent upon staff for their activities of daily living (ADLs, basic skills needed daily to maintain your health and wellbeing). An observation on 05/05/2025 at 12:19 PM, showed Resident 34 in the dining room, sitting in their wheelchair (w/c), leaning down towards their left side. Resident 34 was being assisted with their meal and the NA attempted to reposition the resident to an upright position but then went right back to leaning to their left side. Review of a 10/25/2024 physical therapy (PT) note showed Resident 34 was seen for a left sided lean. The note showed Resident 34 would have a wedge placed to the left side of the back rest of their w/c to assist with positioning. An observation and concurrent interview on 05/06/2025 at 10:08 AM, showed Resident 34 was observed sitting in their wheelchair (w/c), during an activity, leaning over to their left side with their head lying on a white bed pillow. The white pillow was resting on the arm rest of the w/c, and Resident 34's shoulder and left arm were resting in the seat, alongside them. The white pillow had a wet area the size of a softball from where Resident 34 had been lying and had drooled. Staff I, LPN, stated Resident 34 at times would sit straight up and then just gradually start tilting favoring their left side. Staff I stated staff had to assist and reposition the resident to sit up straight when they would lean over to their left side. Staff I stated they used the white pillow for positioning the resident. Staff I did not attempt to reposition Resident 34 to an upright position. There was no wedge observed in the w/c. Staff I stated they had not seen a wedge for Resident 34. An observation on 05/07/2025 at 10:11 AM, showed Resident 34 sitting outside on the patio, in their w/c, with their head resting on a white bed pillow, to their left side. Resident 34 had headphones on listening to music. Staff were not observed attempting to reposition Resident 34 to an upright position. There was no wedge observed in the w/c. During an interview on 05/08/2025 at 11:57 AM, Staff P, Physical Therapy Assistant/Rehab Director, stated Resident 34 was no longer using the wedge in the w/c due to the resident was throwing out the wedge and refusing to use it all the time. Staff P stated they could not find a care plan for the wedge or for the repositioning of the resident, when they were observed leaning to their left side. Staff P stated they did not know where the staff would have documented that the resident was throwing out or refusing the wedge. During an interview on 05/08/2025 at 2:50 PM, Staff D, Resident Care Manager (RCM), stated Staff P would communicate specialized equipment changes to them and then they would update the residents' care plan so staff would know what care to provide. Staff D stated conversations with the PT are falling through the cracks and the wedge was missed. I did not know anything about the wedge. Staff D stated they were not aware of Resident 34's wedge for their w/c so that did not get care planned, therefore staff were unaware Resident 34 was to use it and were unable to document on it. Staff D stated Resident 34 was now leaning more so needed a new PT evaluation. <Resident 57> Review of the resident's medical records showed they admitted with diagnoses to include dementia, liver transplantation (to remove a diseased or injured liver and replace it with a healthy liver from another person), and chronic hepatitis (inflammation of the liver). The 03/26/2025 comprehensive assessment showed Resident 57's cognition was severely impaired and was dependent upon staff for ADLs. Review of Resident 57's 12/23/2024 hospital discharge orders showed Instructions for Follow-up Providers .Patient should be referred to a nearby gastroenterologist (a medical doctor who specializes in conditions affecting the digestive system)/hepatologist (a medical doctor who specializes in conditions affecting the liver and the bile ducts) to manage the liver transplant and immunosuppression (drugs that prevent your immune system from attacking healthy cells and tissues by mistake) therapy. Review of Resident 57's 05/2025 physician orders showed orders on 12/31/2024 for a referral to Gastroenterology for Resident 57's diagnoses of long-term use of immunosuppressants, liver transplantation, hepatitis, and liver cancer (a disease resulting from uncontrolled growth and division of abnormal cells). This order was discontinued and reordered on the evening of 05/05/2025. Review of the provider's note dated 01/19/2025, showed for staff to continue with the current therapies for Resident 57's liver transplantation and routine follow-up with hepatologist. During an interview on 05/08/2025 at 2:43 PM, Staff D stated they did not have a reason for why the referrals were not followed through with other than I have been busy, and it was not in my vision .I just need to find time to work on them. During an interview on 05/08/2025 at 3:55 PM, Staff A, Administrator, stated they expected referrals to be followed through on within a week, but my expectations were more like three to four days. During an interview on 05/09/2025 at 8:42 AM, Staff B, Director of Nursing Services, stated they would have expected referrals to be processed and followed up on immediately and should not have taken this long. Reference WAC 388-97-1060(1) 44922 48368

Based on interview and record review, the facility failed to ensure the supervised fall risk residents received adequate supervision of one staff assistance in the dining room, and proper use of fall prevention devices for 1 of 5 residents (Resident 218) reviewed for falls. Resident 218 experienced harm when they fell forward out of their wheelchair when staff forgot to place the drop-down seat into the reclining position after transferring the resident to their wheelchair and sustained an injury to their left forehead that required hospital intervention for control of bleeding and stitches. Findings included . <Resident 218> Review of the medical record showed Resident 218 was admitted to the facility on [DATE] with diagnoses to include dementia (the loss of thinking, remembering, and reasoning to the extent that interferes with daily living), epilepsy (a brain condition that causes recurring seizures), lack of coordination, and repeated falls. The comprehensive assessment dated [DATE] showed Resident 218's cognition was severely impaired, dependent on staff for activities of daily living (ADL, fundamental tasks individuals perform daily for personal care) and was on hospice (a program that gives special care to people who are near the end of life). Review of the care plan dated 01/19/2025 showed Resident 218 was at risk for falls related to their cognitive loss, lack of safety awareness, and history of seizures with fall. Further review showed interventions which included ensuring appropriate footwear was in place, engage the drop seat (a reclining seat that prevents a resident from going forward) wheelchair for positioning, and monitoring Resident 218's whereabouts frequently, and assist them away from cluttered areas. Review of the facilities incident reporting log dated 04/13/2025 showed Resident 218 had a fall in the dining room that resulted in an injury. During an interview on 05/09/2025 at 11:29 AM, Staff L, Registered Nurse (RN), stated they were alerted to a resident who fell and needed assistance immediately. Upon entering the dining room, Staff L stated they found Resident 218 lying on their left side and was bleeding from their forehead. Staff L, RN stated that it took four staff members to transfer Resident 218 back into their wheelchair, wheel them to their room, and put the resident in bed. Staff L stated they had performed first aid to a laceration on Resident 218's forehead and called the hospice nurse. Staff L stated shortly after the hospice nurse arrived, they spoke to the physician about the resident's laceration and the continued bleeding. The hospice physician ordered Resident 218 to be sent to the emergency room for a higher level of evaluation and treatment. Review of the local hospital records dated 04/13/2025 at 9:32 AM showed that Resident 218's encounter visit was due to an unwitnessed fall when the resident sustained a three-centimeter (a unit of measure) laceration to the left forehead. Further review showed the resident responded to voice, had no pain and back to baseline for discharge to the facility. During an interview on 05/09/2025 at 11:59 AM Staff N, Nursing Assistant (NA), stated the post-fall procedure was that staff were to report the incident to a nurse and filled out a statement form by the end of shift. Staff N stated everyone on the floor was to fill out a witness form, so the facility knew where and what everyone was doing during the incident. During an interview on 05/12/2025 at 2:05 PM Staff O, NA, stated they were present during the incident with Resident 218. Staff O stated they had provided care to the resident, transferred the resident to their drop seat wheelchair, and then sat the resident in the dining room for breakfast. Staff O stated that they had forgotten to place the drop-down seat into the reclining position after transferring Resident 218 to their wheelchair and they had fallen forward a fall. Staff O stated the resident was sent to the emergency room for laceration to the forehead and came back to the facility with dissolvable stitches. During an interview on 05/09/2025 at 12:32 PM, Staff A, Administrator, acknowledged the investigation had not been completed. Reference: WAC 388-97-1060 (3)(g)

Based on observation, interview and record review, the facility failed to ensure residents at risk for weight loss were reviewed for of 1 of 5 sampled residents (Resident 1) reviewed for nutrition. Resident 1 experienced harm as they had a 18.67% significant, unplanned, weight loss from 03/13/2025 to 04/22/2025 (40 days) and was found to have low protein levels and skin issues. This placed residents at risk for unplanned weight changes, health complications and nutritional decline. Findings included . <Nutritional Assessments> Review of the facility's 05/01/2023 Food and Nutrition Services Policies and Procedures showed that residents were assessed on admission and routinely thereafter. The residents' goals, diet order, reason for their diet order and components of the diet were discussed with the residents as well as their likes and dislikes. The dietician completed comprehensive or on-going assessments of any residents with nutritional concerns. Residents with dietary concerns were assessed at least monthly. <Weights> Review of the facility's 06/15/2022 Weight policy, showed residents were weighed on admission, then weekly for four weeks, and then monthly thereafter. Significant weight change management would be reviewed by the licensed nurse for assessment. All significant weight changes must be communicated to the physician and the dietitian. All recommendations would be assessed by the Interdisciplinary team and noted in the progress notes and the care plan. <Resident 1> Review of the medical record showed the resident admitted to the facility on [DATE] with diagnoses to include skin breakdown (Moisture Associated Skin Dermatitis (MASD) skin irritation or erosion caused by prolong exposure to moisture such as urine or stool), protein caloric malnutrition (when a person does not consume enough proteins and calories to meet their nutritional needs), post-surgery of a fractured left thigh bone after a fall and Rheumatoid arthritis(a chronic autoimmune disease that attacks healthy cells and tissues located in the joints of both sides of the body) and a Urinary Tract infection(UTI). Review of the 03/13/2025 comprehensive assessment showed the resident was alert and oriented and weighed 175. 8 pounds. The diet showed Resident 1 was ordered a Lacto-ovo-vegetarian diet (this diet consisted of acceptable amounts of milk products and eggs but no animal meat products). During an observation on 05/05/2025 at 7:48 AM, Resident 1's skin to their tail bone was bright red with purple areas of skin color and redness to the sacrum (triangular bone at the base of the spine) and peeled brown skin to each side of the sacrum. During an interview and concurrent observation on 05/05/2025 at 12:20 PM, Resident 1 was in bed with the over the bed table placed in front of them and their lunch meal on the table. The resident stated they had not had much of an appetite and had lost some weight but were unsure of the amount of weight loss. The resident had eaten a quarter of their lunch meal and stated they had enough. Resident 1 stated they were not on a weight loss plan. Resident 1 stated that since they had been admitted to the facility, they had experienced two episodes of UTIs and had not felt the same since they felt weak and unable to participate with therapies. During an interview on 05/05/2025 at 12:45 PM, Staff W, Nursing Assistant, (NA), stated they do not offer other food if a resident does not want to eat. Staff W stated if the resident wanted something else they would ask the kitchen. Review of Resident 1's facility weights showed: Resident 1's height was five foot seven inches. 03/13/2025 at 12:10 PM 175.8 pounds 04/22/2025 at 1:46 PM 143.0 pounds 05/01/2025 at 2:13 PM 151.6 pounds 04/29/2025 at 11:05 AM 151.6 pounds Review of the total weight loss percentage from 03/13/2025 to 04/22/2025 (40 days) was 18.67% (34.8 pound weight loss), a significant weight loss. Review of the percentage of weight gain from 04/22/2025 and 05/01/2025 was 8.6 pounds. Review of the total weight loss percentage from 03/13/2025 to 05/01/2025 (49 days) was 13.77% (a 32.4 pound eight loss), significant weight loss. Review of Resident 1's 03/10/2025 care plan showed the resident was at nutritional risk related to poor intake at times. The care plan goal was that the resident would consume 75% to 100% of two meals a day. Care plan interventions included encouragement of 100% consumption of all fluids, honor the resident's food preferences within meal plan and evaluate for proper consistency of diet. A review of the 03/14/2025 Nutrition progress note showed a Nutrition Assessment was completed. There were no other nutritional assessments or progress notes after the 03/14/2025 assessment as of 05/05/2025. The Nursing Assistant Task charting from 04/09/2025 through 05/05/2025 showed the documented meals consumed by Resident 1 ranged from 25% to 75%. Review of Resident 1's 05/06/2025 hospital emergency room (ER) visit showed laboratory blood work that the resident had a low protein level of 2.3 (normal reference range is 3.4-5.0), Sodium (an electrolyte) was 132 (normal reference range 135-145). Resident 1 tested positive for pneumonia (respiratory infection) due to aspiration of food and fluids according to the 05/06/2025 physician's emergency room report. Resident 1 was sent to theER on [DATE] at 1:00 PM due to breathing difficulties and non-responsiveness. During an interview on 05/07/2025 at 10:03 AM, Staff U, Advanced Registered Nurse Practitioner (ARNP), stated they were unaware Resident 1 had weight loss and had not been eating well. Staff U stated Resident 1's skin issue would affect their nutrition. Staff U stated Resident 1 probably had fluid buildup in their lungs due to not being out of bed and not moving around much that affected the resident's respiratory issues. During an interview on 05/07/2025 at 10:45 AM, Staff C, Resident Case Manager (RCM), stated they were to inform the Interdisciplinary Team (IDT) about resident's skin issues and weight loss. The dietician, RCMs, and the ARNP were to be involved. Resident 1 was not included for the nutrition at risk discussion for weight loss. Staff C stated there was no report to the IDT concerning Resident 1's significant weight loss. During an interview on 05/09/2025 at 11:17 AM, Staff Q, Registered Dietician, stated they were not aware of Resident 1's weight loss. Staff Q stated they did their assessment and the resident's weight was 175.6 pounds. Staff Q stated Resident 1's documented intake was normal and had no swallowing or chewing issues. Staff Q stated the facility may have not accurately weighed the resident potentially showing a discrepancy in the process. Staff Q stated they completed the comprehensive nutrition assessment within seven days from admission. Staff Q stated they were onsite at the facility one day a month but did have weekly nutrition at risk meetings over the phone with the staff. Staff Q stated that the information on weights and food consumption was not always accurate and if a resident refused meals there was no further documentation of why they refused or what was offered to the residents in place of a meal. Staff Q stated there was a lack of accuracy in the information given and they would try to get clarity. Staff Q stated they did recently notice on 05/03/2025 that Resident 1 was not eating their 75% food consumption. Staff Q stated Resident 1 also had skin issues and there were gaps in information about skin issues and how quickly they were caught and acted upon. Staff Q stated there was not a robust type of meeting, there were missing parts of information about the residents' condition and the care for the residents needed to be better. During an interview on 05/09/2025 at 11:50 AM, Staff A, Administrator, stated they realized the lack of through nutritional at risk and resident weight reviews. Staff A stated they recognized the situation and had to work on the discrepancy. Reference WAC 388-97-1060-(3)(h)

Based on observation, interview, and record review the facility failed to review and validate the Preadmission Screening and Resident Reviews (PASARR, an assessment to ensure individuals with Serious Mental Illness [SMI] or intellectual/developmental disabilities [ID/DD] are not inappropriately placed in nursing homes for long term care) were accurate on admission for 3 of 5 residents (Residents 57, 24, and 45) reviewed for PASARR. This failure placed the residents at risk for not receiving the care and services appropriate for their needs. Findings included . <Resident 57> Review of the resident's medical records showed they were admitted with diagnoses to include dementia, depression, and anxiety. The 03/26/2025 comprehensive assessment showed Resident 57's cognition was severely impaired and they received psychotropic medications. Review of Resident 57's 12/20/2024 PASARR showed the resident had no SMIs and did not require a Level II evaluation (to confirm that an individual has a mental illness or intellectual disability and assessed their need for specialized services), even though depression and anxiety were present upon admission. <Resident 24> Review of the resident's medical records showed they were admitted with diagnoses to include dementia, depression, and anxiety. The 04/10/2025 comprehensive assessment showed Resident 24's cognition was intact and they received psychotropic medications. Review of Resident 24's 02/26/2025 PASARR showed the resident had SMIs and did not require a Level II evaluation (to confirm that an individual has a mental illness or intellectual disability and assessed their need for specialized services), despite the resident's documented diagnoses of depression, anxiety, and dementia upon admission. <Resident 45> Review of the resident's medical records showed they were admitted with diagnoses to include dementia, depression, and obsessive-compulsive disorder (OCD-a pattern of thoughts and fears known as obsessions that lead to repetitive behaviors known as compulsions). The 03/04/2025 comprehensive assessment showed Resident 45 had moderately impaired cognition and received psychotropic medications. Review of Resident 45's 02/26/2025 PASARR showed the resident had no SMI's and did not require a Level II evaluation. The PASARR showed no diagnoses of depression or OCD, even though both diagnoses were present upon admission. During an interview on 05/08/2025 at 9:05 AM, Staff J, Social Services Director, stated the admissions staff reviewed PASARRs during the referral process, prior to the resident coming from the hospital. Staff J stated they reviewed PASARRs after residents admitted to the facility and did not have access to them until they were uploaded into the resident's electronic health record. Staff J stated they reviewed PASAARs quarterly and if there were changes to diagnoses that they were aware of. Staff J stated if a resident was admitted with an incorrect PASARR they would call the hospital and try to get a corrected one, but that's hard to do and rarely did they receive a corrected one. Staff J stated if they reviewed a PASARR and it was incorrect; they would complete a new one. Staff J was not aware that Resident 57's PASARR was incorrect on admission. During an interview on 05/08/2025 at 9:46 AM, Staff K, Admissions, stated when they reviewed PASARRs prior to admission, they verified whether they had a completed PASARR, and if they required a Level II evaluation prior to being admitted to the facility. Staff K stated they did not verify the PASARRs against the residents' diagnoses to ensure they were correct and thought the Director of Nursing Services or the Administrator would do that during their review. Staff K stated they were following the process of the current PASARR form and did not know the form had not been updated with the new process. Staff K stated they had received training on the new process and knew it had become effective as of 07/01/2024. During an interview on 05/08/2025 at 3:53 PM, Staff A, Administrator, stated Admissions staff had been trained on the new process for PASARRs and the PASARRs should have been correct or corrected prior to admission to the facility. WAC Reference: 388-97-1915 (1)(2) 45642 48368

Based on observation, interview, and record review the facility failed to ensure an Omnibus Budget Reconciliation Act (OBRA) registry (a registry that identified, prior to employment, if a Nursing Assistant (NA) was eligible to work in a skilled nursing facility) verification to show that an individual met competency evaluation requirements and had no disqualifying findings for 5 of 5 NAs (Staff AA, BB, CC, O, and S) reviewed for staff qualification and background review. This failed practice placed residents at risk of unmet care needs, abuse, neglect, and misappropriation. Findings Included . Review of the policy titled Abuse Prohibition dated 10/24/2022, showed the facility would screen potential employees for a history of abuse, neglect, and mistreatment of residents by obtaining information from past employees and checking with the appropriate licensing boards and registries. Review of Staff AA's, NA, personnel file showed Staff AA was hired on 08/13/2024 but did not start working until 10/03/2024 as a NA. The file showed the OBRA registry was verified on 03/18/2025 (over five months after providing direct, unsupervised, care to residents). Review of Staff BB's, NA, personnel file showed Staff BB was hired on 12/13/2024 but did not start working until 01/24/2025 as a NA. The file showed no documentation of OBRA registry verification. Review of Staff CC's, NA, personnel file showed Staff CC was hired on 10/04/2024 but did not start working until 12/04/2024 as a NA. The file showed that no OBRA registry had been verified. Review of Staff O's, NA, personnel file showed Staff O was hired on 12/13/2024 but did not start working as a NA until 01/07/2025 as a NA. The file showed that no OBRA registry had been verified. Review of Staff S's, NA, personnel filed showed Staff S was hired on 03/23/2022 but did not start working as a NA until 06/25/2024. The file showed that no OBRA registry had been verified. During an interview on 05/07/2024 at 3:24 PM, Staff DD, Human Resources, stated they had not requested OBRA registry verifications until that morning (05/07/2025) for Staff BB,CC, O, and S. Staff DD stated they were aware of the requirement to complete OBRA registry verifications prior to a NA being employed but had not done that. During an interview on 05/08/2025 at 3:44 PM, Staff A, Administrator, stated they were aware they had an issue with OBRA registry verifications not being completed timely and had realized during an audit they had fixed one part of their problem but not the OBRA registry verifications. WAC Reference: 388-97-1660 (3)(c)

Based on observation, interview, and record review, the facility failed to ensure a safe, comfortable and sanitary environment was maintained for 5 of 8 resident rooms (Rooms 6, 43, 41, 35 and 11) and 2 of 3 shower rooms (A hallway and C hallway), reviewed for environment. This failure placed the residents at risk for potential accidents and not feeling safe/secure with their environment. Findings included . Review of a document titled, Facility Assessment, dated 01/31/2024, showed the facility would provide maintenance and housekeeping services to ensure a safe and comfortable environment for the residents. <Resident Rooms> During the Resident Council meeting on 05/06/2025 at 3:24 PM Resident 217 stated in room [ROOM NUMBER] their bathroom always had water on the floor, and they were unsure where it came from. An observation on 05/06/2025 at 4:09 PM, showed, the bathroom flooring in room [ROOM NUMBER] had a stained area that measured 41 inches, with a strong odor of mildew (damp musty odor). The floor had a three-inch (a unit of measure) area circumference (the distance around something) cracked into the flooring with exposed cement. The bathroom wall to the left of the toilet had paint chips and dry wall damage. An observation of resident room [ROOM NUMBER], on 05/07/2025 at 9:16 AM, showed the back of the door had multiple deep gauges to the wood with chipped and missing paint. An observation of resident room [ROOM NUMBER]-A, on 05/07/2025 at 9:42 AM, showed the wall behind the bed had six feet (a Unit if measure) missing piece of trim mid wall with exposed rough jagged edges. An observation of Resident room [ROOM NUMBER] ' s bathroom, on 05/07/2025 at 9:44 AM, showed the floor had a 3 by 4-inch missing piece of tile with the cement floor exposed. An observation of resident room [ROOM NUMBER]-B, on 05/07/2025 at 9:53 AM, showed the wall behind the head of the bed had multiple vertical deep gouges in the sheet rock with missing paint. Further observation showed the trim that extended the length of the room mid wall behind the beds had multiple deep gouges with exposed wood showing. An observation of resident room [ROOM NUMBER]-A and B, on 05/07/2025 at 9:54 AM, showed the wall behind the head of bed A and B had multiple vertical deep gauges in the sheet rock and was missing paint. Further observations showed the trim behind bed A and Bed B mid wall had multiple deep gouges with exposed wood showing. <Shower rooms> An observation on 05/07/2025 at 9:48 AM, Hall C shower room had tiles missing along the bottom of the wall measuring 10.5 feet (a unit of measure) by 11 feet. The back of the shower door had multiple areas with chips of paint missing. The tile had areas of a black substance. Additionally, the floor tiles in each corner had a slimy brown substance one inch out from the wall and one inch up the wall. An Observation on 05/07/2025 at 10:47 AM, The A-hall shower room had cracked flooring with exposed concrete and broken tiles. The resident handrail/grab bar had a thick white layer of soap scum underneath the bar. In the corners of the flooring had dark exposed concrete. During an interview on 05/09/2025 at 10:02 AM, Staff H, Maintenance Director, stated the staff communicated any issues or repairs needed through an electronic maintenance log (a system on the computer that creates work orders). Staff H stated they had not been made aware of the issues in the rooms or the shower rooms, and they were not notified through their electronic system, so they did not get a work order. Staff H stated they did not walk rounds of the facility on a consistent schedule and only did room checks for any repairs needed when a resident was moved or discharged . Staff H stated they depended on the staff to inform them of any issues. Staff H stated they were working on all the issues, and it was a big project. During an interview on 05/09/2025 at 11:12 AM, Staff A, Administrator, stated they would expect walking rounds of the facility to be done daily, and the interdisciplinary team should be checking rooms at least three times weekly and reporting through the electronic system to Staff H. Staff A stated the process was not followed and these rooms were missed. Reference: WAC 388-97-3220(1) 45642

Based on interview and record review, the facility failed to thoroughly investigate a fall, for one of five sampled residents (Resident 218), reviewed for falls. The failure to complete a thorough investigation placed the residents at risk for potential negative health outcomes. Findings Including . <Resident 218> Review of the medical record showed Resident 218 was admitted to the facility on [DATE] with diagnoses to include dementia, muscle weakness, lack of coordination and repeated falls. The comprehensive assessment dated [DATE] showed Resident 218's cognition was severely impaired and was dependent on staff for activities of daily living (ADLs). Review of the facilities incident reporting log dated 04/13/2025 showed that the resident had a fall in the dining room and that resulted in Resident 218 being sent to the emergency room for evaluation and treatment of a laceration (a cut) to the left forehead. Review of the facilities investigation of Resident 218's fall dated 04/13/2025 did not show witness statements to reflect a thorough investigation. During an interview and observation on 05/08/2025 at 4:20 PM, Staff C, Resident Case Manager (RCM), stated they recognized that there were no witness statements, and would have to speak to the Director of Nurses (DNS). Staff C stated that the DNS would obtain witness statements for all investigations. During an interview on 05/09/25 at 9:57 AM, Staff C, RCM, stated they could not find the witness statements for Resident 218's investigation. Additionally, that the facility had a form for witness statements that should be filled out after an incident. During an interview on 05/09/25 10:40 AM, Staff M, Nursing Assistant (NA), stated when a resident had a fall staff were to report it immediately to the nurse and fill out a form of what, when, where, what was seen during the incident. Staff M stated that sometimes they get busy and forget to fill out the form, the form goes back to the nurse before the end of the shift. During an interview on 05/09/2025 at 11:29 AM, Staff L, Registered Nurse, (RN) stated Yes, I remember I was at the med cart when one of the residents came and said that I needed to come quickly that someone had fallen. Staff L stated they found Resident 218 lying on her left side and was bleeding from the forehead, spoke to the resident to see if they would respond, assessed the resident to see if we could move them. In the same interview Staff L stated that it took four staff members to place Resident 218 back into their wheelchair and put the resident in bed. Staff L stated they had performed first aid and called the hospice. Shortly after the hospice nurse arrived, they spoke to the physician and had to send Resident 218 to the emergency room for evaluation and treatment. Staff L stated they document a change in condition and monitor the resident. During an interview on 05/09/2025 at 11:59 AM Staff N, NA, stated they were aware of Resident 218's fall. Staff N stated post fall they gathered supplies for the team, and they noticed there was blood. Staff N stated they went to the laundry room for towels to clean up and gave the supplies to the team. Staff N stated the post-fall procedure is that they report the incident to the nurse, then we take care of the situation. Staff N stated staff must fill out a report by the end of shift, we are given a form to fill out. Everyone on the floor is to fill out a form, so the facility knows where and what everyone was doing during the incident. During an interview on 05/12/2025 at 2:05 PM Staff O, NA, stated they were aware of the incident with Resident 218, that they had sat the resident in the dining room and had forgotten to place the drop-down seat (a reclining seat that prevents the resident from going forward) and they had sustained a fall. Staff O stated they would normally fill out a form when an incident happened, that they had filled out the witness statement for the fall on 05/11/2025. During an interview on 05/09/2025 at 12:32 PM, Staff A, Administrator, acknowledged the incident report did not have witness statements. Reference: WAC 388-97-0640 (6)(a)(b)

Based on interview and record review, the facility failed to ensure a resident who was admitted with a urinary catheter (a tube which drains urine from the bladder into a collection bag), received a referral to a urologist to determine function and continued use of a urinary catheter for 1 of 3 residents (Resident 1) reviewed for extended urinary catheter use. This placed the resident at risk for continued decline in urinary function. Findings included . <Resident 1> A review of the medical record showed the resident admitted to the facility on [DATE] with diagnoses of urinary retention (inability to empty the bladder) with a urinary catheter, and heart disease. The 03/13/2025 comprehensive assessment showed the resident was alert and oriented, had a urinary catheter and history of UTIs. During an observation and concurrent interview on 05/05/2025 at 9:25 AM, the resident had a urinary retention catheter with the urinary collection bag. During the interview the resident stated they had the catheter on and off but during their hospital stays. Resident 1stated they had many Urinary Tract Infections (UTIs) at the facility and was placed on many antibiotics. The resident stated they were not on a urinary catheter prior to being admitted to the facility. Review of the hospital physician's discharge notes dated 03/10/2025 showed the resident had the urinary catheter placed in the hospital on 03/04/2025. The resident developed a UTI while in the hospital on 03/06/2025 and was placed on antibiotics and discharged with a retention urinary catheter to the facility. Review of the 03/24/2025 urinalysis culture (a sensitivity test used to diagnose UTIs and by identifying the bacteria in the urine and determining which antibiotic to use) report showed the resident had a UTI and started on an antibiotic. Review of the 04/29/2025 progress notes showed the resident complained of a burning sensation and pain in their bladder a urinalysis Review of the 05/01/2025 urinalysis culture report showed the resident had a UTI and started on an antibiotic for five days. During an interview on 05/06/2025 at 11:00 AM, Staff C, Resident Care Manager (RCM) stated they did not refer Resident 1 to a urologist to obtain orders for an assessment whether to trial the resident off from the retention catheter or to determine why the resident had continued UTIs. Reference WAC 388-97-1060-(3)(c)

Based on observation, interview, and record review, the facility failed to ensure continuous oxygen delivery was provided according to physician orders, monitored respiratory status, and the maintaining of respiratory equipment for 2 of 2 residents (Residents 1 and 53), reviewed for respiratory status. This failed practice placed residents at risk of unmet needs, discomfort, and secondary medical complications. Findings included . Review of the facility's 08/07/2023 Oxygen policy showed to label, date and attach pre-filled humidifier bottle. The policy included replacing the disposable set-up (oxygen tubing and nasal canula) every seven days. <Resident 1> Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses to include anemia, heart disease and required continuous oxygen. The 03/13/2025 comprehensive assessment showed the resident was alert and oriented and able to make their needs known. Review of Resident 1's oxygen orders dated 03/10/2025, showed to monitor the resident's oxygen level every shift. Additionally, to clean the oxygen concentrator filter every seven days. During an observation and concurrent interview on 05/05/2025 at 3:01 PM, Resident 1 was lying in bed complaining about the oxygen tubing being irritating to their nose and behind their ears. Observation of Resident 1's oxygen tubing showed the tubing was cloudy and opaque (not transparent) skin around the nasal cannula (tubing carrying oxygen through the nose) was flakey, dry with slight redness at the edges of the nostrils. Resident 1 stated that their nose was irritated, and they had to remove the oxygen cannula because of the irritation. The resident stated their ears where sore where the oxygen tubing was placed behind their ears. Observation of Resident 1's skin behind their ears showed a slight redness. Resident 1 stated the staff did not change the oxygen tubing. During an observation and concurrent interview on 05/05/2025 at 3:10 PM, there were no labels on Resident 1 ' s oxygen tubing, or a label from the last time the tubing had been changed. Additionally, the resident did not have sterile water connected to the oxygen concentrator to humidify the oxygen as ordered by the physician. When asked about the labeling and the sterile water to humidify the oxygen, Staff I, Licensed Practical Nurse (LPN), stated they would inform the resident's nurse about it. During an interview on 05/06/2025 at 9:00 AM, Staff EE, Agency Licensed Practical Nurse (LPN), stated they were unaware of the oxygen tubing not being labeled or having sterile water for humidified air on the concentrator. During an observation on 05/06/2025 at 9:50 AM, Resident 1's oxygen concentrator continued not to have sterile water on oxygen concentrator for humidification of oxygen. Resident 1's oxygen tubing had not been changed. Additionally, the oxygen concentrator filters were not clean and had build-up of white fuzzy dust. <Resident 53> Review of the medical records showed Resident 53 was admitted to the facility on [DATE], with diagnoses to include interstitial pulmonary disease (a group of lung disorders that cause inflammation and scaring to the tissue around the air sacs of the lungs), dementia (the loss of thinking, remembering, and reasoning, to the extent that effects activities of daily living), and the need for assistance with personal care. The comprehensive assessment dated [DATE] showed the residents' cognition was severely impaired and required assistance from one to two staff members for personal care. Review of Resident 53's Physician orders showed the resident was to wear oxygen at 2 L/min (a liter of oxygen flow per minute) via Nasal Cannula (a tubing that enters the nose to deliver oxygen) continuously. Additionally, an order dated 05/02/2025, showed that due to continuous oxygen, verify oxygen saturation (the amount of oxygen circulating in the blood) stayed above 92% when resident was transferred from one location to the other or during showers, every shift. During an observation on 05/07/2025 at 10:27 AM, Resident 53 sitting in their wheelchair in the outside activities with a blanket on their legs and a portable tank of oxygen on the back of their wheelchair. The resident's oxygen tank showed the pressure gauge at zero psi (pounds per square inch) indicating no oxygen. Resident 53 ' s tank was empty. During an observation on 05/07/2025 at 11:18 AM, Resident 53 was sitting in their wheelchair in the dining room with their oxygen tank empty. The resident had an oximeter (a small device that measures blood oxygen levels) on their right finger, the device showed their oxygen saturation was at 86%. Resident 53 was repeating I'm not sure why I feel this way I'm not sure why I feel this way. During an observation on 05/07/2025 at 11:42 AM, Resident 53 was in their wheelchair with a portable oxygen tank on the back of it, sitting in the dining room, and their oxygen tank continued was still empty, (one hour and 15 minutes after the first observation). During an interview on 05/07/2025 at 12:28 PM, Staff L, Registered Nurse stated nurses handled monitoring and the administration of oxygen for a resident. Staff L stated the nursing assistants were to notify a nurse for any issues, such as needing to have oxygen turned on. Staff L stated that they did not realize Resident 53's oxygen was empty. Reference: WAC 388-97-1060 (3)(j)(vi) 45642

Based on observation, interview and record review, the facility failed to ensure 2 of 6 residents (Residents 51 and 57) were free of unnecessary drugs due to lack of monitoring, timely administration, and care planning of high-risk medications. This failed practice placed residents at risk of receiving medications incorrectly, subtherapeutic (relating to drug dosages administered at too low a level to produce a therapeutic effect) treatment, and adverse side effects. Findings included . Record review of an undated patient pamphlet published by [NAME] Cancer Center titled Tacrolimus (a medication to prevent the body from rejecting a transplanted organ) Reference Guide showed, Tacrolimus must be taken at the same time every day to keep steady levels of Tacrolimus in your blood. If there is a missed or late dose, contact your physician. The guide showed to monitor for common side effects that include high blood pressure, headache, tremors or shaking, nausea or vomiting, and diarrhea or constipation and to follow-up with your provider if the side effects are hard to control or won't go away. Review of the Pharmacyclics LLC patient pamphlet revised date 02/2024 titled Imbruvica (Ibrutinib) showed, that Ibrutinib is a cytotoxic medication (which means it is designed to kill cancer cells but can also harm normal cells if absorbed through the skin) and caregivers should wear disposable gloves when handling Ibrutinib capsules or tablets. Additionally, to monitor for side effects that include hemorrhage (large, uncontrolled bleeding from a blood vessel), infections, high blood pressure, liver problems, most common side effects diarrhea, muscle pain, bone pain and joint pain. <Resident 51> Review of the medical record showed Resident 51 admitted to the facility on [DATE] with diagnoses that included chronic lymphocytic leukemia (a type of cancer in the blood and bone marrow), dementia (the loss of thinking, remembering, and reasoning to the extent that interferes with Activities of Daily Living [ADLs]), and muscle weakness. The comprehensive assessment dated [DATE] showed the resident ' s cognition was severely impaired and was independent with ADLs. Review of the care plan dated 02/27/2025, showed there was no focused care plan for cancer, use of cytotoxic medication, no interventions to monitor for adverse side effects nor guidance for specialized handling. During an observation and concurrent interview on 05/08/2025 at 7:34 AM, during a medication pass, Staff R, Medication Assistant Certified (MAC), stated that the medication administration record for Imbruvica (a cytotoxic medication) showed no directives to wear gloves. In the same interview Staff C, Resident Care Manager (RCM), stated that it would be safer to wear gloves when administrating the Imbruvica medication. During an interview on 05/08/2025 at 11:08 AM, Staff D, RCM, stated they were not aware of the precautions for a cytotoxic medication, or the adverse effects such as the increased risk of hemorrhage. Staff D stated they should have used their nursing judgement. During an interview on 05/09/2025 at 1:24 PM, the Contracted Pharmacist stated the monitoring of Imbruvica would be to make sure routine cardiac function tests and labs were done. The monitoring of blood pressures, and to monitor for bleeding or bruising. The facility would also have to ensure administration of the Imbruvica medication was at the same time every day and to give with a full glass of water. <Resident 57> Review of the resident's medical records showed they admitted to the facility with diagnoses to include a liver transplantation (to remove a diseased or injured liver and replace it with a healthy liver from another person), liver cancer, chronic hepatitis (ongoing inflammation of the liver), and immunosuppressive therapy (use of drugs that prevent your immune system from attacking healthy cells and tissues by mistake) . The 03/26/2025 comprehensive assessment showed Resident 57's cognition was severely impaired and was dependent upon staff for their ADLs. Review of Resident 57's physician orders showed an order on 12/23/2024 for Tacrolimus (a brand of an immunosuppressant drug) capsules to be taken twice daily at 7:00 AM and 7:00 PM. On 04/30/2025 the 12/23/2024 Tacrolimus order was discontinued and a new order for Tacrolimus granules in a packet that had to be mixed with water was ordered due to Resident 57 experiencing swallowing issues. Review of the orders showed there were no directions on either of the Tacrolimus orders to show the medication needed to be administered at the same time every day to maintain adequate levels in the blood. The indication for use of the Tacrolimus was for liver transplantation. Review of Resident 57's labs to test for therapeutic levels showed Tacrolimus labs had not been obtained since admission on 12/23/2024. Review of Resident 57's 03/24/2025 care plan showed there was no care plan for the liver transplantation or for the use and monitoring of immunosuppressant therapy for therapeutic range, adverse side effects, or special directions for administration. Review of Resident 57's Medication Administration Records (MARs) from 03/01/2025 through 03/30/2025 showed the Tacrolimus had not been administered on the evening of 03/06/2025, the evening of 03/10/2025, and the morning of 03/21/2025 because the resident refused or was sleeping. Review of the MARs from 04/20/2025 through 05/08/2025 showed Tacrolimus was administered 32 times. The records showed 11 times the medication was administered at least 50 minutes early or late, with the longest time being four hours and 57 minutes late and once where the medication was not given. 04/20/2025 the morning dose was not given due to the resident refusing 04/24/2025 the morning dose was given at 7:50 AM (50 minutes late) 04/26/2025 the morning dose was given at 7:58 AM (58 minutes late) 04/26/2025 the evening dose was given at 6:03 PM (57 minutes early) 4/30/2025 the evening dose was given at 12:37 AM (five hours and 37 minutes late) 05/01/2025 the morning dose was given at 11:57 AM (four hours and 57 minutes late) 05/02/2025 the morning dose was given at 9:37 AM (two hours and 37 minutes late) 05/02/2025 evening dose was given at 8:51 PM (one hour and 51 minutes late) 05/03/2025 the morning dose was given at 8:35 AM (one hour and 35 minutes late) 05/04/2025 the evening dose was given at 8:02 PM (one hour and two minutes late) 05/07/2025 the evening dose was given at 6:03 PM (57 minutes early) 05/08/2025 the morning dose was given at 8:38 AM (one hour and 38 minutes late). During an observation on 05/08/2025 at 11:08 AM, Resident 57 was being assisted to their wheelchair. Resident 57 had tremors (a rhythmic movement of a body part that's involuntary) to their right hand while at rest sitting in their wheelchair (which could be a side effect of the Tacrolimus). Resident 57's hand was tremoring to the point that it would fall off the arm rest of the wheelchair either to their side or to the right side of the wheelchair. During an interview on 05/08/2025 at 2:43 PM, Staff D, Resident Care Manager, stated they were not aware that Tacrolimus had special instructions for administration and handling. Staff D stated they thought therapeutic levels should have been checked at some point but were not sure when that should have been, I probably need to get working on that. Staff D stated they were not familiar with immunosuppressant drugs and needed to learn more about them. During an interview on 05/09/2025 at 1:15 PM, the Contracted Pharmacist stated Tacrolimus was to be administered at the same time every day and Tacrolimus was on the list of hazardous drugs (medications that pose a risk to healthcare workers, patients, and the environment due to their potential to cause serious health effects like cancer, birth defects, or fertility problems) so adverse side effects should have been monitored, and the medication should have been administered with gloves. The Contracted Pharmacist stated they had not ordered Tacrolimus lab tests for Resident 57 and felt the transplant doctor should have been responsible for ordering and monitoring labs, as well as the ones the pharmacist had ordered. During an interview on 05/09/2025 at 8:42 PM, Staff B, Director of Nursing Services, stated they did not have additional monitoring or education for residents on immunosuppressant therapy. Staff B stated they knew the medication should not be handled without the use of gloves but would have expected the pharmacist to alert them to any special instructions if there were any. WAC Reference: 388-97-1060 (3)(k)(i), (4) 45642

Based on interview, observation, and record review, the facility failed to provide appetizing and palatable meals for 3 of 3 residents (Resident 24, 1 and 36) reviewed for the dining experience. These failures resulted in residents expressing dissatisfaction with the food and placed residents at risk for inadequate nutritional intake and weight loss. Findings included . Review of the 05/01/2023 Mealtimes and Delivery policy showed when meal food delivery was ready to begin the nutrition services employee (dietary department) alerted the nursing department that food was ready to be delivered. During an observation on 05/07/2025 at 11:20 AM, showed the lunch meal was checked for holding temperatures for serving the lunch meal. The following temperatures were taken and were within the temperature guidelines to include 135 degrees Fahrenheit (F) and 41 degrees F as follows: Chicken Fried Steak--185 degrees F Puree/Mech Soft------165 degrees F Salisbury Steak -------158 degrees F Potato Wedges--------180 Degrees F Puree Potatoes--------155 Degrees F Green Beans------------170 degrees F Carrots------------------170 Degrees F Milk----------------------38 Degrees F During an observation on 05/07/2025 at 11:35 AM, showed the dietary staff prepared the residents meal trays in serve out. The residents meal trays were placed in the cart for distribution at 11:42 AM. Dietary staff then call for nursing staff on C-Hall to get the cart. The C-Hall staff retrieved the lunch meal cart at 11:43 AM and the C-Hall meal cart and did not start serving residents until 12:00 PM, (more that 17 minutes after preparation of meals). During an interview and observation on 05/07/2025 at 11:50 AM, A test tray for resident tray for Resident 24 was taken from the meal A-Hall cart by Staff N, Nursing Assistant (NA) took the meal tray for Resident 24. Staff N took the meal tray out of the A-Hall cart and uncovered the top of the lunch meal, cut the chicken fried steak, put butter on the dinner roll and re-covered the lunch meal and brought it to the resident's room at 12:08 PM. The test tray (same as Resident 24's meal tray) was also brought at the same time to the resident's room and retrieved the tray by the Staff HH, Dietary Manager and the surveyor for temperature testing. On 05/07/2025 at 12:09 PM lunch was test tray was read at temperature of: Normal Temperatures for food are as follows: Chicken fried steak--118 degrees F Chicken fried Steak------135 degrees F Green Beans--------- 115 degrees F [NAME] Beans--------------145 degrees F Potato wedges-------100 degrees F Potato Wedges-----------145 degrees F Milk-------------------50 degrees F Milk------------------------41 degrees F Pineapple-------------50 degrees F Pineapple------------------41 degrees F During an interview and observation on 05/07/2025 at12:15 PM, Resident 24 stated the meal was okay but cold and it was not too appetizing. The chicken fried steak was cold, and the green beans were cold. During an interview and observation on 05/07/2025 at 12:20 PM, Resident 36 who eats in the C-Hall dining room stated the food was not tasty and cold. During an interview and observation 05/07/2025 at 12:30 PM, Resident 1 who ate in their room on C- Hall stated the food was lukewarm. During an interview on 05/07/2025 at 12:40 PM, Staff HH stated the lunch meal was cold and not at the appropriate temperature and stated it's not good for resident's to not have hot foods hot. Additionally, the milk temperature was 50 degrees F as well as pineapple dessert that was to be cold. During an interview with Staff A, Administrator, stated they were aware that there were concerns about meals served cold and there were delays in serving meal trays. Reference WAC 388-97-1100 (1), (2) 45642

Based on observation, interview and record review, the facility failed to ensure staff followed safe supervision and handling of two trained staff for mechanical lift transfers for 1 of 3 sample residents (Resident 1), reviewed for mechanical lift transfers. Resident 1 experienced harm when they fell out of the mechanical lift sling while being transferred from their wheelchair to their bed with only one staff person assisting and sustained a laceration to the right side of their head that required hospital evaluation and treatment. Findings included . Review of the 03/01/2024 policy titled Safe Resident Handling/Transfer Equipment showed two trained persons are required to operate a total lift (mechanical lift) intervention for dependent lifting, transferring or repositioning. The goal of the safe handling program is to create a safe environment for staff and residents. Staff who use a mechanical device will ensure the appropriate sling will be used to reposition the resident. Review of the education/training overview showed staff were to be trained in the mechanical lift process on hire to their position, annually and as needed. <Resident 1> Review of the medical record showed the resident was admitted [DATE] with diagnoses to include severe dementia (cognitive impairment), brain cysts (fluid filled sacs that put pressure on the brain and spine), and mood disorders. Review of the 08/08/2024 annual assessment showed the resident was cognitively impaired, non-verbal and totally dependent on staff for all needs to include transfers from bed to wheelchair. The resident was not able to bear weight or walk on their own. The resident was dependent on staff to transfer by a mechanical lift with a total body sling attached to the lift by staff. During an observation on 10/07/2024 at 11:00 AM, Resident 1 was seated in their wheelchair in the dining room. The resident did not respond to verbal conversation. There was a four-inch suture line of staples in place on the back right side of Resident 1's head. Review of the 10/03/2024 investigative report showed Staff C, Nursing Assistant (NA), had transferred Resident 1 from their wheelchair in their body sling that Staff C attached to the mechanical lift bar. Staff C then used the mechanical lift controller while they were guiding the resident by themselves to the bed. During the transfer of Resident 1, one of the sling straps loosened from the mechanical lift bar and the resident fell to the floor. Resident 1sustained a head laceration and was sent to the hospital. The conclusion of the 10/03/2024 investigation showed the sling loop was not placed completely over the mechanical lift bar hook and resulted in the sling sliding off. Resident 1 fell and hit their head and sustained a head laceration which required an emergency room visit and six staples to the right backside of the resident's head. During an interview on 10/07/2024 at 11:25 AM, Staff C, NA stated that on 10/03/2024 at 8:20 PM Resident 1 was in their wheelchair. Staff C stated they asked Staff F, Licensed Practical Nurse, (LPN) to assist them in transfer of the resident to their bed. Staff C stated the resident had the body sling underneath them while seated in their wheelchair. Staff C hooked the sling to the mechanical lift bar loops two above the resident head and two below the resident knees on both sides of the resident. Additionally, Staff C stated Staff F, LPN, did not assist Staff C with the mechanical lift controls nor did they assist with positioning the body of Resident 1 during transfer with the mechanical lift but stood on the opposite side of Resident 1's bed. Staff C stated Resident 1 who was six feet and one inch tall, began to move and arched their back. The attachment loop from one side of the sling attached to the mechanical lift bar came off. Resident 1 who was in the body sling mid-air fell to the floor, hit the right side of their head and sustained a laceration that required six staples at the hospital. During an interview on 10/07/2024 at12:30 PM, Staff F, stated they were in Resident 1's room observing Staff C prepare the resident to transfer from their wheelchair to their bed. Staff F stated they did not assist Staff C stated they were just spotting while Staff C transferred the resident. Staff F stated the facility required two staff to be in the room while a mechanical lift was in use for a resident. Staff F stated they were trained to just watch the transfer of a resident but did not participate. Staff F stated that Staff C had Resident 1 parallel to the resident's bed when the sling strap came off the mechanical lift bar and the resident hit their head on the floor. Staff F then called the ambulance and notified the physician and resident's representative. Review of Resident 1's care plan 08/18/2024 intervention showed the resident required assistance of two staff with Hoyer (mechanical lift) transfers. During an interview on 10/07/2024 at 12:10 PM, Staff E, LPN, Staff Development, stated they completed the education for Staff F on Safe Resident Handling/Transfer Equipment and showed Staff F's 06/23/2023 attendance on the education/training requirements. Staff E stated part of the education of insurance of two trained staff be in attendance with mechanical lift transfers was to have both staff have a hands on attention on the resident with one assist with positioning and transfer of the resident and one operated the control of the mechanical lift. Staff needed to be around the resident and not away from the resident with only one staff operating the mechanical lift. transferring the resident. That is not safe transfer. During an interview on 10/07/2024 at 1:15 PM, Staff A, Administrator stated that they understood that it was unsafe practice to have just one staff transfer the resident with a mechanical lift. Staff F, LPN was trained to assist with transfer of Resident 1 with a mechanical lift. Reference WAC 388-97-1060(3)(g)

Based on observation, interview and record review the facility failed to provide the necessary care and services to prevent the development of pressure injuries for three of four residents (3, 4 and 2), reviewed for pressure injuries. Additionally, the facility did not effectively apply comprehensive care plan interventions for pressure injury prevention based on resident assessments of identified skin at risk concerns.These failures resulted in actual harm to Residents 3 and 4 and placed residents at risk for other medical complications [MEDICAL RECORD OR PHYSICIAN ORDER] Findings included: During a record reviewRecord review on 06/29/2022 of National Pressure Injury Advisory Panel Pressure Injury Stages showed . * Stage I pressure injury non-blanchable area of intact skin. * Stage II pressure injury partial thickness skin loss with exposed dermis (the thick layer of skin below other layers of skin). * Stage III pressure injury full-thickness loss in which fatty tissue is exposed. * Stage IV pressure injury full-thickness loss of skin and tissue with exposed bone and tendon. Unstageable pressure injury obscured full-thickness loss in which the full extent of tissue loss cannot be observed. Deep Tissue pressure injury consistent non-blanchable deep red, maroon or purple colored skin. Record review of the facility policy titled Skin Integrity Management, dated 05/26/2021, showed .identify the patients skin integrity status and need for prevention intervention modalities through review of assessment information .Initiate pressure injury prevention for identified risk factors, determine the need for support surfaces, turning and re-positioning based on resident care needs. Resident 3. Record review of the electronic health record (EHR) showed the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment did not show a Stage III pressure injury to the right heel. Review of Resident 3's most recent skin at risk prediction scale for pressure injuries dated 05/06/2022 showed the resident was at risk to develop skin issues. Review of the residents 05/06/2022 care plan showed no appropriate pressure injury prevention measures for the resident until after the right heel pressure injury had developed. Record review of a wound assessment note, dated 06/13/2022, showed the resident had a Stage III pressure injury to the right heel measuring 3.4 x 3.4 x 0.1 centimeters. An observation on 06/27/2022 at 2:52 PM showed Resident 3 positioned on their back in bed with pressure reduction heel boots on however,the blankets were tucked tightly around the resident's feet putting pressure on their feet and heels. An observation of Resident 3's wound care on 06/29/2022 at 1:30 PM Staff J, Licensed Practical Nurse (LPN), measured the wound which showed a 3.5 x 3.0 x 0.1 wound to the right heel. The wound was a full-thickness loss Stage III with observed yellow fat tissue in the wound base. During an interview on 06/29/2022 at 1:45 PM, Staff B, Director of Nursing Services (DNS), stated that Resident 3's right heel pressure injury was facility-acquired and had started out as a blister. Resident 4. Record review of the EHR showed the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's most recent comprehensive assessment, dated 04/25/2022, showed the resident required an extensive assistance of two staff for turning and re-positioning. The assessment did not show that the resident had a pressure injury on their right heel, Record review of the physician's orders for June 2022 showed the resident had a deep tissue injury to the right heel and that pressure relieving boots were to be worn at all times. Record review of the most current nursing assistant Kardex (contains individualized resident directives) dated as of 06/29/2022 showed no current directions for the use of the pressure relieving boots as ordered by the physician on 06/14/2022. Additionally, there were no prevention measures for turning and re-positioning. Observation on 06/29/2022 at 11:22 AM, showed the resident sitting up in their wheelchair in the hallway withou pressure reduction boots on to protect their heels. The resident had shoes and socks on with their feet resting flat on the floor causing pressure to their heels. An observation on 06/29/2022 at 12:50 PM showed the resident's right heel had a 2.0 x 2.0 centimeter yellow-brown intact scab. The surrounding tissue was red ,dry and peeling. The wound bed was not observable, therefore the facility had determined that the wound was a deep tissue injury (non blanchable deep red, maruun or purple. skin). During an interview on 06/29/2022 at 1:45 PM, Staff B, DNS, stated that the resident's pressure injury to the right heel was facility-acquired and staff were expected to use the pressure relieving heel boots as ordered. Resident 2. Review of the resident's EHR showed the resident was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 2's most recent comprehensive assessment, dated 03/02/2022, showed the resident required extensive assistance of two for turning, re-positioning and incontinent care. Review of the resident's hospital records, dated 12/30/2021, showed the resident had a Stage II pressure injury to the coccyx (tailbone), which was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a wound care assessment note, dated 06/20/2022, showed the following orders: * discontinue incontinent brief when in bed * wear incontinent brief when in wheelchair only - remove when in bed * thin draw sheet only on low air-loss mattress Additionally, the note stated the coccyx wound continued to be macerated (moist) which was why it was important to remove the brief while the resident was in bed. Record review of the resident's Kardex, revised 06/08/2022, showed the resident was not high risk for skin issues requiring frequent turning, re-positioning, use of a thin draw sheet, pressure reduction heel boots on, or that no incontinent brief was to be used while the resident was in bed. Observations on 06/27/2022 at 2:48 PM, 4:00 PM and 4:45 PM showed the resident positioned on their back with heel boots on, however the sheet and blanket were tucked tightly around the resident's feet causing pressure to the feet and heels. The resident was also noted to be wearing an incontinent brief while in bed. An observation on 06/28/2022 at 10:00 AM showed Resident 2 was positioned on their back sitting up in bed at a 90 degree angle. They were wearing an incontinent brief and stated their bottom was sore. Additional observations on 06/28/2022 at 11:20 AM, 12:17 PM, and 1:00 PM showed the resident in the same position on their back with the head of the bed up at a 90 degree angle putting pressure on their buttock area and still in an incontinent brief. During an interview on 06/29/2022 at 11:40 AM, Staff H, Nursing Assistant, stated that the Kardex was what they relied on for interventions to provide for residents skin care needs. During a concurrent observation and interview on 06/28/2022 at 1:10 PM, Staff J, Licensed Practical Nurse, (LPN) stated the resident had remained in bed for lunch and staff were supposed to turn and reposition the resident every two hours per the standard of care. Observation of the resident's buttocks and coccyx showed a red hardened skin area with a 0.5 x 0.5 centimeter superficial open area on the testicles. Staff J indicated it was a new area of skin breakdown and had been bleeding. During an interview on 06/28/2022 at 2:10 PM, Staff B, DNS, stated their expectation for Resident 2 was that they were to be turned and re-positioned every two hours, and to not use an incontinent brief while in bed as the resident had issues with moisture associated [CONDITION(S)] and they needed to air out the area as to not cause further damage to their skin. During an interview on 06/29/2022 at 2:00 PM, an anonymous staff stated, Truthfully the turning and re-positioning is not getting done which is why we are getting so much skin breakdown. During an interview on 06/29/2022 at 2:20 PM, Staff B stated their expectation was for the residents to be assessed for skin at risk issues and interventions to be put in the care plan for staff to implement and prevent pressure injuries. Also, their expectations included that skin assessments were completed upon admission, quarterly and with any change in a residents condition. Reference: WAC 388-97-1060(3)(b)

Based on interview and record review the facility failed to provide competent nursing staff with skill sets to provide safe medication administration for one of one resident (1) reviewed for significant medication errors. Failure to recognize the severity of complications that could arise by crushing a medication and attempting to push it through an intravenous (IV) line resulted in harm to the resident and may have contributed to the resident's death. Findings included . Nursing Rights of Medication Administration, by [NAME] A [NAME] LM, updated 09/12/2021, showed it was standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the five rights of medication administration. Those five rights include, the right patient, the right drug, the right route, the right time and the right dose. Resident #1. Per the medical record the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's most recent comprehensive assessment, dated 12/28/2021, showed they were receiving end of life care and required extensive assistance of two caregivers for positioning and bed mobility. Review of a facility medication error report, dated 12/26/2021, written by Staff A, the Director of Nursing, stated, At approximately 8:30 AM, nurse gave [MEDICATION(S)] Hydrate tablet (an antibiotic medication) by IV instead of by mouth. Pill was crushed and reconstituted (made into a liquid form) in sterile saline, then tried to push the reconstituted medication through the IV line. Unknown amount given, but out of the 10 milliliter (ml) syringe used, approximately 1 ml was able to be flushed into the tubing. During an interview with Staff A on 01/27/2022 at 2:00 PM, she stated the error occurred on a Sunday morning and she was called at home and informed by the nurse who made the error, Staff B, Registered Nurse (RN), of the plugged IV line. Staff A stated she informed Staff B that this was the wrong route to administer the medication and immediately called Resident #1's physician, who in turn called the pharmacy's IV department for advice on potential complications of the medication error and what the best course of action should be taken to minimize harm to the resident. Staff A stated the pharmacy reported to the physician, the medication administered into the IV line could mimic a blood clot to major organs and respiratory distress should be monitored. Staff A stated she then educated Staff B of the danger of administering a crushed medication per an IV line, suspended Staff B pending an investigation of the medication error and reported the error to the resident's representatives, Residential Care Services and the Department of Health. Staff A stated during the interview with Staff B about the medication error, Staff B explained she became confused on how to administer the medication when Resident 1 was to have nothing by mouth. Further, Staff B could not explain why she felt this to be a viable or safe route or why she decided to only give that one medication when he had several oral medications listed on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Attempts to reach Staff B by telephone for an interview on 01/27/2022, 02/01/2022 and 02/07/2022 were unsuccessful. Resident #1 passed away on 12/29/2021. Due to his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Reference (WAC) 388-97-1680(2)(a)(b)(i)(ii)

Based on interview and record review the facility failed to ensure one of one resident (1) was free from significant medication errors. This failure resulted in harm to the resident and may have contributed to the resident's death when nursing staff gave an ordered oral medication intravenously. Findings included . Resident 1. Per the medical record the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 1's medical record including nursing, physician, and therapy notes, showed on 12/15/2021, he had a significant decline in condition and was diagnosed with pneumonia, electrolyte (essential minerals that are vital to key functions in the body) imbalances and dehydration. Resident 1 was started on intravenous (IV) fluids and antibiotics at that time but continued to decline in condition. It was noted his swallowing became severely impaired and he was placed on nothing by mouth orders per speech therapy and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 1's medication sheets for December 2021 showed the nursing staff held all of the resident's oral medications as ordered from 12/16/2021 through 12/28/2021 when they were discontinued. Review of a medication error report, dated 12/26/2021, showed that at shift report that morning Staff B, Registered Nurse (RN), was told that Resident #1 had orders to receive nothing by mouth though was still receiving IV hydration. Further review showed at approximately 8:30 AM, Staff B attempted to give one of the resident's held oral medications (an antibiotic) by crushing it, diluting it with sterile saline and pushing it through the IV line with a 10 milliliter (ml) syringe. It was unknown how much of the crushed medication was given before clogging the IV tubing though approximately 1 ml was observed to be flushed into the tubing. The report stated Staff B then called Staff A, the Director of Nursing to report the clogged IV tubing and was told by Staff A at that time that she had made a medication error as that was a dangerous and incorrect route for that medication to be given. During an interview with Staff A on 01/27/2022 at 2:00 PM she stated immediately after Staff B informed her of the error, she called Resident 1's physician to find out the course of action that should be taken as she knew pushing crushed medication through the IV tubing could have serious negative outcomes for the resident. Staff A stated the physician called her back and after consulting with the pharmacy's IV department was told to observe for respiratory distress as the medication could mimic a blood clot in the pulmonary vessels or other organs. Staff A stated the physician ordered to remove the IV which was located in the back of Resident 1's hand and to monitor his respiratory status. Staff A stated she immediately suspended Staff B pending the outcome of the medication error investigation and reported the error to the resident's representatives, the Department of Health and Residential Care Services. She stated Staff B later called the facility and resigned before the investigation was completed. Multiple attempts by Residential Care Services to interview Staff B about the medication error were unsuccessful. Reference (WAC) 388-97-1060(3)(k)(iii)

Based on observation, interview, and record review, the facility failed to assess, monitor, and appropriately treat the worsening of pressure injuries, in accordance with professional standards, resulting in a stage IV pressure injury, for 1 of 1 Resident (49) who admitted to the facility with two Stage II pressure injuries, one on the coccyx (tailbone - a bone structure at the base of the spine) and one on the lower back/spine. Additionally, the facility failed to conduct appropriate monitoring and assessment for 3 of 3 residents (9, 29 and 17) in accordance with professional standards for wound treatment. This failure caused actual harm to residents (49, 9 and 29) when the facility failed to implement pressure injury treatment standards which caused increased pain, unmet needs, and diminished quality of life. Additionally, the failure increased the likelihood of serious harm or death, which constituted an Immediate Jeopardy (IJ) and the need for immediate action. On 12/13/2021 at 5:10 PM, the facility was notified of an IJ at CFR 483.25 (b)(1), F-686 Treatment Services to Prevent/Heal Pressure Injuries related to the facility's failure to ensure standards of wound treatment interventions which included, A) assessment of the pressure injuries; B) development of a care plan related to the management of the wounds; C) completion of on-going, thorough assessments to include monitoring of the injuries and changes to the treatment orders as needed; D) notification to appropriate entities and; E) implementation of preventive measures to ensure or assist in wound healing. The facility removed the immediacy on 12/15/2021 with a validation date of 12/16/2021 at 11:00 AM by implementing a removal plan with interventions to include: house-wide skin assessments; assistance and consultation which included a third party wound specialist; appropriate treatments and pressure healing interventions; training and education to facility staff and; notification to appropriate entities. Findings included . The National Pressure Ulcer Advisory Panel (NPUAP), revised February 2007, Pressure Ulcer (Injury) Stages include: * Stage I: Intact skin with non-bleachable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. May indicate at risk persons. * Stage II: Partial thickness loss of dermis (inner layer of the two main layers of the skin) presenting as a shallow open injury with a red pink wound bed. * Stage III: Full thickness tissue loss which may extend to the subcutaneous (lower most layer) tissue. * Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle .often includes undermining (wounds that extend beneath the wound opening, in just one direction) and tunneling (wounds that extend in all directions beneath the wound opening). Review of the facility's policy titled Skin Integrity Management, dated 05/26/2021 showed To promote safe and effective care to prevent the occurrence of pressure ulcers, manage treatment, and promote healing of all wounds. Staff were to continually observe and monitor the residents for changes and implement revisions to the care plan as needed. Further, the policy showed facility staff would complete a thorough review of all wounds, perform wound observations and measurements of altered skin integrity, weekly. For those wounds with anticipated decline, staff were to perform daily monitoring of wounds or dressings for presence of complications or declines and document if indicated. Finally, staff were to notify a physician to obtain orders for wound treatment and notify the dietitian, as indicated, for nutritional interventions. Resident 49. Review of the medical record showed the resident admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 49's comprehensive assessment, dated 11/08/2021, showed the resident required extensive assistance of two-persons for transfers, bed/positioning mobility and had severely impaired cognition. Review of the facility's admission assessment, dated 11/05/2021, showed two Stage II pressure injuries were identified: one on Resident 49's lower spine which measured 1 centimeter(cm) (length) by 5 cm (width) by 1 cm (depth) and one pressure injury to the right buttock which measured 2 cm (length) by 1 cm (width) with depth unknown. Additionally, the resident had very limited mobility and was unable to make significant changes in position independently. The resident was high risk for pressure injuries related to friction and shear. Review of Resident 49's November 2021 Treatment Administration Record (TAR) orders showed no treatments listed for the pressure injuries until 11/19/2021. The record showed no notification to Resident 49's primary physician or notification to a facility provider of the skin breakdown. Review of an 11/16/2021 physician visit showed the resident admitted to the facility post hospitalization for deconditioning and [CONDITION(S)] (low sodium concentration in the blood). The visit showed the resident had no skin [CONDITION(S)], rashes or altercation on exam and to schedule [follow-up appointment] in 2 months. Return sooner for any worsening problems. Review of Resident 49's nursing care plan and TAR from 11/05/2021 through 11/19/2021 showed there were no ordered treatments to the identified pressure injuries. The only note of skin issues was listed in the KARDEX (care plan directive to unlicensed staff) showed may apply house barrier to excoriated or inflamed areas [as needed]. Review of 11/08/2021 nutrition assessment showed .per nursing documentation, skin is intact, no [swelling], 25-50 % [oral] intake, receiving house supplements [three times a day] with meals . The assessment showed no pressure injuries noted nor interventions of dietary orders for intake/ nutritional management. Review of the November 2021 TAR showed initiation of wound treatment orders on 11/19/2021 (14 days after identification of the Stage II injuries) to the coccyx to cleanse with [MEDICATION(S)] (type of wound cleaner), apply Hydrogel (a paste that helps maintain a moist environment to the wound and promotes healing) and collagen powder (stops bleeding, to recruit immune and skins cells and stimulates new blood vessel formation, to promote wound healing) to wound bed, cover with super absorbent dressing (multilayer wound covering), change every Monday, Wednesday and Friday and as needed . Review of the facility's nursing skin checks showed: *11/12/2021 skin injury of the MASD (moisture acquired skin damage)- coccyx and pressure - mid back on bony prominence *11/20/2021 MASD to coccyx and pressure ulcer on mid spine . *11/26/2021 skin has tunneling pressure wound to the coccyx and pressure . * 12/11/2021 pressure on coccyx The above skin checks showed no additional documentation of the assessment of the wound to include measurements and/or the worsening of the pressure injuries . Additionally, no skin checks or assessments were shown in the medical record from 11/26/2021 through 12/13/2021. Review of Resident 49's current care plan, dated 12/13/2021, showed that the coccyx wound nor the lower spine wound had been added as an actual skin impairment problem and no interventions or treatments were listed on the care plan to treat the current pressure injuries or to prevent the exacerbation of the injuries. During a concurrent observation and interview on 12/13/2021 at 1:22 PM, the resident was in bed, and complained of pain to their bottom. Staff B, Director of Nursing Services (DNS) was observed performing wound care to the resident's coccyx wound. The wound was noted to be a circular 3 x 3 centimeter opening into a deep approximate 4-centimeter crater that had a hard white surface at the bottom of the wound bed. Staff B stated that the resident had a Stage IV (PI) . there is exposed bone on the bottom of the wound. Additionally, the wound was observed to have edges that curled under (the body thinks the wound is healed and the healing stalls). Staff B cleansed the wound with skin cleanser a mixture of hydrogel and a collagen powder was applied to the inner wound bed, calcium alginate rope (a rope dressing used in the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff B stated that due to the resident's weight loss, a recent hospitalization and time spent seated in a recliner in their room, the pressure injury had worsened since admission to the facility. Review of the medical record showed on 12/15/2021 a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Change {every Monday, Wednesday & Friday] for altered skin integrity. During an interview on 12/13/2021 at 2:26 PM with Staff B, DNS, she stated that the facility did not have a wound nurse right now and weekly skin assessments were not occurring. Staff B stated that all residents with pressure wounds or skin integrity issues were to have weekly skin assessments which should include the clinical appearance of the wound bed, measurement and dimensions of the wound, the integrity of the wound edge and exudate (pus) if present. Staff B stated the weekly assessments were not occurring, I'm unable to get to the weekly assessments. Staff B stated that the weekly assessments had not occurred since the end of October [2021]. Further, Staff B stated they had observed Resident #49's wound and changed the order to include alginate rope this morning prior to the dressing change with the surveyor. Staff B stated that they had not obtained an order from the physician, and that the medical records staff were responsible to fax the order to the physician and obtain a signature. During a telephone interview on 12/14/2021 at 7:25 AM, Resident 49's physician stated they were very familiar with the resident and that (Resident 49) was a long-term patient of mine. The physician stated they were not informed of the resident's Stage II injury until the resident was hospitalized (11/26/2021, 21 days after their admission to the facility). Since that notification, they had not been informed of any worsening of the wound. During an observation and interview on 12/14/2021 at 9:00 AM, Resident 49 was observed in their bed watching television. The resident stated that they preferred to sit in the recliner in their room, as they could see the television better, but it hurts my [bottom]. The recliner was stationed directly in front of the television, while the bed did not align to the television and the resident had to lay on their left side to view. During an interview on 12/14/2021 at 9:10 AM, Staff G, Nursing Assistant/Medication Technician, stated that they regularly cared for the resident. Staff G stated the resident enjoyed television and always watched it. However, as of a few weeks ago the resident no longer wanted to sit up in the recliner, as it caused pain to their back and bottom. Staff G did not recall the resident being out of bed for several weeks. During an interview on 12/14/2021 at 10:56 AM, Staff D, Resident Care Manager (RCM), stated that they had worked a shift last week and had changed the dressing on Resident 49's coccyx. Staff D stated it was observed to be a Stage IV with the bone visible. We used to have charts at the nurse's station and then we went paperless .There is not even a skin care plan, that falls on me. Staff D further stated, I cannot explain what happened .I know we were doing things for [Resident 49] . was getting the treatments . we just dropped the ball. When asked why the initial assessment, which showed two pressure injuries, did not integrate to the care plan or TAR, Staff D stated We are trying to figure that out. During an interview on 12/15/2021 at 9:31 AM, Staff E, Registered Dietitian stated they were not aware that Resident 49 had pressure injuries. Staff E stated the resident admitted with dietary supplements, but no other nutritional assessments or interventions had occurred. Staff E stated that the facility was to conduct weekly Nutrition at Risk (NAR) meetings, however those meetings had not occurred for several months. Staff E stated that one such meeting had occurred however Resident 49 was not mentioned in that meeting. During an interview on 12/15/2021 at 11:31 AM, with Staff A, Administrator, acknowledged the facility's failure to provide necessary treatments and services to Resident #49 which resulted in worsening of the wound and potentially other medical complications. Refer to F-580 Notify of Changes, F-658 Services to Meet Professional Standards, and F-692 Nutritional/hydration Status Maintenance. Resident 9. Review of the resident's record showed the resident was admitted to the facility on [DATE] and had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident did ot have a pressure injury on admission. The most recent comprehensive assessment, dated 09/16/2021, showed the resident required extensive assistance of one to two staff for dressing, grooming, transfers, and repositioning. The resident was non-ambulatory and required a wheelchair with staff assistance for mobility needs. During an observation on 12/09/2021 at 9:55 AM the resident was observed up in their wheelchair squirming, attempting to re-position themselves and stated that their bottom hurt from sitting on it as the wheelchair seat was uncomfortable. Observation of the resident's wheelchair cushion was noted to be approximately two inches thick and covered by a blanket. The cushion was dirty and worn out, the only cover was the blanket. During an observation on 12/10/2021 at 8:30 AM the resident was up in the wheelchair sitting in their room. The resident was squirming and stated that they were uncomfortable and wanted to lay down as their bottom hurt while sitting up in their wheelchair. Record review of the resident's November and December 2021, TARs showed the resident had a Stage III pressure injury on their coccyx area. Record review of a wound assessment showed on 11/09/2021 a Physician's Assistant ordered a referral to skilled therapies to evaluate the resident's wheelchair cushion and recommended a new pressure relieving cushion. Further record review showed after 11/09/2021 the resident's wound had not been assessed or measured for over a month. During an interview on 12/13/2021 at 2:10 PM, Staff B, DON stated that the resident had the wound for over one year and it had not healed. In addition, Staff B stated that the resident's wound was no longer under the care of the third party/ consulting wound specialists as the facility did not have time to gather all the information they required prior to the wound care visits. Staff B stated they were unaware of the order for a new wheelchair cushion to provide pressure relief and stated that the Resident Care Manager (RCM) was responsible for selecting and ordering wheelchair cushions, not the therapy department. During an additional observation on 12/14/2021 at 9:45 AM, Resident 9 was in their room up in the wheelchair sitting on the same worn cushion which remained uncovered except for a folded blanket on top. When asked if they were comfortable, the resident stated it's ok but still hurts a little. During an interview on 12/14/2021 at 2:50 PM, Staff D, RCM, stated that the facility no longer had a system in place to assess and measure wounds, it's not a good system anymore. Staff D further stated they were not aware of the PA's order on 11/09/2021 for a pressure relieving wheelchair cushion. Resident 29. Review of the quarterly assessment, dated 10/19/2021, showed that Resident 29 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . They were incontinent. The assessment showed the resident had one unstageable pressure injury and some moisture associated [CONDITION(S)]( MASD). The assessment did not show the locations of these skin issues. A progress note, dated 05/01/2021, showed that a skin check was completed and no skin injury/wounds were noted. A dietary progress note dated 05/03/2021, showed that the resident had a Stage 3 pressure injury to their left foot and two Stage 2 pressure injuries to their bilateral buttocks. An order, dated 05/04/2021, showed to apply house barrier cream to bilateral buttocks with each brief change for altered skin integrity. This order was added to the TAR, for the nurse to initial for each shift when done. Per the TAR, this order was three times a day for the last seven months. In a review of Resident 29's Electronic Medical Record (EMR), there was no documentation found that noted or defined the skin breakdown on buttocks, any description of the skin breakdown or any measurements of the affected area. Review of the the resident's 07/05/2021 care plan showed that they were at risk for and/or had actual skin breakdown including MASD, Stage III pressure injury to left side of the foot, and a history of pressure ulcers to both buttocks. Interventions included to assist the resident to turn and reposition every two hours, Prevalon boots (footwear to reduce pressure to feet) on while in bed, provide wound treatment as ordered, weekly skin assessments by a licensed nurse and weekly wound assessments to include measurements and a description of the wound. An addition to that care plan was added on 08/23/2021, for a third party wound specialist to continue to oversee care to the resident's left foot wound. Review of a 10/04/2021 assessment from the third party wound specialist, showed an unstageable pressure injury on the left foot. The note included measurements of the wound, a description of the wound and recommendations for treatment. There was no mention of any skin assessment of the resident's buttocks. An order, dated 10/04/2021, showed specific wound care to be completed three times a week and as needed for left foot wound. This care is documented on the Treatment Administration Record (TAR) that showed check marks and initials of the nurses who provided the care. There were no measurements, assessments or descriptions of the wounds, as instructed on the care plan. A note from the third party wound specialist, dated 11/10/2021, showed the pressure Injury on the left foot with measurements and a description of wound, which did not include the stage. In addition, it showed a new abscess (pocket of pus) around the existing pressure injury. There was no mention of any skin assessment of the resident's buttocks. A note from the third party wound specialist, dated 11/15/2021, showed the pressure injury on the left foot with measurements and a description of the wound. The document noted the pressure injury as unstageable. In the narrative section, it showed that the resident had a bony prominence along the area of the wounds, making it a high likelihood that the abscess formation was due to friction and rubbing. There was no mention of any skin assessment of the resident's buttocks. A note from the third party wound specialist, dated 12/14/2021, showed the pressure injury on the left foot as a Stage 4. This was the only documentation found which described the wound as a Stage 4 pressure injury. There was no mention of any skin assessment of the resident's buttocks. In a review of the resident's electronic medical record (EMR) progress notes and skin checks, no documentation was found describing the left foot wound nor any measurements of the wound by facility staff. The skin check document showed an occasional notation that the dressing was intact. The only measurements and assessments of the left foot wound were done by the third party wound specialists on: 10/04/2021 11/10/2021 (37 days later) 11/15/2021 (5 days later) 12/14/2021 (29 days later) On 12/15/2021 at 9:26 AM, the resident was observed seated in their wheelchair. They did not have the Prevalon Boots on. The resident's left foot was resting appropriately on the footrest, their right foot was extended beyond it with the back for their ankle resting against the footrest, which could cause pressure injury. On 12/15/2021 at 10:47 AM, observed Resident 29's skin with Staff N, Licensed Practical Nurse. During the observation of their buttocks, Staff N stated the skin on the resident's sacrum was red and excoriated with a small area of skin breakdown. The resident's left foot wound was closed and covered in dry, flaky skin. On 12/16/2021 at 4:29 PM, the resident was observed in bed without the Prevalon boots. In a concurrent interview, Staff I, NA, stated that they sometimes leave the boots off, to let the resident's skin get some air. Resident 17. Resident 17 was admitted to the facility on [DATE]. A quarterly assessment, dated 10/04/2021, showed that Resident 17 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment showed they were at risk for the development of pressure ulcers and had pressure reduction devices on their bed and chair. They had no pressure ulcers at that time. Per a facility incident report, completed 11/11/2021, a clear fluid filled blister/deep tissue injury was found on Resident 17's left heel on 11/04/2021. Per the report, Heels were floated/suspended, if warranted and pressure relief devices were in the bed and chair, at the time of the incident. The report further stated that the resident was often resistant to repositioning and walking, was in bed more frequently and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note, dated 11/11/2021, showed the care team discussed the recent blisters on both of the resident's heels. Per the note, contributing factors were that the resident was resistant to repositioning and just wanted to lay in bed between meals. The resident's care plan, revised 07/03/2021 showed that the resident was at risk for and/or had actual skin breakdown. Interventions included to pat the skin when drying, provide preventative skin care, observe skin for signs and symptoms of skin breakdown and weekly skin checks by a licensed nurse. The goals listed were to remain free of skin tears, bruising and signs of skin breakdown. There were no additions or revisions after the pressure ulcers were discovered, such as wound care, Prevalon boots, or to reposition every two hours. Another part of Resident 17's care plan, initiated on 03/02/2021, and walk in the hall six to seven days a week. There were no additions or revisions after the pressure injuries were discovered, such as the resident was to use a wheelchair instead of walking. related to walking. It showed that the resident was to wear non-skid shoes, walk to the dining room for meals A review of the resident's undated Kardex (a summary of a resident care needs for nursing assistants) did not include the new orders have Prevalon boots on at all times, to use a wheelchair instead of walking, and to reposition every two hours. Under the Task tab (where the nursing assistants documented care) in the EMR, Turn and reposition per resident comfort and as needed was marked as yes 41 times, Not Applicable 33 times and Resident Refused twice in the last 30 days. (11/15/2021 to 12/14/2021). Under the task tab in the EMR, Preventative skin care (protectors heel/elbow____ was not personalized for resident w/ specifics of Prevalon boots to be on at all times. This item was marked as applied 23 times, and Not Applicable 61 times in the last 30 days (11/15/2021 to 12/14/2021). A progress note, dated 11/05/2021, showed fluid filled blisters were intact. No measurements or further description of heels was included. A progress note, dated 11/06/2021, showed left and right heel have clear, liquid filled blisters. No measurements were included. A review of the progress notes and skin checks back to 11/01/2021, did not find any documentation of measurements of heel blisters or detailed descriptions of the resident's heels. On 12/14/2021 at 9:24 AM, Resident 17 was observed seated in the dining room at his table. The resident was wearing regular socks and shoes, not Prevalon boots as ordered. On 12/14/2021 at 10:03 AM, observed Resident 17 lying on their back in bed in bare feet. Prevalon boots were on the bed next to them. Staff N, Licensed Practical Nurse, lifted the resident's legs off the bed to show their heels. Both heels had blackened/purple intact tissue where they were resting on the bed. The surrounding skin color was normal. The edges of discoloration was intact and no drainage was noted on their skin or socks. In a concurrent interview, Staff N stated that they put the heel protectors on when they lay him down and sometimes in the wheelchair, so they don't push against the footrests. They further stated that Staff B, Director of Nursing documented wounds characteristics, not the floor nurses. When asked how they would know if a wound was better or worse if it's not documented, Staff N replied that they are here 5 days a week and would notice any deterioration and notify Staff B. Staff N further stated that they don't fill out any form or report for new wounds, they just tell Staff B. During an interview on 12/14/2021 at 9:28 AM, Staff N, Licensed Practical Nurse stated that if they notice any skin issues like redness, they notify Staff B, Director of Nursing. Staff B would get orders and treatments and would do the measurements, although Staff N could do if asked. They stated that the weekly skin checks were separate from ordered wound care documented on the TAR and were usually done on shower days. Staff N reported that Resident 29's left foot wound was currently closed, but kept reopening. Staff N stated that the pressure ulcers on Resident 17's heels started as clear, fluid-filled blisters, have been dry and black for about one month. They avoided pressure by having them wear Prevalon boots. During an interview on 12/16/2021 at 4:04 PM, Staff I, NA, stated that they repositioned the residents every two hours. When asked if that timing was per policy or your own personal choice, they stated both. It was the expectation if the resident was not moving on their own. If residents refuse, they would ask again later but can't make them. Staff I stated they need to reposition Resident 17, but he tends to move flat on his back again. When asked about where the nursing assistants document positioning and any interventions to relieve pressure, Staff I showed the Tasks tab in the EMR. During an interview on 12/17/2021 at 9:47 AM, when asked about the Task that states to reposition for comfort and prn, Staff H, NA, said that if a resident were lying in one place for more than a couple hours, they would help to reposition them. They further stated that Resident's 17 and 29 were often up, so they weren't sure how you could reposition someone in a wheelchair. Resident 17 had the Prevalon boots on all the time and they were usually on their back, when in bed. When asked Staff H how the nursing assistants know what care a resident should get, they responded that they usually ask the nurse, it's faster than looking through the care plan. They further stated that if they discovered a new skin issue, they would report it to the nurse. Staff H stated the nursing assistants wouldn't do any paperwork on it, but thinks the nurses do. During an interview on 12/17/2021 at 2:31 PM, Staff O, Licensed Practical Nurse, stated that if they discovered a new wound on a resident, they would chart it, tell Staff B, DNS, and the family. Reported that the nursing assistants were informed of changes in care honestly, by word-of-mouth. Staff O stated that they discovered the blister on Resident 17 heel and informed Staff B and the Physician Assistant, who was in the facility at the time. They further stated that the blister on the other heel showed up the very next day. They did not remember any pressure relief measures that were in place before the ulcers were discovered, since the resident was walking and repositioning themselves at that time. Stated that they don't normally fill out any paperwork on new skin issues. During an telephone interview on 12/20/2021 at 4:10 PM, Staff B, Director of Nursing Service, stated that they expected staff to reposition the resident's per facility protocol. They further stated that they were still learning all the policies and procedures, and planned on printing them up and reviewing with the staff, when able. When asked about the Task tab for the nursing assistants that shows to reposition for comfort and prn, they acknowledged that could be worded better. Staff B stated that when new orders were received, the floor nurse or Resident Care Manager should put them in the care plan right then and there, so the staff knew about them. When asked about the process of documenting wound measurements and descriptions, they stated they used to do it weekly, but then stopped. They got behind and didn't get them done, as they should have. Reported they've requested that the third party wound specialists would start following any residents with non-healing wounds. Since the third party wound specialists were already seeing Resident 29, were they also following the skin care to their sacrum? Staff B said that they weren't aware it was an issue, although they had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . When the surveyor reported Staff N's description of the area during the observation on 12/15/2021, Staff B verified that was a Stage 2 pressure injury and that Staff B should have been informed. They stated that residents should have been repositioned, if not doing it on their own. When the surveyor informed them that no update to add the pressure injuries on Resident 17's heel, or the new orders (Prevalon boots, no walking and use wheelchair instead, repositioning every 2 hours) to the resident's care plan had been done, they acknowledged that they should have updated the care plan with the new orders. Reference WAC: 388-97-1060 (3)(b)

Based on observation, interview, and record review, the facility failed to ensure residents received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one of three residents (29) investigated for Position/Mobility. This failure resulted in actual harm to Resident 29, who developed significant contractures (a shortening of a muscle or joint, causing loss of joint motion), functional loss in their upper extremities. Findings included . Resident 29. An admission assessment, dated 07/24/2019, showed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Range of motion (ROM) refers to the amount of movement in a joint. Passive range of motion (PROM) refers to when someone else moves a joint. A palm protector refers to a device to prevent severe finger contractures from causing pressure ulcers in the palm of the hand. A hand splint is a type of palm protector. An occupational therapy evaluation note, dated 01/23/2020, showed the resident had a mild impairment of their fine motor coordination (ability to control the small movements of the hands and fingers). On 12/08/2021 at 10:01 AM, Resident 29 was observed sitting in a wheelchair in the Dining room. Their elbows were bent and forearms were up against their chest. Both wrists were tightly flexed downwards, and all their fingers were tightly clenched around rolled washcloths in their hands. During an interview on 12/17/2021 at 2:52 PM, with Staff D, Registered Nurse, Resident Care Manager ,stated that Resident 29 did not have any contractures when admitted to the facility. A Restorative Nursing/Functional Maintenance referral, dated 02/17/2021, showed instructions for PROM to both upper extremities and to use palm protectors or splints to both hands, to maintain joint mobility. A care plan related to ROM was initiated on 03/02/2021. Interventions included passive ROM. There was no direction about how often or how long the exercise was to be done. The goal was to maintain skin integrity and avoid further loss of ROM. This care plan item had not been revised since it was first initiated. A care plan evaluation progress note, dated 06/14/2021, showed that the resident currently had contractures and that ROM was used to prevent further contractures. It further showed no changes were necessary to the plan. Additional observations of Resident 29 with rolled washcloths in his hands were noted 12/13/2021 at 11:28 AM and 12:35 PM. During observations made in facility between 12/08/2021 and 12/17/2021, the surveyor did not observe staff performing PROM on Resident 29. During an interview on 12/16/2021 at 4:04 PM, Staff I, NA, stated that the facility used to have two Restorative Aides, but now only had one, Staff Q, NA/Restorative Aide. If Staff Q was not working, the NA's working on the floor were supposed to do restorative care. When asked about the resident's hand contractures, Staff I said they used to have splints, but staff used rolled up washcloths instead. Staff I stated it was painful for the resident to have their hands and fingers touched. Staff I, NA said that the nursing assistants documented the ordered care under the Tasks tab, and showed the surveyor in the computer. A care plan related to splints was initiated on 03/02/2021. Interventions included to apply splints in the morning and remove them at bedtime. The goal was to tolerate the splint, reduce further loss in range of motion and to maintain skin integrity. This care plan item had not been revised since it was first initiated. In a review of the Tasks tab for 11/22/2021 through 12/21/2021, the Splint/Palm Guard is listed as applied on 15 of the last 30 days. The entries for Splint/palm guard removed and record of tolerance were either response not required or Not applicable on 28 of the last 30 days. The response of Good/fair/poor tolerance was not checked for any of the last 30 days. Observations of Resident 29 without rolled washcloths in their hands, were noted on 12/09/2021 at 10:10 AM; 12/10/2021 at 9:01 AM and 11:29 AM; 12/14/2021 at 12:25 PM; 12/15/2021 at 9:26 AM, 10:07 AM and 1:30 PM; 12/16/2021 at 9:59 AM, 4:00 PM and 4:29 PM; and 12/17/2021 at 10:08 AM. During an interview on 12/17/2021 at 9:47 AM, Staff H, NA, stated that they had been working at the facility for about three weeks and were taking care of Resident 29. They reported that they weren't doing anything for the resident's hand contractures. Staff H further stated that they knew what care the residents got by asking the nurse instead of looking through the care plan, it's faster. During an interview on 12/17/2021 at 12:38 PM, Staff R, Director or Rehabilitation/Physical Therapy Assistant, stated that therapy had been working with the resident due to their contractures and had obtained splints for their hands and elbows. They reported that therapy had discharged the resident about six months ago and had made recommendations to Restorative therapy, which included PROM. Staff R said that the contractures were not measured, to compare if they were getting worse or not. During an interview on 12/17/2021 at 2:52 PM, with Staff D, Registered Nurse, and Staff K, acting Restorative Manager, Staff K stated that they were working on splints, braces and PROM for Resident 29. If Staff Q, Restorative Aide was not working, both stated that PROM did not get done. When asked how often PROM was ordered, Staff K looked in the resident's chart and said that there was not a frequency listed. They further stated that Resident 29 had received therapy 13 times in the last 30 days, per the Tasks tab. Per Staff D, the resident probably doesn't get therapy as often as he should, as Staff Q frequently is reassigned to work the floor. When asked about the splints, Staff K said that sometimes hand splints may just mean rolled up washcloths. They further stated that Resident 29 did not have any contractures when admitted to the facility, and if contractures were left untreated, they would worsen and their fingernails could dig into their hands. During a telephone interview on 12/20/2021 at 4:10 PM, Staff B, Director of Nursing Services, stated that even if Staff Q was not working, PROM should have been done by the NA's working on the floor. Reference: WAC 388-97-1060(3)(d)

Based on record review and interviews the facility failed to ensure staff provided the necessary supervision to prevent accidents for one of three residents (#1) reviewed for falls. This deficient practice resulted in actual harm to Resident #1, who fell in the facility within ,[DATE] minutes following readmission to the facility from the hospital, due to a previous fall in the facility with substantial head injuries. Resident #1 sustained further head trauma with resultant significant changes in condition. Findings included: Resident #1. review of the resident's medical record revealed [REDACTED]. Review of the resident's plan of care, dated [DATE], showed the resident was at risk for falls due to cognitive loss. As noted per plan of care, dated [DATE], the resident was independent with toileting and ambulation. Review of a facility investigation report showed on [DATE] at 1:50 PM the resident was found lying on his stomach on the floor, following a fall. He sustained a laceration to his right forehead with dilated pupils and noted decrease in level of consciousness. The resident was immediately transferred to the emergency room . The investigation noted the resident had been independent with ambulation prior to the fall, and had not had a fall in the facility since November, 2016. The investigation concluded the resident possibly caught his toe and tripped, causing him to fall forward onto the floor. Review of hospital records, dated [DATE], showed the resident sustained [REDACTED]. The resident remained under close hospital monitoring until [DATE], when he was readmitted back to the facility. Further review of hospital records revealed the resident received four doses of Ativan, medication used to treat anxiety, on [DATE] and received Zyprexa, an antipsychotic medication, at bedtime between ,[DATE]-,[DATE]. Review of hospital nursing documentation between ,[DATE]-,[DATE] revealed the following: [DATE] at 10:34 PM - resident alert/restless, appears to be disoriented, does not answer questions or follow commands; when awake constantly attempting to grab at objects and urinary retention catheter [DATE] at 4:27 AM - resident alert but very confused and restless at times; resident impulsive and does not follow commands, required two person maximum assistance [DATE] at 9:56 AM - following simple commands, remained somewhat impulsive and was up most of the night [DATE] at 2:32 PM - resident alert and confused, difficulty following commands, one to two person assist with gait belt and wallker, maximum assist for activities of daily living and transfers; impulsive - continually pulling on catheter [DATE] at 2:31 PM - resident alert - disoriented to place, time, and situation; follows commands occasionally, intermittent anxiety, pulls on catheter and wrist bands; Ativan given for anxiety [DATE] at 11:32 PM - Ativan not as effective shift - awake, anxious, jumping .difficult to redirect, pulling at catheter most of the shift Review of Progress Notes, dated [DATE] at 3:02 PM, showed the resident was readmitted to the facility. He was assessed as being at high risk for falls. A facility investigation report noted on [DATE] at 3:30 PM, shortly following readmission to the facility, the resident had been placed in bed approximately 30 minutes prior to falling, with a pressure pad alarm under him and the bed in low position. The alarm sounded and the resident was found by staff seated on the floor by the room door with his back and head leaning against the wall. He had sustained an abrasion to the top of his head, measuring four by four centimeters, and left knee. The investigation concluded the resident had attempted to ambulate independently and fell due to recent changes in his condition: change in mobility, blood pressure, and abnormal labs, with poor safety awareness and confusion. The resident's family member was notified of the fall and requested to keep the resident in the facility on comfort measures. Review of PN's following the fall on [DATE] showed the resident had a few episodes of vomiting, was restless despite administration of Ativan, and attempted to get out of bed on several occasions. He was placed on one to one staff monitoring following the fall on [DATE]. Due to significant changes in his condition he expired at 11:30 AM on [DATE]. A telephone interview on [DATE] at 9:00 AM with the resident's family member revealed that during the transport of the resident from the hospital to the facility on [DATE] he attempted to get out of the wheelchair, and had fallen in the transport van. The van driver stated during a telephone interview on [DATE] at 9:21 AM he had transported the resident to the facility from the hospital. During that time the resident had released his seat belt and transferred himself from the wheelchair to another seat in the van. When the driver instructed the resident to return to his wheelchair he stood up and landed slowly on the floor of the van on his left side. He did not hit his head during the fall, however was anxious during the transport. He was unable to recall if he had informed staff of the resident's fall and anxiety. Staff A, Registered Nurse, stated on [DATE] at 9:30 AM, he had met the resident and van driver upon the resident's readmission to the facility on [DATE]. He stated the van driver did not inform him of the resident's fall in the van. However, despite the 75 mile van trip Staff A did not question the van driver as to the resident's condition during the transport. Staff A also stated on [DATE] at 3:40 PM that when he placed the resident into his room the resident took off his seatbelt and stood up unassisted. Two staff members then assisted him to bed. Staff A stated the resident was not following directions well, and when he stood up he was weaker with a stooped type posture. He stated the resident used to stand upright. Interviews on [DATE] at 2:05 PM, 2:45 PM, and 3:30 PM with Staff B, Registered Nurse, showed that upon observing the resident coming down the hall on [DATE], following the van ride from the hospital, he was somewhat restless and fidgeting with his seatbelt. Due to his behaviors and recent fall Staff B made the decision for the resident to receive one to one monitoring by Staff C, Nursing Assistant. She stated Staff C was told to stay with the resident, and she felt Staff C understood her instructions. An interview on [DATE] at 2:25 PM with Staff D, Nursing Assistant, revealed the information she had received on the resident following readmission was he no longer was able to walk and required two person assistance. She stated Staff A had informed the three caregivers they could not leave the resident alone, and had told Staff C to provide one to one monitoring of the resident. The resident was only in the facility approximately 30 minutes on [DATE] prior to his fall. When the resident was observed following the fall Staff D stated, Where's (Staff C) as he was to be one to one with the resident. Staff C, Nursing Assistant, stated on [DATE] at 3:05 PM, he was aware staff was told to keep an eye on him (the resident), to be a team effort. He stated that if Staff B had instructed him to provide one to one monitoring immediately following the resident's readmission he did not hear it. Staff C stated the resident should have received one to one monitoring due to his previous injuries. At the time of the resident's fall on [DATE] Staff C was at the other end of the hallway obtaining vital signs on other residents. Reference (WAC) [DATE](3)(g) This is a repeat deficiency from the Statement of Deficiencies dated [DATE].

Based on record review and interview, the facility failed to provide appropriate, timely care and services to 1 of 4 sampled residents (#1) who exhibited a change of condition. The lack of monitoring/assessments, and timely reporting of a significant change in condition to the physician, resulted in delayed treatment and unnecessary pain for Resident #1. Findings include: Resident #1: admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a facility investigation report and the resident's medical record revealed on 8/19/14 at 8:50 a.m. Staff A (Nursing Assistant) was wheeling the resident out of the dining room in his wheelchair. Initially, the resident was holding both feet up, however he dropped his right foot as the wheelchair was moving forward, and his foot got caught under the wheelchair. Documentation stated Staff A heard a "pop" and the resident cried out in pain. A review of the resident's medical record revealed [REDACTED]. However, the fax did not reach the physician's office, so a second fax was sent at 12:45 p.m. on 8/19/14. A physician's orders [REDACTED]. The x-ray was not completed until the following day (8/20/14) at approximately 1:00 p.m., with results identifying a fractured right ankle. review of the resident's medical record revealed [REDACTED]. swollen. Review of documentation on 8/20/14 at 5:20 p.m. by the physician (upon his exam of the resident in his office), noted the resident grimmaced at any attempt to move or touch his right ankle. There was moderate swelling noted and range of motion was limited due to the swelling. During an interview with the resident on 8/28/14 at 1:30 p.m. he was able to accurately explain how the incident occurred. He stated he had pain in his ankle following the incident especially when he moved his foot. A telephone interview on 9/3/14 at 11:20 a.m. with Staff A revealed the resident seemed to be in pain following the incident and he could tell he was "distressed." He stated when he questioned the resident relative to any pain the resident acknowledged he had pain. He described the resident as being "stoic" and not a complainer. Staff B (Licensed Nurse) stated during an interview on 8/28/14 at 4:30 p.m. that when they laid the resident down on his bed immediately following the incident his ankle was just starting to swell. She stated the resident complained of pain so staff decided to get an x-ray order. A telephone interview conducted with the resident's spouse at 3:45 p.m. on 9/2/14 revealed she routinely visited the resident at the facility twice daily. She had seen the resident at approximately 10:30 a.m. on 8/19/14 and stated his pain was "very bad, and his ankle was big." Despite the above documentation and interviews with staff relative to the resident's right leg/ankle pain, review of his Medication Administration Record [REDACTED]. The resident experienced harm as evidenced by increased swelling, a decrease in mobility, and susbstantial unrelieved pain.

Based on record review and interviews the facility failed to ensure adequate supervision was provided to prevent accidents for 1 of 3 residents (#1) reviewed for falls. Resident #1 was left unattended by staff in her wheelchair in the dining room despite significant changes in her condition. During that time she fell out of her wheelchair onto the floor and sustained a fractured hip. Findings include: Resident #1: admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Rerview of a facility investigation report dated 4/16/14 at 1:56 a.m. revealed the resident was on the floor of her room with the right side of her head covered in blood. She stated she had fallen and landed on her nose. Due to her complaints of right hip pain and noted swelling to her forehead she was transferred to the emergency room (ER). The investigation report stated the resident had no previous history of falls. She had been independent with ambulation and toileting. Review of hospital records dated 4/16, 17/14 noted the resident had a seizure while in the ER and was given Ativan (antianxiety medication with side effects which included drowsiness, dizziness, confusion, and blurred vision). She was transferred from the ER to a hospital room at 7:50 a.m. on 4/16/14. A personal alarm was placed on the resident at that time to alert staff. At 8:55 a.m. on 4/16/14 she had another seizure for which she was again given Ativan. Documentation stated at 4:07 a.m. on 4/17/14 she was found trying to climb out of bed, thus she was moved to a room closer to the nursing station for closer observation. Documentation at 8:00 a.m. that same morning noted the resident was confused at all times and was impulsive at times. A Nursing Assistant sat with the resident in her room and "frequent rounding" was required. review of the resident's medical record revealed [REDACTED]. Review of Progress Notes dated 4/17/14 at 3:45 p.m. revealed the resident returned from the hospital in a wheelchair. She was only able to stand briefly on the scale to obtain her weight. Review of a facility investigation report dated 4/17/14 at 7:00 p.m. revealed the resident was found on the floor in the dining room on her left side next to her wheelchair. Her pressure pad alarm was sounding which had alerted Staff A (Licensed Nurse) who was walking towards the dining room. The resident complained of severe left hip pain, thus was sent to the ER. X-ray results revealed she had a fracture of her left hip. A telephone interview on 5/2/14 at 2:05 p.m. with Staff A revealed there was no staff in the dining room at the time of the resident's fall on 4/17/14. A pressure pad alarm had been placed when the resident returned from the hospital as she was weaker and needed "alot more verbal cues." Staff A stated the resident was "way more confused than before" her hospitalization . She stated she administered the evening dose of Dilantin at 5:00 p.m. that evening (4/17/14). On 5/6/14 at 2:10 p.m. Staff B (evening shift Nursing Assistant who cared for the resident on 4/17 and prior to her hospitalization on ,[DATE]) was interviewed. She stated that prior to her hospitalization the resident was independent with ambulation and feeding. Her speech was clear and she could tell staff what she needed. She would ask for the bathroom and staff would show her where it was located and she then self toileted. Upon her return from the hospital on [DATE] she required two staff members to assist her from the car into a wheelchair and was only partial weight bearing. At that time she appeared like she was drowsy from medications. She stated the resident was "very different" that evening. She was "very confused," and became very upset in the dining room calling staff names and yelling at them. She required total assistance with eating and it appeared she had forgotten how to chew her food. Despite the resident's recent hospitalization with new [DIAGNOSES REDACTED].

Based on record review and interview, the facility failed to ensure 1 of 3 sampled residents (#1) with choking incidents received food in accordance with their assessed diet and texture. Resident #1 was provided a soft sandwich which resulted in a choking incident that was determined to be a factor in his death. Findings include but were not limited to: Resident #1: Review of the medical record revealed the resident was admitted to the facility on [DATE]. His medical [DIAGNOSES REDACTED]. The resident's plan of care identified he was on a restorative feeding program. At the start of the meal the resident was allowed to take 1-2 bites. Then, he was to be assisted with the remainder of his meal due to his choking risks. The resident required nectar thick liquids with straws for all drinks. The 10/25/13 physician's orders [REDACTED]. The plan of care also identified a risk for choking with oral intake. The resident tended to over-feed himself and eat too fast. Staff were to feed the resident to prevent him from over-stuffing his mouth. He was to be allowed plenty of time to chew and swallow before the next bite. Speech therapy services were available when needed. The plan of care also identified the resident wandered throughout the facility (typically in his wheelchair) and exhibited agitation at times. According to an 11/14/13 facility investigative document, Resident #1 had a choking episode during his meal. Although he received the appropriate diet, he was "groggy off and on during the meal" and dozed off while eating resulting in a choking incident. Staff performed the [MEDICATION NAME] maneuver (thrusts applied to the stomach area to aid in forcing food out of the airway) and he was able to clear his airway. The resident lost consciousness, was provided oxygen, and gradually returned to baseline. An 11/14/13 physician's orders [REDACTED]. The resident received multiple courses of speech therapy over time to treat the resident and assess the appropriateness of his diet. Facility investigative documents, dated 12/18/13, noted the resident was provided with a "mechanical texture instead of pureed texture." Kitchen staff had placed the mechanical texture instead of the puree texture. The resident was feeding himself while the staff member was feeding another resident. The resident appeared to have [MEDICAL CONDITION] activity. Staff did a finger sweep, removed the food in the resident's mouth, and suctioned the resident. The [MEDICATION NAME] maneuver was performed and he was able to cough. Emergency 911 services were obtained and the resident was taken to the hospital emergency room for evaluation. Speech therapy services were provided after the choking incident. The resident's diet remained unchanged. Review of a 3/28/14 nursing entry by Staff Member A, a licensed nurse (LN), revealed at around 2:00 a.m. Resident #1 was restless and was up sitting at the nurses' station with two of the nursing assistants (NAs), Staff Member B and Staff Member C. At 3:00 a.m. Staff Member B placed a call to the nurses' station and requested assistance from the nurse as the resident was not doing well. Upon arrival the resident was pale and ashen. Staff Member C stated the resident seemed to have choked and he was performing the [MEDICATION NAME] maneuver. The LN extracted sandwich from the resident's mouth and throat (not part of a puree diet). The resident's face was "becoming more pale so 911 was called. The resident's pulse was "weak and thready" and respirations were "shallow and < (less than) 4 BPM (breaths per minute)." There was no notation of the resident's oxygen saturation or use of oxygen (to be used for decreased oxygen saturation levels). The nursing entry further stated the paramedics arrived and tried to resuscitate him but had no success. He was pronounced dead at 3:20 a.m. on 3/28/14. The facility investigation for the 3/28/14 choking incident revealed Staff Member B offered the resident pieces of an egg salad sandwich, a mechanical soft diet, instead of a pureed diet as required. After the third piece of the sandwich, Staff Member B saw an acute change in the resident's color, facial expression, and lack of response. Staff Member B presumed the resident had choked and summoned assistance from a LN and a NA co-worker. Staff Member B was not aware the resident was to receive a puree texture diet. Review of Resident #1's Kardex, with caregiver directives, identified the resident's diet as "House" and "Mechanically Altered Diet." Resident #1's Washington State Certificate of Death, dated 3/28/14, identified the resident's immediate cause of death as "Cardiac [MEDICAL CONDITION]" and Choking (the underlying cause, disease or injury that initiated the events resulting in death)." On 4/08/14 at approximately 2:45 p.m. the Speech Therapist stated Resident #1 could not safely handle diets other than the puree diet. Staff needed to ensure the resident received the appropriate diet and had a straw while drinking. Staff Member B was interviewed on 4/08/14 at approximately 10:20 p.m. and stated the resident was up on 3/28/14 during the night and was restless. The resident stated he was hungry and she took him to the dining room to get him something to eat. Staff Member B stated she knew he required thickened liquids but was not aware of where the information on the resident's diet was kept. She had seen him eating a sandwich at night in the past and gave him an egg salad sandwich on 3/28/14. She broke the sandwich into 1/4 sections. There was a change after she provided the third 1/4 of the sandwich. He wheeled toward her, had only a raspy voice, and his eyes were wide. She perceived the resident was choking so summoned help from the nurse and other NA. They provided back thrusts and the [MEDICATION NAME] maneuver but no oxygen was applied. The resident appeared to be breathing. Staff Member C was interviewed on 4/08/14 at approximately 10:35 p.m. He recalled responding and initiating the back trusts and [MEDICATION NAME] maneuver when summoned on 3/28/14. Staff Member C stated did not recall the resident talking and noted his breathing was "lighter and at a slow rate." No oxygen was used. Staff Member C stated he had forgotten the resident was on a puree diet and recalled seeing the resident eating a sandwich at night sometime in the previous month (approximately timeframe). When interviewed on 4/10/14 at approximately 10:30 a.m., Staff Member A recalled that on 3/28/14 she was called by Staff Member B who reported something was wrong with Resident #1. Staff Member A responded quickly. Upon arrival, she noted the resident was pale and his eyes were bulging. Staff Member C was performing the [MEDICATION NAME] maneuver. He reported to Staff Member A that the resident had been eating a sandwich. Staff Member A was aware the resident required a puree diet and had history of choking. She extracted food out of the resident's mouth. The resident's vital signs were taken. His pulse was weak and thready, recalled as less than 30 beats per minute and his respirations were less than 4 per minute and were not full breaths but were more like "a sigh." No efforts were made to suction the resident's airway or to provide oxygen. However, 911 was called and Staff Member A stated she took direction from the 911 dispatcher until the paramedics arrived. The facility failed to maintain a system that ensured the resident consistently received the appropriate diet. Deviations from his diet resulted in choking that eventually contributed to his death.