Every finding on record at Life Care Center of Port Orchard

Based on interview and record review, the facility failed to ensure grievances were completed for 1 of 3 residents (Resident 1) reviewed for quality of care. This failure placed residents at risk for continuation of concerns, decreased quality of care, and a diminished quality of life. Findings included.Review of the facility's policy titled, Grievance Program (Concern and Comment) review dated 09/26/2025, showed residents had a right to voice grievances which included their care and treatment that had been furnished as well as which had not been furnished, the behavior of staff or other residents, and other concerns regarding their facility stay. The facility will post in prominent locations throughout the facility the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously [.]. The facility allowed any associate to assist in completing the Concern & Comment Form if a resident, family member, or guest expressed a concern or comment. The staff would then work to resolve the concern if possible, and if it could not be resolved immediately then they would let the individual know that another staff member would be assigned to investigate the concern and would contact them timely. The facility would bring, all concerns to the supervisor on duty who would then contact the Executive Director/Administrator, the Director of Nursing, and/or other personnel as needed. Additionally, the facility would facilitate meetings and/or conversations with residents and families who have repeated concerns to better meet their needs. The facility would maintain records of the grievances, with a date received, summary statement of the grievance, steps taken to investigate the grievance, summary of findings/conclusion, statement as to whether the grievance was confirmed or not, any corrective actions taken, and a date the written decision was issued.Resident 1 was admitted to the facility on [DATE]. Review of the Minimum Data Set Assessment, dated 07/24/2026, showed they were moderately cognitively impaired. Review of the prior 30 days of progress notes, showed Resident 1 was documented as having episodes of forgetfulness and confusion, and was not fully alert and oriented (scored 2/4 for answering correctly person, place, time, and event/situation).Review of the facility's August 2026 Grievance Log, showed no grievance had been logged on the behalf of Resident 1. Review of Resident 1's electronic health record showed they had a banner for staff to see special instructions that said, if resident refuses, please notify daughter [CC1, Resident 1's Power of Attorney]On 08/21/2026 at 03:51 AM, CC1, Resident 1's Power of Attorney, said Staff C, Certified Nursing Assistant, did not want to elevate Resident 1's legs. 08/26/2026 at 03:36 PM, CC1 said they had talked to staff on 08/16/2026 about Resident 1 not getting their shower on 08/15/2026, and one was then given on 08/16/2026 after they talked to staff. CC1 said they had a care meeting on 08/13/2026, where they told the staff that if Resident 1 did not take a shower/refused a shower, that they were supposed to be called. CC1 said they were not notified of the shower refusal on 08/15/2026, and it was an ongoing issue of not being told of refusals. During an interview on 08/26/2026 at 5:16 PM, CC1, said Staff C did not ask Resident 1 to walk, and instead wheeled Resident 1 in a wheelchair. CC1 stated, If you put a walker in front of her, she will walk. CC1 said they had spoken to the Director of Nursing Services about Staff C.During an interview on 08/27/2026 at 10:24 AM, CC2, Resident 1's family member, said they had concerns about Resident 1 not getting showers, and said after one shower the facility had left Resident 1's bandage on during the shower and it was soaked afterwards. During an interview on 08/27/2026 11:28 AM, CC1, when asked if the facility offered to file a grievance regarding the incident with Staff C, said no they did not offer to file a grievance. CC2 said they had turned in a grievance because they arrived at the facility and found Resident 1 in the bathroom and it took an additional 14 minutes before they could get help from staff. During an interview on 08/27/2026 at 2:57 PM, Staff B, Assistant Director of Nursing, when asked if they had heard of any concerns regarding Staff C related to Resident 1, said during a meeting the family had said Staff C did not always help Resident 1 walk to the restroom with a walker. Staff B said they educated Staff C, and this was resolved as they had interviewed Staff C who said they could not make Resident 1 use a walker if they did not want to.During an interview on 08/27/2026 at 4:20 PM, Staff A, Executive Director/Administrator, when asked when should staff file a grievance, said they should file a grievance when there was a concern by the resident or family that could not be resolved very quickly. When asked if this aligned with their grievance policy, Staff A said they did not remember their grievance policy, but if a grievance required a multidisciplinary approach, it was better to fill one out. Staff A reviewed the August 2026 grievance log and confirmed they did not see any grievances listed for Resident 1. At 4:29 PM, Staff A went to discuss grievances with Resident 1's family. CC2 said they had filed a grievance last Friday, filled it out with a younger female staff at the front desk regarding the fact that no staff came to help Resident 1 for at least 14 minutes after they arrived and found Resident 1 needing assistance. Staff A asked if CC2 filled out a form, CC2 stated, Yes, it was a blue paper and I put my number on it and have not been contacted. At 4:39 PM, the interview with Staff A resumed. When asked if Resident 1's family concerns about Staff C not using a walker should have been filed as a grievance, Staff A stated, I am not sure what the resident's range of motion should be. When asked if you need to know that information to file a grievance, Staff A said no. Reference WAC 388-97-0460

Based on observation, interview and record review, the facility failed to provide care and services according to professional standards for 1 of 4 residents (Resident 1) reviewed for quality of care, when the facility failed to assess and document respiratory status for a newly admitted resident. This failure placed residents at risk for unidentified and/or unmet care needs, negative health outcomes, and a decreased quality of life Findings included. Resident 1 was admitted to the facility on [DATE]. The hospital Discharge summary, dated [DATE], showed the resident had a diagnosis of pulmonary fibrosis (a progressive disease where lung tissue becomes scarred and stiff. This scarring thickens the walls of the tiny air sacs (alveoli), making it difficult for oxygen to pass into the bloodstream. Common symptoms include persistent shortness of breath, a dry, hacking cough, and severe fatigue). The hospital discharge orders included use of a BiPap (Bilevel Positive Airway Pressure- a non-invasive ventilator used to assist breathing. It delivers pressurized air through a mask into the airways. It is unique because it provides two pressure levels: a higher pressure when you inhale and a lower pressure when you exhale) as needed. On 6/23/2026 at 4:33pm, Collateral Contact 1 (CC1), Resident 1's FM (family member) said the resident was in the facility for a few hours. CC 1 said when the resident arrived at the facility the facility did not have the correct mask for the BiPap machine, they had to ask several times for staff to place the BiPap on, and they could tell Resident 1's breathing was distressed due to facial hair not allowing the mask to fit properly. CC 1 said Resident 1 was at the facility for a few hours, and staff did not seem concerned and were very blase about it telling them, if you want to take him to the hospital, then take him. CC 1 said they requested a wheelchair, and they transported Resident 1 back to the hospital, when they arrived at the hospital Resident 1's oxygen levels were reported to be in the 70's. Review of Resident 1's electronic health record showed no nursing assessments documented, no vital signs documented, there were no respiratory assessments documented. There were no diagnosis entered. There was no baseline careplan initiated. Review of the progress note dated 05/28/20256 at 6:34pm by Staff C, showed CC 1 took Resident 1 to the ER due to not having the appropriate BiPAP mask at the facility. On 07/13/2026 at 3:38pm, CC 1 said they did not see any staff member assess Resident 1 during the time they were in the facility, when their concerns that Resident 1 was having difficulty breathing were brought to nursing staff attention, staff did not provide a respiratory assessment, or check oxygen levels to ascertain function of the BiPap mask/machine. Later when Resident 1 FM told staff Resident 1 was distressed and felt he needed to return to the hospital, staff did not assess the resident or offer non urgent transport or call 911. Again, reporting staff replied, If you're going to take him, then take him.On 7/13/2026 at 4:14pm, Staff B, Assistant Director of Nursing, Registered Nurse (RN) said residents were usually assessed upon admission and that would include a respiratory assessment and oxygen levels. Staff B said they would expect the vital signs and assessments to be included in the electronic health record. Staff B said she recalled the situation as staff had called her at home and was only aware of the issue of having the wrong mask, not that the resident was having difficulty breathing. If a resident was reported to be having difficulty breathing, they would expect staff to assess the resident and depending on the results offer urgent or non-urgent transport, if they desired to return to the hospital.On 07/13/2026 at 5:00pm Staff C, Licensed Practical Nurse (LPN) said, when residents are admitted they do an assessment that would include a respiratory assessment and oxygen levels. These would be documented in the electronic health record. Staff C said if a resident or family were reporting having difficulty breathing, they would assess the resident to determine if they needed oxygen or urgent or non-urgent transport. Staff C recalled the situation with Resident 1 and reported they were not aware they were having trouble breathing, but rather the issue was the correct mask was not delivered. Staff C said she did not evaluate the resident and assumed it had been done by the previous nurse, Staff D. Staff C said when CC1 reported the resident felt he needed to return to the hospital they did not offer to call 911 or non-urgent transport. On 07/14/2026 at 11:45am Staff A, DNS, RN was asked if there were any hardcopy records (actual paper documents, notes, etc. not located in the electronic health record) for Resident 1. On 07/14/2026 at 11:55am Staff A reported there was no hardcopy chart for Resident 1. On 07/14/2026 at 12:26pm Staff D, LPN said when a resident is admitted to the facility they would obtain vital signs which would include oxygen levels, and these would be documented in the electronic health record. If a resident or family member reported concerns with breathing, they would assess the resident and notify the provider if additional orders were needed. If a resident or family reported they felt they needed to go back to the hospital, Staff D said they would assess the resident and determine if they needed 911 or non-urgent transport. Staff D said they recalled the situation with Resident 1, and they were only in the building a few hours, and thought it was just an issue with not having the correct mask, they reported they were unaware of any breathing issues. When the resident requested to go back to the hospital, Staff D said she did not recall if she offered to call non urgent transport but believed she did. Staff A, Director of Nursing, RN said generally when a resident is admitted they are assessed within the first hour and this would include vital signs, and oxygen levels. This would be documented in the electronic health record. If a resident or family member expressed a concern about not getting enough oxygen, they would expect staff to assess the resident and report any identified concerns to the provider, they would expect this to be documented in the electronic health record. If a resident or family member felt their needs were not being met specifically in regard to oxygen management, Staff A said they would expect staff to get to the bottom of the concern and notify the provider. Staff A would expect this to be documented in the electronic health record. Staff A said if a resident or family was requesting transport back to the hospital, they would expect staff to assess the resident to determine the appropriate form of transport, either urgent or non-urgent. Staff A would expect staff to document assessments, and interventions taken in response to the reported concerns. With regard to Resident 1, Staff A said there was not an assessment documented in Resident 1's record, they would have expected staff to assess if the resident was having respiratory difficulties and to offer the appropriate mode of transport back to the hospital based on that assessment. Reference WAC 388-97-1620(2)(b)(i)(ii) (6)(b)(i)

Based on interview and record review, the facility failed to obtain labs as ordered, review and report to provider abnormal labs timely, and failed to fully implement neurological assessments for 1 of 4 residents (Resident 1) reviewed for Quality of Care. This failure places all residents at risk of unmet care needs, decreased quality of life, and other potential health complications. Findings included. LabsReview of the facility policy titled, Laboratory Services, dated 09/23/2025, showed the facility would, ensure that laboratory services met the needs of residents, that results were reported promptly to the ordering provider to address potential concerns, and the facility would notify the provider of laboratory results that fall outside of clinical reference ranges and document the provider notification and any changes in treatment in the medical record.Resident 1 was admitted to the facility on [DATE] with a diagnosis including SIADH, (syndrome of inappropriate antidiuretic hormone- a condition where the body produces too much antidiuretic hormone leading to water retention and low blood sodium levels, and electrolyte imbalances), was cognitively impaired and required moderate assistance from staff for completion of activities of daily living.Review of the physician's order dated 03/30/3036 showed Resident 1 was receiving a daily medication to treat hyperkalemia (too much potassium). Review of the medication manufacturer guidelines showed the medication binds to potassium to prevent absorption, and potassium levels should be monitored to ensure they stayed within the recommended range of 3.5 to 5.0. Adverse side effects also included edema (fluid retention) due to increased sodium in the medication. Review of the physician's order dated 04/01/2026, showed the facility was to obtain a BMP (basal metabolic panel- blood test) every Friday for three weeks; scheduled on 04/03/2026, 04/10/2026, and 04/16/2026. Review of Resident 1's electronic health record (EHR) showed lab results for 04/03/2026. Review of the Provider note dated 04/09/2026 showed Resident 1 was noted to have 2+ bilateral feet and ankle edema (swelling). There were no lab results for the scheduled 04/10/2026 lab order.Review of the Provider note dated 04/14/2026 showed Resident 1 had Lower extremity edema and a BMP was ordered.Review of the provider note dated 4/16/2026 showed a BMP was ordered on 4/14 and there were no results yet. Resident 1 continued to have 3+ bilateral pedal (both feet) edema. Review of Resident 1's EHR showed the lab results for the 04/16/2026 draw was received on 04/17/2026 at 2:21am, with multiple abnormal results, including a potassium level of 3.3 and Carbon dioxide level of 39 (normal 20-32, elevated levels can indicate serious health issues, respiratory failure and acidosis) There was no documentation the provider was notified and no provider acknowledgement of the low potassium level or other abnormal values. The lab results were electronically reviewed by the provider on 04/21/2026 at 1:52pm.Review of the Alert Note dated 4/21/2026 at 4:12pm by Staff D showed the resident had experienced a change in condition, the family was notified and requested the resident be treated in the facility, the provider was notified and orders were received for a chest x-ray. Review of the SBAR note dated 04/22/2026 showed facility staff contacted the provider to report the change in condition and received orders. The documentation also included that Resident 1's family member was aware and preferred to have resident treated in the facility. Review of the provider note dated 04/22/206 showed the resident had a change in condition, stat labs, x-rays, intravenous fluids and intravenous antibiotics were ordered. Review of the lab results received on 4/22/2026 showed worsening abnormal values including Resident 1's potassium level was now 3.0, the carbon dioxide value was now 43, additionally the sodium level was elevated at 151 (normal range 135-146).On 5/5/2026 Resident 1's family member said they were concerned when the resident began having swelling in her legs, they said they told nursing staff and they told him that was normal, then a few days before the resident was transported to the hospital the resident had a change in condition and was not really responding. Resident 1's family member said they felt the facility was not doing anything to help the resident and finally called 911 himself, to have the resident transported. On 06/02/2026 at 3:32pm, Staff D, Licensed Practical Nurse (LPN), said that when labs are ordered, they fill out a slip and place the order in the online portal for the lab service provider. When results come in, they are placed in the provider box. If there were abnormalities, they would call the provider or let them know if they were in the facilities. On 06/02/2026 at 3:59pm Staff C, LPN, Resident Care Manager (RCM), said labs results are printed off and placed in the provider box. If there were abnormal results they would be called to the provider. On 06/02/2026 at 4:14pm Staff B, Registered Nurse, Director of Nursing, said lab results show up on her dashboard, and she or an RCM will print them up and place them in the provider box and load them into the resident record. The provider is there daily to review, abnormal labs would be placed in the box, and the provider would be called if the labs were critical. On 06/02/2026 at 5:13pm Staff B said they were unable to locate any lab results for Resident 1 for 04/10/2026, or any documentation the provider was informed or noted the abnormal labs received on 04/17/2026 for Resident 1. Neuro Assessments Review of the facility policy titled, Neurological Checks, dated 08/09/2026, showed Neurological assessments would be initiated when a resident had a fall and or head injury and would be completed and documented in the electronic health record (EHR). Review of the facility fall incident report dated 04/20/2026 at 4:15pm showed Resident 1 was found on the floor on their left side and reported pain to their left forehead. Neurological assessments were initiated. Review of Resident 1's Neurological assessments showed that 13 of 21 scheduled assessments were completed; the first 4 every 15 minutes were completed, only 2 of 4 were completed for every 30 minutes, 4 of 4 for every 2 hours were completed, 3 of 4 were completed for every 4 hours, 0 of 4 were completed for every 8 hours, and 0 of 1 were completed for 24 hours after last 8 hours assessment.On 06/02/2026 at 3:32pm Staff D, LPN said Neuro assessments are completed every 15 minutes time 4, then every 30 minutes times 4, then every 2 hours times 4, then every 4 hours times 4, then every 8 hours times 4, then 24 hours after last 8-hour assessment. Staff D said they may not be completed if the resident was eating or in physical therapy. On 06/02/2026 at 3:59pm Staff C, LPN RCM, said Neuro assessments should be completed every 15minutes, 30 minutes, 2,4,8 hours in sets of 4. Staff C said they may not be completed if the resident was sleeping or the staff were not aware they were supposed to do it. Staff C said they would expect documentation if the neuro assessment was not completed.On 06/02/2026 at 4:14pm Staff B, RN DNS, said neuro assessments should be completed every 15 minutes times 4, then every 30 minutes times 4, then every 2 hours times 4, then every 4 hours times 4, then every 8 hours times 4, then 24 hours after last 8-hour assessment. Staff B said they may not be completed if the resident refused or was not in the building. Staff B said they would expect documentation if they were not completed as indicated. Reference WAC 388-97-1060

Based on interview and record review, the facility failed to ensure sufficient qualified nursing staff were available to provide care and services as evidenced by information provided in Resident/Surveyor interviews for 11 residents (Resident 56, 4, 60, 40, 71, 2, 34, 7, 50, 36 & 97) interviewed, and 3 staff (Staff L, G & M) interviewed. The facility had insufficient staff to ensure residents received assistance with care in a timely manner without long wait times. These failures placed residents at risk for unmet care needs and a diminished quality of life. Findings included . Resident InterviewsOn 04/06/2026 at 11:25 AM, Resident 56 said wait times for care was up to an hour on the morning and afternoon shifts. Resident 56 said they need more Certified Nursing Assistants (CNAs) to help answer call lights. On 04/06/2026 at 11:39 AM, Resident 4 said they have had to wait for cares from 30 minutes to an hour. On 04/06/2026 at 11:47 AM, Resident 60 said the facility had long waits for care, usually over an hour. Resident 60 said they pressed their call light that morning and at that point they had been waiting 45 minutes for staff to respond to the call light. On 04/06/2026 at 12:18 PM, Resident 40 said on average they have had to wait 30 minutes for staff to respond. On 04/06/2026 at 12:27 PM, Resident 71 said on the night shift they have had to wait over an hour for assistant. On 04/06/2026 at 1:39 PM, Resident 2 said wait times on weekends and night shift were over an hour. On 04/06/2026 at 2:50 PM, Resident 34 said on Sunday they had to wait over 30 minutes for staff to come and clean and replace their leaking colostomy bag. Resident 34 said it was always a lengthy wait for staff to provide care. On 04/06/2026 at 3:35 PM, Resident 7 said staffing was frustrating, they have had to wait for 30 minutes or up to an hour for staff to provide care. Resident 7 said some staff would respond to the call light, tell them they would be back and they did not return for up to an hour. Resident 7 said when they have had to wait that long, by the time staff would respond to them, they were in so much pain. Resident 7 said they had a booklet where they would write down all the times staff would take over hour to respond to cares. On 04/07/2026 at 8:08 AM, Resident 50 said it usually took staff 45 minutes to respond to call lights. On 04/07/2026 at 9:10 AM, Resident 36 said the facility had long waiting times for staff to provide care. Resident 36 said on average they have had to wait anywhere between 30 minutes and an hour for staff to provide care. Resident 36 said they had gotten to the point where they would write down the times when they would press the call button and how long it took the staff to respond. Resident 36 said sometimes it had been over an hour for cares. On 04/07/2026 at 9:56 AM, Resident 97 said there were not enough staff on the weekends. Resident 97 said they told staff multiple times, they wanted to get up on Easter Sunday, because they had plans, but they ended up spending all day in bed, because there were not enough staff. Staff InterviewsOn 04/08/2026 at 3:31 PM, Staff L, Certified Nursing Assistant (CNA) said the facility has been short staffed weekly and the biggest concerns were not being able to give 4-5 showers plus provide routine care. Staff L said they normally covered B Hall but were covering C Hall today. On 04/09/2026 at 10:28 AM, Staff G, CNA, said the facility has a problem with staffing levels, it has not been manageable with only two aids, due to things like Hoyer transfers and the hardest task to do was making sure all the residents received showers. Staff G said the weekends were even harder because management was not available to help. On 04/09/2026 at 11:31 AM, Staff M, CNA, said sometimes they were by themselves working on the hall and it was unmanageable, if they was another aid on the hall they would split the hall, which helped but it was still difficult to complete all daily tasks, between routine care, transfers and showers. Staff M said it was nice to have a 3rd aid or a float aid to help. Staff M said they recently completed a double weekend shift (for the past two weekends) and the facility was short staffed then too. Staff M said the most difficulty tasks to complete were showers and getting the residents out of bed. Payroll Based Journal (PBJ-a Center for Medicaid and Medicare Services, a mandated system for long-term care facilities to electronically submit daily, auditable, and verifiable direct care staffing data) triggered excessively low weekend staffing for the 1st Quarter 2025 (October 1-Decmeber 31). Grievances A grievance filed on 10/22/2025 stated, RSD [resident] reports she waited longer than expected for call light to be answered. A grievance filed on 10/24/2025 stated, RSD [resident] reports he waited longer than expected for call light to be answered. A grievance filed on 11/05/2025 stated, RSD [resident] reports she waited longer than expected for call light to be answered. A grievance filed on 01/03/2026 stated, RSD [resident] reports he waited longer than expected for call light to be answered. A grievance filed on 01/13/2026 stated, Resident states that she was not provided W/A shower as she expected. A grievance filed on 01/16/2026 stated, RSD [resident] reports she waited longer than expected for call light to be answered. A grievance filed on 01/16/2026 stated, RSD [resident] reports he waited longer than expected for call light to be answered. Staffing RecordOn 04/06/2026 the Staff C, Assistant Director of Nursing Services, observed working A Hall medication cart, due to staff call out. On 04/07/2026, Staff N, Staffing Coordinator, worked 6AM-2PM A Hall medication cart, due to staff call out and Staff V, Infection Preventionist, worked 2PM-6PM medication cart, due to staff call out. On 04/08/2026, Staff U, Resident Care Manager, covered the North Hall medication cart, and Staff B, Director of Nursing Services (DNS), covered Resident Care Manager (RCM) concerns. On 04/09/2026 11:53 AM, Staff N, Staffing Coordinator, said they focus on census for staffing levels, each hall has 2 aids with a float aid and shower aid available to help when needed. Staff N said for example if the facility census was above 75 then each hall would have two and a float aide to help. When asked about emergencies and call outs, Staff N said they had a list of staff they would call for over time, PRN (as needed) staff and when required management staff (Assistant Director of Nursing, Director of Nursing or herself) would come in. When asked about weekend staffing, Staff N said they do double weekend staff (meaning staff working 6AM-10PM Saturday and Sundays) and again managers would come if needed. When asked about the PBJ report- triggered low weekend staffing, Staff N said they did not know what the PBJ report was. After PBJ was explained, Staff N said weekend staffing has been difficult due to call outs. ON 04/09/2026 at 12:38 PM, Staff B, DNS, said they follow the PPD Patients Per Day for staffing levels, meaning 2 aides per hall and floats available when needed. When asked how the facility handles call outs, Staff B said they would call other staff, use PRN staff, or ask current staff to work overtime. When asked about the low weekend staffing reported on the PBJ, Staff B said weekends have been difficult but did not elaborate on what that meant. When it was explained that the CNAs reported a difficult time completing daily tasks, including showers and getting residents out of bed, Staff B said they have an open-door policy and staff have come to them in the past about the staff shortages in the facility. Reference WAC 388-97 -1080 (1), 1090 (1)

Based on observation, interview and record review, the facility failed to provide food that was palatable, attractive, and served at an appetizing temperature for 4 of 4 sampled Halls (Halls A, B, North 1 and North 2) reviewed for food . This failure placed residents at risk of weight loss, depressed mood, and a diminished quality of life.Findings included .Test TrayObservation of a test food tray on 04/10/2026 at 12:43 PM, showed a test tray with a white plate on a heated base system and had an insulated cover. The heated base system and white plate were both room temperature to the touch. Observation showed the white plate consisted of baked fish, coleslaw, corn and an Oreo dessert. Taste testing of corn showed it was mushy and overcooked. Taste testing of the fish showed lack of seasoning and was room temperature. Staff S, Dietary Manager, took the temperature of the fish at 112 degrees Fahrenheit, the corn at 129.5 degrees Fahrenheit, the coleslaw at 48.2 degrees Fahrenheit and stated the Oreo dessert was out of temperature range as it was just made.Resident InterviewsResident 50During an interview on 04/07/2026 at 8:11 AM, Resident 50 stated the food does not really look good and I don't always get what I ordered on the menu.Resident 7During an interview on 04/06/2026 at 3:41 PM, Resident 7 stated they would not eat the food it tasted like dead ashes and looked bad. Resident 47During an interview on 04/06/2026 at 12:23 PM, Resident 47 stated the food was not hot when they receive it and sometimes it was unidentifiable.Resident 56During an interview on 04/06/2026 at 9:52 AM, Resident 56 stated the food was not good, they have the same thing repeatedly and they have their family purchase food.Resident 60During an interview on 04/06/2026 at 11:51 AM, Resident 60 stated the vegetables were mush, the food was never hot just warm.Resident 71During an interview on 04/06/2026 at 12:28 PM, Resident 71 stated the food was terrible.Resident Council MinutesReview of the Resident Council Meeting Minutes showed food complaints from members in October 2025, November 2025, December 2025, January 2026, February 2026 and March 2026.Grievance LogReview of the facility's Grievance Log from October 2025 through April 2026 showed six food grievances in October, four food grievances in November, five food grievances in December, four food grievances in January, six food grievances in February, and 11 food grievances in March.During an interview on 04/10/2026 at 1:21 PM, Staff S, Dietary Manager, stated they were aware of issues with food temperature and had been waiting over 2 months for new plate warmers. Staff S stated the food temperatures and lack of palatability did not meet their expectations.During an interview on 10/27/2026 at 9:14 AM, Staff A, Administrator, stated that the facility's lack of temperature and quality did not meet their expectations.Reference WAC 388-97-1100(1), (2)

Based on interview and record review, the facility failed to notify the resident's representative of a new medication order and a doctor's appointment for 1 of 2 residents (Resident 6) reviewed for notification of change. This failure placed the resident at risk for not having their representative involved in their health care decision making and a diminished quality of life. Findings included .Resident 6 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set, an assessment tool, dated 03/06/2026, documented Resident 6 had a diagnosis of Non-Alzheimer's Dementia (a cognitive disorder caused by diseases other than Alzheimer's, often presenting with distinct symptoms like early personality shifts, movement issues, or rapid decline) and was moderately cognitively impaired.A review of the electronic health record (EHR) showed Resident 6 had a resident representative through a court appointed guardianship. On 04/06/2026 at 2:10 PM, Resident 6's representative said they were not notified of a new medication order for metformin and were never told about an appointment to see an eye doctor until they saw Resident 6 wearing new glasses.<New Medication Order>A review of Resident 6's April 2025 Medication Administration Record (MAR) showed a medication order for metformin, dated 04/12/2025, to be given daily in the morning and discontinued on 04/14/2025. The MAR documented metformin was given on 04/14/2025.A review of Resident 6's EHR did not show where their representative was notified of the new order. On 04/09/2026 at 10:47 AM, Staff U, Resident Care Manager C/S Hall, said Resident 6 had a new order for metformin and their representative was not called and notified. Staff U said Resident 6 received one dose of metformin on April 14th. Staff U said Resident 6's representative was notified after the first dose and should have been notified of the new order prior to receiving the medication. <Eye Appointment>A review of Resident 6's EHR showed a documented titled, Attending Physician Request for Services and/or Consultation dated 04/24/2025 for Eye Care and documentation that stated, History of Present Illness 1. Glasses Mailed Adj. that was signed by the provider on 02/05/2026.A review of Resident 6's EHR did not show where their representative was notified of the appointment.On 04/09/2026 at 10:47 AM, Staff U, Resident Care Manager C/S Hall, said there was a referral for Resident 6 to see the in-house eye doctor on April 24th, 2025, and was seen for glasses on February 5th, 2026. Staff U said they probably had an eye appointment sometime in between. Staff U said they know Resident 6's representative takes them to an eye doctor in the community. Staff U said they should have contacted Resident 6's representative for new appointments and they should have notified the representative of the eye appointment for new glasses.On 04/09/2026 at 12:07 PM, Staff B, Director of Nursing Services, said they did not find anything regarding the representative having been notified of the new medication order of metformin or the eye appointment in the EHR. Staff B said their expectation was for there to be communication with the resident's representative.Reference WAC 388-97-0320

Based on interview and record review, the facility failed to initiate, investigate, and resolve a grievance for 1 of 1 sampled resident (Resident 3) reviewed for personal property and grievances. This failure placed the residents at risk for emotional distress and a diminished quality of life.Findings included .Review of the electronic health record (EHR) showed Resident 3 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease (gradual loss of kidney function), hyperlipidemia (high cholesterol or fats in the blood) and diabetes (too much sugar in the blood). Resident 3 was able to make needs known. During an interview on 04/06/2026 at 3:31PM, Resident 3 stated they had recently moved to a new room in February 2026 but did not receive all their personal belongings. Resident 3 stated they reported they were missing approximately 3 pairs of pants and a few shirts to Staff P, Registered Nurse (RN). Resident 3 stated Staff P went back to the previous room to look for the clothing, but they were unable to locate the items.Review of the grievance logs for February 2026, March 2026 and April 2026 showed no grievances filed on behalf of Resident 3 related to the missing clothing.During an interview on 04/07/2026 at 12:21 PM, Staff P, RN, confirmed Resident 3 reported missing clothing after their room move. Staff P stated they looked for the clothing but were unsuccessful. Staff P stated they did not complete a grievance but instead obtained clothing from the donation bin for Resident 3.During an interview on 04/09/2026 at 12:53 PM, Staff A, Administrator, stated when residents reported missing items to staff the expectation was that staff would complete a grievance form and submit it to the social services department for follow up.Reference WAC 388-97-0460

Based on interview and record review, the facility failed to ensure pharmacy recommended gradual dose reductions (GDR, a stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) of psychotropic medications (prescription drugs that alter chemical levels in the brain, affecting mood, perception, thoughts, and behavior) were carried out, or if declined, a clinical rationale that indicated why a GDR attempt was likely to impair function or cause psychiatric instability in the individual was documented by the provider in the residents record, for 1 of 5 residents (Resident 56) reviewed for unnecessary medications. This failure placed residents at risk of receiving unnecessary psychotropic medications, experiencing adverse side effects, decline in physical function, and a diminished quality of life. Findings included . Resident 56 was admitted to the facility on [DATE]. Review of the Annual Minimum Data Set, an assessment tool, showed the resident had moderate cognitive impairment, diagnoses of anxiety disorder (a group of mental health conditions characterized by persistent, excessive, and uncontrollable fear or worry that interferes with daily life), depressive disorder (a common, serious mental health condition characterized by persistent sadness, loss of interest in activities, and low energy, lasting at least two weeks) and insomnia (a common sleep disorder characterized by persistent difficulty falling asleep, staying asleep, or waking too early, resulting in poor sleep quality and daytime fatigue), and received antidepressant and antianxiety medications during the assessment period. Record review showed Resident 56 had the following psychotropic medication orders:a) A 11/02/2025 order for lorazepam (an antianxiety medication) twice a day for target behaviors of increased agitation, shortness of breath, increased heart rate related anxiety disorder.b) A 02/22/2025 order for citalopram (an antidepressant medication) 20 milligrams (mg) once a day for target behaviors of self-isolation and statements of sadness related to major depressive disorder. Review of the electronic health record (EHR) showed Resident 56 had received citalopram 20 mg daily for major depressive disorder since 10/08/2022. The current citalopram order date was 02/22/2025 because on 02/21/2025 an order was input to discontinue the citalopram. On 02/22/2025 an order was obtained to start citalopram 20 mg daily (same dose). Review of the February 2025 Medication Administration Record (MAR) showed that Resident 56 received citalopram 20 mg on both 02/21/2025 and 02/22/2025, no dose was missed. This scenario (discontinuing citalopram on one day and restarting it at the same dose the next day) also occurred on 11/20/2024 and 11/21/2024, and 12/04/2023 and 12/05/2023. Review of the pharmacist Consultation Report, dated 02/02/2026, showed Resident 56 had received citalopram 20 mg daily since 2022. The consultation documented Per IDT [psychotropic committee interdisciplinary team], [Resident 56] exhibits behaviors of anger and increased falls with GDR attempts, [Resident 56] may discharge soon, team recommends no changes, benefits outweigh risks. A GDR of citalopram from 20 mg daily to 10 mg daily was recommended. On 02/19/2026 the provider reviewed the consult and under Physician's Response selected the response The resident's target symptoms returned or worsened after the most recent GDR attempt within the facility and a GDR attempt at this time is likely to impair this individual's function or cause psychiatric instability by exacerbating an underlying medical condition or psychiatric disorder AS DOCUMENTED BELOW. A space was provided below on the document that had the following instruction Please provide CMS [Center for Medicaid and Medicare Services] REQUIRED patient-specific rationale describing why a GDR attempt is likely to impair function or cause psychiatric instability in this individual The space provided for the documentation was left blank. A 02/19/2026 IDT note documented reviewed pharmacy recommendation for GDR of medication Citalopram with team citing contraindication due to presence of maladaptive behaviors and potential for increase in TBS [target behaviors]. PCP [primary care physician] in agreement with IDT with no changes to be made with Citalopram at this time. The IDT note did not indicate what Resident 56's maladaptive behaviors were or how, if at all, they were associated with the resident's citalopram use. Review of the EHR showed there had been no attempted GDR of Resident 56's citalopram since it was ordered on 10/08/2022, to treat the target behaviors of self-isolation and statements of sadness related to the resident's depression diagnosis. Anger and/or agitation, as referred to in the pharmacy consult, were identified target behaviors for the use of lorazepam, which had a successful GDR on 11/20/2024, when it was decreased from three times a day, to two times a day. No documentation of a failed GDR of a psychotropic medication was found in Resident 56's electronic health record. Nor was there a resident-specific clinical rationale documented by the provider, as required, that indicated why a GDR of the citalopram was likely to impair function or cause psychiatric instability for Resident 56.During an interview on 04/10/2026 at 12:37 PM, documentation of Resident 56's prior failed GDR that allegedly caused Resident 56 to experience increased anger and falls, and the providers documented resident-specific clinical rationale indicating why a GDR of the citalopram was likely to impair function or cause psychiatric instability for Resident 56 was requested. Staff B, Director of Nursing Services, said they needed to look through Resident 56's record and would provide any documentation that was found. No further documentation was provided.Reference WAC 388-97-0620 (1)(a)

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS), an assessment tool, accurately reflected the status for 2 of 18 sampled residents (Resident 28 & 5) reviewed for accuracy of assessments. This failure placed the residents at risk for unmet care needs and a diminished quality of life.Findings included .Resident 28 Resident 28 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented Resident 28 was moderately cognitively impaired and required substantial to dependent assistance with activities of daily living (ADLs). A review of the electronic health record (EHR) showed a document titled Hospice Certification and Plan of Care with a start of care date of 05/16/2025. The Quarterly MDS, dated [DATE], documented Resident 28 received Hospice Care and no was marked when asked Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? The Quarterly MDS, dated [DATE], documented Resident 28 received Hospice Care and no was marked when asked Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? On 04/09/2026 at 1:39 PM, Staff R, Registered Nurse (RN)/Minimum Data Set (MDS) Coordinator, said Resident 28 was receiving Hospice Services. Staff R reviewed the MDSs dated 02/20/2026 and 08/22/2025 and said they should have been marked yes for the question Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? Staff R said she would fix this right away. On 04/10/2026 7:46 AM, Staff B, Director of Nursing Services (DNS) said her expectation was for the MDS to be marked appropriately. Resident 5 Resident 5 was re-admitted to the facility on [DATE]. Review of the admission MDS, dated [DATE], showed the resident was cognitively intact, had a diagnosis of end stage renal disease (permanent kidney failure, usually the final stage of chronic kidney disease (CKD), where kidneys function at less than 10-15% of normal capacity), required dialysis (a life-sustaining medical treatment that filters waste products, toxins, and excess fluid from the blood when the kidneys have failed) services, but did not admit with a central line (a long, flexible tube inserted into a large vein, usually in the chest, neck, or groin, that reaches near the heart ) and did not have intravenous access (a medical technique where a small, flexible tube (catheter) is inserted into a vein to provide direct, rapid, and continuous delivery of medications, fluids, blood products, or nutrition into the bloodstream). Review of the 05/27/2025 Quarterly MDS, also assessed Resident 5 without intravenous access. Review of a nephrology progress note, dated 03/03/2025, documented Resident 5's dialysis access was via TDC [tunneled dialysis catheter, a long-term central vascular access device, usually placed in the neck into the internal jugular vein or subclavian vein and tunneled under the skin for patients needing chronic or urgent hemodialysis]. Record review showed from 03/03/2025 - 03/06/2025 there were no orders in place or direction to staff to assess and/or monitor Resident 5's TDC. A 03/07/2025 order directed nurses to monitor the resident's dialysis catheter site for signs and symptoms of infection or bleeding every shift, and a 03/08/2025 order directed staff to assess Resident 5's right subclavian port upon return from dialysis. A dialysis care plan, initiated 03/04/2019, directed staff to assess Resident 5's subclavian access site. On 04/08/2026 at 2:24 PM, when asked if central line and/or intravenous access were coded on the 03/06/2025 admission MDS and 05/27/2025 Quarterly MDS, Staff R, MDS Coordinator, stated, No. Staff R then acknowledged the resident had a TDC and the MDS was inaccurate. Reference WAC 388-97-1000 (1)(b)

Based on interview and record review the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) assessments were accurately completed for 1 of 5 residents (Resident 3) reviewed for PASRRs and unnecessary medications. This failure placed the residents at risk for inaccurate mental health diagnoses and a diminished quality of life.Findings included .Review of the electronic health record (EHR) showed Resident 3 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease (gradual loss of kidney function), hyperlipidemia (high cholesterol or fats in the blood) and diabetes (too much sugar in the blood). Resident 3 was able to make needs known. Review of Resident 3's PASRR, dated 12/15/2025, completed by the hospital prior to Resident 3's admission to the facility on [DATE], showed mood disorders indicated as a diagnosis on the form.Review of Resident 3's medical diagnosis list and providers orders showed no mental health diagnosis or behavioral health medication prescribed.During an interview on 04/09/2026 at 9:59 AM, Staff O, Social Services Director, stated the PASSR was incorrect and a new one should have been completed. During an interview on 04/09/2026 at 12:32 PM, Staff A, Administrator, stated the expectation was for staff to ensure PASRR's were correct upon admission and if not, a new one should have been completed to reflect accurate resident information.Reference WAC 388-97-1975

Based on interview and record review, the facility failed to ensure residents received the bowel care in accordance with provider orders for 2 of 7 residents (Resident 97 &1) reviewed for bowel management, and routine assessment and monitoring of edema (swelling caused by excess fluid trapped in the body's tissues) occurred for 1 of 2 residents (Resident 1) reviewed for edema management. These failures placed residents at risk for abdominal pain/discomfort, nausea, decreased appetite, delayed identification of fluid volume changes and other negative health outcomes.Findings included .<Bowel Management>Resident 1Resident 1 was admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS, an assessment tool), dated 02/25/2026, showed the resident had moderate cognitive impairment and did not have constipation. On 04/06/2026 at 2:15 PM, Resident 1 reported constipation had been an ongoing problem. Record review showed Resident 1 had the following 11/22/2025 PRN bowel management orders:a) Milk of Magnesia (MOM) PRN (as needed), if no bowel movement (BM) for 72 hours, administer on day four. b) Bisacodyl suppository PRN, if no results from MOM, administer on day five. c) Fleet enema PRN, if no results from suppository, administer on day six. Review of Resident 1's bowel monitor for February and March 2026 showed the resident went the following periods without a BM: 02/12/2026 - 02/15/2026 (4 days). 02/04/2026 - 02/07/2026 (4 days). 03/07/2026 - 03/10/2026 (4 days). Review of the February and March 2026 Medication Administration Record (MAR) showed facility nurses failed to administer MOM on the fourth day without a BM (02/07/2026, 02/15/2026 and 03/10/2026) as ordered. On 04/09/2026 at 3:01 PM, when asked if on the above referenced occasions, facility nurses administered Resident 1's PRN bowel medication on the fourth day without a BM as ordered, Staff B, Director of Nursing Services (DNS), stated, No. Resident 97Resident 97 was admitted to the facility on [DATE]. Review of Resident 97's March 2026 bowel record showed the resident had no BM from 03/12/2026 - 03/16/2026 (5 days).Record review showed Resident 97 had the following 03/12/2026 as needed (PRN) bowel management orders:a) MOM PRN, if no BM for 72 hours, administer on day four.b) Bisacodyl suppository PRN, if no results from MOM, administer on day five. c) Fleet enema PRN, if no results from suppository, administer on day six. Review of the March 2026 MAR showed facility nurses failed to administer MOM on the fourth day without a BM (03/15/2026) as ordered.During an interview on 04/09/2026 at 3:01 PM, when asked if facility nurses administered Resident 97 PRN bowel medication on the fourth day without a BM as ordered, Staff B, DNS, stated, No. <Edema Monitoring>Resident 1Resident 1 was admitted to the facility on [DATE]. Review of the Quarterly MDS, dated [DATE], showed the resident was moderately cognitively impaired, had a diagnosis of renal insufficiency and required diuretic medication during the assessment period. A renal insufficiency care plan, initiated 01/18/2026, directed staff to observe and report dependent edema, weight gain greater than two pounds in 24 hours, neck vein distension and /or shortness of breath. A hypertension (high blood pressure) care plan, initiated 01/18/2026, directed staff to notify the physician of edema. Record review showed a 12/09/2025 order directing nurses to apply ace wrap to left lower extremity PRN for edema and a 04/09/2026 order directing nurses to monitor Resident 1's edema every shift. The March 2026 MAR showed facility nurses signed every shift that they monitored Resident 1's edema as ordered, but no place was provided and nurses did not document whether there was edema or not, and if so, where and to what extent (e.g., 3+ pitting edema to the left lower extremity from foot to mid-shin).During an interview on 04/09/2026 at 3:04 PM, Staff U, Resident Care Manager, was asked to clarify what it meant when a nurse initialed off on the MAR that they monitored Resident 1's edema as ordered. Did it mean the resident had edema, if so, where and to what extent, or did it mean the resident did not have edema? Additionally, Staff U was asked how a nurse would know if Resident 1's edema was worse, better or the same, without knowing the location and extent of edema that was identified on previous assessments. Staff U explained that nurses should have documented the location of the edema and used the 0-4+ edema monitoring method to grade it. After reviewing the MAR and Resident 1's electronic health record Staff U acknowledged facility nurses had not documented the amount (0-4+), location, or whether edema was present and indicated the edema monitoring order was incorrectly input into the computer without direction to document or a place provided to record the presence/absence of edema, and if present, the location and extent assessed. Reference WAC 388-97-1060 (1)

Based on observation, interview, and record review the facility failed to monitor and accurately document fluids consumed to ensure fluid restrictions (a diet which limits the amount of daily fluid intake) was implemented per provider's orders for 2 of 4 residents (Resident 48 and 96) reviewed for nutrition. These failures placed the residents at risk for medical complications and a diminished quality of life.Findings included .Review of the electronic health record (EHR) showed Resident 48 admitted to the facility on [DATE] with diagnoses that included heart failure, diabetes (too much sugar in the blood) and muscle weakness. Resident 48 was able to make needs known. Observation on 04/06/2026 at 11:20 AM, showed Resident 48 with a water pitcher and a straw stuck in it on the overbed table for easy access to consume fluids. During an interview on 04/07/2026 at 11:53 AM, Resident 48 stated they were upset that their water pitcher had been taken by Staff Q, Certified Nursing Assistant (CNA) and they did not understand why. Resident 48 stated Staff Q, CNA had provided and filled the water pitcher since admission, and they did not understand what changed. Review of Resident 48's providers orders showed a 03/20/2026 order to monitor fluid intake and document amount. An additional order, dated 03/20/206, showed Fluid Restriction Total 2000 milliliters (MLS) per day; Nursing to provide 240 MLS for day and evening shift. 80 MLS for night shift, 480 MLS for breakfast and dinner and 480 MLS for lunch related to CHF [congestive heart failure]. During an interview on 04/07/2026 at 11:56 AM, Staff Q, CNA stated they were instructed to take Resident 48's water pitcher due to a fluid restriction. Staff Q stated they were aware Resident 48 was on a fluid restriction and did not recall providing or filling Resident 48's water pitcher in the past. During an interview on 04/07/2026 at 11:59 AM, Staff R, Registered Nurse/ MDS Coordinator (RN/MDS), stated during medication administration they noticed Resident 48 had a water pitcher on the overbed table and instructed Staff Q, CNA to take the water pitcher and provide a cup of water. Staff R stated they were not aware if Staff Q explained to Resident 48 why the water pitcher was taken. Review of the Resident 48's meal tray card did not show a fluid restriction. During an interview on 04/07/2026 at 3:00 PM, Staff S, Dietary Manager, reviewed a Diet Order and Communication form dated 04/04/2026 completed by nursing. Staff S stated the order did not reflect that Resident 48 was on a fluid restriction. Staff S stated communication between nursing and dietary had been an ongoing concern. During an interview on 04/09/2026 at 12:01 PM, Staff B, Director of Nursing Services, stated that residents on fluid restrictions should not have a water pitcher at the bedside. After reviewing Resident 48's April 2026 Medication Administration Record (MAR), Staff B stated the MAR had inaccurate totals and that did not meet expectations. Staff B stated Resident 48's diet slip should have accurately reflected the fluid restriction and the lack of communication between nursing and dietary did not meet expectations. Resident 96 Resident 96 was admitted to the facility on [DATE] with an order for a 1500 milliliter (ml) per day free water restriction (medical strategy to limit the intake of low-sodium, low-protein, or hypotonic fluids to manage conditions like hyponatremia, heart failure and kidney disease) for hyponatremia (low sodium levels). On 04/07/2026 at 9:37 AM, Resident 96 was not in their room. A water pitcher was on the overbed table containing 750ml of a clear liquid. On 04/07/2026 at 12:37 PM, a male visitor was observed entering Resident 96's room and pulled a bottle of arrowhead water from his jacket and handed it to Resident 96 who was sitting in a wheelchair at bedside. A pitcher containing 600 ml of clear fluid was on the overbed table in front of Resident 96. On 04/09/2026 at 2:08 PM, Resident 96 was observed sitting up in a wheelchair at bedside. An overbed table was positioned in front of the resident with a pitcher containing a clear fluid sitting on top of it. Review of the March 2026 MAR showed nurses were directed to document the amount of free fluid provided by nursing each shift. Each shift was allotted up to 500 ml of free fluid. A space was provided to record the resident's free water intake each shift, but there was no direction to staff to calculate, or place provided to record Resident 96's total 24-hour intake of free water. When Resident 96's 24-hour free water intake for the seven-day period of 04/01/2026 - 04/07/2026 were totaled, it showed the resident exceeded the free water restriction on three of seven days, as follows: 04/01/2026- total free water intake= 2750 ml. 04/05/2026- total free water intake= 1600 ml. 04/06/2026- total free water intake= 1750 ml. Review of the EHR showed there was no documentation that staff had calculated Resident 96's 24-hour free fluid intake totals, identified they frequently exceeded the restriction, performed patient education or notified the provider. On 04/09/2026 at 3:36 PM, Staff B, DNS, explained for residents with orders for fluid restrictions staff would record the resident's fluid intake each shift and then calculate the total 24-hour intake total. If a resident was non-adherent with the restriction (exceeding) patient education would be performed and the provider notified. When asked if staff had calculated Resident 96's 24-hour free water intake totals, identified they exceeded the restriction on three of seven days (04/01/2026, 04/05/2026 and 04/06/2026), and whether there was documentation of patient education and/or provider notification Staff B said no, and explained that the fluid restriction order had been input into the computer system incorrectly, without direction to nurses to calculate the resident's 24-hour free fluid intake total. Reference WAC 388-97 -1060 (3)(i)

Based on observation, interview and record review, the facility failed to ensure respiratory services were provided according to professional standards of practice for 1 of 2 sampled residents (Residents 2) reviewed for respiratory care. Failure to have a provider's order for oxygen placed residents at risk for discomfort, unmet needs and a diminished quality of life.Findings included.Review of the electronic health record (EHR) showed Resident 2 admitted to the facility on [DATE] with diagnoses that included chronic kidney disease (gradual loss of kidney function), hyperlipidemia (high cholesterol or fats in the blood) and diabetes (too much sugar in the blood). Resident 2 was able to make needs known. Observations on 04/06/206 at 9:36 AM, 04/07/2026 at 10:48 AM and 04/08/2026 at 8:40 AM showed an oxygen concentrator on set to 2 liters per minute near Resident 2's bed. Resident 2 was not observed wearing a nasal cannula during the observations.Review of Resident 2's Care Plan initiated 03/19/2026, showed an intervention for oxygen via nasal cannula at 2 liters per minute as needed for shortness of breath.Review of the EHR showed no active provider's order for oxygen.During an observation and interview on 04/08/2026 at 8:42 AM, Staff C, Assistant Director of Nursing Services, asked Resident 2 when they used the oxygen. Resident 2 stated they only used oxygen at night. Staff C checked the EHR and stated there was no active order on file for oxygen but should have been.During an interview on 04/09/2026 at 11:38 AM, Staff B, Director of Nursing Services, stated the oxygen order was discontinued however since Resident 2 was still using oxygen a new order should have been obtained.Reference WAC 388-97-1060(3)(j)(iv)-(vi)

Based on interview and record review, the facility failed to complete Certified Nursing Assistant's (CNA) annual performance reviews as required for 3 of 5 sampled nursing assistants (Staff H, I, & J) reviewed for performance reviews. This failure placed residents at risk of receiving care from inadequately trained and/or under-qualified care staff, and a diminished quality of life. Findings included .Staff H, CNA, was hired on 04/09/2025. Record reviewed on 04/09/2026, showed no annual performance review had been completed. Staff I, CNA, was hired on 04/25/2024. Record reviewed on 04/09/2026, showed an annual performance review was completed on 09/17/2025 (5 months past annual review date). Staff J, CNA was hired on 06/20/2024. Record reviewed on 04/09/2026, showed an annual performance review was completed on 09/17/2025 (3 months past annual review date). On 04/09/2026 at 12:38 PM, Staff B, Director of Nursing Services, said annual performance reviews needed to be completed and pointed to a binder (indicating CNA annual performance reviews that needed to be completed). When shown the listed staff above without or past due annual performance reviews, Staff B said the annual performances were completed within the year. It was explained that the regulation reads from hire date to hire anniversary and not calendar year, Staff B said the annual performance reviews should have been completed within timeframe. Reference WAC 388-97 -1680 (1), (2)(a-c)

Based on observation, interview and record review, the facility failed to ensure medications were dated when opened for 2 of 3 medication carts (A hall cart & North hall cart) reviewed for medication storage. Additionally, the facility failed to ensure medications were secured for 1 of 1 resident (Resident 28) observed with medications at bedside. These failures placed residents at risk for medication discrepancies and an impaired quality of life.Findings included. <North Hall Medication Cart>An audit of the North Hall medication cart on 04/10/2026 at 9:26 AM showed the following:a) Resident 104's latanoprost eye drops were opened and undated. Review of the package insert showed the medication should be discarded six weeks after opening.b) Resident 104's fluticasone propionate was opened and undated. Review of the package insert showed the medication should be discarded 90 days after opening.c) Resident 103's latanoprost eye drops were opened and undated. Review of the package insert showed the medication should be discarded six weeks after opening.d) Resident 14's Spiriva Respimat was opened and undated. Review of the package insert showed the medication should be discarded 90 days after opening. On 04/10/2026 at 9:38 AM, when asked if the above referenced medications should have been dated when opened, Staff U, Resident Care Manager (RCM), said the nurse who opened the eye drops and/or inhalers should have recorded the date opened, but failed to do so. <A Hall Medication Cart>An audit of the A Hall medication cart on 04/10/2026 at 9:52 AM showed the following:a) Resident 47's Wixela inhaler was opened and undated. Review of the package insert showed the medication should be discarded 30 days after opening. On 04/10/2026 at 9:56 AM, Staff U, RCM, said Resident 47's Wixela inhaler should have been dated when opened, but was not. <Medications at Bedside>Resident 28 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set, an assessment tool, dated 02/20/2026, documented Resident 28 was moderately cognitively impaired and required substantial to dependent assistance with activities of daily living (ADLs). A review of Resident 28's electronic health record showed orders for:1) Apply calmoseptine to the coccyx (a small triangular bone at the base of the spinal column) blanchable redness (a red area of skin that turns white or paler when pressed) every 24 hours as needed after each incontinent (the inability to voluntarily control bladder or bowel movements, leading to involuntary leakage) episode dated 03/11/2026 2) Apply calmoseptine to the coccyx blanchable redness every shift dated 03/11/2026 On 04/06/2026 at 11:13 PM, creams observed on the bedside table of Resident 28 in 2 different medicine cups, one cream pink and one cream white, with Resident 28's last name written on the medicine cups. On 04/07/2026 at 8:28 AM, observations of a white and pink cream located on Resident 28's bedside table in 2 medicine cups labeled with the first letter of Resident 28's last name. On 04/08/2026 at 8:27 AM, Resident 28 had 2 medicine cups with a pink and white cream, on the bedside table with Resident 28's name written on the outside of the medicine cups. On 04/08/2026 at 11:05 AM, 2 medicine cups with a white and a pink cream inside were observed on the table of Resident 28. On 04/08/2026 at 11:11 AM Staff P, Licensed Practical Nurse went into Resident 28's room and said they observed 2 medicine cups with cream in them by Resident 28's bed. Staff P was observed throwing the medicine cups with a pink cream and a white cream in the garbage. Staff P said they believed the white cream was a zink paste and the pink cream was calmoseptine. Staff P said some nurses may ask the nurse aides to apply the cream to the resident's skin when they are proving care and Staff P believed this was not permissible. Staff P said the creams in the medicine cups should not be left at the bedside. On 04/08/2026 at 11:22 AM, Staff B, Director of Nursing Services, said the 2 medicine cups with creams in them should not have been left in the resident's room. Staff B said it was the facility's policy for nurse aides to let the nurse know when they are providing resident care so the nurse can go in and apply the creams to the resident's skin. Reference: WAC 388-97 -1300 (2), -2340, -1300(1)(b)(ii), (c)(ii-v)-1300 (2)

Based on interview and record review, the facility failed to ensure dental services were provided for 1 of 3 Medicaid residents (Resident 1) reviewed for dental services. The facility's failure to follow up on dental referrals and to assist with appointment scheduling and transportation arrangements that resulted in Resident 1 not receiving the dental services they were assessed to require (tooth extraction(s) and new upper and lower dentures). These failures placed residents at risk for unmet dental needs including difficulty chewing, oral pain, decreased self-image and diminished quality of life.Findings included .Resident 1 was admitted to the facility on [DATE]. Review of the 10/06/2025 admission Minimum Data Set, an assessment tool, showed the resident was cognitively intact and had mouth or facial pain, discomfort or difficulty with chewing. On 04/06/2026 at 2:10 PM, Resident 1 reported they had chipped and cracked teeth on the bottom that needed work and stated, I pulled one out last week. Resident 1 went on to state, I don't have upper teeth see . I had spaghetti, how am I supposed to eat that? A resident has the potential for oral/dental health problems r/t [related to] natural carious and broken teeth, pain and difficulty with chewing care plan, initiated 10/14/2025, directed staff to coordinate arrangements for dental care and transportation as needed and/or as ordered. Record review showed a provider order, dated 11/22/2025, for the resident to receive dental services as needed. Review of a dental consult, dated 11/10/2025, showed a referral for Resident 1 to get x-rays, and evaluated for extraction of tooth 18. Resident 1 was then to be referred for new dentures. The dentist hand wrote on the consult that (Resident 1) would like tooth extraction and new dentures made. Review of the electronic health record showed no documentation that staff followed up to Resident 1's dental referral for tooth extraction and/or new dentures. On 04/10/2026 at 12:37 PM, when asked if the facility had documentation to show Resident 1's referral for x-rays, evaluation and tooth extraction and/or referral for new dentures had been followed up on Staff B, Director of Nursing Services, stated, No. Reference WAC 388-97-1060 (1), (3)(j)(vii)

Based on observation, interview and record review the facility failed to ensure food preferences related to portion sizes were honored for 7 of 19 sampled residents (Residents 87, 77, 63, 61, 57, 37 and 4) reviewed for resident rights. This failure placed the residents at risk for dissatisfaction and diminished quality of life.Findings included.Review of the Diet spreadsheet showed the 04/10/2026 breakfast menu consisted of cheese scrambled eggs, bacon, buttered toast and choice of cereal. The entree was to be served with a #10 scoop for residents who received a regular diet.Observation on 04/10/2026 at 7:30 AM, showed Resident 61 preferred small portions and a small serving of starch. Staff T, Cook, used the size #12 scoop to plate a regular portion size and regular portion size of starch.Observation on 04/10/2026 at 7:32 AM, showed Resident 77 preferred small portions. Staff T used the size #12 scoop to plate a regular portion sizeObservation on 04/10/2026 at 7:41 AM, showed Resident 57 preferred small portions. Staff T used the size #12 scoop to plate a regular portion size.Observation on 04/10/2026 at 7:42 AM, showed Resident 37 preferred a small serving starch. Staff T used the size #12 scoop to plate a regular portion size of starchObservation on 04/10/2026 at 7:43 AM, Resident 87 preferred small portions. Staff T used the size #12 scoop to plate a regular portion size. Observation on 04/10/2026 at 7:53 AM, Resident 63 preferred a small serving of starch. Staff T used the size #12 scoop to plate a regular portion size of starch.Observation on 04/10/2026 at 7:55 AM, showed Resident 4 preferred a small serving of starch. Staff T used the size #12 scoop to plate a regular portion size of starch.During an interview on 04/10/2026 at 9:27 AM, Staff T stated they were unable to locate the #10 scoop for the breakfast entree and instead used the #12. Staff T stated for residents who preferred small portions of small starch they should have been using a smaller scoop.During an interview on 04/10/2026 at 9:30 AM, Staff S, Dietary Manager, stated they expected staff to follow the diet spreadsheet and use the correct scoop sizes when serving meals. Staff S stated when residents requested smaller portion sizes or a smaller amount of starch the expectation was for staff to provide half the regular serving size as requested.Reference WAC 388-97-1100(1).

Based on interview and record review, the facility failed to implement a system to ensure Certified Nursing Assistants (CNAs) received the required training for continued competency of no less than 12 hours per year for 2 of 5 sampled staff (Staff I & K) reviewed for training. The failure to implement a system to provide mandatory training placed residents at risk for abuse, neglect, emotional distress, physical injury and a diminished quality of life. Findings included .Staff I, CNA, was hired on 04/25/2024. Record reviewed on 04/09/2026, documented Staff I had 3.75 hours of training annually (from 04/25/2024-04/25/2025). Staff K, CNA, was hired on 07/15/2024. Record reviewed on 04/09/2026, documented Staff K had 11.25 hours of training annually (from 07/15/2024-07/15/2025). On 04/09/2026 at 12:38 PM, when shown the staff that did not meet the required annual 12-hour training minimum, Staff B, Director of Nursing Services, said the training hours should have been completed. Reference WAC 388-97-1680 (2)(a-c)

Based on interview and record review, the facility failed to provide care and services adequate to prevent hospitalization for 2 of 3 residents (Residents 1 & 2) reviewed for hospitalization . The facility failed to provide and monitor for adequate hydration, recognize and intervene when decline occurred, and failed to notify physician and family of abnormal laboratory results. This failure placed residents at risk for dehydration, hospitalization , and a diminished quality of life. Findings included . Review of the facility policy, Hydration and Nutrition, revised [DATE], showed that each resident would receive sufficient fluids to maintain acceptable parameters of nutritional and hydration status. Review of the facility policy, Laboratory Services, revised [DATE], showed that laboratory services would meet the needs of residents and results would be promptly reported to the provider to address potential concerns, diagnose, and treat. <Resident 1> Resident 1 was admitted to the facility on [DATE] for aftercare and therapy services following lumbar and pelvic fractures. The admission Minimum Data Set (MDS), an assessment tool, dated [DATE], showed the resident had severe cognitive impairment, was dependent on staff for activities of daily living (ADLs), and had an indwelling catheter. The care plan, initiated [DATE], showed the resident was nutritionally at-risk secondary to swallowing difficulty and interventions included easy to chew texture, nectar thick liquids, assistance with meals, and for staff to report loss of appetite or refusals to eat. Review of the initial provider note, dated [DATE], showed Resident 1 was clinically stable and the provider ordered a CBC (complete blood count) and a BMP (basic metabolic panel), and nursing was to support with adequate oral hydration. A Skilled Nursing note, dated [DATE] at 4:39 PM, showed the resident was alert and oriented with clear speech, was receiving assistance with meals in the assisted dining room, was encouraged to increase fluid intake, and had a foley catheter that was draining yellow urine. A skilled nursing note, dated [DATE] at 2:28 PM, showed the resident was alert, able to make needs known, pleasant and cooperative with care, eating meals in the dining hall, and had a catheter in place which was draining dark amber urine and their lung sounds were clear. Review of the provider note, dated [DATE], showed the resident was stable, with no reported concerns and the provider was awaiting the previously ordered lab results. A skilled nursing note, dated [DATE] at 1:56 PM, showed the resident was eating in the assisted dining room, required supervision and assistance with meals and the resident was encouraged to increase their fluid intake. Review of the laboratory sample received by an outside lab provider on [DATE] at 12:10 AM showed the results were reported to the facility at 2:40 PM, showed Resident 1 had elevated WBC's (white blood cells- a potential indicator of infection) of 11.8 (normal range is 3XXX,d+[DATE].8) and elevated sodium level (a potential indication of dehydration) at 147 (normal range is ,d+[DATE]). The lab results were review by facility staff and noted by the provider on [DATE]. An alert note, dated [DATE] at 11:32 PM, showed the resident was observed with a swollen penis and reports of pain. The provider was contacted, and an order was obtained to remove the catheter. A skilled nursing note, dated [DATE] at 2:41 PM, showed the resident was found with decreased oxygen saturations [no initial oxygen level was documented in the note], increased respiratory rate, and shallow breathing. Oxygen was applied and oxygen saturations were in the high 80's [normal with oxygen is 100%]. Provider and Family Member (FM) 1 were notified and instructions to transport the resident to the emergency room (ER) were given. Emergency Medial Services arrived and assessed the resident to be stable and a decision with FM 2 was made to not transport the resident. Review of the provider note, dated [DATE], showed the nurse reported at 9:30 AM the resident had cyanosis (when your skin, lips or nails turn blue due to a lack of oxygen in your blood) and oxygen saturations in the low 60's. The provider assessed the resident found to be sitting in his wheelchair, with oxygen saturations in the 70's on room air and a wet cough was noted. The provider spoke to FM 2 and recommended transport to ER, they agreed. When EMT's arrived their assessment was resident's oxygen was in the 90's on room air and a 12 lead EKG (electrocardiogram- a non-invasive medical test that records the electrical activity of the heart) was normal, the EMT's called FM 2, who declined resident transport to the ER. The provider note included that lab results were not available for the resident and new orders were given including a chest x-ray, CBC and CMP (complete metabolic panel). A skilled nursing note, dated [DATE] at 2:44 PM, showed the resident was alert and oriented, able to make his needs known, compliant with care and medications, was using supplemental oxygen. The note showed resident preferred eating in his room and was documented as independent after set up . A skilled nursing note, dated [DATE] at 11:37 AM, showed resident with weak hand grasps bilaterally and with 1+ non pitting edema to BLE [bilateral lower extremities] A skilled nursing note, dated [DATE], at 2:32 PM, showed Resident 2 was alert but was not oriented and unable to make wants and needs known, non-compliant with medications and treatments during the shift. Oxygen was 98% on 2 liters. Hand grasps were weak bilaterally, 2+ non pitting edema to Bilateral lower extremities, resting in bed with eyes closed. A skilled nursing, dated [DATE], at 2:33 PM, showed Resident 1 was unresponsive to verbal and physical stimuli, Vital signs were stable although oxygen saturation was 67% [critically low oxygen level - life threatening] with 5 liters continuous oxygen . family was notified and resident transported to ER. Review of the Hospital admission record for [DATE] showed that Resident 1 was found to have received a significant fluid bolus enroute to and in the ER to correct dehydration with admitting diagnosis of shock, multi organ failure, acute renal failure, was positive for Influenza A (a highly contagious respiratory illness caused by influenza viruses that infects the nose, throat and lungs) and RSV (Respiratory Syncytial Virus - a common respiratory virus that primarily affects the lungs and respiratory tract), a UTI [urinary tract infection], and had elevate WBCs of 13.4 and a sodium level of 151 [frequently indicated dehydration]. Resident 2 expired on [DATE]. Review of the facility's infection control log for February 2025 showed the facility had identified cases of RSV on [DATE] and Influenza A on [DATE]. Review of Resident 1's February 2025 Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not show that fluid intake or urinary output was recorded. Review of Resident 1's Task Record for Eating [DATE] through [DATE] showed the following: Date Breakfast Lunch Dinner ,d+[DATE] ,d+[DATE]% ,d+[DATE]% ,d+[DATE]% ,d+[DATE] ,d+[DATE]% ,d+[DATE]% ,d+[DATE]% ,d+[DATE] ,d+[DATE]% ,d+[DATE]% ,d+[DATE]% ,d+[DATE] ,d+[DATE]% ,d+[DATE]% ,d+[DATE]% ,d+[DATE] no record no record ,d+[DATE]% ,d+[DATE] ,d+[DATE]% ,d+[DATE]% ,d+[DATE]% ,d+[DATE] ,d+[DATE]% Refused ,d+[DATE]% ,d+[DATE] ,d+[DATE]% ,d+[DATE]% ,d+[DATE]% ,d+[DATE] ,d+[DATE]% ,d+[DATE]% ,d+[DATE]% ,d+[DATE] no record On [DATE] at 1:37 PM, Resident 1's FM1 said they visited the resident regularly and could see him getting weaker and weaker, he had previously been going to the dining room but then remained in his room, and staff fed him in bed and his last few days. FM1 said they could see he was not really responsive. FM1 said Resident 1 had a situation with his catheter, and the facility was supposed have done a urine test for infection and a chest x-ray but FM1 said they did not think that happened. FM1 said they moved Resident 1's room to keep a better eye on him, but it seemed his care completely disappeared. FM1 said staff knew about his concerns. On [DATE] at 1:18 PM, Resident 1's FM 2 said they received a call from EMTs on [DATE] reporting they arrived at the facility to transport Resident 1, but their assessment was he was medically stable at that time with improved oxygen levels, and she decided it was best not to transport the Resident to the ER based on that information. On [DATE] at 3:30 PM, Staff F, Nursing Assistant (NA), said Resident 1's changes in behavior, mood, appetite, or lethargy (abnormal sleepiness or inactivity) would cause concern and she would report those to the nurse. Staff F said they tried to monitor fluid intake for all residents, but it was only recorded for residents on fluid restriction. Staff F, said they did not recall Resident 1 having a decline, but he did not want to get up or eat at times and they would offer to feed him in his room. Staff F said they did not report concerns to LN staff other than he did not want to get up. They did not recall hearing concerns from family other than he was tired and not adjusting to the facility. On [DATE] at 3:55 PM, Staff E, Licensed Practical Nurse (LPN), said changes in vital signs or respiratory status would cause concern and they would report to the RCM (resident care manager), provider, and family. Staff E, said they didn't monitor fluid intake for all residents, only if they were on a fluid restriction or had a catheter or were receiving intravenous fluids. Staff E said documentation would be found in the nurses notes or flow sheet. Staff E said lab results were in the computer [electronic health record] or the RCMs would tell them what the results were. Staff E said the floor nurse was usually the one to notify the provider of lab results. Staff E said she could not recall anything specific regarding Resident 1's care and thought she only provided care for him once. Review of Resident 1's Progress notes from [DATE] to [DATE] show Staff E provided care to Resident 1on [DATE], [DATE], [DATE], and [DATE]. On [DATE] at 11:23 AM, Provider A, Nurse Practitioner, said, staff notify them of changes in condition usually by SBAR [situation-background-assessment-request often in written form left for provider], for non-urgent issues or a phone call for more urgent matters. Provider A said staff received lab results when staff placed them in her box to review or if she was called for abnormal or urgent labs results. Provider A said she ordered labs for Resident 1 and did not recall being informed of the results. Provider A said she recognized a decline in Resident 1 and requested he be sent to the ER and was not aware there were lab results in the resident record on that day. Provider A said the results may have changed her plan of care but most likely she would have requested they be repeated and the resident monitored. Provider A reviewed the signed copy of labs results and said she would have expected to receive them sooner. Provider A would have expected Resident 1 to be tested for respiratory viruses based on his symptoms and per facility's protocol. On [DATE] at 12:09 PM, Staff C, Infection Preventionist, Registered Nurse (RN), said in the beginning of the facility outbreak they were not testing all residents, just if they were symptomatic. When asked if a resident experienced shortness of breath, decreased oxygen levels and a cough, would she expect the resident to have been tested for influenza or RSV, Staff C said, not necessarily. Staff C said she was not aware of a decline in Resident 1. Staff C said she was not made aware Resident 1 was having signs or symptoms of influenza or RSV. Staff C noted there was a chest x ray and urine analysis ordered but was not able to locate the results. Regarding Resident 1's entry on the infection control log, Staff C said that was logged after his admission to the hospital and the facility was not yet in outbreak status at that time. Staff C said after the hospital notified them, they put a plan into place. At 12:21 PM, Staff D, LPN, RCM, said staff would notify the provider if a resident had experienced a change in condition such as increased weakness, altered mental status, falls with injuries, or shortness of breath and decreased oxygen levels. They would notify the provider by phone for acute changes or a written SBAR for non-urgent changes. When asked how they monitor resident fluid intake, Staff D said there was not a process. Staff D said they monitor food intake and if the residents were on a fluid restriction they would document on the MAR and the nurse documents intake in those instances. When asked how they monitor residents for dehydration, Staff D said they watch for signs and symptoms such as decreased output, lethargy, and skin tenting. Dehydration prevention included offering fluids and verbal cueing, and the kitchen supplied water pitchers. When asked if they monitor intake and output for resident with catheters, Staff D said they should be monitoring output, and it should be recorded. Staff D said they would expect a resident with shortness of breath, decreased oxygen levels and a cough to be tested for the flu, and RSV once the facility was aware they were in outbreak status. Regarding Resident 1, she recalled his family visited frequently and he ate in assisted dining unless he did not want to go, he was transported to the ER for unresponsiveness after previous decline in condition [on [DATE]] when EMTs were called but resident was not transported from the facility. Staff D said the resident had labs drawn on [DATE] and would have expected the provider to have been made aware on [DATE]. Staff D said staff usually print the labs out and place them in the provider box. Staff D said the labs showed the resident had elevated white blood cells and an elevated sodium level. When asked when the record showed those results were reviewed by facility staff, Staff D said, 8 days later. At 1:07PM, Resident 1's FM2 said, if they would have known Resident 1 had abnormal lab results on the 6th that potentially indicated infection and/or dehydration they would have absolutely told the EMTs to transport Resident 1 to the hospital on the [DATE]. <Resident 2> Resident 2 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], showed the resident had moderate cognitive impairment, and required substantial to maximum assistance from staff for ADLs. The care plan initiated on [DATE] identified the resident was at risk nutritionally secondary to variable intake, among other factors, with interventions including regular texture diet and thin fluids, and staff were to provide assistance with meals as needed. Review of Resident 2's progress notes from [DATE] to [DATE] showed no skilled nursing assessment documentation. Review of the Alert Note, dated [DATE] at 11:09 PM, showed Resident 2's family was concerned about increased lethargy and requested pain meds be held. Resident was placed on alert to monitor. Review of the Alert Note, dated [DATE] at 1:30 PM, showed the resident was found to be lethargic with elevated blood pressure and pulse. The Provider and family were notified, and the Resident was transported to the ER. Review of the Inpatient Hospital History and Physical Report, dated [DATE], showed an admitting diagnosis for Resident 2 included hypernatremia (high sodium level) and hypomagnesium (low magnesium level) and noted it was more likely related to poor oral intake. Resident was administered intravenous fluids. The resident remained hospitalized until [DATE] and then returned to the facility. Review of Resident 2's task record for eating from [DATE] to [DATE] showed the following: Date Breakfast Lunch Dinner ,d+[DATE] ,d+[DATE]% ,d+[DATE]% ,d+[DATE]% ,d+[DATE] ,d+[DATE]% ,d+[DATE]% ,d+[DATE]% ,d+[DATE] ,d+[DATE]% ,d+[DATE]% ,d+[DATE]% ,d+[DATE] no record no record ,d+[DATE]% ,d+[DATE] ,d+[DATE]% ,d+[DATE]% ,d+[DATE]% ,d+[DATE] ,d+[DATE]% ,d+[DATE]% ,d+[DATE]% ,d+[DATE] ,d+[DATE]% ,d+[DATE]% ,d+[DATE]% ,d+[DATE] no record ,d+[DATE]% ,d+[DATE]% ,d+[DATE] no record no record ,d+[DATE]% On [DATE] at 5:46 PM, Resident 2's FM1 said they were concerned about the decline the resident had following admission to the facility, she initially required a sit to stand (mechanical lift in which the resident participates and bears weight) for transfers and was talking and then she needed a Hoyer lift (mechanical lift in which the resident does not bear weight) and wasn't drinking water. They were putting her tray in front of her, but she didn't eat it. She went to the hospital with dehydration and an acute kidney injury. On [DATE] at 3:28 PM, Staff F said she was familiar with Resident 2 and recalled prior to her going to the hospital she just seemed drowsier and required more frequent checks. On [DATE] at 3:55 PM, Staff E said she recalled the resident's name but could not recall anything else regarding the resident. On [DATE] at 1:23 PM, Staff D said the day before hospital transport Resident 2's [family member] reported lethargy and requested pain medication be held. The resident was transported to the hospital the next day for decreased level of consciousness. At 2:07 PM, Staff B, RN, Director of Nursing Services said there was a structured process for identifying and addressing a resident's change in condition: the NA would report changes to the LN (licensed nurse) and the LN would assess and report to the RCM, or Herself or Provider. Staff B said they do not monitor fluid Intake for all residents, only if they were on a fluid restriction or if a resident was identified at risk for dehydration. If a resident had a catheter they would monitor output. Regarding Resident 1 Staff B said she was not aware of a change in condition but recalled the resident was alert on the Thursday before he went to the hospital, he was transported due to non-responsiveness. Staff B did not know if Resident 1 was tested for influenza, stating they only had one case of RSV as of that Friday and did not recall if they had an influenza outbreak at that time. Staff B said Resident1 had labs drawn on [DATE] and they were reviewed by staff on [DATE]. Staff B said the lab results showed elevated WBCs, and an elevated sodium level which could have been a sign of mild dehydration. Staff B said the floor nurse usually reviewed labs and reported them to the provider but said there was not a system in the electronic charting that alerted staff that lab results were ready. Regarding Resident 2, Staff B said she was not aware of a decline in condition prior to them being sent to the hospital. Staff B said Resident 2's hydration status was not monitored prior to them going to the hospital. At 3:23 PM, Staff B said they would have expected staff to inform family and provider of test results for Resident 1 by [DATE]. Staff B was unable to provide documentation that fluid intake was being monitored for Resident 1 or Resident 2 prior to hospitalization . Reference WAC [DATE](1)

Based on interview and record review, the facility failed to accurately assess Minimum Data Set (MDS) assessments for 2 of 24 sampled residents (Residents 12 & 39) reviewed. Failure to ensure accurate assessments regarding Preadmission Screening and Resident Review (PASRR) and oxygen requirements, placed residents at risk for unidentified and/or unmet care needs. Findings included . 1) Resident 12 was admitted to the facility on [DATE]. The Annual MDS, dated [DATE] and 03/10/2024, documented no that the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. A review of the Level II PASRR Initial Psychiatric Evaluation Summary and Notice of Determination, dated 12/28/2023, said Resident 12 was determined to require a Level II for depressive disorder. On 02/26/2025 at 1:54 PM, Staff H, Registered Nurse (RN) and MDS Coordinator, said Resident 12 was assessed to need a Level II PASRR and received specialized services on 12/28/2023. Staff H said Resident 12 should have been coded for a Level II on both annual MDSs, dated 03/10/2024 and 02/02/2025. On 02/27/2025 at 3:08 PM, Staff B, Director of Nursing, said her expectation was the MDSs be coded appropriately. 50945 2) Resident 39 was admitted to the facility on [DATE] and had diagnoses of acute and chronic respiratory failure and dependence on supplemental oxygen. The Admission MDS, dated [DATE], showed Resident 39 was cognitively intact, but did not code for oxygen usage. Review of Resident 39's orders showed an order, initiated 01/27/2025, for oxygen at two liters per minute continuously via nasal cannula. Review of Resident 39's oxygen saturation vitals, showed they had vitals taken with the resident on oxygen via nasal cannula, on 01/30/2025 and 01/31/2025. The other vitals showed Resident 39 was on room air when the vitals were taken. Review of Resident 39's Medication Administration Record, showed licensed nursing staff had signed off, from 01/27/2025 to 01/31/2025, on Resident 39's order for two liters per minute of continuous oxygen. During an interview on 02/28/2025 at 9:10 AM, Staff G, Licensed Practical Nurse, said Resident 39 had been on oxygen since admit, believed they had tried titrating off the oxygen, but the resident got lung infiltrates (shown on imaging, can indicate infection of the lungs) and had been on oxygen since. During an interview on 02/28/2025 at 11:11 AM, Staff H, RN/MDS Coordinator, provided documentation of Resident 39's vitals, reported the capture period for the MDS was 01/25/2025 to 01/31/2025, and said oxygen therapy should have been coded. Reference WAC 388-97-1000 (1)(b)

Based on interview and record review, the facility failed to ensure freedom from significant medication errors for one of three residents (Resident #75) reviewed for anticoagulant therapy. This failure caused harm to the resident which resulted in medical complications, unexpected hospitalization , diminished quality of care and a diminished quality of life. Findings included . Refer to F726 for Competent Nursing Staff related to training [MEDICATION NAME] is a prescription medication used to treat blood clots by thinning the blood. Blood clots can travel in the blood stream to legs or organs such as lungs, heart and/or brain and can be life threatening. Side effects of [MEDICATION NAME] include bruising easily, and prolonged bleeding time. International Normalized Ratio (INR) is a lab test given that indicates the clotting tendency of blood. INR lab tests are conducted routinely when [MEDICATION NAME] is prescribed. Dosing for [MEDICATION NAME] is based on the INR value and is frequently changed until stabilized. Side effects of an INR that is too high include pain, bleeding gums, nosebleeds, and unusual bruising. Review of the admission Minimum Data Set (MDS, a required assessment tool), dated 12/25/18 showed Resident #75 was admitted to the facility on [DATE]. The MDS further showed that Resident #75 was able to make needs known. Review of Resident #75's [DIAGNOSES REDACTED]. caused by blood clots that travel to the lungs from the legs or other parts of the body) and venous [MEDICAL CONDITION] (blood clot that partially or completely blocks a large vein). Review of the progress notes dated 01/02/19 at 7:05 PM, showed Resident #75 was on several medications that could have a moderate to severe drug interaction with [MEDICATION NAME] that may increase the risk of bleeding. Review of the facility incident investigation dated 01/17/19 at 11:10 AM, showed a significant medication error had occurred for Resident #75. Details included: resident's INR of 1.7 was called to the physician. Staff R, Licensed Practical Nurse (LPN), had informed the physician that the current dose of [MEDICATION NAME] was 4 milligrams (mg), when in actuality the dose was 1.5 mg. Based on Staff R, LPN's, report, the physician ordered the [MEDICATION NAME] dose to be increased to 4.5 mg and to recheck the INR on 01/14/19. Resident #75 continued to receive the [MEDICATION NAME] at a dose of 4.5 mg for five days. The (MONTH) 2019 Medication Administration Record [REDACTED]. Resident #75's INR was not rechecked until 01/15/19 at which point the resident's INR was 8 (desired range for INR was 2 to 3). Review of the progress notes dated 01/15/19 at 9:36 PM, showed, Resident #75's spouse reported the resident had a nose bleed. The staff checked Resident #75's INR and discovered that it was 8 and notified the physician. The physician ordered immediate labs, to give Vitamin K (the antidote for bleeding related to [MEDICATION NAME]), and to hold [MEDICATION NAME] for two days and then recheck the INR. The progress note further showed that Resident #75's nose continued to bleed mildly. Two hours after Vitamin K was provided, Resident #75's INR was 7.01. Review of the progress note dated 01/16/19 at 12:43 PM, showed that Resident #75 complained of pain in her back and hip. The nurse and the Nursing Assistant Certified (NAC) uncovered the resident to reposition her and found the left thigh to be larger than it normally appeared. The physician was notified and ordered immediate lab work and an ultrasound of the left thigh. The lab results showed a low red blood cell count that was reported to the physician who then ordered additional lab work to prepare Resident #75 for a blood transfusion. Review of skilled progress note dated 01/16/19 at 3:13 PM, showed that Resident #75 was sent to the hospital for a blood transfusion and was admitted . During an interview on 01/30/19 at 9:34 AM, Staff P, Registered Nurse/Infectious Disease/Staff Development Coordinator (RN/ID/SDC), stated that licensed Nursing staff were trained on the new Electronic Medication Administration Record [REDACTED]. Reference WAC 388-97-1060 (3)(k)(iii)

Based on interview and record review, the facility failed to ensure services provided met professional standards of quality for 6 of 7 residents (#s 6,22, 47,57,58,182) when licensed nurses did not accurately document pain medication. This failure created a potential for drug diversion by staff and placed all residents in immediate jeopardy for receiving excessive doses of medication. Findings include: According to Smith, Duell, and Martin, Clinical Nursing Skills, Sixth Edition, pages 518-521, Nurses are to administer medications as ordered by the physician. Additionally, nurses are to document the time of administration, route, dosage, and assess and document the resident's response to the medication. Nurses are to review the Medication Administration Records daily to validate all medications are in accordance with the physician's orders [REDACTED].>Resident #58 Review of Resident #58's October 2016 MAR revealed; 10/1/16 - documentation on the MAR that pain medication was administered two times. Documentation on the pain flow sheet indicated one pain pill was given at 2:00 a.m. Documentation on the schedule ll sign out book indicated staff removed two pills at four different times. Four pills were not accounted for. 10/2/16 - no documentation of administering schedule ll pain medications on the MAR. Review of the narcotic book revealed two pills signed out. No medication administration was documented on the pain flow sheet. Two pills were signed out for the day, but there was no documentation the medications were ever administered to the resident. 10/3/16- the MAR indicated two pain pills were administered for the day, the pain flow sheet indicated 1 pill had been administered for the day. The schedule ll sign out book indicated four pills had been signed out for the day. Review of the September 2016 MAR revealed two entries of schedule ll pain medications given. Review of the pain flow sheet indicated schedule ll pain pills were given eight times. The schedule ll narcotic sign out book indicated pill had been signed out 12 times. In an interview on 10/7/16 at 2:01 p.m., Staff T reviewed the narcotic sign out book in comparison to the administration record and confirmed not all of the schedule ll medications were documented as actually given to the resident. Staff T reported, based on the documentation, she could not determine if Resident #58 actually received all of the signed out medications. Staff T reported based on her nursing experience, if you give a medication, it should be documented on the MAR. Staff T reported during her orientation at the facility, it was not discussed if schedule ll medications should be documented on the pain flow sheet or in the MAR. In an interview on 10/7/16 at 10:58 a.m. Staff C reported the management's expectation of nursing staff was to sign schedule ll medications out of the schedule ll log book, document the medication on the Medication Administration Record (MAR) and document the medications on the pain flow sheet. In interview on 10/07/16 at 4:32 p.m., Staff D stated the facility completed a review of all of the medication administration records and discovered Sloppy documentation on every shift S/he stated it was believed the residents were getting their pain medication however it was a system wide problem. Resident #182 Record review of October 2016 medication administration record (MAR) for Resident #182 revealed an order for [REDACTED]. In addition, an order was written for [MEDICATION NAME] 5 mg capsule 3 tabs every 4 hours as needed for 7-10/10 pain. and no initials on the MAR to indicate medication was given on 10/7/16. Record review of October 2016 Pain Flow Sheet for Resident #182 revealed documentation for [MEDICATION NAME] given on 10/7/16 at 4:30 a.m.,11:00 a.m, and 4:45 p.m. In interview on 10/07/16 at 6:00 p.m., when asked where pain medication was documented as given, Staff S stated the MAR was to show what the physician ordered. The majority of what we document on is the pain tool instead of the MAR. RESIDENT #22 Review of Resident #22 September 2016 MAR revealed 9 entries indicating staff gave her schedule ll pain medication. Review of the schedule ll sign out book revealed 20 entries that staff signed out pain pills. RESIDENT #57 Review of the October 2016 MAR revealed there were 15 schedule ll pain pills administered. The schedule ll sign out book indicated 21 pills had been signed out. In an interview on 10/7/16 at 6:06 p.m., Staff U reviewed Resident #57 medications in the medication cart and reported there were four different cards that contained [MEDICATION NAME] 30 mg. Staff U confirmed all four cards had been accessed by staff. Staff U then reviewed the narcotic book and reported the medications were recorded on four different pages, 51, 63, 65 and 71. Staff U reported if Resident #57 requested a pain pill staff would first look at the MAR. Staff U reported, based on the MAR, the resident had not received any of the pain medication that day, so she would be able to administer it. Staff U reported she would then review the pain flow sheet, which also indicated no medications had been administered that day. Not documenting medication administration on the MAR or on the pain flow sheet resulted in a situation for the likelihood and immediacy of Resident #57 receiving an overdose of [MEDICATION NAME]. RESIDENT #47 Observations of the medication card on 10/7/16 at 7:00 p.m., with Staff NN confirmed there were multiple blister packs of the same schedule ll medications for several residents. Staff NN reported she tries to arrange the packs in order and sticks post-it notes to some of them as a reminder to not use that pack, but confirmed some staff pull from multiple cards for the same resident. Review of Resident #47's medication orders revealed he had two different orders for schedule ll medications; 1. Dated 8/20/15 for [MEDICATION NAME] 10mg by mouth every 6 hours 2. Dated 9/26/16 for [MEDICATION NAME] 5 mg by mouth every three hours as needed for pain Review of the narcotic sign out book in comparison to the MAR revealed staff were signing out medications from the [MEDICATION NAME] 10 mg page for both the 10 mg order and the 5 mg order. When staff were administering the 5mg dose, they were wasting half the medication. Further review of the narcotic sign out book revealed an entry dated 9/28/16 at 6:00 am where two [MEDICATION NAME] 10 mg pills were signed out and written wasted next to it. However, the medication was documented as being administered on the MAR. Staff NN confirmed the discrepancies between the sign out book and the MAR. RESIDENT #6 Observations of the South Wing medication cart on 10/7/16 at 6:24 p.m., with Staff MM revealed multiple blister packs of the same medication for residents. Further observations revealed staff had signed had already documented the HS (bedtime) dose of medication for that evening. Staff MM reported it was the dose that had been signed out of the narcotic book on 10/6/16. Staff MM explained staff were not sure what to write as the time for midnight. Staff MM confirmed staff were signing medications out of the narcotic book each day, but documenting them on the MAR for the following day (signing out the medication on 10/6/16 but documenting the administration on the MAR on 10/7/16). In an interview on 10/7/16 at 5:00 p.m., Staff D reported, after the survey team brought forward concerns related to the discrepancies of narcotics, and the potential of medication errors related to pulling from multiple medications cards, the facility did a self-check and confirmed the practice of pulling from multiple medications sources, and lack of documentation was noted on every medication cart and was occurring on all shifts. refer to 425

Based on observation, interview and record review it was determined that the facility failed to ensure each resident was adequately assessed and treated for [REDACTED].#s 22 & 58) reviewed for pain. Additionally, the facility failed to ensure and establish a plan for coordinating care and services provided by the facility and Hospice for 1 of 1 sampled residents (#103 ) reviewed for hospice services. This failure placed Resident #103 at potential risk of care not being provided. Failure to recognize and treat pain resulted in Resident #58 experiencing unrelenting pain and subsequent transfer to the hospital, and resulted in an immediate jeopardy situation for all residents needing pain management. Findings include: RESIDENT #58 Review of Resident #58's record revealed she admitted from the hospital on [DATE] with a [DIAGNOSES REDACTED]. Additionally, the paper work indicated, due to her conditions and chronic pain her chronic pain Rx (prescription) will be a challenge. Observations on 10/3/16 at 10:15 a.m. revealed Resident #58 sitting in her wheelchair crying. Observations on 10/3/16 at 10:58 a.m., revealed Resident #3 continued crying in the hallway. Staff E asked Resident #58 if she was having pain. Resident #58 replied yes and gestured to her abdomen. Staff E then took Resident #58 into the nearby dining room and gave her ice cream. Resident #58 remained upset. In an interview on 10/11/16 at 10:10 a.m., the medical director reported due to Resident #58's cognitive status she is not able to report pain, therefore, staff must monitor and assess. PAIN MANAGEMENT PLAN Review of Resident #58's record revealed a pain a pain assessment completed on 9/21/16, the day of admission to the facility. The assessment indicated Resident #58 was grimacing and calling out. The assessment indicated Resident #58 had cognitive impairment, so pain level was determined by using the Abbey Faces pain scale. The documentation showed a score of zero, meaning no pain. Review of Resident #58's pain care plan dated 9/30/16 revealed she was at risk for pain related to discitis. Interventions included: 1. Educate resident to request medication early 2. Notify the physician if resident does not demonstrate relief 3. Provide [MEDICATION NAME] Further review of Resident #58's medical record revealed Brief Interview for Mental Status (BIMS) dated 9/21/16 which indicated she had severe cognitive impairment. In an interview on 10/7/16 at 9:10 a.m., Staff E confirmed due to Resident #58's dementia, She was not comprehending anything. Staff E described Resident #58's pain as all consuming. Resident #58's record contained a BIMS score of zero and staff interviews indicating the resident was not able to comprehend, yet the care plan was to educate the resident related to her pain level and request pain medication before the pain level rises. During an interview on 10/10/17 at 10:58 a.m., Staff C reported pain care plans should be specific to each resident including the characteristics of the pain and what level of pain is acceptable for that individual resident. treatment of [REDACTED].>Review of Resident #58's September 2016 Medication Administration Record [REDACTED]. There was no documentation to support why it was not given. The MAR indicated [REDACTED]. Eight of the nine days were documented that the patch had been removed (although three of the days it was not ever put on). In an interview on 10/7/16 at 1:03 p.m., Staff E was asked why the [MEDICATION NAME] was not being consistently used. Staff E stated, she was not sure, but it may have been due to the resident having to leave the facility in the morning a few times each week to go to an outside appointment. Staff E was asked if the patch could have been placed prior to the resident leaving, therefore it would be in effect for the trip to the appointment and during the appointment. Staff E again stated she did not know why the patch was not being used. In an interview on 10/7/16 at 2:00 p.m., Staff T was asked why the [MEDICATION NAME] was not being used. Staff T reported she was not sure why, and was not able to determine why based on the documentation on the MAR. Staff T reported she had heard that a family member removed the patch one time, but that was only one time, and it was not documented in the record. In an interview on 10/11/16 at 10:10 a.m., the medical director reported he was not aware Resident #58 was not receiving her pain patch. The medical director reported he would expect the staff to contact him if they were not routinely giving an ordered medication. Review of Resident #58's medical record revealed a physician's order for a pain relieving medication that could be administered as often as every four hours as needed. In an interview on 10/7/16 at 9:10 a.m., Staff E stated before Resident #58 went to the hospital on [DATE], she was in all consuming pain for 72 hours. Staff E reported Resident #58 had pain throughout her stay but it was increased during that time. Staff E was asked why Resident #58 did not have a routine pain medication to take every day to treat her pain. Staff E responded well she has to leave a lot to go to her appointments. Staff E further reported on the morning of 10/3/16, prior to going to the hospital, staff gave Resident #58 a pain pill at 7:00 a.m., and she spit it out. Staff E was asked when the resident was observed crying during the day and stating she had pain, why staff did not offer her another dose of the pain medication. Staff E confirmed Resident #58's pain medication was ordered for every four hours, and the last dose was given at 7:00 a.m. A progress noted dated 10/3/16, indicated Resident #58 did not leave the facility until 4:45 p.m., almost 10 hours after the 7:00 a.m. dose. Staff E responded well she spit them out earlier so you figure she's going to spit them again. Observations revealed Resident #58 was in pain. Staff described her pain as all consuming. There was an active order for pain medication, yet staff did not offer it. In an interview on 10/11/16 at 10:10 a.m., the medical director reported he had not been made aware of the increased pain. There was no documentation in the medical record to support staff had attempted to reach the physician. CHANGE IN PAIN STATUS Review of Resident #58's MAR indicated [REDACTED]. Review of the September 2016 MAR indicated [REDACTED]. The remaining 5 were all in different days and were marked 2, 3, 7 and 8, with the highest (8) being on September 30, 2016. Review of the October 2016 MAR indicated [REDACTED]. Review of Resident #58's record revealed she was found lying on her left hip on the floor in her room on the evening on 9/28/16. The facility investigation indicated staff member stated Resident #58 stated her hip hurt, and was screaming. A pain assessment was done by the nurse using the Abbey Faces scale, and it was determined Resident #58 was having moderate pain. The record revealed a noted dated 9/29/16 to the physician stating that Resident #58 had non injury fall and had complained of hip pain. The note stated can we have orders for an x-ray if the resident continues to have pain? The physician signed the note, however there was no date to indicate when he received the information. There were no x-rays taken. In an interview on 10/11/16 at 10:10 a.m., the medical director reviewed the every shift pain assessments and confirmed there was a change in Resident #58's pain level. The medical director also confirmed Resident #58 continued to have pain after the fall. The medical director reported he was not made aware of these changes, but would have expected to be, so more measures could have been implemented and injury could be ruled out. Resident #58's record revealed a progress noted dated 10/31/6 that stated she was sent to the hospital for intractable pain. Resident #58 was observed throughout the day in pain. Staff had an order for [REDACTED]. Resident #58's pain level worsened while at the facility. Staff did not provide the ordered [MEDICATION NAME] prescribed to treat pain, with no documentation why it was not given. Staff did not alert the physician to worsening pain or attempt to get a different type of medication or routine medication. When Resident #58's pain was all consuming staff did not attempt to provide her pain medication every four hours as it was ordered. Staff failed to use all available resources to relieve Resident #58's pain, thus causing her harm. RESIDENT #22 Record review of the 14-day MDS assessment dated [DATE], revealed Resident #22 was admitted on [DATE] with multiple [DIAGNOSES REDACTED]. Cognitive assessment indicated resident was cognitively intact and was able to make needs known. The pain assessment section revealed resident was receiving scheduled as well as PRN (as needed) pain medication. Resident #22 rated his/her pain 5 out of 10 during time of assessment. Record review of physician's order dated 6/14/16, revealed orders for pain medication Tylenol 650mg orally given on scheduled times twice a day and [MEDICATION NAME] (a combination of [MEDICATION NAME] and [MEDICATION NAME]) 7.5mg-325mg orally one tablet every 6 hours as needed for pain. There was an order for [REDACTED]. Record review of resident's care plan dated 3/17/16, revealed resident was at risk for pain related to decreased mobility. Pain goal was to minimize her pain with medication and positioning. Pain goal was not measurable as stated in the plan of care. In interview on 10/10/16 at 10:09 a.m., Staff JJ stated the resident had chronic back pain and if in pain was able to tell the nurse. According to staff, the resident's pain does not get totally relieved but can go down to a rating of 2 out of 10 which was tolerable for resident. Record review of the quarterly pain assessment for the month of August and September 2016, revealed resident's pain was 100% completely relieved. Review of the PRN Administration Record for [MEDICATION NAME] for September 2016 revealed 20 entries of medication being signed out. When compared to the MAR, only 9 entries were made, leaving 11 doses unaccounted for. Record review of the pain flow sheet for the month September 2016, revealed 6 of 33 entries had no documentation related to intensity of pain after the intervention. The facility failed to ensure effective pain management based on the inconsistencies in the pain monitoring and documentation. This failure placed residents at risk for potential mismanagement of pain medication, uncontrolled pain and a diminished quality of life. RESIDENT #103 Resident # 103 was readmitted to the facility from an acute care hospital on [DATE] for multiple [DIAGNOSES REDACTED]. Additionally, a health care directive was initially signed on 5/7/16 revealing resident was a Do Not Attempt Resuscitation (DNAR); allowing for natural death comfort measures only and no artificially provided nutrition and hydration. Review of the Hospice Agreement between the hospice agency and the facility dated August 25, 2015, identified the responsibilities of both parties individually and jointly to provide care and services to the resident in Exhibit C, Delineation of Services/Responsibilities form including care planning by the interdisciplinary care group, personal services (assistance with activities of daily living (ADL's), i.e. bathing , dressing,skin care) and a copy of legal documents showing informed consent and a physician's order to provide care to the resident. Additionally Exhibit A, Hospice Current Criteria for admission revealed the terminal prognosis of six (6) months or less must be confirmed by patient's physician and hospice medical director. A review of resident records did not reveal documents had been provided to the facility. Record review of the residents Minimum Data Set (MDS-an assessment tool) dated 8/2/16 revealed the documentation for Section J1400 Health conditions-prognosis was marked No, as to whether resident had a condition or chronic disease that may result in a life expectancy of less than 6 months? (Requires physician documentation). No physician order was revealed in residents medical records. In interview on 10/7/2016 at 12:52 p.m., Staff C stated the MDS was coded wrong the document should have been changed to reflect the resident was on hospice. In interview on 10/7/16 at 1:35 p.m., Staff L stated this resident is on end of life comfort care I'll see if I can find the order in the chart it may be in medical records. Initially the resident was referred to receive hospice at home but while s/he was in the hospital but the family said they could not take care of h/her needs so s/he was admitted here for care. We also coordinate the resident's care with hospice team but I can't find the hospice care plan. In interview on 10/07/16 at 2:06 p.m., Staff C stated the facility is supposed to have a coordinate plan in place and social service staff assists with that process. In interview on 10/10/16 at 2:14 p.m., Staff L stated I do not see any hospice order for this resident I will have to get the order and mark it as a late entry. I also will follow up with hospice and see if we can get a Hospice care plan for this resident. Record review of the physician's order revealed resident #103 had a hospice order written and placed into the residents medical records on 10/10/16 at 2:15 p.m.; 70 days after being admitted to the facility. In interview on 10/12/16 at 10:52 a.m., Staff G stated I support the communication between the resident or family and hospice and assist with the coordination of care conferences. After the initial care conference the hospice and the facility staff would each develop a specific care plan for the resident. I would have to say this was an oversight in getting a coordinated care plan in place. Record review of the facility's Hospice policy and procedures revealed a resident who has elected hospice services, the facility will coordinate care planning with the hospice provider. In addition a coordinated care plan must identify each aspect of care the hospice provider or nursing facility is responsible for regarding the resident. Record Review of the resident's care plan revealed no specified or coordinated plan of care identifying the care and services which the facility and/or hospice would provide for the unique needs of Resident #103.

Based on observation, interview and record review it was determined that the facility failed to implement a process for safely storing, administering and documenting controlled medications in 4 of 5 wings (Wing North, South, A & B) reviewed for schedule ll (drugs which must remain separately locked due to their high likelihood of being abused) medication administration. This failure placed residents at potential risk for medication errors. This resulted in an immediate jeopardy situation for all residents. Findings include: In an interview on 10/7/16 at 10:58 a.m. Staff C reported the management's expectation of nursing staff would sign schedule ll medications out of the schedule ll log book, document the medication on the Medication Administration Record (MAR) and document the medications on the pain flow sheet. In an interview on 10/12/16 at 9:00 a.m., the consulting pharmacist reported schedule ll medications should be signed out on the schedule ll log book and on the MAR. The pharmacist stated the MAR should always reflect what has been given to the resident. RESIDENT #58 - NORTH WING Observations 10/3/16 at 11:00 a.m. revealed Resident #58 crying. Staff stated she was in pain and they had given her pain medication earlier in the day. Review of Resident #58's October 2016 MAR revealed: 10/1/16 - documentation on the MAR that pain medication was administered two times. Documentation on the pain flow sheet indicated one pain pill was given at 2:00 a.m. Documentation on the schedule ll sign out book indicated staff removed two pills at four different times. Four pills were not accounted for. 10/2/16 - no documentation of administering schedule ll pain medications on the MAR. Review of the narcotic book revealed two pills signed out. No medication administration was documented on the pain flow sheet. Two pills were signed out for the day, but there was no documentation the medications were ever administered to the resident. 10/3/16- the MAR indicated two pain pills were administered for the day, the pain flow sheet indicated 1 pill had been administered for the day. The schedule ll sign out book indicated four pills had been signed out for the day. Review of the September 2016 MAR revealed two entries of schedule ll pain medications given. Review of the pain flow sheet indicated schedule ll pain pills were given eight times. The schedule ll narcotic sign out book indicated pill had been signed out 12 times. In an interview on 10/7/16 at 2:01 p.m., Staff T reviewed the narcotic sign out book in comparison to the administration record and confirmed not all of the schedule ll medications were documented as actually given to the resident. Staff T reported, based on the documentation, she could not determine if the Resident #58 actually received all of the signed out medications. Staff T reported based on her nursing experience, if you give a medication, it should be documented on the MAR. Staff T reported during her orientation at the facility, it was not discussed if schedule ll medications should be documented on the pain flow sheet or in the MAR. RESIDENT #22 - NORTH WING Review of Resident #22 September 2016 MAR revealed 9 entries indicating staff gave her schedule ll pain medication. Review of the schedule ll sign out book revealed 20 entries that staff signed out pain pills. RESIDENT #57 - A WING Review of the October 2015 MAR revealed between there was 15 schedule ll pain pills administered. The schedule ll sign out book indicated 21 pills had been signed out. In an interview on 10/7/16 at 6:06 p.m., Staff U reviewed Resident #57 medications in the medication cart and reported there were four different cards that contained oxycodone 30 mg. Staff U confirmed all four cards had been accessed by staff. Staff U then reviewed the narcotic book and reported the medications were recorded on four different pages, 51, 63, 65 and 71. Staff U reported if Resident #57 requested a pain pill she would first look at the MAR. Staff U reported, based on the MAR, the resident had not received any of the pain medication that day, so she would be able to administer it. Staff U reported she would then review the pain flow sheet, which also indicated no medications had been administered that day. Staff U then opened the medication cart and pulled a card containing 19 oxycodone. Staff U reported she would sign it off on the page the corresponded with the card, page 63. She would also note that page 63 did not have medications signed out for the day, so she would sign her medication and administer it. Staff U confirmed that since the MAR indicated there had been no medications administered and there were multiple pages to sign out the medications, and multiple card to get the medications, Resident #57 was at risk of a medication error, and potential overdose. RESIDENT #182 - NORTH WING Record review of October medication administration record (MAR) for Resident #182 revealed an order for [REDACTED]. also an order [REDACTED]. and no initials to indicate medication was given on 10/7/16. Record review of October Pain Flow Sheet for Resident #182 revealed documentation for oxycodone given on 10/7/16 at 4:30 a.m., 11:00 a.m, and 4:45 p.m. In interview on 10/07/16 at 6:00 p.m., when asked where pain medication was documented as given, Staff S stated the MAR was to show what the physician ordered. The majority of what we document is on the pain tool instead of the MAR. RESIDENT #47 - B WING Observations of the medication card on 10/7/16 at 7:00 p.m., with Staff NN confirmed there were multiple blister packs of the same schedule ll medications for several residents. Staff NN reported she tries to arrange the packs in order and sticks post-it notes to some of them as a reminder to not use that pack, but confirmed some staff pull from multiple cards for the same resident. Review of Resident #47's medication orders revealed he had two different orders for schedule ll medications: 1. Dated 8/20/15 for oxycodone 10mg by mouth every 6 hours 2. Dated 9/26/16 for oxycodone 5 mg by mouth every three hours as needed for pain Review of the narcotic sign out book in comparison to the MAR revealed staff were signing out medications from the Oxycodone 10 mg page for both the 10 mg order and the 5 mg order. When staff were administering the 5mg dose, they were wasting half the medication. Further review of the narcotic sign out book revealed an entry dated 9/28/16 at 6:00 am where two Oxycodone 10 mg pills were signed out and written wasted next to it. However, the medication it documented as being administered on the MAR. Staff NN confirmed the discrepancies between the sign out book and the MAR. RESIDENT #6 - SOUTH WING Observations of the South Wing medication cart on 10/7/16 at 6:24 p.m., with Staff MM revealed multiple blister packs of the same medication for residents. Further observations revealed staff had signed had already documented the HS (hour of sleep) dose of medication for that evening. Staff MM reported it was the dose that had been signed out of the narcotic book on 10/6/16. Staff MM explained staff were not sure what to write as the time for midnight. Staff MM confirmed staff were signing medications out of the narcotic book each day, but documenting them on the MAR for the following day (signing out the medication on 10/6/16 but documenting the administration on the MAR on 10/7/16). In an interview on 10/7/16 at 5:00 p.m., Staff D reported, after the survey team brought forward concerns related to the discrepancies of narcotics, and the potential of medication errors related to pulling from multiple medications cards, the facility did a self-check and confirmed the practice of pulling from multiple medications sources, and lack of documentation was noted on every medication cart and was occurring on all shifts. In an interview on 10/7/16 at 6:53 p.m., Staff C reported the consulting pharmacist comes in to the facility every month and he checks the narcotic sign out book and compares it to the number of actual medications in the cart. Staff C reported the pharmacist does not compare the sign out book to what is documented in the medical records. Staff C confirmed there was not a system in place to compare what medications signed out of the schedule ll book versus what is documented as actually administered to the resident. In an interview on 10/12/16 at 9:00 a.m., the consulting pharmacist confirmed he does not compare the medication signed out to the medications administered. The facility's failure to document medications being administered and practice of using multiple sources simultaneously, placed all residents who received schedule ll medications at immediate risk of medications errors, including possible overdose. These same failures placed residents at risk of having their medications diverted by staff. These failures placed residents in immediate jeopardy.

Based on deficient practices identified throughout the annual and extended survey process, it was determined the facility failed to use its resources to ensure effective facility practices, promote quality of life and deliver quality of care to its residents. The facility failed to ensure administration staff identified, reported and thoroughly investigated abuse. The facility staff failed to adequately assess and treat pain. The facility failed to coordinate with the consulting pharmacist to ensure medications were properly stored and accounted for. The facility failed to use its Quality Assurance program to not only identify concerns, but implement plans of action to correct deficient practice. Additionally, the facility failed to ensure nursing care was provided in accordance with professional standards. These failures resulted in harm to Resident #48 and represented immediate jeopardy situations for all of the residents in the facility. Findings include: The information below is more detailed in the individual citations: ADMINISTRATION STAFF - ABUSE PREVENTION, IDENTIFICATION, INVESTIGATION Refer to 42CFR 483.13(c),F226: The facility must develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property. The purpose is to assure that the facility is doing all that is within its control to prevent occurrences. In an interview on 10/3/16 at 10:19 a.m., Staff D reported administration had determined the week prior to bring two corporate staff in for oversight of the Director of Nursing (DNS) as they determined she was not correctly able to identify potential abuse and/or neglect. Staff D reported the facility had recent citations related to abuse prevention, identification and investigation. During the Stage 1 survey, two additional incidents of resident abuse, both witnessed by staff, were not reported immediately. ASSESSMENT AND treatment of [REDACTED].>Refer to 42CFR 483.25,F309: Quality of Care. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, memtal, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Observations on 10/3/16 at 10:20 a.m., revealed Resident #48 crying in the hall. Staff reported the resident had uncontrolled pain. Review of resident records revealed missing and incomplete pain assessments, missing documentation of pain medication administration, and pain management care plans that were not resident specific. In an interview on 10/7/16 at 3:25 p.m., Staff C reported it is the job of the Resident Care Managers to review each resident's pain program and monitor its effectiveness. PHARMACY SERVICES Refer to 42CFR 483.60(a)&(b)(1) F425: The facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and admistering of all drugs and biologicals) to meet the needs of each resident. In an interview on 10/12/16 at 9:00 a.m., the consulting pharmacist reported he visits the facility on a monthly basis to review the medication storage systems, reconciliation of controlled substances, and waste procedures. In an interview on 10/11/16 at 4:28 p.m., Staff C confirmed although the facility has a system in place for the pharmacy to review and track the controlled substances signed out to each resident, there was not a system in place to compare how much medication was signed out versus how much medication was documented as being administered in the resident's medical record. NURSING PROFESSIONAL STANDARDS Refer to 42CFR 483.20(k)(3)F281: The services provided or arranged by the facility must meet professional standards of quality. Deficiencies identified during annual and extended survey related to pain assessment documentation, pain care plan documentation and documentation of medication administration indicated professional nursing standards were not consistently implemented. QUALITY ASSURANCE PROGRAM Refer to 42CFR 483.75(o)(1) F 520 QAA, for failure of the Administrator to ensure the quality deficiencies were identified, and an action plan was developed and implemented to track and trend resident outcome related to standards of practice and to prevent substandard practices in the delivery of care and services to the residents, for all the residents in the facility. Interviews with members the Quality Assurance (QA) committee on 10/11/16 at 4:30 p.m., indicated the program did not consistently identify quality deficiencies and did not consistently implement plans to correct the deficiencies that were identified.

Based on observation, interview and record review it was determined that although the facility's Quality Assurance committee identified quality deficiencies, they failed to implement plans to correct the deficient practices and improve resident care. This failure resulted in actual harm to Resident #58 and represented immediate jeopardy situations for all residents in the facility. Findings Include: The information below is more detailed in the individual citations: In an interview on 10/11/16 at 4:05 p.m., Staff A and Staff C reported the Quality Assurance Committee meets on a monthly basis. Staff C reported the committee used comment/concern cards, clinical checklists, staff input and mock survey results to identify potential quality deficiencies. ABUSE Refer to 42CFR 483.13(c),F226: The facility must develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property. The purpose is to assure that the facility is doing all that is within its control to prevent occurrences. In an interview on 10/11/16 at 4:05 p.m., Staff C reported as a result of recent harm level citations during abbreviated surveys, the facility recognized Staff B Director of Nursing (DNS) did not effectively identify potential abuse and/or neglect. Staff C reported corporate nursing had come into the facility for oversight of the DNS. Staff C reported corporate nurses were reviewing the facility incident log and corresponding investigations as oversight. When asked, Staff C confirmed that if the DNS did not identify abuse/neglect, it would not be on the log, and there would not be an investigation of the incident, therefore, resulting in in-effective oversight. Additionally, there were two more incidents of resident abuse that were not reported during the Stage 1 survey. PAIN Refer to 42CFR 483.25, F309: Quality of Care. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. In an interview on 10/11/16 AT 4:30 P.M., Staff C reported at the July 2016 QA meeting pain management was identified as not being effective and that pain care plans were not individualized for each resident. Staff C reported the committee had not developed or implemented a plan to address the deficiency since July because they have a quarter to review. Staff A stated they did not want to implement too many plans at once and since they were focused on the kitchen, a pain management plan had not been put into action yet. PHARMACY SERVICES Refer to 42CFR 483.60(a) &(b)(1) F425: The facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. In an interview on 10/11/16 at 4:28 p.m., Staff C reported the consulting pharmacist visits the facility monthly and had not identified any issues. Staff C said the pharmacist did not review MARs while reconciling medications during monthly reviews. There was not a coordination of services between pharmacy and the facility. KITCHEN Refer to 42CFR 483.35(i) (2), F 371: The facility must Store, prepare, distribute and serve food under sanitary conditions In an interview on 10/11/16 at 4:05 p.m., Staff C reported the committee had received many comment/concerns cards related to the kitchen and dietary issues. Staff C reported the facility brought in a dietary consultant, who confirmed the concerns. Staff C reported the kitchen had been a focus of the committee over the past quarter. Although the committee had been working with a consultant over the past 3 to 4 weeks, many concerns were identified in the kitchen. INFECTION CONTROL Refer to 42CFR483.65(a) F 441: the facility must establish an Infection Control program under which it (1) Investigates, controls, and prevents infections in the facility; (2) Decides what procedures, such as isolation, should be applied to an individual resident; and (3) Maintains a record of incidents and corrective actions related to infections. In an interview on 10/11/16 at 4:25 p.m., Staff A confirmed the Infection Control Nurse had only been in the position for approximately 6 months. Staff A reported the expectation of the Infection Control Nurse was to bring forward any tracking/trending and monitoring of any current infections within the facility. Staff A further reported the Infection Control Nurse had presented the infection rate to the committee, but not the specific organism, or tracking/trending of the current infections, and no concerns were brought forward. Staff A confirmed the committee was not aware of any concerns until brought forward by the survey team.

F 225 Based on interview, and record review, the facility failed to ensure staff members who had been determined by the State board to not be suitable to work with vulnerable adults, continued to work in the facility for 1 of 27 sampled staff members (Staff C) reviewed for personnel records. This failure resulted in actual abuse of one resident, and placed other residents at a potential risk for abuse and neglect. Findings include: Review of DSHS (Department of social and health services) dated 3/29/16 revealed a background check (BGI) result of Disqualify for Staff C. In addition, Staff C's personnel records indicated that a character, competency, and suitability review was completed based on the BGI result, prior to hiring Staff C. In interview on 9/21/16 at 3:50 p.m., Staff B stated when Staff C was hired it was a crazy time. Staff B treated the BGI results that actually disqualified Staff C from providing care to vulnerable adults, as though it was a nondisqualifying BGI, and provided reference check reviews instead of not hiring the staff.

Based on interview and record review, the facility failed to ensure residents received care consistent with the care plan, related to behavioral care needs. for 1 of 1 residents (#1) with behavioral expressions of distress. This failure resulted in psycho-social harm for the resident, requiring the resident to be sent to the emergency room for evaluation, and placed other residents at a potential risk of harm related to inappropriate approaches toward residents with behavioral expressions of distress. Findings include: According to the quarterly MDS (minimal data set) dated 9/6/16, Resident #1 had [DIAGNOSES REDACTED]. (a disorder of the central nervous system that affects movement), anxiety and depression. In addition, the MDS dated [DATE] revealed Resident #1 required supervision to limited assistance with his ADL's (activities of daily living) and mobility. S/he had a BIMS (brief interview for mental status) score of 6 which indicated impaired cognition. Resident #1's 3/21/14 care plan pertaining to interventions for behavioral expressions of distress, directed staff to discuss with the resident ways to utilize coping skills to deal with situations, encourage and allow open expression of feelings, report to the physician changes in mood status. Instead of following the care plan when Resident #1 expressed agitation, Staff C further antagonized and provoked the resident to further agitation, and increasing psychological distress. According to the incident report dated 9/6/16 at 1:00 p.m., two nursing assistant students overheard Staff C speaking to Resident #1 stating phrases such as, Don't talk to me, you called me a son of a [***] , go away, I don't want to see you, and I bet you can't get past me. When Resident #1 asked Staff C if s/he respected him, Staff C replied,not at the moment, no. A document dated 9/8/16 at 10:00 a.m., presented a conversation that took place between Staff B and Staff C. Staff C confirmed that s/he made the comments of you called me a son of a [***] , keep going, and get away from me. Nursing notes dated 9/6/16 at 5:57 p.m. described Resident #1 to have increased confusion, behaviors, agitation, paranoia and suicidal thoughts after Staff C's approach to the resident. The physician was notified and orders received to send Resident #1 to the emergency room for evaluation and treatment. In interview dated 9/21/16 at 3:50 p.m. Staff B stated the conversation between Resident #1 and Staff C, could have been construed differently.

Based on interview and record review, the facility neglected to ensure a resident received necessary care and treatment to avoid pressure ulcers for 1 of 1 sampled residents (R#1), identified at risk for neglect. The facility failed to remove the resident from a bed pan for over 12 hours, resulting in 3 pressure ulcers, bruises and placed the resident at risk of psychological harm. This failure resulted in actual harm, and put other residents at risk of harm related to neglect. Findings include: Refer to 314 During a record review on 7/20/16, in a facility investigation, dated 7/11/16, R #1 was found to have multiple avoidable pressure ulcers after being left on a bed pan for 12 hours. The investigation substantiated neglect, and revealed R #1 was on a bed pan from 7/10/16 at 11:00 p.m. until 7/11/16 11:00 a.m. the next day, and pressure ulcers were reasonably caused by being on a bed pan for 12 hours. In an interview on 7/20/16 at 9:40 a.m., Staff A said, R#1 was to be turned every two hours, unless he was eating. According to Staff A, care staff conducted change of shift reporting with on-going and on-coming staff going room to room to check each resident and report the care needs. Staff A said care staff did not follow the facility policy when the resident was left on the bedpan for a prolonged period of time, and when staff did not check on the resident for 12 hours. Staff A said the facility standard of practice was that all residents were checked at least every two hours. According to Staff A, one night shift care staff and two day shift care staff, did not reposition the resident, and did not check on the resident. The night caregiver did not check on the resident during the night, leaving him on the bedpan, and the two day shift care givers did not check on the resident until 11:00 a.m. when the resident used a call light, however, the day shift started at 6:00 a.m. In an interview on 7/20/16 at 9:10 a.m., R #1 stated, he fell asleep while on the bedpan and could not feel anything from the waist down, so he did not realize he was even on a bed pan. R #1 said the incident made him feel upset. In an interview on 7/20/16 at 9:15 a.m., a Collateral Contact stated, what happened to his/her family member was .so wrong . In an interview on 7/20/16 at 11:18 a.m., Staff B stated neglect is not getting the care the resident needs; a failure to give care. In a follow up interview with R #1 on 7/20/16 at 11:20 a.m., he/she stated it is hard to lay from side to side, and is uncomfortable. I can't believe (the staff) didn't know (the bedpan) was there. I was upset. In an interview of 7/20/16 at 11:24, Staff C stated, neglect can result in mental harm, and neglect is not helping a resident when the resident has needs; ignoring them. The facility failed to prevent neglect of a resident, when staff did not provide care and services for a 12 hour period, leaving the resident on the bedpan, and causing harm to the resident. .

Based on observation, interview, and record review, the facility failed to ensure a resident was removed from a bedpan in a time consistent with avoiding pressure ulcers for 1 of 3 sampled residents (R#1), identified at risk for skin breakdown. The facility failed to remove the resident from a bed pan for 12 hours, resulting in 3 pressure ulcers, and bruises. Failure to monitor, reposition, and to report resulted in not preventing an avoidable pressure ulcer, and placed all residents at risk of harm from similar deficient practice. Findings include: R #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the resident's significant change Minimum Data Set (MDS- a comprehensive nursing assessment), dated 7/14/16, R #1's cognition was moderately impaired, had inattention and disorganized thinking. The resident was a weight bearing assist with two persons for most Activities of Daily Living (ADL), which included bed mobility and toileting. The MDS revealed the resident had functional limitation to the lower extremities and developed 3 pressure ulcers. During a record review of a facility investigation, dated 7/11/16, R #1 was found to have multiple avoidable pressure ulcers after being left on a bed pan for 12 hours. The investigation substantiated R #1 was on a bed pan from 7/10/16 at 11:00 p.m. until 7/11/16 11:00 a.m. the next day. In an interview on 7/20/16 at 9:10 a.m., R#1 stated, I cant feel anything from the waist down . and added the staff usually repositioned him every 2 hours, but no one came into the room. In an observation on 7/20/16 at 9:15 a.m., 2 Nurse Aides (NA) were turning R #1 from facing the door to facing the window. The resident had a ring around his bottom area, similar to a bed pan opening with black eschar to the lower left side of the wound and a red open area to the right upper side with a dressing covering the bottom half of the wound. During a record review, on 7/20/16 a physicians progress note stated the location of the wound was bilateral buttocks of lateral sides 0.5- 1cm width and 12-15cm length with C shaped linear areas. a description of the wound was as follows: Maroon localized discoloration intact skin with deep bruising that is boggy to the touch. Adjacent tissue is warm to the touch. The resident does not have sensation below the waist, thus, cannot feel pain. In an interview on 7/20/16 at 9:40 a.m., Staff A said, R#1 was to be turned every two hours, unless he was eating and tha NA reporting was usually done from room to room with out-going and on-coming staff. Per the care plan, dated 1/1/16, the resident was to be repositioned frequently, as he/she was at risk for developing a pressure ulcer. In an interview on 7/20/16 at 11:18 a.m., Staff B said NA supervision was usually done with vision, helping, and communication and added tha NA's alert her to who was repositioned and when. In a nursing document (undated) titled Offering and Removing the Bedpan stated: Do not allow the resident to sit on a bedpan for extended periods. NOTE: This is not only uncomfortable to the resident, it also causes skin breakdown. Although the facility had systems in place for preventing skin breakdown, the facility failed to assure R #1 received the care required during a prolonged bed plan placement, which resulted in significant physical harm.

Findings include: Based on interview and record review, the facility failed to ensure residents were not subjected to potential verbal abuse and involuntary seclusion when placing a call light out of reach, for 1 of 3 residents (R#1) reviewed for abuse and neglect. This failure caused Resident #1 psycho-social harm, as the resident expressed fear of a staff member and fear of retaliation. Resident #1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to Resident #1's Minimum Data Set (MDS), a comprehensive nursing assessment, dated 4/13/16, the resident was an extensive assist (weight bearing assist) for most of the activities of daily living. During a record review, a facility investigative report, dated 5/4/16, was reviewed. In an incident on 5/2/16, 3 Nurse Assistants (NA) overheard Staff A yell at Resident #1 for using her call light too frequently in a matter of 10 minutes. It was reported at shift change from Staff A to Staff B, the frequency of the call light and that the call light was clipped out of Resident #1's reach. When Staff B went into Resident #1's room, it was noted the resident was upset and angry. The call light was then put back in reach of the resident. In reviewing the Suspension Pending Investigation Form of Staff A, it was noted Resident #1 was afraid of Staff A. In a nursing progress note, dated 5/3/16 at 7:53 a.m., the resident did not want Staff A to know about the situation as Resident #1 did not want Staff A to be mad and take revenge on the resident. The facility allowed Staff A to come back to work following the investigation, and did not substantiate that an abuse occurred. Staff A was not working with Resident #1 any longer. During an interview on 5/16/16, at 5 p.m., Staff C stated Staff A was counseled and felt remorse, and Staff C felt a warning was the best course of action. During an interview at 6:10 p.m., Resident #1 stated she feels safe in the facility. During an interview on 5/17/16, at 1:35 p.m., Staff D revealed leaving the call light out of a resident's reach is a huge no-no as it is an involuntary seclusion, and would result in staff termination. The facility failed to protect residents from actual harm related to verbal abuse and involuntary seclusion.

Findings include: Based on interview and record review, the facility failed to monitor a resident with a significant change in condition, in a time consistent with the resident's changed needs, for one of four residents (R#1) sampled for monitoring of health conditions. This failure resulted in the resident's continuing decline and subsequent death related to a delay in providing medical interventions. According to the updated face sheet, physician notes, and [DIAGNOSES REDACTED].#1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. in the abdominal cavity), diabetes, depression and weakness. Review of the resident's Minimum Data Set (MDS), a nursing assessment tool, dated [DATE], revealed, the resident had short term memory problems and was moderately impaired with decision making, inattention, disorganized thinking, psychomotor [MEDICAL CONDITION] and an altered level of consciousness, which was an acute change in mental status from the resident's baseline. Life expectancy was more than 6 months, and there was an active discharge plan for Resident #1 to return to the community. During a record review of Resident #1's care plan, it did not identify specific interventions for staff to follow, or what signs and symptoms to monitor related to Resident#1's liver disease, a condition when the liver could no longer breakdown toxins to the body when the liver was diseased. During a record review of the nursing progress notes, Resident #1 was alert and oriented to self and family on [DATE] to [DATE]. In a nursing progress note, dated [DATE], the resident was lethargic and sleeping all evening shifts and did not eat or drink anything. Resident #1 accepted eye drops, but quickly went back to sleep. The [DATE] note revealed the resident was usually independent with moving about in bed, but needed a one person assist, on that day. The physician was not notified of a change in condition. Further review of the nursing progress notes revealed on [DATE], Resident #1 was unable to keep eyes open and was minimally able to follow instructions. The resident was assisted to drink a supplement drink with multiple cues to drink and swallow and drank 60 cc's (cubic centimeters-a measurement for fluid amount). The resident refused to allow staff to remove soiled clothing. The physician was not notified of these changes in condition. Nursing progress notes dated [DATE] revealed the resident was in a wheelchair .lethargic and unarousable and medications were held as the resident did not have a swallow reflex. Two [MEDICATION NAME]es were discovered on the residents' body. At this time, the physician ordered staff to remove both patches, and in an undated incident report, Staff A conducted an investigation. The physician concluded Resident #1's pain management .should be decreased related to the drowsiness. On [DATE], a physician's orders [REDACTED]. It was not confirmed between the nurse and the physician what labs were actually taken, per an undated incident report from the facility. An ammonia level was not taken by the facility during Resident #1's stay. On [DATE], in a nursing progress note written at 2:23 p.m., Resident #1 had a definite decrease in level of consciousness, and did not respond to touch or verbal, but responded to pain stimuli. Resident #1 was writhing and contorting her face and body, and had episodes of somnolence and agitation. The resident had [MEDICAL CONDITION](heart rate above normal range) and hypertension (increased blood pressure). The physician was then called and the resident was sent out to the emergency room , and was diagnosed with [REDACTED]. It was confirmed in the emergency room Resident #1 had a critical high ammonia venous blood level of 63.0 umol/L (micromole/liter) (normal being 9.0 to 30.0 umol/L). On [DATE] at 10:49, the hospital called the Director of Nursing Services (DNS) and alerted the facility of the critical high ammonia value. This was discovered 4 days after family and staff noted a change in Resident #1's level of consciousness. During an interview on [DATE] at 4:51 p.m., Collateral Contact (CC) #1 stated, comments were made to the facility regarding Resident #1's decreasing level of consciousness on [DATE] on evening shift, [DATE] on eve shift, and an ammonia level (due to Resident 1's decreased LOC) was demanded by CC#1 on [DATE]. During an interview on [DATE] at 2 p.m., Staff B thought leaving a [MEDICATION NAME] on the resident longer than 72 hours caused the resident's decrease in level of consciousness. Staff B said the [MEDICATION NAME] was dated [DATE], and was discovered on [DATE], the day before Resident #1 was admitted to the facility. During an interview at 2:14 p.m., Staff C stated, if there was a change in the level of consciousness in a resident, he/she would assess the patient, notify the physician and supervisor and place the resident on alert charting. At 2:20 p.m., Staff D stated, if there was a change in the level of consciousness in a resident, he/she would immediately report to a nurse and turn the report into a supervisor. During an interview on [DATE] at 11:53 a.m., Staff F did not recall the [MEDICATION NAME] medication error, and stated the nurse told him/her the labs were already drawn. Staff F explained, the elevated ammonia levels were typically not an accurate reflection of symptoms of ammonia toxicity, and he/she ordered an increase in [MEDICATION NAME] on [DATE]. ([MEDICATION NAME] is used specifically to lower ammonia blood levels though bowel movements.) On [DATE] at 8:30 a.m., Staff A reported the facility did not have a specific pathway for nursing staff to review for residents with a history of hepatic [MEDICAL CONDITION]. The facility did not have a care plan specific for providing care and service to residents with hepatic [MEDICAL CONDITION]. We use books or consult the physician. The facility did not provide a care plan related to liver disease for Resident #1 and did not identify signs and symptoms staff should consistently continue to assess, monitor and document. The facility failed to assess, monitor and alert the physician of a change in Resident #1's level of consciousness, which lead to a critical elevation of ammonia levels. The resident died in the hospital on [DATE].

Based on observation, interview, and record review it was determined that the facility failed to implement interventions consistent with the resident's needs, goals, plan of care, and current standards of practice in order to reduce the risk of an accident. This failure caused harm when Resident #1 sustained stage I and stage II pressure sores when left on the bed pan for over eleven hours. Findings include: Resident #1 readmitted to the facility from the hospital on [DATE] with multiple [DIAGNOSES REDACTED]. The minimum data set (MDS), an assessment tool dated 4/22/14 documented the resident had a BIMS score of 13 which indicated the resident was cognitively intact. The MDS dated [DATE] documented the resident required extensive assist of two people for bed mobility, transfers, and toilet use. The care plan dated 1/26/14 with a goal date of 7/31/14, documented the resident was at risk for developing pressure ulcers related to decreased bed mobility secondary to [DIAGNOSES REDACTED]." The care directive with a date of 5/22/14 (a care guide for nursing assistants) documented in the "notes" reposition every 2 hours as patient allows. According to the facility's investigation dated 5/21/14, the resident was placed on the bedpan by the evening shift nursing assistant (Staff B) at 9:55 p.m. The night shift nursing assistant (Staff C) failed to turn and reposition the resident during her shift. The day shift nursing assistants (staff D) turned the resident three hours into her shift, to the resident's side at 9 a.m. The resident had a red blanchable ring around the right and left buttocks. The facility ' s investigation identified the resident had been lying on the bedpan for 11 hours. On 6/4/14 at 3:30 p.m., observation of Resident #1's wounds with the director of nursing (Staff A) and two unidentified staff members revealed the resident had a 4.1 x .5 cm stage I pressure ulcer to the left buttock, .5 x 1.9 cm stage II pressure ulcer to the left upper thigh, .5 x 1 cm stage II pressure ulcer to the left gluteal fold, and 6.5 x 2 cm stage I pressure ulcer to the right buttock. Observations revealed a noted red blanchable ring shaped discoloration to the right and left buttocks. According to the facility's investigation, the nursing assistant (Staff D) documented the resident requested to get up at 6:15 a.m. on 5/21/14, and the resident was informed the nurse (Staff E) wanted to first do a treatment and the resident agreed. Staff D returned at 6:45 a.m., to prep the resident to get up, dressed the resident, but did not roll the resident. Staff D with the help of another nursing assistant (Staff F) pulled the resident up in bed, and Staff E performed the treatment. According to Staff D's statement, breakfast was delivered to the resident between 7:15 a.m. and 7:30 a.m. At 9:00am Staff D returned to get the resident up, rolled resident and found the bed pan under the resident. On 6/5/14 at 12:00 p.m., during an interview, nursing assistant (Staff F), stated she was unable to find a sling to get the resident up before breakfast. Staff F stated she assisted Staff D to pull the resident up to eat breakfast, and confirmed the resident was not turned or repositioned at that time. On 6/5/14 at 11:45 a.m., during an interview, Staff E stated about 9:00 a.m., or so, the resident was found lying on the fracture pan (bed pan). On 6/5/14 at 9:40 a.m., during an interview, resident #1 reported staff placed him on the bed pan at about 9 p.m., and did not remove the bed pan until late morning the following day. Resident #1 reported he had limited feeling to the buttock area due to his disease process. Resident #1 reported staff informed him that he was on the bedpan for 12 hours. Staff did not reposition Resident #1 according to the plan of care and standards of practice. According to the resident's plan of care, Resident #1 should have been repositioned every two hours. Staff C failed to reposition the resident for her entire eight hour shift. Staff D did not reposition the resident until three hours into her shift. This failure caused harm when Resident #1 sustained stage I and stage II pressure ulcers after being left on the bed pan for over 11 hours.

Based on interview and document review the facility failed to provide the necessary timely assessment, care and services in response to trauma for 1 of 5 (#2) Residents when Resident #2 suffered uncontrolled bleeding after sustaining a laceration to her lower leg. This failure to timely, thoroughly assess and notify the physician led to Resident #2 being hospitalized with low blood pressure, needing a blood transfusion and surgical intervention for the wound on her leg. Findings include: Resident #2 was assessed by facility as being alert and oriented and able to make her needs known. She had [DIAGNOSES REDACTED]. She was on medications to include [MEDICATION NAME] (anti-coagulant). In the nursing note written 12/8/13 at 1:07P.M., it stated, " ...0945 (9:45A.M.) resident came out of her room in wheelchair with pant leg rolled up, blood noted to be dripping from left leg, laceration noted to left lower extremity 7cm x 14 cm x 1 cm, floor in room covered with puddles of blood. Steri-strips applied as best as possible to site, ABD pads and [MEDICATION NAME] applied tight to area. At 11:15A.M. dressing noted to be saturated with blood. Manager on duty in to see wound, puddle of blood noted under resident wheelchair, old dressing removed covered in blood and clots. INR ( test to check for clotting time) obtained = 3.4 (elevated), blood pressure 117/46, dressing reapplied immediately saturated, on call physician made aware, orders to send to emergency room , transferred at 11:45A.M. " There was no evidence to support there was any assessment done of the resident between 9:45A.M. and 11:15A.M. even though the resident was on [MEDICATION NAME], which could make bleeding worse, and documentation indicated blood had been "dripping" down her leg and there were "puddles of blood" in her room. There was no indication a blood pressure had been obtained at the time of injury or the physician had been notified. In an interview with S-A on 1/9/13, he stated staff had come to tell him the dressings were saturated. When asked why he did not immediately contact the physician, S-A stated, "I did not realize how deep it was until I had re-dressed it 3 times." He said he initially did not feel it was emergent which was why he did not inform the physician. According to the physician notes written 12/26/13 after the resident returned to the facility, the resident had been sent to the emergency room where she was noted to have significant amount of bleeding from the leg. The wound was an avulsion type of wound (skin torn away) with active arterial bleeding. It was also noted she was hypotensive (blood pressure low) and was started on a [MEDICATION NAME] drip (to prevent blood pressure from dropping further and patient going into shock). She received 4 units of plasma. She had to have surgical debridement of the wound and a subsequent skin graft.