Every finding on record at Lea Hill Rehabilitation and Care Center

Based on observation, interview and record review the facility failed to implement their abuse policies and procedures including identification of an allegation of verbal abuse and neglect, protecting residents after an allegation of verbal abuse and neglect, making required notifications, logging the allegation on the abuse/incident log, completing an incident report, a thorough investigation, and post incident resident monitoring for psychological harm for 2 of 2 residents (Resident 1 & 2) reviewed for staff and resident incidents. These failures placed all residents at risk for unidentified abuse and neglect, on-going abuse, and diminished quality of life.Findings included.Review of the 10/05/2022 facility Abuse, neglect and Exploitation policy showed the facility would provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse and neglect. The policy showed verbal abuse was defined as the means of oral, written or gestured communication that willfully includes disparaging (belittle, demeaning, disrespectful) and derogatory terms towards residents regardless of their age or ability to comprehend. The policy defined neglect as failure to provide goods and services to a resident that were necessary to avoid physical harm, pain, mental anguish, or emotional distress. The policy showed the facility would have written procedures to assist staff to identify different types of abuse, an immediate investigation would be warranted when suspicion or reports of abuse or neglect occurred, the investigation would identify and interview all involved persons including witnesses and others that may have knowledge of the allegations, provide complete and thorough documentation of the investigation, staff would respond immediately to protect the alleged victim, and report immediately, but not later than two hours after the allegation was made if the events that caused the allegation involved abuse. <Resident 1>Review of the 04/28/2026 Minimum Data Set (MDS, an assessment tool) showed Resident 1 had mild cognitive impairment, was able to make their own decisions, and had diagnoses including heart failure, shortness of breath, and chronic respiratory failure that required Resident 1 to use oxygen continuously. The MDS showed Resident 1 was dependent on staff for toileting hygiene and transfers to/from bed to wheelchair and on and off the toilet.Review of a 04/08/2026 Activities of Daily Living (ADL) self-care deficit care plan showed Resident 1 required up to two-person assistance with dressing, toileting, and transfers. A 11/18/2025 at risk for falls care plan showed Resident 1 was at risk for falls due to poor balance, poor endurance, shortness of breath, and impaired strength.Review of a grievance form dated 05/06/2026 showed Staff D (Resident Care Manager/Licensed Practical Nurse (LPN)) filled out the form for Resident 1 for an incident that occurred on 05/05/2026 in the evening. The grievance showed Resident 1 had concerns that Staff G (Certified Nurse Assistant) assisted them to the bathroom without their oxygen, left them on the toilet and the resident had to walk themselves back to their bed, and Staff G told Resident 1, I should not have to help you, you can take yourself.Review of Resident 1's nursing progress notes dated 05/05/2026-05/12/2026, showed no indication the facility documented the incident, reported the allegation to the Physician, and monitored the resident for psychological harm post incident.Review of a 05/07/2026 Grievance Investigation Report, showed Staff B (Director of Nursing) interviewed Resident 1 regarding their concerns about staff conduct and assistance with care needs. Resident 1 told Staff B they requested a nightgown from Staff G, they left the room, came back and tossed the nightgown towards the resident. Resident 1 told Staff G they needed assistance with their nightgown and Staff G placed it on Resident 1's lap and did not assist the resident to put on the gown. Resident 1 told Staff B that Staff G stated, what else do you want? and Resident 1 requested assistance to the bathroom and Staff G responded, you look perfectly capable of doing it by yourself. Resident 1 told Staff G they were not cleared to ambulate independently by physical therapy and recently experienced four falls, Staff G left the room, did not return, and Resident 1 had to urgently use the bathroom, ambulated themselves without assistance, and made it to the bathroom but was dizzy and weak from not wearing their oxygen. Resident 1 stated they activated their call light in the bathroom, Staff G returned and stated to Resident 1, Oh, so I see someone learned to use their legs. Resident 1 told Staff B these interactions made them feel unsafe, unsupported and concerned about their well-being and informed Staff D who assisted them to fill out a grievance form.In a phone interview on 06/16/2026 at 11:30 AM Resident 1 stated Staff G refused to assist them to the bathroom, they had no choice but to ambulate without assistance to the bathroom because they were afraid, they would have an accident and wet themselves. Resident 1 stated it made them angry and upset because Staff G didn't listen to what they had to say, was unprofessional, it took them a lot longer to get themselves to the toilet, they were not cleared by therapy to ambulate alone, and they were taking the risk of falling.<Resident 2>Review of a 04/27/2026 admission MDS showed Resident 2 was able to make their needs known, own decisions, had no cognitive deficits, and had diagnoses including acute respiratory failure, diabetes, and a neurological disorder. The MDS showed Resident 2 was dependent on staff for toileting hygiene, lower body dressing, bed mobility, and transfers to/from the bed.Review of a 04/20/2026 ADL self-care deficit care plan showed Resident 2 required assistance with bed mobility, bathing, dressing, and transfers. A 04/20/2026 fall risk care plan showed Resident 2 was at risk for falls related to impaired vision, impaired strength, pain, and shortness of breath with exertion.Review of a grievance form, dated 05/07/2026, showed Staff H (Social Worker) filled out a grievance form for Resident 2 that showed on the evening of 05/05/2026 Resident 2 had felt that Staff G was disrespectful. Resident 2 told Staff H that they requested assistance from Staff G who was on their cellphone the whole time. Resident 2 called again to get assistance with picking a remote off the floor and Staff G told Resident 2, you call too much, picked up the remote and left the room.Review of Resident 2's nursing progress notes dated 05/05/2026-05/12/2026, showed no indication the facility documented the incident, reported the allegation to the Physician, and monitored the resident for psychological harm post incident.Review of a 05/07/2026 Grievance Investigation Report showed Staff B interviewed Resident 2 regarding concerns of feeling disrespected by Staff G. Staff B documented that Resident 2 stated during their interactions with Staff G, staff remained on their cell phone, they had concerns regarding the interactions and reported their concerns to staff. The grievance investigation report showed Staff B would interview staff and review Resident 2's medical record.Attempts to interview Resident 2 on 06/16/2026 at 1:08 PM were unsuccessful as the resident had been discharged from the facility and no return call was received.Review of a 05/07/2026 investigation summary showed Staff B documented the facility received allegations on 05/07/2026 from two residents regarding Staff G's disrespectful communication, failure to provide requested assistance, distracted care while speaking on the phone, Resident 1 attempting ambulation without assistance despite a history of falls and need for oxygen therapy, and both resident's perceptions of these interactions as dismissive and demeaning. The summary showed that Staff G was immediately removed from assignment involving the resident's who reported concerns and nursing leadership had initiated staff interviews, review of relevant documents, the investigation remained on-going, and additional interviews, documentation review, and determination findings would be completed in accordance with the facility policy and regulatory requirements.Review of a 05//12/2026 investigation conclusion showed Staff B reviewed all information, statements, and could not substantiate the allegations, as the findings were inconclusive and based on conflicting accounts between the resident and Staff G who denied all allegations made against them.Review of the May 2026 facility abuse log showed no indication staff logged Resident 1 and Resident 2's allegation of verbal abuse and neglect.Review of Staff G's timecard showed on 05/05/206, the date the allegation was received by Staff D, that Staff G worked 6:01 AM-2:05 PM in the memory care center and 2:10 PM-10:04 PM in the care center. The documentation showed Staff G was not removed from all resident care after the allegation was made in the evening and was allowed to continue to work with other residents. The timecard showed on 05/06/2026 and 05/07/2026 Staff G worked both days from 6:00 AM-2:00 PM in a memory care unit, indicating they were not removed from the floor after the allegation and continued to work with other residents.In an interview and observation on 06/04/2026 at 1:08 PM Resident 3 was observed sitting in their wheelchair knitting. Resident 3 stated there was a female staff member, they did not recall their name, but the staff member was on their cell phone during care. Resident 3 stated they were on the toilet and the staff was not aware as they were distracted by their cell phone. Resident 3 stated this made them upset, they hate to complain, ended up sitting on the toilet for 20 minutes, and the staff member told them, You are okay, I'll be back. Resident 3 found it offensive, stated cell phones should not be allowed in the care area, and left in the breakroom.In an interview on 06/04/2026 at 1:34 PM Staff E (Registered Nurse, RN) stated verbal abuse was being rude, yelling, or raising your voice and neglect was when care services were not provided to the resident. When asked what they would do when a resident made a statement that a staff member was rude and refused to toilet them, Staff E stated they would first talk to the resident, then talk with staff, and then report to the management who would have a meeting to discuss the incident. When asked if the staff member should be removed from the floor, Staff E stated the staff would be restricted from going into the room of the resident who made the complaint and if it was a serious complaint then they would remove the staff from the floor. When asked how to identify a serious complaint from a not serious complaint Staff E stated it depended on how upset the resident was. When asked how they would ensure the staff did not continue to verbally abuse and neglect other residents if they were allowed to continue to work on the floor, Staff E then stated the staff should be removed from the floor.During an interview on 06/04/2026 at 1:45 PM, Staff F (Licensed Practical Nurse, LPN) stated verbal abuse was anything that hurt a resident's feelings, like being rude, yelling, acting bothered by the resident's requests and neglect was not providing care to a resident who needs the care. Staff F stated if a resident alleged verbal abuse or neglect they would talk to the resident, talk to the staff and remove the staff from caring for the resident who made the complaint. Staff F stated if it was unsafe then they would send the staff member home. When asked how they determined if it was unsafe, Staff F stated they would talk with the resident and see their behavior, if the resident felt unsafe, they would send the staff member home. When asked how they would ensure the staff member did not continue to verbally abuse or neglect the other residents if not sent home, Staff F hesitated and stated the staff member should be sent home after a resident made an allegation or complaint that was considered abuse.During an interview on 06/04/2026 at 1:51 PM Staff C (Infection Preventionist/LPN) stated staff should have but did not remove Staff G immediately after the allegation was made on 05/05/2026 to ensure all residents were protected from abuse. Staff C reviewed Resident 1 & Resident 2's medical record and stated there were no progress notes on the incident, no documentation of physician notification, and no documentation of post incident monitoring for psychological harm, no social services follow-up after the incident, and would expect the documentation to be in the resident's records. Staff C reviewed the abuse/incident log and stated the allegations for both Resident 1 and Resident 2 were not but should be on the abuse log. When asked to provide staff interviews for the investigation, Staff C stated they did not know if Staff B had completed staff interviews for the investigation, could not find staff interviews, and would expect staff working on 05/05/2026 to be interviewed about witnessing any events or interactions related to the allegations.In an interview on 06/04/2026, Staff A (Administrator) stated they could not produce documents but would expect a thorough investigation, an incident report to be completed, thorough documentation of the incident including physician notification, resident alert charting and monitoring for psychological harm, an allegation of neglect or abuse to reported immediately, and the staff removed from the floor immediately following the allegation. REFERENCE: WAC 388-97-0640(2)(b)(5)(6)(a-b)

Based on observation, interview and record review, the facility failed to ensure 2 of 2 residents (Resident 8 & 7) reviewed for English as a second language, were provided a functional communication system. Failure to provide and follow the services which enhanced and/or ensured effective communication placed the residents at risk for unmet care needs, social isolation and a diminished sense of well-being. Findings included .<Policy>According to the facility policy titled, Culturally Competent Care, dated 09/18/2025, showed the facility would treat each resident with dignity and respect. The policy showed the facility would identify unique cultural characteristics such as language and implement appropriate communication assistance methods. The policy showed staff would consistently implement the communication methods in place for resident with each interaction.<Resident 8> According to the 07/08/2025 Quarterly Minimum Data Set (MDS – an assessment tool), Resident 8 admitted to the facility on [DATE] with multiple medical conditions including heart failure and kidney failure and had no memory issue. The MDS showed Resident 8 had clear speech and made self-understood and able to understand others. The MDS showed Resident 8’s preferred language was not English and needed interpreter to speak with health care staff. Review on 03/04/2025 revised communication Care Plan (CP) showed Resident 8 had communication problem related to language barrier and Resident 8 spoke their preferred language. Interventions included instructions for staff to use phone translator through google and to use the language line interpretive services. Observation and interview on 09/15/2025 at 8:55 AM, Resident 8 was lying in bed in their room, door was open, and Resident 8 was talking to this surveyor in their preferred language. Resident 8 did not understand English at all. Resident 8 talked in their language and interpreted in English on their phone. Resident 8 could not understand the surveyor in English. Observation on 09/15/2025 at 9:02 AM and 11:37 AM nursing staff visited Resident 8 in their room and did not use phone or interpreter while providing medications and care. Observation on 09/16/2025 at 9:41 AM showed Resident 8 was lying in their bed, their door was open, and Resident 8 was screaming loud in their language. Observation on 09/16/2025 at 9:45 AM showed Staff F (Registered Nurse) walked in the hallways and stayed in front of Resident 8’s room in hallways, told the resident in English to use the call light and went back to the medication cart. Observation on 09/16/2025 at 9:48 AM showed Staff F came back to Resident 8’s room, talked to the resident in English, gave them call light and bed controller to use. The observation showed Staff F did not use any device to communicate and Resident 8 was still screaming in their language. Finally Resident 8 stated, “Peepee” and pointed toward their incontinent brief. Staff F stated in English that they would send an aide to help them and left the room. Observation and interview on 09/16/2025 at 9:55 AM showed Staff H (Certified Nursing Assistant) came to Resident 8’s room, closed the door and start talking to the resident in English. Resident 8 was louder and kept talking in their language. Staff H kept saying they did not understand the resident. This surveyor knocked on the resident’s door and entered the room. Resident 8 was crying and talking in their language. Staff H stated they gave the resident call light already and did not understand what Resident 8 was saying. Resident 8 again said, “peepee”. When asked Resident 8 if they wanted to use the bathroom, Resident 8 stated, “yes”. Then Staff H provided care to Resident 8 to change their brief. Staff H did not use any communication device to talk to Resident 8 during the whole conversation. In an interview on 09/16/2025 at 10:15 AM, Staff H stated Resident 8 usually screams at times. Staff H stated Resident 8 used their phone to communicate but that day Resident 8’s phone was not working. When asked Staff H about how staff communicate with Resident 8 to meet their needs. Staff H stated they should use their personal phones to communicate with Resident 8, but they did not. In an interview on 09/17/2025 at 1:22 PM, Staff B (Director of Nursing) stated the facility staff should use phone translator services or interpretive services to communicate with Resident 8 but they were not using the services. <Resident 7> According to a 11/12/2024 Annual MDS Resident 7’s primary language was not English. The MDS showed Resident 7 wanted an interpreter to communicate with health care staff. Review of Resident 7’s communication CP, Resident 7’s primary language was not English with interventions for resident to use communication binder to communicate. In an interview on 09/15/2025 at 9:48 AM Resident 7’s representative stated Resident 7 was rarely confused, could get a little mixed up occasionally, but for the most part understood others and what was going on around her. Resident 7’s representative stated Resident 7’s primary language was Russian but had not seen staff attempt translation using an interpreter or a communication board. Observations on 09/15/2025 at 9:36 AM and 11:42 AM, 09/16/2025 at 12:16 PM, 09/17/2025 at 7:46 AM and 10:32 AM, 09/18/2025 at 9:49 AM showed no communication binder readily available for Resident 7. On 09/17/2025 at 7:46 AM Resident 7 was speaking to Staff F in a language other than English. Staff F did not offer Resident 7 interpreter services or use of a communication board and stated they always speak in their language but did not need anything. When Staff F was asked how they knew Resident 7 did not need anything, Staff F stated they were confused and had been in the facility for a long time. In an interview on 09/18/2025 at 10:43 AM G (Resident Care Manager) stated Resident 7 did not have a communication binder available for basic needs communication but should. Staff G stated it was important to provide interpretation services to non-English speaking residents to ensure good care and the residents needs are being met. Reference: WAC 388-97-1620(2)(a)(v).

Based on observation, interview, and record review the facility failed to ensure cold food was held at 41-degree Fahrenheit (F) or lower during lunch preparation. Failure by the facility to ensure food was at the proper temperature when served, placed residents at risk for food borne illness, less than adequate nutritional intake, dissatisfaction with meals, and other negative outcomes.Findings included <Facility Policy>According to the facility's 09/18/2025 revised Food Temperature Policy, the facility would record food temperatures daily to ensure food was at the proper serving temperature before trays were assembled. The policy showed potentially hazardous cold food temperatures would be kept at or below 41degrees F.<Facility Lunch Preparation>Observations of the unit kitchen pantry on 09/17/2025 at 12:00 PM showed staff distributing food from the steam table in trays to load the food cart to deliver lunch trays in the hallways. At 12:02 PM, Staff removed a tray with Jello (desert) cups from the pantry refrigerator and started placing the Jello on the trays. Another tray of Jello cups were sitting in the cart on ice, outside the pantry. At that time, Staff I (Dining Services) was asked to check the Jello temperature. Staff I checked the temperature which measured at 45 degrees F. At this same time, Staff J (Registered Dietitian) checked the temperature of the Jello containers sitting on ice in the cart outside the pantry. The temperature of this Jello measured at 50 degrees F.In an interview on 09/17/2025 at 12:57 PM, Staff J stated keeping cold food temperatures below 41 degrees F while serving to residents was important for food safety and reducing the risk of foodborne illness. Staff J stated cold food temperatures should be below 41degrees F when served to residents, but the Jello did not temp below 41 degrees F.REFERENCE: WAC 388-97-2980

Based on observation, interview, and record review, the facility failed to offer nonpharmacological interventions to 3 of 5 residents (Residents 3, 29, & 45), monitor specific target behaviors for 1 of 5 residents (Resident 45), complete an Abnormal Involuntary Movement Scale (AIMS - an assessment) for 1 of 5 (Resident 45), and monitor for adverse side effects from psychotropic medications for 1 of 5 residents (Resident 45) reviewed for unnecessary medications. Failure to monitor resident specific target behaviors, monitor for psychotropic medication adverse side effects, and provide nonpharmacological interventions placed residents at risk of mismanaged behaviors, discomfort, receiving unnecessary psychotropic medications, and a diminished quality of life.Finding included.<Facility Policy>According to the facility's Use of Psychotropic Medications policy, revised 02/19/2025, the facility would only use psychotropic medications when the practitioner determined the medication was appropriate to treat the resident's specific and diagnosed condition. The policy showed the facility would monitor and document the resident's response to the medication. The policy showed non-pharmacological interventions must be attempted unless contraindicated, to minimize the need for psychotropic medications. The policy showed residents who received an antipsychotic medication would have an AIMS completed upon admission.<Resident 3> According to a 08/18/2025 admission Minimum Data Set (MDS – an assessment tool) Resident 3 had a diagnosis of Depression. The MDS showed Resident 3 received an antidepressant medication during the assessment period. Review of Resident 3’s health records showed a 08/14/2025 physician order for two Antidepressant medications, both to be administered daily. Resident 3’s health records did not show a physician order for nonpharmacological interventions for the Antidepressant medications. <Resident 29> According to a 08/29/2025 admission MDS Resident 29 received an antidepressant medication during the assessment period. Review of Resident 29’s health records showed a 08/26/2025 physician order for an Antidepressant medication to be administered daily. Resident 29’s health records did not show a physician order for nonpharmacological interventions for the Antidepressant medications. In an interview on 09/18/2025 at 10:43 AM Staff G (Resident Care Manager) reviewed Resident 3 and 29’s records and stated there was not an order for nonpharmacological interventions for the psychotropic medications but they should have one. Staff G stated it was important to implement nonpharmacological interventions to ensure the facility was not unnecessarily administering psychotropic medications to residents when behaviors could be managed without pharmaceuticals. <Resident 45> According to the 09/16/2025 admission MDS Resident 45 had diagnoses including anxiety, depression, and a mood disorder. The MDS showed Resident 45 received an antipsychotic and an antidepressant medication during the lookback period. Review of Resident 45’s physician orders showed a 09/11/2025 order directing staff to administer an antidepressant medication daily and an antipsychotic medication twice daily to the resident. Review of Resident 45’s assessments on 09/19/2024 showed staff did not complete an AIMS assessment for the resident related to the antipsychotic medication. Resident 45’s records showed staff were not monitoring the resident for adverse side effects, target behaviors, or attempting nonpharmacological interventions for the resident’s antidepressant medication. In an interview on 09/19/2025 at 9:39 AM, Staff B (Director of Nursing) was unable to provide documentation of an AIMS assessment related to the antipsychotic medication or documentation showing staff were monitoring Resident 45 for adverse side effects, target behaviors, or attempting nonpharmacological interventions related to the antidepressant medication. Staff B stated they expected staff to monitor residents for adverse side effects, target behaviors, and provide nonpharmacological interventions when residents were taking psychotropic medications. REFERENCE: WAC 388-97-0620. .

Based on observation, interview, and record review the facility failed to ensure privacy for 1 of 1 resident (Resident 7) observed for medication administration via Gastric Tube (GT -tube inserted through the wall of the abdomen directly into the stomach). The failure to provide privacy during medication administration via GT placed residents at risk for a loss of privacy and a diminished quality of life.Findings included.<Policy>According to the facility policy titled, HIPPA - Organization - Requirements, revised 09/18/2025, showed the facility would ensure compliance with HIPPA requirements for securing protected resident health information.According to the facility policy titled, Resident Rights, dated 06/20/2024, the facility would ensure all direct and indirect care staff members, were educated on the rights of residents and the responsibility of the facility to properly care for its residents. The facility policy showed the resident had the right to a dignified existence.<Resident 7>Observation on 09/17/2025 at 7:46 AM Staff F (Registered Nurse) walked away from the medication cart without locking Resident 7's medical information on the computer, leaving it unsecured and viewable to all. Staff F entered Resident 7's room leaving the door wide open to the hallway and did not pull privacy curtain around the resident. Staff F pulled Resident 7's shirt up, exposing Resident 7's GT and abdomen area and proceeded to administer all of Resident 7's medications via GT.In an interview on 09/17/2025 at 7:47 AM Staff F stated it was important to protect residents' information to stay in compliance with HIPPA (Health Insurance Portability and Accountability Act - a law protecting sensitive resident health information aiming to ensure privacy and security in healthcare). Staff F stated they were expected to pull the privacy curtain when providing cares but did not. Staff F stated it was important to provide privacy when providing care for residents' rights. In an interview on 09/17/2025 at 8:34 AM Staff B (Director of Nursing) stated they expected staff to always protect resident identifiable health information for resident's rights to privacy. Staff B stated they expect staff to provide privacy for residents during cares by pulling the privacy curtain or closing the door. Staff B stated it was important to provide privacy for resident rights.Reference: WAC 388-97-0360

Based on observation, interview, and record review the facility failed to ensure staff used appropriate Personal Protective Equipment (PPE - disposable barriers such as gloves, eyewear, and gowns used to prevent exposure to infectious materials) for 3 residents (Resident 46, 7, & 19) reviewed for Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce the transmission of multidrug-resistant organisms), ensure staff used appropriate Hand Hygiene (HH) during resident care/resident contact (Staff D - Certified Nursing Assistant - CNA & Staff N - CNA) who were observed for care, and staff failed to provide sanitary practices when delivering meals to residents (Staff N) who were reviewed. These failures placed residents and staff at risk for exposure to and development of contagious, communicable infectious diseases.Findings included .<Facility Policy>According to the facility's Enhanced Barrier Precautions policy, revised 12/07/2022, the facility would implement EBP to prevent transmission of multidrug-resistant organisms. The policy showed residents with urinary catheters (tube inserted into the bladder) would be placed on EBPs and gowns and gloves would be made available to staff immediately outside of the resident's room.According to the facility's Hand Hygiene policy, revised 10/01/2022, staff would perform proper HH to prevent the spread of infection to other personnel, residents, and visitors. The policy referred to a HH Table which showed staff would perform HH between resident contacts.<Enhanced Barrier Precautions> <Resident 46> According to the 09/08/2025 admission Minimum Data Set (MDS – an assessment tool), Resident 46 admitted to the facility on [DATE] and had an indwelling urinary catheter (tubing inserted into the bladder to drain urine). Review of a 09/04/2025 nursing progress note showed staff documented Resident 46 admitted to the facility and the resident had a urinary catheter. Observation on 09/15/2025 at 8:56 AM showed Resident 46 sleeping in bed and they had a catheter hooked onto the bed. There was no EBP sign on the resident’s door or a cart inside or outside of the room containing gowns or gloves for staff to put on prior to providing direct care to Resident 46. In an interview on 09/18/2025 at 10:47 AM, Staff C (Infection Control Nurse) stated they expected residents with urinary catheters to be on EBP. Staff C stated a gown, and gloves should be worn for catheter care. <Resident 7> Observation on 09/17/2025 at 7:32 AM showed an EBP sign was posted outside Resident 7’s room instructed staff to wear gown and gloves while providing direct care to Resident 7. Observation and interview on 09/17/2025 at 7:46 AM Staff F (Registered Nurse) entered Resident 7’s room and administered medications via Gastric Tube (tube inserted in the abdominal wall straight to the stomach) without putting on personal protective equipment per direction on EBP signage posted on Resident 7’s door. Staff F stated Resident 7 was on EBP so they should wear a gown, mask, and gloves when providing all cares for Resident 7 but did not. Staff F stated they were expected to, and it was important to follow precaution signs for infection prevention when caring for residents. In an interview on 09/17/2025 at 8:34 AM Staff B (Director of Nursing) stated they expected staff to follow EBP per physician orders. Staff B stated it was important to follow EBP for residents that require precautions to ensure staff are not spreading infections to the vulnerable residents. <Resident 19> According to the 06/19/2025 admission 5 Day MDS, Resident 19 admitted to the facility on [DATE] and had an indwelling catheter in their bladder. Observation on 09/14/2025 at 8:32 AM showed an EBP sign was posted outside Resident 19’s room instructed staff to wear gown and gloves while providing direct care to Resident 19. Observation on 09/14/2025 at 9:02 AM showed Resident 19 was sitting in a wheelchair in their room and indwelling catheter bag was hanging under their wheelchair full of urine. Observation on 09/14/2025 at 9:38 AM showed Resident 19 was sitting in a wheelchair in their room and Staff R (CNA) was emptying Resident 19’s catheter bag, was not wearing a gown as instructed on the posted sign outside Resident 19’s room. In an interview on 09/14/2025 at 9:55 AM, Staff R stated they should wear a gown and gloves while emptying the catheter bag, but they forgot. In an interview on 09/17/2025 at 11:02 AM, Staff B stated their expectations from staff to follow the signs outside resident’s rooms to prevent spreading infections. Staff B stated Resident 19 had an indwelling catheter and EBP sign was posted outside the room. The staff should wear gown and gloves while taking care of Resident 19’s catheter bag, but they did not. <Hand Hygiene> <Staff D> Observation of the lunch service on 09/14/2025 at 12:38 PM showed staff delivering all meal trays to resident rooms due to the facility being in a Covid (respiratory infection) outbreak. Staff D was observed delivering a lunch tray to the resident in room [ROOM NUMBER]. Staff D placed the lunch tray on the over-the-bed table and removed a used coffee cup from the table. Staff D left the room with the coffee cup, touching the lid of the cup, took it to the pantry, and set the cup on top of a cart that held meal trays to be delivered. Staff D put their hands in their pockets while waiting for a new cup of coffee. The pantry staff handed Staff D a fresh cup of coffee and delivers it to room [ROOM NUMBER]. Staff D did not perform HH. At 12:41 PM, Staff D returned to the pantry, did not perform HH, took a lunch tray from the pantry staff and delivered the tray to room [ROOM NUMBER]. Staff D moved a cup of water on the resident’s over-the-bed table and set the tray down. Staff D did not perform HH between the two resident rooms and after touching items in the rooms. In an interview on 09/18/2025 at 10:49 AM, Staff C stated it was their expectation staff performed HH prior to delivering meal trays and upon exiting the resident’s room after delivering a meal tray. <Staff N> Observation and interview on 09/14/2025 at 12:38 PM showed Staff N pass a lunch tray to a resident’s room, set the resident up and then exit the room without performing HH. Staff N collected another meal tray from the on-unit pantry and delivered it to another resident room. Staff N stated they were expected to perform HH between residents but forgot to. Staff N stated it was important to perform HH between resident’s care for infection prevention. <Sanitary Practices> <Staff N> Observation and interview on 09/14/2025 at 12:52 PM showed Staff N getting a mustard packet for a resident request. Staff N dropped the mustard packet on the floor of the main dining room and picked it up and delivered it to the resident without washing it off or getting a new one. Staff N stated they shouldn’t deliver the mustard packet that fell on the floor to the residents for infection prevention. Reference: WAC 388-97-1320(1)(a), (2)(b).

Based on observation, interview, and record review, the facility failed to ensure proper storage of medications for 1 of 2 staff (Staff F - Registered Nurse) observed during medication administration and proper labeling of medications on 1 of 1 medication carts (West Medication Cart) reviewed for medication storage. These failures placed residents at risk of injury, receiving expired medications, and a diminished quality of life.Findings included.<Policy>According to the facility policy titled, Medication Storage, dated 09/18/2025, the facility would ensure all medications and biologicals would be stored in locked compartments. The policy showed only authorized personnel would have access to the medications and keys to locked compartments. The policy showed the facility would ensure all outdated and mislabeled medications were destroyed in accordance with federal and state requirements. <Staff F>In an observation and interview on 09/15/2025 at 8:59 AM Staff F prepared medications for a resident by dispensing pills and liquid medications into a small pill cup and pulling two respiratory inhaled medications out and leaving them on top of the medication cart unsecured and walked away. Staff F stated they were expected to secure all medications in a locked medication cart before leaving them but did not.In an observation and interview on 09/17/2025 at 7:46 AM Staff F prepared medications for a resident by dispensing pills and liquid medications into a small pill cup and left them on top of the medication cart unsecured and walked away. Staff F stated they should not leave medications unattended and unsecured. Staff F stated it was important for residents' safety to secure all medications behind a lock to ensure a resident did not mistakenly ingest the medications.In an interview on 09/17/2025 at 8:15 AM Staff B (Director of Nursing) stated they expected staff to secure medications behind a lock before walking away from them. Staff B stated it was important to store and secure medications appropriately to ensure residents' safety.<West Medication Cart>In an observation and interview on 09/17/2025 at 10:24 AM the [NAME] medication cart had a bottle of a supplement with the expiration date of July 2024 crossed off with black ink and 11/25 written next to it. Staff K (Licensed Practical nurse) stated they believed the supplements were brought in by a family member and they crossed off the expiration date. Staff K stated staff should not except medications with an expired date crossed off and a new expiration date written in. Staff K stated the facility should provide the supplement for the residents.In an interview on 09/18/2025 at 11:24 AM Staff B stated they expected staff to discard medications upon expiration. Staff B stated it was important to ensure residents were receiving the correct potency as medications can lose their effectiveness upon expiration.Reference: WAC 388-97-1300(2), -2340

Based on observation, interview, and record review, the facility failed to ensure enteral nutrition (the delivery of nutrients through a feeding tube directly into the stomach) was administered in accordance with physician orders and professional standards for 1 of 1 resident (Resident 7) reviewed for enteral nutrition. The facility failed to accurately document the amount of enteral formula (liquid food products) and fluids a resident received were reconciled with the amount they were ordered to receive and deliver per physician order. This failure placed residents at risk for inadequate nutrition, dehydration, and other adverse outcomes.Findings included.<Policy>According to the facility policy titled, Care and Treatment of Feeding Tubes, dated 09/18/2025, the facility would ensure tube feedings were administered per physician orders. The policy showed staff would evaluate the amount of feeding administered to ensure the resident received the correct enteral nutrition consistent with and following the physician orders. <Resident 7>According to a 08/08/2025 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 7 had a tube feeding during the assessment period. The MDS showed Resident 7 received 51% or more of their total calories through the feeding tube with 501 Milliliters (ml) or more of fluids daily.Review of Resident 7's health records) showed a 07/25/2024 tube feeding order to run for 12 hours a day at 60ml/hour (total 720ml) congruent with water flush at 40ml/hour for 12 hours (total 480ml). The tube feeding order was scheduled to start at 8:00 AM and stop at 8:00PM.Observation and interview on 09/17/2025 at 7:25 AM showed Staff F (Registered Nurse) stop the tube feeding pump, which was set to 60ml/hour with a bag of water running at 40ml/hour. The tube feeding bottle showed no date or time that the bottle was started. The pump was reading 1038ml of feeding and 2409ml of water had been administered to Resident 7. Staff F returned to cart entering last used documentation when documented the amount of tube feeding and water the resident received. Staff F stated they did not calculate on the pump how much Resident 7 received and never did that because the order showed how much they should be receiving. When asked how they knew the tube feeding was started at 8:00 AM and Resident 7 had received the correct amount ordered, Staff F stated they never totaled the amount administered on the pump and that was a good question for the nurse that started the pump.In an interview on 09/17/2025 at 8:34 AM Staff B (Director of Nursing) stated they expected staff to total the pump each shift for amount of formula and water administered and document in the residents' records. It's important to ensure residents receive the ordered amount of formula and water to ensure adequate nutrition and hydration. Reference: WAC 388-97-1060(3)(f)

Based on observation, interview, and record review the facility failed to ensure weekly skin assessments were completed for 1 (Residents 15) of 1 residents reviewed and 1 (Resident 5) supplemental resident who were reviewed for skin impairments, ensure post fall assessments were completed for 1 (Resident 20) of 4 residents who were reviewed for falls, ensure the therapy department provided a referral for a restorative nursing program to maintain range of motion once a resident discharged from therapy services for 1 of 4 residents (Resident 31), and ensure accurate weight monitoring was done per physician orders for 1 of 1 residents (Resident 7) reviewed for nutritional status. These failures placed residents at risk for skin breakdown, injuries, malnutrition, decreased range of motion, and decreased quality of life.Findings included.<Weekly Skin Checks> <Resident 5> According to the 08/18/2025 admission Minimum Data Set (MDS – an assessment tool), Resident 5 had diagnoses including malnutrition and cancer. The MDS showed Resident 5 required substantial/maximal assistance from staff to roll left and right in bed, was dependent on staff for lying to sitting on the side of the bed, and required partial/moderate assistance from staff for using the toilet or commode. The MDS showed Resident 5 did not have pressure ulcers and was not at risk for developing pressure ulcers. Review of Resident 5’s 08/11/2025 “Risk for Impaired Skin Integrity” Care Plan (CP) showed an intervention directing staff to perform weekly skin checks for Resident 5. Review of Resident 5’s weekly skin checks showed staff assessed the resident’s skin on 08/20/2025 and documented the resident had redness to their tailbone area. The next skin check was completed 09/10/2025, three weeks after the skin check completed on 08/20/2025. The 09/10/2025 skin check showed Resident 5 developed a pressure ulcer to their tailbone. Review of Resident 5’s August 2025 Treatment Administration Record (TAR) showed staff documented a skin check was completed on 08/27/2025. Review of Resident 5’s September 2025 TAR showed staff completed a skin check on 09/03/2025. Resident 5’s record showed staff did not complete skin assessment forms showing the results of the skin checks. Review of Resident 5’s progress notes from 08/20/2025 to 09/10/2025 showed staff did not document the resident refused the weekly skin checks. Observation on 09/18/2025 at 10:31 AM showed Staff K (Licensed Practical Nurse) providing wound care to Resident 5’s tail bone. In an interview on 09/18/2025 at 10:41 AM, Staff K stated skin checks were completed weekly for residents. Staff K stated if a resident refused a skin check, they would reapproach the resident and endorse to the next shift if the resident continued to decline. Staff K stated refusals were documented in the TAR. In an interview on 09/19/2025 at 9:32 AM, Staff B (Director of Nursing) stated skin checks were triggered on the TAR to alert staff as to when a skin check was due. Staff B stated it was their expectation staff completed the skin check assessment form and documented if a resident refused. Staff B reviewed Resident 5’s records and confirmed staff did not document a skin check assessment for 08/27/2025 and 09/03/2025. <Resident 15> Review of the 07/23/2025 admission MDS showed Resident 15 had major surgery prior to admission to the facility. The MDS showed Resident 15 did not have current pressure ulcers but was at risk for developing pressure ulcers. Review of Resident 15’s revised 08/04/2025 “…potential/actual impairment to skin integrity…” CP showed interventions to staff to perform weekly skin checks for Resident 15. Review of Resident 15’s weekly skin checks showed staff completed a skin assessment on 07/26/2025 showing the resident had bruising to the back of their hand. The next skin assessment documented was 08/29/2025, nearly five weeks later. In an observation and interview on 09/14/2025 at 9:52 AM, Resident 15 was sitting in their wheelchair in their room. They had scattered bruising to the back of both hands. Resident 15 stated they had a wound to their foot that staff were treating. In an interview on 09/19/2025 at 9:32 AM, Staff B reviewed Resident 15’s record and confirmed staff did not complete weekly skin checks as ordered. <Fall Assessments> <Resident 20> According to the 08/13/2025 admission MDS, Resident 20 had some memory issues and had recent falls. The MDS showed Resident 20 required substantial/maximal assistance for rolling left and right, sitting to lying, lying to sitting, and sitting to standing. Review of an 08/09/2025 Fall Risk Assessment showed Resident 20 was at moderate risk for falls. Review of a 09/07/2025 facility incident report showed Resident 20 had a fall in the bathroom while being assisted by staff. Per Resident 20’s request, staff stepped outside of the bathroom to provide privacy and heard the resident yell for help. Staff found the resident on the floor. Review of Resident 20’s records show staff did not complete an updated fall assessment at the time of the 09/07/2025 fall. In an interview on 09/19/2025 at 10:00 AM, Staff B stated it was their expectation that staff completed a fall assessment after each fall a resident had. Staff B was unable to provide a fall assessment for Resident 20’s fall on 09/07/2025. <Restorative Nursing Program Referral> <Resident 31> According to the 08/21/2025 5 Day MDS, Resident 31 admitted to the facility on [DATE], was cognitively intact, and had multiple medically complex diagnoses including a right leg fracture with impairment of functional limitation in range of motion to one arm and leg. The MDS showed Resident 31 required substantial to maximum assistance from staff for rolling side to side in bed, sitting to stand, transferring, toileting, and showers. The MDS showed Resident 31 had no rejection of care during the assessment period. Observation and interview on 09/14/2025 at 12:13 PM showed Resident 31 was sitting up in a wheelchair in their room. Resident 31 stated they came to this facility for therapy because they had fractured their right leg. Resident 31 stated therapy stopped working with them more than two weeks ago because of their insurance. Observations and interviews on 09/15/2025 at 11:21 AM and on 09/16/2025 at 2:01 PM showed Resident 31 sitting in a wheelchair in their room. Resident 31 stated they wished therapy would work with them to make their leg stronger to walk again. Review of Resident 31’s 08/29/2025 Occupational Therapy (OT) discharge summary showed Resident 31 required partial to moderate assistance from staff with daily activities, showers, transfers, and toileting needs. The discharge summary did not have a referral for a restorative nursing program. In an interview on 09/17/2025 at 10:53 AM, Staff L (Restorative Coordinator) stated they were responsible for managing restorative nursing programs. Staff L stated when the therapy department discharged residents from therapy, they provided a referral form to a restorative program, and they initiated restorative programs in the resident’s plan of care and educated restorative aides. When asked for Resident 31’s restorative program, Staff L stated Resident 31 did not have a restorative program. Staff L stated a restorative program was very important to maintain the resident’s physical activities and range of motion. In an interview on 09/18/2025 at 9:42 AM, Staff S (Rehab Director) stated Resident 31 was discharged from therapy services on 08/29/2025 and was in process in getting authorization for more therapy from insurance. Staff S stated they referred Resident 31 for a restorative nursing program upon discharging from therapy services. Staff S reviewed Resident 31’s discharge summary and stated they did not refer Resident 31 to restorative program. Staff S stated they should refer Resident 31 to restorative program to maintain their range of motion, but they missed it. <Weight Monitoring> <Resident 7> According to the 08/08/2025 Quarterly MDS Resident 7 received more than 51% of their caloric and fluid intake via a gastric tube (tube inserted through the abdominal wall directly into the stomach). Review of Resident 7’s records showed a 12/12/2024 physician order to monitor the resident’s weight monthly for nutritional health. Resident 7’s records showed no weight monitor for February, May, and July of 2025. Resident 7’s records showed a 02/12/2024 nutrition at risk CP with an intervention of tube feeding and the facility would monitor Resident 7’s weight per order. In an interview on 09/19/2025 at 8:43 AM Staff B stated they expected staff to monitor Resident 7’s weights per physician orders. Staff B stated it was important to monitor residents’ weight to track nutritional and cardiac status. REFERENCE: WAC 388-97-1060(1).

Based on observation, interview, and record review the facility failed to ensure residents who were dependent on staff for assistance with Activities of Daily Living (ADLs - i.e. grooming, bathing, eating, etc.) received the assistance they required for 3 of 7 sample residents (Residents 2, 8, & 7) reviewed for ADLs. The failure to provide nailcare, bathing, getting out of bed, and shaving left residents at risk of embarrassment, poor personal hygiene, decreased quality of life, and other negative health outcomes.Findings included .<Facility Policy>According to the facility's 09/18/2025 revised ADLs Policy, residents who were unable to perform ADLs independently would receive the necessary services to maintain mobility, good nutrition, grooming, and personal hygiene as they required. The policy showed based on resident's assessment, the facility would ensure resident's abilities in ADLs would not deteriorate unless deterioration was unavoidable. <Resident 2> According to the 06/10/2025 Quarterly Minimum Data Set (MDS – an assessment tool), Resident 2 had weakness on right side of their body and was dependent on staff for their personal hygiene. Review of the 05/09/2025 revised ADLS Self Care Deficit Care Plan (CP) showed Resident 2 required one person assistance from staff for their personal hygiene needs. Observations on 09/15/2025 at 10:23 AM, on 09/16/2025 at 11:57 AM, and on 09/18/2025 at 10:50 AM showed Resident 2 was lying in their bed and had long fingernails with black debris under their fingernails. In an interview on 09/17/2025 at 10:29 AM, Staff B (Director of Nursing) stated they expected staff to provide ADL assistance to residents including personal hygiene during daily morning care. Staff B stated staff should clip Resident 2’s fingernails weekly on shower days and as needed, but they did not. <Resident 8> According to the 07/08/2025 Quarterly MDS, Resident 8 was admitted to the facility with weakness on both arms and required one person assistance from staff with personal hygiene. Review of the 07/28/2025 revised ADL Self Care Deficit CP showed Resident 8 required extensive one person assistance from staff with their personal hygiene including bathing, oral care and shaving. Observations on 09/16/2025 at 10:12 AM and on 09/17/2025 at 11:43 AM showed Resident 8 lying in their bed and had long facial hair. In an interview on 09/17/2025 at 1:27 PM, Staff B stated they expected staff to provide ADL assistance to residents including personal hygiene during daily morning care. Staff B stated staff should shave Resident 8’s facial hair per preference and document if the resident refused, but they did not. <Resident 7> According to the 08/08/2025 Quarterly MDS Resident 7 had impairment on one side of their upper and lower extremities. The MDS showed Resident 7 was dependent on two staff for hygiene, bathing, transfers, and positioning. Review of an 11/13/2024 ADL CP day shift staff would get Resident 7 out of bed daily. The ADL CP showed Resident 7 preferred showers in the morning. Review of Resident 7’s health records showed no documentation of showers offered. In an interview on 09/15/2025 at 9:48 AM Resident 7’s representative stated Resident 7 was bedridden. Resident 7’s representative stated staff told them the facility was short staffed so they were unable to get Resident 7 out of bed daily and for showers, but they would offer bed baths. Resident 7’s representative stated they wanted Resident 7 out of bed daily and given showers per Resident 7’s preference, “not bed baths for quality of life.” Observations on 09/15/2025 at 9:36 AM and 11:42 AM, 09/16/2025 at 12:16 PM, 09/17/2025 at 7:46 AM and 10:32 AM, 09/18/2025 at 9:49 AM showed Resident 7 lying on back in bed. In an interview on 09/18/2025 at 10:38 AM Staff M (Certified Nursing Assistant) stated they don’t get Resident 7 out of bed and offered them bed baths, not showers, when they were assigned to care for them. Staff M stated there was no place in Resident 7’s records for staff to document bathing or getting out of bed. In an interview on 09/18/2025 at 10:43 AM Staff G (Resident Care Manager) stated they worked for the facility for the last two months and had only seen Resident 7 out of bed once. Staff G was unable to provide documentation of staff offering Resident 7 assistance to get out of bed daily or up for showers. Staff G stated they expected staff to offer and document assistance with getting out of bed and offer and document showers per Resident 7’s preference. Staff G stated it was important to assist dependent residents to get up daily, attend activities, and provide assistance with showers for quality of life. Reference: WAC 388-97-1060(2)(c).

Based on observation, interview, and record review the facility failed to clarify physician orders to include medication dosing and pain medication parameters for 2 (Resident 45 & 3) of 5 residents reviewed for unnecessary medications and 2 (Resident 5 & 48) supplemental residents. The facility failed to obtain/monitor labs for medications requiring lab monitoring, failed to ensure pain management included nonpharmacological interventions, and failed to ensure staff monitored for signs and symptoms of low/high blood glucose levels for 2 (Residents 3 & 29) of 5 sample residents reviewed for unnecessary medications. These failures placed residents at risk for unmet needs, and ineffective and/or delayed treatments.Findings included. <Clarifying Physician Orders> <Resident 5> Review of Resident 5’s 09/2025 Medication Administration Record (MAR) showed an 08/11/2025 order for an over-the-counter pain medication to be administered every six hours as needed for a pain level of “1-3/10” on the pain scale. The MAR showed an 08/11/2025 order directing staff to administer an opioid pain medication (Medication A) every two hours as needed for a pain level of 4-10/10 on the pain scale. The MAR showed an 08/28/2025 order directing staff to administer a different opioid pain medication (Medication B) every four hours as needed. This order did not direct staff at what pain level to administer the pain medication for. Review of the 09/2025 MAR showed on one occasion, staff administered the over-the-counter medication to Resident 5 for a pain level of 4, despite the medication instructing staff to administer for a pain level of 1-3/10. Review of the 09/2025 MAR showed staff administered Medication B for pain levels of 0, 3, 4, 6, 7, & 8. The MAR showed staff did not administer Medication as ordered and did not clarify when Medication B should be administered to Resident 5. <Resident 45> Review of Resident 45’s 09/2025 MAR showed a 09/11/2025 order directing staff to administer an over-the-counter pain medication every six hours as needed. This order did not include directions to staff for what pain level to administer the pain medication to the resident. The MAR showed a 09/11/2025 order directing staff to administer an opioid medication every six hours as needed for pain. This order did not include directions to staff for what pain level to administer the pain medication to the resident. Review of the 09/2025 MAR showed staff administered the over-the-counter medication for pain levels of 4 and 5 on the 0-10 pain scale. The MAR showed staff administered the opioid medication for pain levels of 4, 6, 7, and 8 on the 0-10 pain scale. In an interview on 09/19/2025 at 9:29 AM, Staff B (Director of Nursing) stated the facility process was to have a pain scale with each as needed pain medication, so staff knew which medication for what pain level a resident was experiencing. Staff B reviewed Resident 5 and Resident 45’s records and confirmed a pain scale should be associated with the as needed pain medications. <Resident 48> Review of Resident 48’s record showed Resident 48 admitted to the facility on [DATE] after they had back surgery. Review of the 09/2025 MAR showed Resident 48 had a 09/12/2025 physician order directing staff to administer two tablets of a pain-relieving medication to the resident every six hours for pain and not to exceed three grams in 24 hours. Another 09/12/2025 order directed staff to administer one tablet of a narcotic pain medication every six hours as needed for moderate pain and two tablets every six hours as needed for pain 7/10. There were no instructions to staff about which medication should be administered to Resident 48. In an interview on 09/17/2025 at 8:00 AM, Staff K (Licensed Practical Nurse) stated the physician order was not clear as to which medication should be administered for pain because there were no pain scale parameters. Staff K stated staff should clarify the order with the provider and receive orders with parameters, but they did not. <Resident 3> Review of Resident 3’s record showed Resident 3 admitted to the facility on [DATE] with multiple medical conditions including back pain, heart failure, and kidney failure. Review of the September 2025 MAR showed Resident 3 had an 08/16/2025 physician order directing staff to apply a medicated pain patch topically one time a day for pain and remove the patch “per schedule.” The order did not include the strength for the pain patch and did not direct staff where the patch should be applied to Resident 3. In an interview on 09/17/2025 at 8:02 AM, Staff K stated the pain patch order did not have a dosage. Staff K stated staff should clarify the order with the provider to include the dosage and location to apply the patch, but they did not. In an interview on 09/18/2025 at 10:01 AM, Staff B stated it was their expectation nursing staff review the orders prior to administering medications to residents, clarify with the provider for dosage, parameters for pain medications, location for pain patches, and follow the orders, but they did not. <Lab Monitoring and Nonpharmacological Interventions> <Resident 3> According to the 08/18/2025 admission Minimum Data Set (MDS - an assessment tool) Resident 3 had diagnoses of chronic pain, high cholesterol, diabetes (unstable blood glucose levels), and malnutrition. The MDS showed Resident 3 received scheduled and as needed pain medications, and non-medication interventions for pain management. The MDS showed Resident 3 experienced pain frequently and experienced a level 10/10 pain during the assessment period. The MDS showed pain occasionally interrupted Resident 3’s sleep and frequently interfered with their therapy activities and day-to-day activities. Review of Resident 3’s health records showed 08/14/2025 physician orders for cholesterol lowering medication and a high dose supplement order. Resident 3’s health records did not show cholesterol levels or a lab level for the high dose supplement being administered. Resident 3’s health records did not show physician orders for nonpharmacological pain interventions or documentation of staff monitoring the resident for signs and symptoms of low/high blood sugar levels. Observation on 09/14/2025 at 8:22 AM showed Resident 3 sitting on the edge of the bed with their breakfast tray in front of them and stated their blood glucose level was low and they were having symptoms, so they needed to eat to feel better. Resident 3 stated they experienced symptoms of low blood glucose often since being in the facility and thought their insulin (blood sugar lowering medication) orders might need to be adjusted. In an interview on 09/18/2025 at 11:24 AM Staff B stated Resident 3 did not have cholesterol levels or labs for the high dose supplement ordered but should. Staff B stated it was important to ensure the resident was at safe blood levels and required the medications. Staff B stated they expected staff to implement orders for nonpharmacological pain interventions and to monitor for signs and symptoms of low/high blood glucose levels for residents with diabetes every shift. Staff B stated it was important to offer nonpharmacological pain interventions and to not resort straight to pharmaceuticals, giving the resident unnecessary medications, when the pain could be managed without medicine. Staff B stated monitoring residents with diabetes for signs and symptoms of low/high blood glucose levels was important for overall management of diabetes and that some residents present these symptoms even when a blood glucose test showed normal range. <Resident 29> According to an 08/29/2025 admission MDS, Resident 29 admitted to the facility on [DATE]. The MDS showed Resident 29 had diagnoses including thyroid disorder and high cholesterol. Review of Resident 29’s health records showed an 08/26/2025 physician order for a cholesterol lowering medication and a 09/11/2025 physician order for a thyroid medication. Resident 29’s health records did not include a cholesterol level or a blood level lab for thyroid medication. In an interview on 09/18/2025 at 11:24 AM, Staff B stated Resident 29’s health records did not include a cholesterol level or a level of the thyroid medication but should. Staff B stated it was important to obtain these levels to ensure the medication was safe for the residents. REFERENCE: WAC 388-97-1620(2)(b)(i)(ii), (6)(b)(i).

Based on observation, interview, and record review, the facility failed to develop and/or implement comprehensive Care Plans (CP) for 3 of 16 residents (Resident 29, 7, & 3) whose CPs were reviewed. Failure to develop comprehensive, individualized CPs to address resident care needs placed residents at risk for unmet care needs, frustration, and other negative health outcomes.Findings included.<Policy>According to the facility policy titled, Documentation in Medical Record, dated 2024, the facility would ensure medical records were accurate, relevant, and complete, containing sufficient details about the resident's care.<Resident 29>According to a 08/29/2025 admission Minimum Data Set (MDS - an assessment tool) Resident 29 received Oxygen (O2) therapy continuous and at a high concentration while a resident at the facility.Review of Resident 29's health records showed a 08/26/2025 physician order for O2 to be administered continuously. Review of Resident 29's records showed no CP for Covid 19 or oxygen therapy.Observation on 09/14/2025 at 9:22 AM showed staff removing Resident 29's transmission-based precautions sign and personal protective equipment cart for Covid 19. Resident 29 was receiving O2 via nasal canula at 2 liters/minute.In an interview on 09/18/2025 at 10:43 AM Staff G (Resident Care Manager) stated Resident 29 should have a CP for Covid 19 and the continuous use of O2 but did not. Staff G stated it was important to develop a Covid 19 and O2 CP to ensure the residents were receiving necessary respiratory care.<Resident 7>According to a 08/08/2025 Quarterly MDS Resident 7 required two-person assistance for rolling side to side in bed, sitting to lying, lying to sitting, sitting to standing, and with chair/bed to chair transfers. The MDS showed Resident 7 had diagnoses of stroke (occurs when blood flow to the brain is interrupted, leading to brain damage) with hemiplegia (complete paralysis of one side of the body).Review of Resident 7's records showed a 11/13/2024 Activities of Daily Living CP instructing two staff to reposition in bed, it did not instruct staff on when to reposition Resident 7 in bed. Resident 7's records did not show instructions to staff for reposition frequency or staff documentation of repositioning being offered/done.In an interview on 09/18/2025 at 10:43 AM Staff G stated they expected staff to reposition dependent residents at least every two to three hours. Staff G stated Resident 7's CP should reflect reposition frequency but did not. Staff G stated it was important, so care staff knew when to reposition the resident to ensure skin breakdown didn't occur and the resident was comfortable.<Resident 3>According to a 08/18/2025 admission MDS Resident 3 had a diagnosis of Diabetes (unstable blood glucose levels).Review of Resident 3's health records showed a 08/14/2025 and 09/06/2025 physician orders for two different insulins for Diabetes. Record review showed no CP for Resident 3's Diabetes.Observation on 09/14/2025 at 8:22 AM Resident 3 was sitting on edge of bed with breakfast tray in front of them and stated their blood glucose level was low and they were having symptoms, so they needed to eat to feel better. Resident 3 stated they experienced symptoms of low blood glucose often since being in the facility and thought their insulin orders might need to be adjusted.In an interview on 09/18/2025 at 11:24 AM Staff B (Director of Nursing) stated Resident 3 should have a Diabetes CP but did not. Staff B stated it was important to have a Diabetes CP to ensure proper care for the residents.Reference: WAC 388-97-1020(1), (2)(a)(b)

Based on record review and interview, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR - a mental health screening required before transfer to a nursing home) assessments were revised to reflect mental health changes for 1 of 5 residents (Resident 8) reviewed for PASRRs. This failure left residents at risk for not receiving timely and necessary services to meet their mental health care needs.Findings included .<Facility Policy>According to the facility's 03/29/2025 revised Behavioral Health Services Policy, the facility would ensure all residents received necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial well-being. The policy showed the facility staff would review resident's medical records and obtain history from resident's family to complete PASRR screening. The policy showed PASRRs would be reviewed periodically for potential changes.<Resident 8>According to the 11/18/2024 admission 5 Day Minimum Data Set (MDS - an assessment tool), Resident 8 was admitted to the facility on [DATE] and had a diagnosis of depression. The MDS showed Resident 8 received antidepressant medication every day during the assessment period.Review of Resident 8's record showed a 11/21/2024 PASRR Level 1 with Depression and Anxiety marked under serious mental illness. This PASRR Level 1 showed Level 2 evaluation not indicated.According to the 01/02/2025 Psychiatrist note, Resident 8 had diagnosis of depression and anxiety, worsened gradually over time and needed treatment.In an interview on 09/18/2025 at 9:49 AM, Staff E (Social Services Director) stated they were responsible for reviewing resident's PASRR Level 1 and 2, correcting them upon admission and as needed. Staff E reviewed Resident 8's record including PASRR Level 1 and stated the PASRR level 1 was not accurate because Resident 8 received treatment for depression and anxiety. Staff E stated PASRR Level 2 evaluation was required for Resident 8, but the facility did not update PASRR Level 1.REFERENCE: WAC 388-97-1975(1)(4)

Based on observation, interview, and record review the facility failed to ensure 3 (Residents 2, 8, & 5) of 12 sample residents Minimum Data Sets (MDS - an assessment tool) were completed accurately to reflect the resident's condition. This failure placed residents at risk for unidentified and/or unmet care needs.Findings included .<Resident 2> According to the 06/10/2025 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 2 had diagnoses including a brain bleed with right side weakness. The MDS showed Resident 2 did not have a Restorative Nursing Program to maintain their functional limitations in range of motion. Review of the June 2025 RNP documentation showed restorative staff provided range of motion programs to Resident 2 up to five times a week. Review of the 05/09/2025 revised Activities of Daily Living Care Plan (CP) showed Resident 2 received range of motion for both of their arms and legs up to five days a week, to maintain their mobility. In an interview on 09/17/2025 at 9:17 AM, Staff L (MDS Coordinator) reviewed Resident 2’s record and stated the MDS was not accurate. <Resident 8> According to the 02/18/2025 Quarterly MDS, Resident 8 admitted to the facility on [DATE] and had a diagnosis of depression. The MDS showed Resident 8 received antidepressant medication every day during the assessment period. Review of Resident 8’s record showed an 11/21/2024 Preadmission Screening and Resident Review Level 1 with depression and anxiety marked under the “serious mental illness” section. According to the 01/02/2025 Psychiatrist note, Resident 8 had a diagnosis of depression and anxiety that had worsened gradually over time, and the resident needed treatment. In an interview on 09/17/2025 at 9:25 AM, Staff L reviewed Resident 8’s record and stated Resident 8 had depression and anxiety diagnoses. Staff L stated the anxiety diagnoses should be but was not identified accurately on the 02/18/2025 Quarterly MDS. <Resident 5> According to the 08/18/2025 admission MDS, Resident 5 had diagnoses including malnutrition and cancer. The MDS showed Resident 5 required substantial/maximal assistance from staff to roll left and right in bed, was dependent on staff for lying to sitting on the side of the bed and required partial/moderate assistance from staff for using the toilet or commode. The MDS showed Resident 5 did not have any pressure ulcers and was not at risk for developing pressure ulcers. Review of a 09/06/2025 incident report showed staff identified a pressure injury to Resident 5’s tailbone area. Observation on 09/18/2025 at 10:31 AM showed Staff K (Licensed Practical Nurse) performing wound care for the pressure ulcer to Resident 5’s tailbone. In an interview on 09/19/2025 at 8:53 AM, Staff L stated it was unusual for a resident to be coded as “not at risk” for pressure ulcers. Staff L reviewed Resident 5’s records and stated the resident should be coded as “at risk” for pressure ulcer development and the MDS required modification. REFERENCE: WAC 388-97-1000 (1)(b).

Based on interview and record review, the facility failed to provide the resident and/or the resident's representative and Ombudsman with a written notice of the transfer/discharge, at the time of transfer or within 24 hours, for 2 of 4 sample residents (Resident 2 & 18) reviewed for hospitalization. This failure placed the residents and their representatives at risk of not being informed of their right while hospitalized that was necessary for decision-making.Findings included .<Facility Policy>According to the facility's 09/18/2025 revised Transfer and Discharge Policy, the facility would provide transfer/discharge notice to the resident and /or resident's representative in a language and manner they could understand including reason and basis, effective date, location for the transfer/discharge, and an explanation of the right to appeal. The policy showed the facility would maintain evidence that the transfer/discharge notice was sent to the Ombudsman office.<Resident 2>According to the 01/11/2025 and 05/01/2025 Discharge Return Anticipated Minimum Data Set (MDS - an assessment tool), Resident 2 discharged to the hospital on [DATE], on 01/11/2025, and again on 05/01/2025 related to a change in the resident's medical condition. The MDS showed Resident 2 had medical conditions including stroke (a medical condition prevents the brain from getting enough blood supply) and heart failure.Record reviews showed the facility staff provided Resident 2 or their representative with a written notification of the reason for transfer to the hospital as required only on 05/01/2025. In an interview on 09/17/2025 at 1:05 PM, Staff B (Director of Nursing) stated they expected the facility staff to notify resident's family about transferring residents to the hospital, sent e-interact forms to the hospital with residents, and provide a written notification with the reason for transfers to residents/representatives. Staff B reviewed Resident 2's record and stated the facility did not provide a written notification about the reason for transfer to Resident 2 and/or their representatives as required on 01/01/2025 and 01/11/2025 transfers to the hospital.In interview on 09/18/2025 at 10:14 AM, Staff E (Social Services Director) stated they were responsible for notifying the Ombudsman about resident's transfers, discharges, and hospitalizations as required. Staff E reviewed Resident 2's record and stated they did not notify the Ombudsman about Resident 2's hospitalization on 05/01/2025.<Resident 18>According to the 01/09/2025 and 01/27/2025 Discharge Return Anticipated, Resident 18 discharged to the hospital on [DATE] and again on 01/27/2025 related to a change in their condition. The MDS showed Resident 18 had medical conditions including heart failure.In an interview on 09/17/2025 at 1:15 PM, Staff B reviewed Resident 10's record and stated the facility did not provide a written notification about the reason for transfer to Resident 18 and/or their representatives as required on 01/09/2025 and 01/27/2025 to the hospital as required.REFERENCE: WAC 388-97-0120 (2)(a-d), -0140 (1)(a)(b)(c)(i-iii).

Based on observation and interview, the facility failed to ensure resident meals were prepared in accordance with professional standards of food safety for 2 of 2 facility kitchens. The failure to ensure surface sanitizer solutions were maintained at effective concentrations, food was stored in a manner to preserve its quality, and food preparation areas were free from potential contaminants, placed residents at risk for food contamination, food borne illnesses, and spoiled food. Findings included . Observation on 06/26/2024 at 9:12 AM showed dietary staff cleaning up after breakfast service. At that time Staff P (Dining Services Director) reached for a test strip to verify the kitchen's surface sanitizer was at the correct consistency (100-440 PPM - Parts Per Million). The test strip package was empty. Staff P then looked in the desk drawer of their office before departing the kitchen. Staff P returned at 9:16 AM. Staff P tore off a strip of orange test paper from the container and held it in a sanitizer bucket for over 10 seconds. The strip remained orange and did not turn green indicating the fluid in the bucket was not at an effective concentration. Staff P retested the bucket with another strip. The second strip remained orange. Staff P tested a second bucket with a new strip. The third strip did not change color after being held in the fluid, indicating this fluid was also not an affective concentration. In an interview on 07/02/2024 at 10:02 AM Staff P stated it was important to ensure the kitchen surface sanitizer was maintained at the correct concentration. Staff P stated if the sanitizer was not at the correct concentration, it was less effective. Staff P stated it was important to ensure the sanitizer test strips were readily available. Observation on 06/26/2024 at 9:14 AM showed a small chest freezer with a glass lid contained four large tubs of ice cream. The lids of all four ice cream tubs sat crookedly and loose on top of the tubs with visible gaps showing the ice cream inside. At that time Staff P stated the lids should be fastened securely to ensure the ice cream did not deteriorate (i.e. freezer burn). Staff P stated the lids did not close easily but staff should make sure they were fully closed. Observation of the facility's dry storage area on 06/26/2024 at 9:23 AM showed two large, dented cans of fruit cocktail and a large, dented can of peaches stored with the other cans. In an interview at that time Staff P stated dented cans should be returned to the vendor as the contents may be spoiled. Observation of lunch service on 07/01/2024 at 11:59 AM showed lunch was served from a small kitchen located between the two dining rooms after being prepared in a larger kitchen in a different area of the campus. Meals were prepared from a steam table behind an open window through which a cook passed the plates to other dietary staff who assembled other items for the residents' trays. Attached to the window was as a slatted metal door that rolled up on to a spool when the kitchen was open. The door and closing mechanism were open at this time and noted to covered in a layer of dust and grime. The spooled, slatted door and mechanism were directly above the steam table where resident meals were prepared. In an interview at this time Staff P stated the buildup of dust and grime combined with the location of the door created a contamination risk. Staff P stated the door and mechanism needed to be cleaned. REFERENCE: WAC 388-97-2980.

Based on interview and record review, the facility failed to implement a system to ensure residents received required written notices at the time of transfer/discharge, or as soon as practicable for 2 (Residents 21 & 29) of 2 residents reviewed for hospitalization s. Failure to ensure written notification to the resident and/or the resident's representative of the reasons for the discharge in writing and in a language and manner they understood, placed residents at risk for a discharge that was not in alignment with the resident's stated goals for care and preferences. Findings included . <Facility Policy> According to a revised 09/06/2023 facility Transfer and Discharge (including AMA [Against Medical Advice]), policy, the facility would provide a written transfer notification to the resident or resident representative in a language and way they could understand. The policy showed the notification would include the reason and basis for transfer, effective date of transfer, and the location to which the resident was transferred. The policy showed the notice would be provided to the resident or resident representative as soon as practicable. <Resident 21> Review of Resident 21's health records showed they were transferred emergently to the hospital on 04/03/2023 for lethargy (abnormal drowsiness) and diaphoresis (cold sweats), on 06/22/2023 for blood in their urine, on 08/22/2023 after a fall, and on 01/13/2024 and 02/08/2024 for blood in their stool. In an interview on 06/26/2024 at 12:55 PM, Resident 21 stated they were sent to the hospital several times but could not remember what they were sent for each time. In an interview on 07/01/2024 at 7:40 AM Staff H (Social Services Director) stated they did not know who was responsible for sending a written notice of discharge to the resident or their representative but thought possibly Staff G (Admissions Director) was responsible. In an interview on 07/01/2024 at 9:13 AM Staff G, stated nursing sent the written notices to residents or their representatives. 43642 <Resident 29> Review of Resident 29's 06/15/2024 Discharge Minimum Data Set (an assessment tool) showed the resident was transferred to an acute care hospital on 06/15/2024 with their return anticipated. Record review showed no documentation staff provided the required written notification to Resident 29 and/or their representative regarding their discharge. In an interview on 07/02/2024 at 10:56 AM, Staff E (Resident Care Manager) stated they did not provide anything in writing to residents and/or their representatives for hospital discharges. In an interview on 07/02/2024 at 11:54 AM, Staff B (Nursing Services Director) stated they were not aware of any written discharge notices completed by nursing staff for hospitalization s. REFERENCE: WAC 388-97-0120 (2)(a-d).

Based on observation, interview, and record review, the facility failed to consistently perform Hand Hygiene (HH) before and after resident care/contact, change gloves after dirty care/before clean care, and failed to ensure glucometers were maintained clean and sanitary. These failures placed residents at risk for facility acquired or healthcare-associated infections and related complications. Findings included . <Facility Policy> According to a facility policy titled, Hand Hygiene, revised 10/01/2022, showed the facility would perform proper HH procedures to prevent the spread of infection. The policy showed HH applied to all staff working in all locations within the facility. The policy showed that using gloves does not replace HH and staff would perform HH before and after care provision, prior to donning gloves, and immediately after removing them. The policy showed HH would be performed between resident contacts, after handling contaminated objects, and when, during resident care, moving from a contaminated body site to a clean body site. <Glove Change> During an observation and interview on 06/28/2024 at 8:38 AM showed Staff I (Certified Nursing Assistant - CNA) and Staff J (CNA) providing pericare with a brief change after Resident 339 had an episode of diarrhea in their brief. After providing personal care, Staff I was observed wiping visible diarrhea from one of the fingers on their glove and proceeded to grab a clean brief and bed pad. Staff I put the clean brief on the resident and placed the clean bed pad under the resident all while still wearing the dirty gloves. Staff I stated they should have changed their gloves and performed HH between dirty and clean care, but they did not. In an interview on 06/28/2024 at 10:00 AM Staff O (Infection Control Nurse) stated they expected staff to change gloves and perform HH between clean and dirty care. Staff O stated this was important to prevent infections. <Glucometers> During a medication pass observation on 07/02/2024 at 12:03 PM, Staff F (Registered Nurse) was preparing to check Resident 21's blood sugar levels and administer insulin (a medication that helped to control blood sugar levels in the body). Resident 21 was observed to be on Enhanced Barrier Precautions related to having a colostomy (a surgical opening in the belly). Staff F donned personal protective equipment and entered the room. Staff F placed a shared glucometer (device used to check blood sugar levels) directly on Resident 21's over-the-bed table. Staff E then took a retracting lancet (device used to prick a finger for a blood sample) and pricked Resident 21's finger. Staff F placed the used lancet directly on Resident 21's table, picked up the glucometer, checked the residents blood sugar, and put the glucometer directly on the over-the-bed table. Staff F did not place a barrier between the glucometer and the surface of the over-the-bed table. Staff F completed their task and exited the room without cleaning the over-the-bed table. In an interview on 07/02/2024 at 12:10 PM, Staff F confirmed they should use a barrier between the glucometer and surfaces in a resident's room but they did not. 43642 <Hand Hygiene> On 06/27/2024 at 9:26 AM, Staff Q (Lead Housekeeping Aide) was observed wearing gloves while cleaning the public bathroom next to the dining room. Staff Q cleaned the sink, then the toilet before return to clean the sink further. Staff Q then cleaned the mirror, all while wearing the same soiled gloves they started with. Staff Q then used their hand with the contaminated glove to move their glasses from their face to the top of their head. Staff Q then continued to clean the bathroom more using the same soiled gloves, touching the toilet paper dispenser, handrails, their mop handle, the sink faucet handle, and a door handle before removing the soiled gloves and performing hand hygiene. On 06/28/2024 at 12:54 PM, Staff Q put on gloves, picked up a toilet scrubber and container from the housekeeping cart, and brought them into room [ROOM NUMBER]'s bathroom. Staff Q cleaned the resident's toilet seat riser using the shower nozzle, left it to dry in shower, and then began cleaning the sink with the same soiled gloves used to clean the toilet seat. Staff Q then used their hand with the contaminated glove to move their glasses from their face to the top of their head. Staff Q, without removing the soiled gloves or performing hand hygiene, then cleaned the sink and handrails, used the toilet brush in the toilet, and used a cleaning cloth to wipe the toilet rim. Staff Q returned to their housekeeping cart with the toilet brush, did not remove their gloves or perform hand hygiene, and returned to the room [ROOM NUMBER] to wipe down the toilet seat riser. At 1:07 PM Staff Q, still wearing the same soiled gloves, left room [ROOM NUMBER] carrying a mop handle and two soiled mop pads. Staff Q placed the mop handle on their cart and discarded the soiled mop pads. Staff Q removed their gloves, performed hand hygiene, but did not disinfect the mop handle prior to going back into room [ROOM NUMBER] to continue cleaning. REFERENCE: WAC 388-97-1320 (1)(a)(c)(2)(a)(3).

Based on observation, interview, and record review the facility failed to ensure Physician's Orders (POs) were clarified as needed for 3 residents (Residents 2, 242, 238) of 13 sample residents reviewed, followed for 6 residents (Residents 13, 240, 8, 28, 238, & 240) of 13 sample residents reviewed, and nurses signed only for care provided for 1 resident (Resident 8) of 13 sample residents. These failures left residents at risk for unmet care needs, unnecessary care, and other negative health outcomes. Findings included . <Clarifying POs> <Resident 2> According to the 05/24/2024 Significant Change Minimum Data Set (MDS - an assessment tool) Resident 2 had diagnoses including heart failure and dementia. The MDS showed Resident 2 received pain medication. Record review showed Resident 2 had two orders for pain medication: a 05/20/2024 PO for a non-narcotic pain medication, give 650 milligrams every six hours as needed for pain, and a 05/20/2024 PO for an opioid pain medication, give 0.25 milliliters as needed for pain. Neither PO had parameters directing staff when each medication would be appropriate to administer. In an interview on 07/02/2024 at 9:42 AM Staff E (Resident Care Manager) stated when a resident had more than one pain medication it was important for there to be parameters so nurses knew which medication to administer when. Staff E stated Resident 2's pain medication POs should have but did not have parameters for administration. 43642 <Resident 242> During observations of medication pass on 06/27/2024 at 12:33 PM, Staff S (Registered Nurse) prepared two grams of a non-steroidal ointment that reduced swelling for Resident 242. Staff S applied the two grams of ointment to Resident 242's right shoulder/upper back area, to their lower back, and to the resident's left shoulder, per the resident's directions. In an interview at this time, Staff S stated the resident directed which areas to apply the ointment. Review of Resident 242's June 2024 Medication Administration Records (MAR) showed an PO for the non-steroidal ointment to be applied to the affected areas four times a day for chronic right sided low back pain and gave directions to apply two grams to the localized area. In an interview on 07/02/2024 at 10:56 AM, Staff E reviewed the order and stated their expectation was for staff to apply the ointment to Resident 242's lower back, but was aware of their shoulders hurting as well. Staff E stated the order should be clarified. <Resident 238> According to the 06/25/2024 Admission MDS, Resident 238 had multiple medically complex diagnoses including cancer and a hip fracture and required the use of pain medications during the assessment period. Review of Resident 238's June 2024 MAR showed a 06/21/2024 PO for a non-narcotic pain medication to be administered every 12 hours as needed for pain. A second 06/26/2024 order, for the same medication, was also ordered to be administered every four hours as needed for pain. Review of Resident 238's June 2024 MAR showed a 06/21/2024 PO for a medication to prevent nausea and vomiting. A second 06/21/2024 order for an antipsychotic medication was also ordered to prevent nausea and vomiting. There were no directions to staff to determine which medication should be administered versus the other if Resident 238 had nausea and vomiting. In an interview on 07/02/2024 at 10:56 PM, Staff E stated the duplicate orders needed to be clarified to reduce the risk of staff administering both POs and to know which medication to give to Resident 238 for pain and/or nausea and vomiting. 46479 <<Following Physician Orders> <Resident 13> According to the 06/01/2024 MDS, Resident 13 was unable to control their blood sugars and received insulin (medication that helped to control blood sugar levels in the body) injections during the look back period. Review of the 06/27/2024 order summary showed a 06/06/2024 PO instructing staff to check Resident 13's blood sugar levels three times per day and administer insulin to Resident 13 according to their blood sugar levels. This PO directed staff to administer 20 units of insulin and notify Resident 13's physician if their blood sugar was between 351 and 400. Review of Resident 13's June 2024 Medication Administration Record (MAR) showed Resident 13 had blood sugar readings between 351 and 400 on nine occasions. Review of Resident 13's records showed staff did not notify Resident 13's physician per the PO. In an interview on 07/01/2024 at 11:13 AM, Staff E stated it was their expectation nursing staff documented in the resident's progress notes if the physician was notified. Staff E stated they expected nursing staff to follow the PO and notify Resident 13's physician of the elevated blood sugar levels. <Resident 240> According to a 06/24/2024 Admission MDS, Resident 240 had medically complex diagnoses including pain in their right ankle and right foot and required the use of a narcotic pain medication during the assessment period. Review of Resident 240's June 2024 MAR showed an order for a narcotic pain medication. This order showed staff were to administer the 10 mg medication every 4 hours as needed for a pain level of 7 out of 10 or higher. The June 2024 MAR showed on 06/23/2024 a nurse administered the medication for a pain of 4 out of 10. In an interview on 07/02/2024 at 10:56 AM, Staff E stated their expectation was for staff to follow the parameters of an order and administer the correct medication as instructed. <Pain Orders> <Resident13> Review of Resident 13's POs showed a 05/28/2024 PO directing staff to assess Resident 13's pain level every shift. This PO directed staff to document the pain level on the Medication Administration Record (MAR). Review of Resident 13's June 2024 MAR showed staff did not document Resident 13's pain level when assessed. Staff documented a check mark instead of the resident's pain level. <Resident 8> Review of Resident 8's POs showed a 06/10/2024 PO directing staff to assess Resident 8's pain level every shift. This PO directed staff to document the pain level on the MAR. Review of the June 2024 MAR showed staff did not document Resident 8's pain level when assessed. Staff documented a check mark instead of Resident 8's pain level. Review of Residents 28's, 238's, and 240's June 2024 MARs showed each resident had POs directing staff to assess their pain levels each shift. On Residents 28's, 238's, and 240's June 2024 MARs nurses added checkmarks instead of a numeric value. In an interview on 07/02/2024 at 10:23 AM, Staff B stated it was their expectation nursing staff documented a numerical value for a resident's pain level each shift. Staff B stated nursing staff should not document a check mark. <Signing for Orders not Completed> <Resident 8> According to the 05/22/2024 Quarterly MDS, Resident 8 had diagnoses including a stroke and weakness to one side of their body. This MDS showed Resident 8 was at risk for developing pressure injuries (bed sores) and utilized a pressure reducing device on their bed. Review of Resident 8's order summary showed a 07/28/2021 PO for an air mattress. This PO instructed staff to ensure the air mattress settings were on comfort level soft 3 each shift. Observation on 06/28/2024 at 9:11 AM showed Resident 8 lying in bed. Their air mattress was set to level 5 alternating. Review of the June 2024 treatment administration record on 06/28/2024 at 1:28 PM showed Staff F (Registered Nurse) signed that they verified the air mattress was on the correct setting. In an observation and interview at that time, Staff F confirmed the air mattress was on the incorrect setting. Staff F stated the air mattress should be set to comfort level 3 but was not. REFERENCE: WAC 388-97-1620(2)(b)(i)(ii),(6)(b)(i).

Based on interview and record review, the facility failed to obtain and/or have Advanced Directives (AD - a document describing a resident's wishes for care if they became incapacitated) readily available in resident records for 3 of 5 residents (Residents 240, 241, & 13) and 1 supplemental resident (Resident 238) reviewed for ADs. This failure left residents at risk for losing the right to have their preferences and choices honored during emergent and end-of-life care. Findings included . <Facility Policy> According to the facility's revised 03/23/2023 Residents' Rights Regarding Treatment and AD policy, if a resident had an AD in place upon admission, copies would be made and added to the chart, and communicated to the staff. <Resident 240> Resident 240 was admitted to the facility on [DATE]. According to the 06/24/2024 Admission Minimum Data Set (MDS - an assessment tool), Resident 240 was assessed with no memory impairment, clear speech, was understood by others, and able to understand others conversation. In an interview on 06/26/2024 at 11:10 AM, Resident 240 stated they had an AD and identified a family member as their Power of Attorney (POA). According to the uploaded 06/19/2024 Admission Documentation in Resident 240's records, Resident 240 was identified to have ADs. Review of records revealed no ADs were found for Resident 240. <Resident 241> Resident 241 was admitted to the facility on [DATE]. According to the 06/24/2024 Admission MDS, Resident 241 had medically complex diagnoses including heart failure, kidney disease, and lung disease. According to Resident 241's uploaded 06/28/2024 Admission Agreement, Resident 241 was identified to have an AD and included documentation showing the resident's family member was their POA. Review of records revealed no ADs were found for Resident 241. On 07/01/2024 at 1:29 PM, Staff L (Office Manager) provided Resident 241's POA paperwork and stated they were found in a pile of records that needed to be uploaded into the resident's records. <Resident 238> Resident 238 was admitted to the facility on [DATE]. According to the 06/25/2024 Admission MDS, Resident 238 was assessed with no memory impairment, clear speech, to be understood and to be able to understand conversation. In an interview on 06/26/2024 at 10:48 AM, Resident 238 stated their family member was their POA and completed the admission documentation on their behalf. According to Resident 238's uploaded 06/25/2024 Admission Documents, Resident 238 was identified to have an AD. The documentation showed the resident's family member was their POA. The POA identified on the paperwork signed the admission agreements for Resident 238. Review of records revealed no ADs were found for Resident 238. In an interview on 07/02/2024 at 10:56 AM, Staff E (Resident Care Manager) stated ADs were important so staff were aware of and could follow what the resident's wishes were. Staff E stated ADs should be readily available in a resident's records. In an interview on 07/02/2024 at 1:01 PM, Staff H (Social Services Director) stated their expectation was if someone other than the resident was signing admission agreements, the facility would have a copy of the POA paperwork on file. Staff H stated ADs were usually scanned into the resident's records and should be readily available for staff to review. Staff H reviewed Resident 240, 241, and 238's records and stated they were unable locate their ADs. 46479 <Resident 13> Review of a 06/01/2024 Admission MDS, Resident 13 had difficulty hearing, was sometimes understood, and could sometimes understand others in conversation. This MDS showed Resident 13 had impaired thinking abilities. The MDS showed Resident 13 had diagnoses of traumatic brain dysfunction, heart failure, a progressive memory loss disorder, and a history of falling. Review of Resident 13's 05/28/2024 Admission Agreement showed Resident 13 had an identified legal health and financial care authority who signed Resident 13's admission paperwork. Record review on 06/27/2024 at 2:47 PM showed there was no ADs available in Resident 13's records identifying they had an established POA. In an interview on 06/28/2024 at 12:43 PM, Resident 13's family member stated they were Resident 13's POA. The family member stated they thought the staff requested copies of the POA documentation. In an interview on 07/01/2024 at 1:29 PM, Staff L provided a paper copy of the POA documentation. Staff L stated the facility did not have medical records, they were trying to get caught up with scanning documents. In an interview on 07/02/2024 at 10:06 AM, Staff B (Nursing Services Director) stated ADs should be readily available in the resident's record so staff knew who a resident's responsible party was. Staff B stated they expected AD's to be scanned into the resident's record within a couple of days of receiving the documents. REFERENCE: WAC 388-97-0280(3)(c)(i-ii).

Based on observation, interview, and record review, the facility failed to ensure 1 of 3 residents (Resident 23) reviewed for pressure ulcers (PU) received physician ordered wound care, and a recommended air mattress on a timely basis to prevent skin breakdown and the development and worsening of PUs. These failures resulted in harm to Resident 23 due to worsening of PU on the heels and increased risk for severe infection and further deterioration of skin integrity. Findings included . According to the 10/2022 facility policy Pressure Injury Risk Assessment residents who were determined at risk for developing pressure ulcers would have interventions documented in the Care Plan (CP) based on specific individualized factors identified in the risk assessment. According to the Heal University Wound Care Fundamentals PU stages are defined as; Unstageable PU: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar (dead tissue). Deep Tissue PU (DTI); Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. Resident 23 The 03/17/2023 Admission Minimum Data Set (MDS, an assessment tool) showed Resident 23 admitted to the facility on [DATE] with multiple complex diagnoses including stroke, peripheral vascular disease, right sided weakness, malnutrition, polyneuropathy (numbness in lower extremities), and a PU on the right heel. Resident 23 was assessed as moderate risk for PU development, and extensive assistance for bed mobility. On 03/28/2023 at 08:49 AM, Resident 23 was observed lying in bed with heels directly on the standard mattress. Straw colored fluid was observed on the sheets beneath Resident 23's heels. The left heel was observed to have a blister and the right heel had black eschar. Review of the 03/21/2023 wound care provider note showed Resident 23 had one DTI PU to the right heel involving 76-100% eschar, a DTI PU to the outer aspect of the right foot involving 76-100% eschar, and a newly identified Diabetic foot ulcer on the left heel involving 76-100% eschar. Review of the 03/21/2023 Physician Orders (PO) from the physician, generated from the wound care provider visit, was to treat the left heel daily with betadine and leave open to air. The PO was signed by the facility nurse on 03/21/2023 but review of the 03/2023 Treatment Administration Record (TAR) showed the PO for betadine was not implemented until 03/30/2023, nine days after the order was provided to the facility. Review of the 03/23/2023 Wound Care Provider's note recommended an air mattress for pressure distribution for Resident 23's DTI PU on the right heel and new ulcer on the left heel. The 03/23/2023 physician visit note showed the Physician ordered an air mattress for Resident 23 for treatment to both heel ulcers, the order was not implemented until 03/28/2023. In an observation and interview on 03/28/2023 at 12:47 PM the delivery person installed the air mattress to Resident 23's bed. The delivery person showed a copy of the air mattress order to the surveyor. The order showed the facility ordered the air mattress that morning, 03/28/2023 at 9:08 AM, five days after the wound care provider recommendation was made on 03/23/2023. Review of the 03/11/2023 CP showed the facility did not modify the CP to include the left foot DTI PU at the time of survey exit on 04/03/2023, 13 days after the left DTI PU was identified. In an interview on 03/28/2023 at 02:15 PM, the wound care provider stated both heel wounds were worse and now there was a concern for a bone infection. In an interview on 03/30/2023 at 11:20 AM, Staff B (Director of Nursing) stated Resident 23 should have had a treatment to the left heel at the time it was identified on 03/21/2023. Staff B was unable to provide an answer for why it took five days to order and receive the air mattress or an answer why the CP was not updated. During the interview, Staff B was not able to answer many of the questions during the interview, and stated I will have to check the policy, I will have to get back to you, I will have to ask the team. Staff B was not forthcoming with information on the care and treatment of Resident 23's ulcers or the competency of the facility nursing staff in managing wound care or timely implementing physician and wound provider orders. Refer to F-726 Competent Nurse Staff REFERENCE: WAC 388-97-1060(3)(b).

Based on observation, interview and record review, the facility failed to ensure 3 (Residents 21, 10 & 11) of 3 residents received the therapeutic altered liquids they were assessed to require. These failures increased the likelihood of choking, aspiration (breathing fluid or food into the lungs), pneumonia and death for these residents and constituted an immediate jeopardy. On 12/01/2021 an IJ was identified and the Provider was informed. On 12/01/2021, the facility removed the immediacy by ensuring residents were correctly assessed for the proper textured liquids, staff were trained to provide the correct textured liquids, and residents were provided with the correct textured liquids. Additionally, failure to adequately secure oxygen storage placed residents at risk for falls with injury. Failure to ensure chemicals were safely secured placed residents at risk for injury due to exposure or ingestion. Findings included . Resident 21 Record review showed Resident 21 admitted to the facility on [DATE]. According to the 07/31/2017 Admission Minimum Data Set (MDS - an assessment tool), the resident was assessed with diagnoses of dementia and stroke (bleeding in the brain), no coughing or choking during meals or when swallowing medications, no complaints of difficulty or pain when swallowing, and required Tube feeding (artificial nutrition infused through a tube inserted into the stomach). According to a 07/24/2017 Nutrition Assessment, the resident was assessed as NPO (nothing by mouth) and required Tube Feeding with the possibility of resuming oral feedings. Staff documented, inadequate .intake related to dysphagia (difficulty swallowing) and inability to safely consume (nutrition) orally status post stroke as evidenced by 14 lbs (pounds)(9.3%) weight loss x (in) 2 weeks. Record review showed the resident signed a risk and benefits form on 06/18/2018 which explained the potential consequences of the resident's choice to consume thin liquids, including aspiration and death. Review of the revised 08/04/2021 Nutrition Care Plan (CP) showed an intervention added on 05/27/2018 that the risks and benefits were explained if the resident drank un-thickened water they would be at risk for aspiration pneumonia which could lead to death. Record review showed no indication the resident's assumption of risk and review of benefits was reviewed again. Record review showed a 11/26/2019 Physician's Orders (POs) which indicated the resident required a regular texture diet with nectar thick consistency liquids related to dysphagia (difficulty in swallowing). In an interview at 5:45 PM on 12/01/2021, Staff B (Director of Nursing) stated staff did not, but should have, reviewed the resident's risks and benefits of choosing to consume liquid consistencies which were assessed as unsafe, after the 06/18/2018 initial assessment, at least annually. The 08/26/2021 Quarterly Nutrition Assessment showed the resident was frequently discussed by the IDT (Interdisciplinary Team) for weight changes triggers/tube feeding. Staff documented the resident had inadequate oral intake related to dysphagia as evidenced by the need for enteral feeding to supply more than 50% of needed nutritional intake and required a regular diet with nectar thick and small portions with fortified foods cut to bite sized pieces. Review of the 08/27/2021 Quarterly MDS showed staff identified the resident had no problems chewing or swallowing but required the use of tube feeding and a mechanically altered diet (a diet which requires change in texture of food or liquids (e.g., pureed food, thickened liquids). Progress notes dated 08/13/2021 showed the resident, declined feeding [assistance], however, seen drinking water and having snack. Progress notes dated 11/04/2021 showed, .resident request refill of drinking water PO [orally] and doing lil [a small amount] snacking that her family brought. [Medical Doctor], staff and family aware, will continue to monitor On 12/01/2021 at 11:53 AM Resident 21 was observed with a cup of un-thickened water on the overbed table in front of them. At 3:33 PM on 12/01/2021 the resident was observed with a cup of un-thickened water and a cup of nectar thick milk on the overbed table. Review of the undated Kardex (quick reference of CP) on 12/01/2021 showed direction to staff to provide and serve diet as order. Additionally, the Kardex directed staff that risks, and benefits were explained if the resident drank water in their teacup it could lead to aspiration pneumonia and death. The Kardex did not specify the consistency of fluids the resident should receive (nectar thick) and did not instruct staff to provide un-thickened water. In an interview on 12/01/2021 at 3:48 PM Staff B stated that staff should not serve Resident 21 water and confirmed the resident should receive nectar thick liquids. Staff B elaborated the Kardex (the part of the care plan directing staff what care to provide) should, but did not include, information instructing staff the resident required nectar thick liquids. Resident 10 A 9/10/2021 Quarterly MDS showed Resident 10 was cognitively intact, understood others and was able to be understood. Resident 10 was assessed with no swallowing disorder, no coughing, no choking during meals or when swallowing medication. A record review showed a current diet order dated 04/23/2020 for a regular textured diet with thin liquids. A 07/15/2021 physician encounter note showed Resident 10 was diagnosed with choking and referred the resident to speech therapy for coughing and choking with solid foods. A 07/16/2021 Speech Therapy (ST) evaluation showed referral for ST due to signs and symptoms of aspiration with cereal at breakfast. The evaluation showed Resident 10 had a history of dysphagia with prior ST services in July 2020 and February 2021 and a past procedure for dilation (widening) of the esophagus (tube from throat to stomach). The recommended diet from the evaluation on 07/16/2021 was regular texture and thin liquids, because this diet was requested by Resident 10. A 07/23/2021 swallow evaluation report showed a recommendation for the resident to have a regular texture diet with thin liquids and to consider a trial of nectar thickened liquids with medications. A PO dated 07/25/2021 directed staff to give medications one at a time with nectar thick liquids. A 08/19/2021 ST discharge summary showed a recommended diet of regular texture and thin liquids. A 10/20/2021 PO showed Resident 10's diet was changed to a dysphagia mechanical soft diet with honey thick liquids. A 10/21/2021 physician encounter note showed, Resident 10 had dysphagia as a chronic ongoing problem and to continue current diet. The note did not state the current diet. The record showed the current physician ordered diet in place on 10/21/2021, used by staff to provide food / fluids, was dated 10/20/2021 Gluten (a wheat protein) Free, Dysphagia Mechanical texture, Honey thick fluid consistency. In an interview on 12/02/2021 at 4:10 PM, Staff J, RCM- Resident Care Manager, stated Resident 10's diet was changed on 10/21/2021 from honey thick liquids back to thin liquids but the staff did not enter the new order into the physician orders. Staff J stated Resident 10 was approved to be on thin liquid consistency by the ARNP and there was an error in the physician order for honey thick consistency. Staff J stated the resident was not receiving what the current physician order on file required, and a documentation error occurred. In an interview on 12/01/2021 at 8:58 AM, Resident 10 stated they were served un-thickened coffee and milk for breakfast. There was a glass of un-thickened water on the bedside table. An observation on 12/01/2021 at 12:00 PM showed Resident 10 had cups of un-thickened milk, water, and a container of resource (a protein supplement drink) on the bedside table. On 12/01/2021 at 3:40 PM, Resident 10 stated they drank thin fluids at meals and between meals and only had thickened water with medications. Resident 10 stated they usually had ice water at the bedside, and it was not thickened. After the interview, Resident 10 asked for some water. At 3:50 PM, Staff J delivered a cup of thin ice water to Resident 10. In an observation and interview on 12/01/2021 at 3:52 PM Staff J, showed Resident 10 had a cup of ice water, not thickened, on the bedside table. Staff J verified the diet order stated resident was required to have honey thick liquids and the ice water in front of Resident 10 was not a honey thick consistency. In an interview on 12/01/2021 at 3:54 PM, Staff B verified the diet order was for honey thick liquids and water at the bedside was not consistent with the PO. Staff B stated the staff should look at the Kardex for instructions of liquid consistency for each resident. Staff B stated the person who entered honey thick liquids to the CP did not check the button to add the instruction to the Kardex. Staff B stated direct care staff would not know the liquid consistency to provide if not written on the Kardex. In an interview on 12/01/2021 at 4:01 PM, Staff G, Agency CNA - Certified Nursing Assistant, stated they were required to look on the Kardex to check the liquid consistency for a resident. In an interview on 12/01/2021 at 4:04 PM Staff F, On-call Registered Nurse, stated they did not know how to check the PO for the liquid consistency; they received a shift report that Resident 10 was on nectar thick liquids. Resident 11 According to the 09/11/2021 Quarterly MDS, Resident 11 admitted on [DATE] with diagnoses including dysphagia and adult failure to thrive. According to a 11/11/2021 progress note, Resident 11 had a history of aspiration pneumonia that resulted in hospitalization prior to admission. A 06/20/2021 progress note showed Resident 11's diet was changed to, nectar thick consistency d/t [due to] noted coughing after drinking fluids, diet changed until ST [speech therapy] will evaluate. Record review showed Resident 11 had a 06/20/2021 PO for Nectar thick liquids to be provided with one-to-one assistance (a situation where one staff member stays with and assists the resident) with drinking, secondary to dysphagia. The 06/22/2021 ST Evaluation and Plan of Treatment (EPoT) indicated Resident 11 was assessed to have difficulty swallowing. The EPoT included a long-term goal for Resident 11 to increase their ability to tolerate thin liquids. Record review showed Resident 11 was discharged from ST on 07/05/2021 having failed their trial for thin liquids, and was assessed to continue to require nectar thick liquids. In an interview on 12/01/21 at 4:06 PM, Staff E, CNA, stated they used the Kardex (care instructions to aides) to verify if a resident required an altered consistency, or if a resident's ordered consistency had changed. Resident 11's Kardex, reviewed on 12/1/2021, stated I am encouraged to drink fluids and am assisted with intake as needed . The Kardex included no indication Resident 11 required nectar thick liquids, or that aides were required to provide one-to-one support to the resident while drinking. Failure to secure Oxygen Storage On 12/08/2021 at 9:19 AM a portable oxygen tank was observed in Resident 30's room on the floor leaning against the resident's reclining chair. At 9:23 AM on 12/08/2021, Staff R stated they were not sure who removed the portable oxygen tank from the resident's wheelchair and the oxygen should not be on the floor, but should be stored on the back of the resident's wheelchair because it is a tripping hazard and unsafe to have the portable oxygen tank on the floor. In an interview on 12/08/2021 at 4:06 PM Staff B stated they would expect the portable oxygen tanks to be stored on the back of the resident's wheelchair or in a secured oxygen holder. Failure to secure Chemicals in Storage Areas On 12/01/2021 at 9:59 AM the door to the clean linen room on the west hall was observed to be unlocked. A bottle of peroxide multi-surface cleaner was observed in the bottom cabinet, underneath the sink and the label read keep out of reach of children. A cabinet above the sink was observed with a key in the keyhole that was unlocked, the cabinet contained razors, deodorant, skin cleanser, toothpaste, lotion and shaving cream. Similar findings on 12/02/2021 at 8:49 AM, 12/03/2021 at 8:32 AM and 12:23 PM, 12/08/2021 at 9:18 AM. On 12/01/2021 at 10:04 AM the door to the soiled utility room was observed unlocked. Three breaker boxes were observed on the left wall upon entering that were able to be opened with minimal effort. Multiple bedside commodes and garbage cans were observed blocking the pathway to the eye wash station and the sink. A bottle of Buckeye Eco floor cleaner was observed sitting on the sink counter. During an interview on 12/01/2021 at 12:25 PM Staff I (Registered Nurse) stated they and housekeeping had a master key to open the clean linen and soiled utility room. Staff I stated the soiled utility is always locked and they usually leave the clean linen room unlocked. During an interview on 12/01/2021 at 2:29 PM Staff I stated either they open the soiled utility room door for the CNA's or I give them (CNA's) the keys. Staff I stated the keys on the keyring are for the medication room, medication cart, treatment cart, outside patio key, central supply key and a master key. On 12/01/2021 at 2:26 PM Staff EE (CNA) stated they aren't sure why the doors are locked today, usually I walk right in. In an interview on 12/08/2021 at 4:06 PM Staff B stated they keep the soiled utility room locked to keep residents safe from chemicals and the clean linen room to keep the room clean. Staff B acknowledged the soiled utility and clean linen door were un-locked and stated the residents shouldn't have access to those rooms. REFERENCE: WAC 388-97-1080 (3)(g).