Every finding on record at Life Care Center of Puyallup

Based on interview and record review the facility failed to provide bathing (shower, bath, and/or bed bath), according to the care plan, for one of three residents (Resident 2) reviewed for bathing. This failure placed the resident at risk for skin irritation, fungal infections and bacterial infections, body odor, feelings of shame and loss of dignity, and a decreased quality of life.Findings included. Review of the quarterly Minimum Data Set (MDS, a required assessment tool), dated 07/22/2026, showed that Resident 2 admitted on [DATE]. The MDS showed that Resident 2 used a wheelchair for mobility and required staff assistance for transferring from bed or to wheelchair and for activities of daily living to include dressing, grooming, oral hygiene, and bathing. During interview on, 08/13/2026 at 1:32 PM, Resident 2 stated that they preferred bed baths, and didn't know why they would go so long without a bed bath, and that it wasn't very nice to wait as long as they did. Review of the facility Kardex (a quick refence that outlines a resident's daily care plan), dated 07/24/2026, showed that Resident 2 was scheduled for bathing every Friday. Review of a 30-day lookback of the bathing documentation, 07/13/2026 through 08/13/2026, showed that Resident 2 had two bed baths in 30 days, with over three weeks in between: on 07/18/2026 and 08/10/2026. There was no additional documentation showing that Resident 2 had been offered a bath, and had refused, on other dates in the 30-day lookback. During interview on 8/13/2026 at 3:30 PM, Staff A, Director of Nursing Services (DNS), stated that every resident should be offered at least one bath/shower/bed bath per week. Staff A, DNS, further stated that if a resident refused bathing, the staff were to document the refusal and notify the resident's nurse so they could follow-up with the resident. WAC Reference 388-97-1060(2)(c).

Based on observation, interview and record review, the facility failed to ensure freedom from abuse, during resident-to-resident altercations, for 3 of 3 residents (Residents 2, 3, and 4) reviewed for resident abuse. Three physical altercations occurred between 1 aggressor (Resident 1) and 3 victimized residents (Residents 2, 3 and 4) within 24 hours. This failure placed the residents at risk for injury, psychological harm, diminished feelings of safety and security, and a decreased quality of life. Findings included.Resident 1Review of the electronic health record (EHR) on 07/01/2026 showed that Resident 1 was admitted to the facility on [DATE] and had diagnoses to include vascular dementia with mood disturbance.Review of the Annual Minimum Data Set (MDS, a required assessment tool), dated 04/08/2026, showed that Resident 1 used a manual wheelchair and was able to wheel at least 150 feet, on their own, once set up in their wheelchair. The MDS further showed that Resident 1 had severe cognitive impairment (trouble thinking, learning, remembering, and making decisions), but was able to communicate and make their needs known.Review of the care plan focus, dated 05/18/2023 and revised on 04/22/2026, showed that Resident 1 had potential to be verbally or physically aggressive, had poor impulse control, and had a history of altercations with other residents. Interventions to address the concerns included redirection, activities (including 1-to-1 monitoring by staff) when agitated, and attempting to calmly intervene before agitation escalated.Review of the care plan focus, dated 06/30/2026, showed that Resident 1's discharge plan was to transition to a higher level of care that could safely accommodate their increasing cognitive and behavioral needs.During interview on 07/01/2026 at 9:43 AM, Staff C, Licensed Practical Nurse (LPN), stated that they were very familiar with Resident 1. Staff C, LPN, stated that there was no way to predict Resident 1's behaviors, and that they could be in a good mood, but suddenly a switch would flip, and if Resident 1 were to see something they didn't like, Resident 1 would react.Observations on 07/08/2026, between 9:15 AM and 12:15 PM, showed Resident 1 independently mobile in their wheelchair, wheeling throughout the hallways and common areas of the facility. Resident 1 and Resident 2 Physical AltercationReview of the EHR showed that Resident 2 was admitted to the facility on [DATE] and was able to independently walk through the facility using a walker. The EHR further showed that Resident 2 was alert and oriented and able to make their needs known.Review of a facility incident investigation, dated 06/21/2026 at 4:00 PM, showed that Resident 1 cornered Resident 2 in a room with a vending machine. Resident 1 proceeded to knock snacks out of Resident 2's hands and kicked Resident 2. Resident 2 stated, stop, and reached to the floor to pick up the snacks, then Resident 1 hit Resident 2 on the left chest with pointed straight fingers. Resident 2 called for help, and staff responded and separated Residents 1 and 2. Documented actions taken to prevent recurrence showed, Care plan reflects impulsive aggressive behavior. Redirection.During interview on 07/01/2026 at 9:50 AM, Resident 2 recalled the events consistent with the facility incident report, and stated that Resident 1 scared them, and that they moved to a different room to be far away from Resident 1. Resident 2 further stated that the staff were keeping an eye out for Resident 1, on behalf of Resident 2, and would warn them when Resident 1 was around so that they could go somewhere else to avoid being near them. Resident 1 and Resident 4 Physical AltercationReview of the EHR showed that Resident 4 was admitted to the facility on [DATE], had severe cognitive impairment, would sometimes understand people and be able to make themselves understood, used a wheelchair, and was dependent on staff for mobility in their wheelchair and for all daily care needs.Review of a facility incident investigation, dated 06/22/2026 at 1:50 PM, showed that Resident 4 was near a nurses' station, in their wheelchair, when Resident 1 passed by and became agitated that Resident 4 was too close, kicked Resident 4's leg out of the way and started speaking profanities. Staff separated Residents 1 and 4. Documented actions taken to prevent recurrence showed, Increased supervision in common areas.During observations and attempted interview on 07/01/2026 at 9:37 AM, Resident 4 was dressed and lying in bed on top of the covers. Resident 4 stated they did not feel well and did not engage in further conversation. Resident 1 and Resident 3 Physical AltercationReview of the EHR showed that Resident 3 was admitted to the facility on [DATE], had memory problems, was able to recall location of their room and recognize staff names and faces. Resident 4 could not clearly communicate verbally. Resident 4 used a wheelchair and was dependent on staff for mobility in their wheelchair and for all daily care needs.Review of a facility incident investigation, dated 06/22/2026 at 2:30 PM, showed that Resident 1 was leaving their room, agitated because staff were attempting to collect a urine sample. Resident 1 was being verbally abusive toward staff, cursing at them and threatening to cut them. Resident 1 proceeded to self-propel down the hall in their wheelchair, approached Resident 3, who was sitting in their wheelchair, and hit them in their right leg/ankle. Staff immediately separated Residents 1 and 3 and provided ice for Resident 3's leg. Documented actions taken to prevent recurrence showed that Resident 1 was placed on 1-to-1 supervision with a staff member and then transferred to the emergency department for evaluation and treatment due to increasing behaviors and aggression.During observation and interview on 07/01/2026 at 9:49 AM, Resident 3 was non-verbal but understood questions and was able to communicate using yes and no head movements, facial expressions, and arm movements. Resident 3 indicated that Resident 1 had hit them in the right leg, made a facial grimace, and shook their head no when asked if they felt safe around Resident 1. Observation of Resident 3's right leg showed no skin impairments or discolorations.During interview on 07/01/2026 at 12:01 PM, Staff B, Director of Nursing Services (DNS), stated that they had not yet started in their position with the facility when the resident-to-resident altercations had taken place between Residents 1, 2, 3 and 4, but upon review of the incidents, they advocated for staff refresher training on assessments and dementia/behavior training. Staff B, DNS, stated that the physical altercations between Residents 1 and Residents 2, 3 and 4 did constitute abuse. WAC reference 388-97-0640(1).

Based on observations, interviews, and record review, the facility failed to provide the necessary treatment and services consistent with professional standards of practice to prevent the development and/or promote healing of PU/PI (Pressure Ulcers/Pressure Injuries) for 4 of 5 Residents (Residents 11, 128, 13, and 134) reviewed for PU/PIs. Resident 11, who was identified to be at risk for developing PU/PI, experienced harm when they developed an avoidable right heel Stage II (partial-thickness skin injury that breaks through the epidermis and exposes the dermis) that worsened to an unstageable (a full-thickness wound whose depth cannot be determined because it is covered by obstructive material) PU/PI and pain after admission to the facility, when the facility failed to develop/implement/update a resident-centered care plan (CP) for the prevention of PU/PIs that included timely pressure offloading interventions for PU/PI prevention, accurately follow physician orders (PO) for wound care, and consistently implement CP interventions after the PU/PI developed to promote healing. These failures placed residents at risk for the development of new PU/PIs, delayed healing, unnecessary discomfort, infection, and diminished quality of life/quality of care. Findings included.<POLICY>Review of the facility's Pressure Injury Prevention and Unavoidable Pressure Ulcer/Injury policy, revised 06/12/2025, showed the facility utilized the professional standards of the National Pressure Injury Advisory Panel (NPIAP) and the Wound, Ostomy, Continent Nurses Society (WOCN) for PU/PI prevention and care. The facility's process included evaluation of the resident's clinical condition and risk factors, define and implement interventions that were consistent with the resident's needs, goals, and professional standard of practice, monitor/evaluate the impact of the interventions, and revise the CP as needed.Review of the facility's Pressure Ulcer Prevention policy, reviewed 06/11/2025, showed all residents upon admission were at risk to develop PU/PIs due to medical issues that required nursing care, disease process, illness, or need for rehabilitation services. The facility would routinely use the Braden Risk Assessment (Braden Scale - a standardized assessment tool used to estimate risk of developing PU/PIs by evaluating six key criteria: sensory perception, moisture, mobility, nutrition, and friction/shear to help prioritize preventative measures for CP development) to evaluate the resident's risk of developing PU/PIs. After a comprehensive assessment, a resident-centered care plan would be developed. Measures to protect the resident against the adverse effects of external mechanical forces such as pressure, friction, and shear were implemented in the plan of care, including: repositioning at least every two-four hours, utilizing positioning devices to keep boney prominences from direct contact, ensuring proper body alignment when side-lying, heel protection/offloading, maintaining head-of-bed at the lowest degree of elevation consistent with medical conditions, use of lift devices to move the resident in bed, pressure redistribution mattress, and a pressure reduction surface for the wheelchair.According to the NPIAP Pressure Injury Prevention Points: Risk Assessment, updated 2016, use of a structured risk assessment at routine intervals (such as the Braden Risk Assessment) to identify individuals at risk for PU/PIs should be used to develop a CP based on the areas of risk, rather than on the total risk assessment score and provided potential interventions to consider based on each risk category. <RESIDENT 11>Review of the 03/11/2026 admission Minimum Data Set (MDS-assessment tool) showed Resident 11 admitted to the facility on [DATE] and had no problems with cognition. Resident 11 had limited range of motion of one side of their lower extremity, was dependent on staff for assistance with toileting, bed mobility, transfers, and was incontinent of bladder. Resident 11 diagnoses included a right hip fracture, diabetes, and respiratory failure. Resident 11 had pain rated 8/10 and received both scheduled and as needed pain medication. Resident 11 had no unhealed PU/PIs and their formal risk assessment determined they were at risk for the development of PU/PIs.Review of the 03/09/2026 Braden Scale assessment showed Resident 11 had problems related exposure to moisture, they were confined to the bed, had very limited mobility, and problems with friction/shearing. Resident 11's identified risk factors for clinically unavoidable PU/PIs included bowel/bladder incontinence, pain that effects movement, chronic kidney/liver/heart disease, a hip fracture, diabetes, and use of anticoagulants. Review of the 03/09/2026 Skin Integrity care plan (CP) showed their skin was at risk due to diabetes, incontinence, fragile skin, anemia, and limited mobility. Interventions to maintain skin integrity were to clean and dry the skin after each incontinent episode and monitor for signs of infection or breakdown. The CP did not include resident-centered interventions to address the pressure related identified risk factors in the Bradens or clinical assessments for the prevention of PU/PIs.Review of the Kardex (an abbreviated CP tool for the Certified Nursing Assistants [CNAs] to identify/implement immediate care needs and special alerts), dated 03/23/2026, did not show Resident 11 was at risk for PU/PI and did not include resident-centered CP interventions for direct care staff to implement for the prevention of PU/PIs. <DEVELOPED PU/PI>Review of the facility's Wound Observation Tool (WOT), dated 03/24/2026, showed Resident 11 developed a right heel Stage II PU/PI (partial-thickness skin loss that does not extend to the underlying fat tissue) that measured 5.5 centimeters (cm) x 0.1 cm. Resident 11's pain related to the wound was 8/10(pain scale where 0=no pain and 10= extreme pain). Interventions implemented were wound treatment and cushion boots to wear when in bed.Review of the 03/24/2026 right heel PU/PI CP showed the goal was to show signs of healing and remain free of infection by implementing the following interventions: administering treatments as ordered, education to the resident/family/caregivers of the cause of skin breakdown, placement of cushion boots to both feet while in bed, and to follow policies and protocols for the prevention/treatment of skin breakdown.Review of the Wound Care Consultant (WCC) progress note, dated 03/30/2026, showed Resident 11 had a right heel unstageable PU/PI (a full-thickness tissue injury where the base of the wound is completely covered by dead tissue making it impossible to determine the true depth of tissue damage) that measured 3.0 cm x 4.2 cm x unknown depth. The wound bed contained dead tissue that needed to be removed to determine the extent of tissue damage. The WCC recommended a wound care treatment: cleanse with wound cleanser, apply skin prep around the wound, apply medical honey to the wound bed, cover with a bordered dressing, change daily (and as needed), and float heels with pillows or wedge heel lift device.Review of the facility's WOT, dated 04/06/2026, showed Resident 11's right heel wound remained an unstageable PU/PI. The documentation did not show wound measurements or wound characteristics and referred to the WCC progress notes.Review of the clinical record on 04/07/2026 did not show the WCC progress notes for 04/06/2026.In an interview on 04/07/2026 at 8:50 AM, Staff Q, Registered Nurse-RN, stated they were not aware of any residents that had PU/PIs on their hall but the facility had a wound treatment nurse who would know.In an interview on 04/07/2026 at 9:06 AM, Staff J, Licensed Practical Nurse-LPN/Treatment Nurse, stated they performed the wound care on all PU/PIs, diabetic foot ulcers, and vascular ulcers on the days they worked, and the medication nurses were responsible to perform the dressing changes on their days off. Staff J stated Resident 11 developed an unstageable PU/PI after admission to the facility. Staff J stated they had a wound care consultant who saw patients on Mondays, but they had not received the most recent wound care progress notes. Staff J stated they also completed WOTs of the wounds they monitored weekly. Staff J stated the CNAs and nurses knew who had PU/PIs and the care residents required for PU/PI prevention by reading the CP and/or Kardex.During an observation on 04/07/2026 at 11:37 AM, Resident 11 was observed sitting up in their wheelchair with slip socks on, no shoes or heel protection boots on, and feet were resting on hard metal wheelchair foot pedals. At the bottom of Resident 11's right closet were two blue and grey soft heel lift boots (the only two items on that side of the closet). In an interview on 04/07/2026 at 11:38 AM, Resident 11 stated they had a bad wound on their right heel that was not there when they admitted to the facility. Resident 11 stated they could not move their right leg independently due to increased pain in their hip, they did not get repositioned frequently by staff and did not get their heels lifted off the bed but thought it would help their wound. Resident 11 was not aware of any special heel boots they were supposed to have on when they were in bed to keep the heels off the bed. During subsequent observations on 04/07/2026 (at 2:45 PM, 3:30 PM, and 4:20 PM) and 04/08/2026 (at 7:50 AM and 2:36 PM) Resident 11 was observed lying in bed with their heels lying directly on the mattress, and no heel lift boots were in place or pillows to elevate the heels off the mattress.During an observation and interview on 04/09/2026 at 8:04 AM, Resident 11 was observed lying in bed, their heels were directly on the mattress with no pillow or heel lift boots in place. Resident 11 stated their right heel hurt awfully bad, rated their pain a 10/10 and they were trying to move their heel off the bed. Resident 11 stated their heels had been on the mattress throughout the night and they asked a CNA to bring them a pillow they could use to place under their leg to help relieve their pain. Resident 11 stated the CNA said they needed to find a pillowcase and left the room but never returned with a pillow. Resident 11 stated they did not wear any special heel lift boots during the night. <WRONG WOUND CARE TREATMENT>Review of the April 2026 Treatment Administration Record (TAR) showed a physician order for wound care dated 04/06/2026 to cleanse the right heel wound with wound cleanser (or saline), pat dry, apply skin prep around the wound, place an iodine based ointment into the wound bed, cover with a clean dry dressing, and change daily (or as needed).During an observation on 04/09/2026 at 9:39 AM, Staff J, Licensed Practical Nurse-LPN/Treatment Nurse, performed Resident 11's wound care of the right heel PU/PI. Staff J removed Resident 11's right heel dressing and an unstageable PU/PI was observed; the wound bed covered greater than 75 percent of the wound with adherent moist black eschar (dead tissue). When Staff J cleaned the wound with saline, Resident 11 winced in pain. Resident 11 stated their pain was 10/10 coming from the center of the right heel wound. Staff J then began to apply the new dressing; they applied medical honey to dressing and then placed the dressing on the wound and secured it in place with kerlix. The observation showed Staff J did not follow the 04/06/2026 wound care treatment order as directed by the physician. After completing the wound care, Staff J stated to Resident 11, Where is your cushion boots? and Resident 11 Stated I have no idea. Staff J began to place a thin pillow under Resident 11's right calf to elevate the right heel, then looked in the closet and found the heel lift boots. As Staff J placed the soft blue/grey heel lift boots on Resident 11, Staff J stated, They [the CNAs] are not putting the boots on you like they are supposed to.During an interview on 04/09/2026 at 10:15 AM, Staff J stated [they] realized they placed the incorrect treatment on Resident 11's wound so they redressed Resident 11's right heel wound with the correct wound treatment. Staff J stated they should have reviewed the order prior to performing the dressing change but did not.In an interview on 04/09/2026 at 5:16 PM, with Staff J and Staff P, LPN/Unit Care Coordinator, Staff P stated their expectation was the staff follow the facility's policy and procedures for PU/PI prevention and care. Staff P stated the residents should be assessed timely for their risk of developing PU/PIs and have a care plan developed and implemented timely as soon as the risks were identified. Staff J stated the interventions that were in Resident 11's CP were not resident-centered and did not provide interventions to manage the problems that were identified in the Bradens and clinical assessments, but should have. In an interview on 04/10/2026 at 1:03 PM, Staff G, LPN/Unit Care Coordinator, stated it was their expectation that when a new resident was admitted to the facility, their skin was assessed as soon as possible after they arrived, and then assessed timely for their risk of developing PU/PIs. Staff G stated they would expect to see person-centered interventions in the baseline CP to help prevent new wounds from developing starting the day of admission. Staff G stated resident education, keeping skin clean and dry, and doing weekly skin checks were not person-centered PU/PI prevention interventions and did not meet professional standards of care for prevention of PU/PIs. <RESIDENT 134>Review of the 04/06/2026 admission MDS showed Resident 134 admitted to the facility on [DATE], had some problems with cognition, and required staff assistance for bed mobility, toileting, and transfers. Resident 134 was incontinent of bowel/bladder, and their diagnoses included heart disease, diabetes, and peripheral vascular disease (PVD-a circulatory condition that causes narrowing of the blood vessels/arteries restricting blood flow to the extremities and/or back to the heart from the extremities). Resident 134 had no unhealed PU/PIs and was assessed to be at risk for the development of PU/PIs.Review of the 04/02/2026 Braden Scale assessment showed Resident 134 had problems with activity and friction/shear, pain that affected movement or mood, acute illness, PVD, and diabetes.Review of the baseline CP, dated 04/02/2026, showed Resident 134 was at risk for skin alterations due to fragile skin, diabetes, and PVD. The CP interventions directed staff to clean and dry skin after each incontinent episode and perform weekly skin checks. The CP did not provide person-centered interventions to prevent PU/PIs or address the risk areas identified in the Bradens and clinical assessment.In an observation on 04/08/2026 at 10:41 AM, Resident 134 was lying in bed with nonskid socks on their feet, and their heels were lying directly on the mattress. Resident 134 stated their heels hurt a lot and an unidentified CNA assisted Resident 134 to sit up, then removed their socks. Resident 134's right heel was red in the area where they stated the heel hurt.During an interview on 04/09/2026 at 8:16 AM, Resident 134 stated their heels continued to hurt and they reported their pain to staff. Resident 134 stated they had not received any treatment or interventions to relieve their heel pain.During subsequent observations on 04/09/2026 (at 8:16AM, 11:52 AM, and 3:40 PM) and 04/10/2026 (at 8:03 AM and 8:29 AM) Resident 134 was observed with their heels lying directly on the bed and not elevated with pillows or other heel lifting devices. Review of Resident 134's Kardex, dated 04/09/2026, did not show any interventions consistent with professional standards of care for the prevention of PU/PIs.During an observation and interview on 04/10/2026 at 8:29 AM, Staff P, Licensed Practical Nurse/Unit Care Coordinator (LPN/UCC), removed Resident 134's socks. Both heels were observed to be red. Staff P measured the left heel redness (2.0 cm x 3.0 cm) and the right heel redness (3.0 cm x 2.5 cm and boggy [a soft, spongy texture of the heel tissue, often indicating the early stages of a pressure injury or deep tissue injury]). <RESIDENT 128>Review of the 04/03/2026 Entry MDS showed Resident 128 admitted on [DATE] from an acute care hospital.Review of Resident 128's Braden Scale Assessment, dated 04/03/2026, showed they had problems related to excessive moisture, chairfast (unable to walk), very limited mobility, and problems with friction and shear. Resident 128's clinical risk factors for an unavoidable PU/PI included the presence of an existing PU/PI, bowel incontinence, edema, acute illness, diabetes, and chronic kidney/liver/heart disease.Review of the admission Skin Assessment, dated 04/03/2026, showed Resident 128 admitted with a Stage I (an area of intact skin with localized non-blanchable redness) on the sacrum (just above the tailbone area) that extended down to the buttocks and measured 15.0 cm x 7.0 cm.Review of the wound care physician order, dated 04/03/2026, directed staff to cleanse the sacrum/buttocks with soap and water, pat dry, and apply a zinc-based ointment every shift and as needed.Review of Resident 128's baseline CP, dated 04/03/2026, showed they were at risk for a break in skin integrity with actual impairment to the skin. The CP interventions were to ensure the skin was clean and dry after each incontinent episode, educate the resident/family on causative factors and measure to prevent skin injury, encourage/assist with turning and repositioning, and perform weekly skin checks. The baseline CP did not indicate Resident 128 admitted with a Stage I PU/PI on the buttocks/sacrum and the CP interventions were not person-centered to address their assessed risks identified in the Braden Scale and Clinical Assessment.Review of a facility WOT, dated 04/06/2026, showed Resident 128 had a Stage I on their right lower back that measured 0.5 cm x 0.5 cm. The wound was not documented on the admission Skin Assessment. The documentation showed the treatment plan was repositioning but did not indicate how often.Review of Resident 128's Kardex, dated 04/07/2026, did not show they had two Stage I PU/PIs or direct the care staff on how to remove the pressure from the affected areas (and prevent new PU/PIs). The CP directed staff to encourage/assist to turn and reposition (but did not state how often), to clean and dry the skin after each incontinent episode, and to perform weekly skin inspections. Review of Resident 128's clinical record on 04/06/2026, did not show a wound care treatment physician order for the Stage I.During an observation and interview on 04/07/2026 at 11:12 AM, Resident 128 was observed lying in bed, flat on their back, with their feet almost touching the footboard of the bed, and their heels were flat on the bed without offloading. Resident 128 stated they had a wound on their butt that was very sore and treated with a cream the staff put on it. Resident 128 stated the staff did not turn/reposition them frequently and could not recall a time staff put pillows behind their back to get the pressure off their butt. Resident 128 stated the staff did not get them up for meals and they ate in bed with their head of the bed elevated.During subsequent periodic observations on 04/07/2026 (a 2:40 PM, 3:38 PM, 4:10 PM), 04/08/2026 (at 8:01 AM, 11:22 AM, and 1:00 PM), and 04/09/2026 (at 8:50 AM, 10:36 AM, 12:15 PM, and 3:25 PM) Resident 128 was observed lying in bed, flat on their back, without side-lying support to relieve pressure to their buttocks, and their heels were flat on the bed.In an interview on 04/09/2026 at 10:15 AM, Staff J stated Resident 128 admitted with a Stage I on their sacrum/buttocks and it was treated with zinc/barrier ointment every shift, and they were looking at getting them an air mattress.During an observation and interview on 04/10/2026 at 7:52 AM, Resident 128 was sitting up in a wheelchair in their room. Resident 128 stated they asked to get up out of bed in the middle of the night because they had been in bed so long. Resident 128 stated that since they got up out of bed, their butt felt better and they had no pain in their back. The mattress on Resident 128's bed was not an air mattress.In an interview on 04/10/2026 at 8:05 AM, Staff V, CNA, stated they were unsure if the facility had a standard of care protocol for PU/PI prevention but stated some of the residents had air beds, [they] used pillows to position residents on their sides and to place under their legs to keep the heels off the bed, and they were repositioned every two hours. Staff V stated they looked at the Kardex, or the nurse would notify them, if a resident required PU/PI prevention care. <RESIDENT 13>Review of the 01/08/2026 Medicare 5-Day Assessment showed Resident 13 admitted to the facility on [DATE], had some problems with cognition, and required staff assistance for eating, bed mobility, toileting, and transfers. Resident 13 was incontinent of bowel/bladder and diagnoses included pneumonia, anemia, heart failure, diabetes, vascular disease, malnutrition, and required a feeding tube to receive adequate nutrition. Resident 13 was assessed to be at risk of developing PU/PIs and admitted to the facility with two-unstageable PU/PIs and two-DTIs for a total of four PU/PIs.Review of the hospital Post Acute and Transition of Care orders, dated 01/06/2026, showed pictures and measurements of Resident 13's four PU/PIs prior to discharge from the hospital: one Stage I PU/PI (Wound #1) on the top of the right foot and three deep tissue injuries (DTI - ) on the back of their right heel (Wound #2), left inner ankle (Wound #3), and top of the left foot (Wound #4). Review of the facility's nursing admission Assessment, dated 01/06/2026, showed Resident 13 had the same four PU/PIs and measurements identified on the Post Acute Transition of Care Orders, plus one left heel DTI (Wound #5). The documentation did not provide measurements for Wound #5. Review of the 01/06/2026 Bradens Scale assessment showed Resident 13 had problems related to sensory perception, mobility, activity, and friction/shear. Other risk factors included existing PU/PIs, medical devices, peg tube, head of bed elevated majority of the time. The documentation showed the remainder of the assessment was incomplete.Review of the comprehensive CP showed two skin focus problems. The At-Risk Skin integrity CP, dated 01/06/2026, directed staff to clean and dry the skin after each incontinent episode. The Actual Impairment to Skin Integrity CP, dated 01/06/2026, showed Resident 13 had four PU/PIs and listed Wounds #2, # 3, #4, and #5. Wound #1 was not indicated on the CP. The interventions directed the nurses to educate the resident, perform treatments as ordered, and perform weekly skin checks. The interventions directed the CNAs to encourage/assist with turning and repositioning. The CP did not show person-centered interventions consistent with Resident 13's identified risks/care needs or professional standards of practice for prevention/promoting healing of PU/PIs.Review of the 01/15/2026 Kardex did not show Resident 13 had multiple PU/PIs on their lower extremities and did not provide the care staff with directives consistent with professional standards of care to promote healing of PU/PIs. During an interview and record review of Resident 13's 04/09/2026 Kardex and CP on 04/10/2026 at 9:58 AM, Staff U, CNA, stated PU/PIs were caused by sitting too long in one place (or prolonged pressure), excessive skin moisture, and shearing. Staff U stated the professional standards of care for the prevention of PU/PIs depended on each residents care needs but could include: turn/reposition every two hours, pressure relieving air mattress and/or wheelchair cushion, getting up for meals to sit in a chair (not in bed with the head of the bed elevated so they slide down in bed), turning side to side (or side lying to keep them off their tailbone) with the use of pillows, keeping their skin clean and dry, applying barrier ointment to protect their skin, using pillows or a wedge device/heel lift boots to keep their heels off the bed, keeping pressure off their boney prominences (defined as back of the ears if wearing oxygen, spine, elbows, tailbone, sides of the hip, sides of the ankle bone, back of the heel, top of the toes) using pillows to elevate the body part, and using a draw sheet to lift them in bed (not drag them in bed). Staff U stated they would read their Kardex to find out what each resident needed for care. Staff U stated the information should be simple and to the point so they could quickly get the information they needed to provide the care. Staff U stated Resident 13's Kardex and CP did not provide sufficient information or interventions related to the care they required. REFERENCE WAC: 388-97-1060 (1), (3)(b).

Based on interview and record review, the facility failed to implement an effective Antibiotic Stewardship Program to promote appropriate use of antibiotics, reduce the risk of unnecessary antibiotic use, and decrease the development of adverse side effects and antibiotic resistance for 2 of 2 sampled residents (Residents 80 and 52) reviewed for antibiotic stewardship. This failure placed residents at risk for potential adverse outcomes associated with the inappropriate and/or unnecessary use of antibiotics. Findings included.Review of the facility policy titled Antibiotic Stewardship revised 07/22/2025 showed the facility would implement Antibiotic Reassessment at two to three days after empiric antibiotic initiation [the immediate prescribing of antibiotics based on clinical suspicion, patient symptoms, and risk factors before specific laboratory culture or susceptibility results are known] or first dose in the facility, each resident should be reassessed for consideration of antibiotic need. At this time, laboratory testing results, response to therapy and resident condition will be considered. Resident 80Review of the electronic health record (EHR) showed Resident 80 admitted to the facility on [DATE] with a diagnosis of Parkinson's disease (a movement disorder of the nervous system). The resident was able to make needs known. Review of a provider's order, dated 01/27/2026, showed Resident 80 received Macrobid (an antibiotic) for a UTI for five days. Review of a provider's order, dated 02/10/2026, showed Resident 80 received Cephalexin (an antibiotic) for a skin infection for five days. Review of Resident 80's provider note dated 03/08/2026 showed, Treat with Keflex [an antibiotic] (Cephalexin) per susceptibility for E Coli [a bacteria] UTI. Review of Resident 80's provider orders showed Cephalexin with a start date of 03/08/2026 for a urinary tract infection (UTI) for seven days. Review of the progress notes dated between 01/22/2026 and 03/12/2026 showed no documented signs and symptoms of a UTI for Resident 80. During an interview on 04/09/2026 at 11:27 AM, Staff C, Registered Nurse/Infection Preventionist (RN/IP), stated the provider was responding to a laboratory report that was collected on 01/27/2026 but they had not received the results until 03/07/2026. Staff C stated Resident 80 should have been assessed using the McGeers criteria (an infection assessment) and an Antibiotic Reassessment should have been done but was not. Resident 52Review of the EHR showed Resident 52 admitted to the facility on [DATE] with a diagnosis of broken leg. The resident was able to make needs known. Review of Resident 52's EHR showed an order for Macrobid for a UTI for four days with a start date of 03/18/2026. Review of Resident 52's EHR showed no laboratory results were received or reviewed, and no antibiotic reassessment was completed. Review of the progress notes dated between 03/18/2026 and 03/22/2026 showed no reports of symptoms of a UTI for Resident 52. During an interview on 04/09/2026 at 11:27 AM, Staff C, RN/IP, stated they should have requested and reviewed the lab results and completed an antibiotic reassessment but had not. During an interview on 04/10/2026 at 1:38 PM, Staff E, Regional Registered Nurse, stated it was their expectation that the Infection Preventionist review all infection associated lab results and follow up with antibiotic reassessments to ensure appropriate treatment and this did not happen for Residents 80 and 52 but should have. Reference WAC 388-97-1620(2)(b)(i)(ii)

Based on observation, interview, and record review, the facility failed to implement an infection control program to track all infectious organisms present in the facility for 2 of 3 months (January and February 2026) and failed to implement transmission-based precautions for 1 of 4 halls (400 hall) reviewed for infection control. The facility also failed to follow infection control practices during wound care for 1 of 2 residents (Resident 11) when reviewed for wound care. These failures placed the residents at risk for poor clinical outcomes, and a decreased quality of life. Findings included.TrackingReview of the infection control line listings for January, February and March 2026 showed no documentation that the organisms present for residents with a diagnosis of urinary tract infection (UTI) were identified and tracked for the months of January and February 2026. During an interview on 04/10/2026 at 12:40 PM, Staff C, Registered Nurse/Infection Preventionist (RN/IP), stated they were aware of the missing organisms on the monthly tracking for January and February 2026 and stated the laboratory results should have been reviewed for all infections but were not. Transmission Based Precautions (TBP)Review of the posted contact precautions signs on 04/09/2026 showed staff were to perform hand hygiene and put on a gown and gloves when entering the room. Observation on 04/07/2026 at 9:35 AM showed room [ROOM NUMBER] with contact precautions sign posted at the door. An unidentified staff member was observed entering the room without performing hand hygiene or putting on a gown or gloves and failed to perform hand hygiene when exiting the room. Observation and interview on 04/10/2026 at 1:24 PM showed room [ROOM NUMBER] with a contact precautions sign posted at the door. Staff H, Licensed Practical Nurse, was observed standing in room [ROOM NUMBER] next to the resident and did not have on a gown or gloves. Staff H stated they should have followed the posted sign. Wound CareObservation on 04/09/2026 at 9:39 AM showed Staff J, Licensed Practical Nurse/Treatment Nurse, provided wound care for Resident 11. Staff J removed the soiled bandage and with the same gloves cleansed the wound and applied a new bandage. No hand hygiene or glove changes were performed during the bandage change. During an interview on 04/10/2026 at 12:40 PM, Staff C, RN/IP, stated it was their expectation staff followed the posted precautions signs. Staff C stated when changing a bandage staff should perform hand hygiene after removing the soiled bandage before cleansing and applying a new one. During an interview on 04/10/2026 at 1:38 PM, Staff E, Regional Registered Nurse, stated it was their expectation for the infection preventionist to review lab results and track the identified organisms, and staff should have followed the posted precautions signs. Staff E stated wound care should have been performed following proper infection control procedures. Reference WAC 388-97-1320(2)(b)

Based on observation, interview, and record review the facility failed to ensure residents were free from chemical restraints for 1 of 5 sampled residents (Resident 125) reviewed for unnecessary medications. The failure to evaluate and document a clinical rational for continued use of a psychotropic medication and ensure adequate indications for the use of the medications placed residents at risk for decline in activities of daily living, potential adverse consequences, and diminished quality of life. Findings included.Review of the facility's Unnecessary Medications policy, dated 08/09/2023, showed each resident's drug regimen would be free from unnecessary drugs, including antipsychotic drugs without adequate indications for its use. The resident's medical record should show documentation of adequate/appropriate indications for the medication's use, the diagnosed condition for which a medication was prescribed, and in accordance with clinical practice guidelines and standards of practice. Review of the 03/25/2026 admission minimum data set (MDS, a required assessment tool) showed Resident 125 admitted to the facility 03/23/2026 and had some problems with cognition but was able to understand and be understood. Resident 125 had no behaviors, symptoms of delirium, or rejection of care. Resident 125's diagnoses included an infection, depression, and non-Alzheimer's dementia (diminished cognition skills). Resident 125 received an antipsychotic medication (medication affecting the brain). Review of the 03/23/2026 antipsychotic (AP) medication care plan (CP) showed the medication was administered due to behavior management and dementia with behavior and psychosis. The interventions directed staff to administer the AP medications as ordered by the physician, observe for adverse effects, and effectiveness every shift. The non-person-centered target behaviors for the AP medication use were agitation, anxiety, delusions, hitting/kicking and the non-medication interventions included redirection, providing reassurance, talking with the resident to problem-solve, encourage activities, and return the resident to their room. Review of the March and April 2026 Medication Administration Records (MAR) showed a physician order (PO) dated 03/23/2026 to administer Seroquel (an antipsychotic medication) 12.5 milligram (mg, unit of weight) every night at bedtime. The indication for use showed unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety. The documentation showed the medication was administered every night. Review of the target behavior documentation showed Resident 125 had no behaviors. During an interview on 04/09/2026 at 4:19 PM, Staff D, Social Services Director, stated dementia was never an appropriate indication for use of antipsychotic medication and Resident 125 should have been evaluated for the use of the medication and/or it should have been discontinued, but was not. Reference WAC 388-97-1060 (1)(3)(e)(k)(i)

Based on interview and record review, the facility failed to offer bed holds and provide notice of transfer to the resident or Ombudsman (advocacy program to assist residents living in nursing homes) in writing at the time of transfer for 3 of 4 sampled residents (Residents 20, 12, and 3) reviewed for hospitalization. These failures placed the residents at risk for lack of knowledge of their rights and a decreased quality of life. Findings included.Resident 20 Review of the electronic health record (EHR) showed Resident 20 was admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (COPD, lung disease that makes breathing difficult due to damaged or inflamed airways), diabetes (high blood sugar), and hypothyroidism (condition where an underactive thyroid [ endocrine gland that regulates metabolism] fails to produce enough hormones). Resident 20 was able to communicate their needs During an interview on 04/08/2026 at 9:29 AM, Resident 20 stated they were sent to the hospital and had to wait three days before they could come back to their room. Review of the EHR showed Resident 20 was transferred to the hospital on [DATE] with new onset of weakness on one side, and there was no written nursing home transfer/discharge form or bed hold. During an interview on 04/09/2026 at 8:24 AM, Staff B, Director of Nursing Services (DNS), reviewed Resident 20's EHR and could not locate any information related to the 02/09/2026 discharge. During an interview on 04/10/2026 at 12:36 PM, Staff A, Administrator, stated they would look for Resident 20's discharge documentation, but none was provided. Resident 12 Review of the EHR showed Resident 12 admitted to the facility on [DATE] with diagnoses of diabetes, kidney disease and heart disease. The resident was able to make needs known. During an interview on 04/07/2026 at 12:31 PM, Resident 12 stated they had gone to the hospital two to three months ago. Review of the EHR showed Resident 12 had been sent to the emergency room on [DATE] and returned to the facility on [DATE]. Review of the EHR on 04/09/2026 showed no documentation that a bed hold was offered for Resident 12 at the time of transfer and no record that a notice of transfer was completed and provided to the resident, their representative, or the ombudsman. Resident 3 Review of the EHR showed Resident 3 admitted to the facility on [DATE] with diagnoses of congestive heart failure (CHF, when the heart cannot pump blood effectively), COPD and diabetes. The resident was able to make needs known. Review of the EHR showed Resident 3 was transferred to the emergency room (ER) from a doctor's appointment on 01/26/2026 and returned to the facility on [DATE] and was also sent to the ER from a doctor's appointment on 02/23/2026 and returned to the facility on [DATE]. Review of the EHR showed no documentation that a bed hold was offered or a notice of transfer was provided to the ombudsman for the discharges on 01/26/2026 or 02/23/2026. During an interview on 04/09/2026 at 11:10 AM, Staff D, Social Services Director (SSD), stated it was their expectation that the nursing staff offer the bed hold and complete the transfer form to provide to the resident and ombudsman when a resident was sent to the hospital but this did not happen for Resident 12 or Resident 3. During an interview on 04/09/2026 at 2:17 PM, Staff E, Regional Registered Nurse, stated it was their expectation that bed holds would be offered when residents were transferred to the hospital and a notice should have been provided to the Resident, 3, Resident 12, and the ombudsman. Reference WAC 388-97- 0120(1)(2)(a)-(d)(3)(a)(4)(b)(5), -0080 -0140(1)(a)-(c)(i)-(iii)

Based on observations, interviews, and record reviews, the facility failed to ensure the accuracy of assessments for 3 of 4 residents (Residents 56, 62, and 11) reviewed for accuracy of assessments. These failures placed the residents at risk for unmet care needs, diminished quality of care/quality of life. Findings included . <RESIDENT 56> Review of the electronic health record (EHR) showed Resident 56 readmitted to the facility on [DATE] with diagnoses to include heart failure, diabetes (high blood sugar), and respiratory failure. Resident 56 was able to make needs known. Review of the significant change minimum data set assessment (MDS) dated [DATE] showed Resident 56 was coded No for Hospice care. Review of the EHR showed Resident 56 had an order dated 11/22/2025 to admit to Hospice services and documentation showed Resident 56 was visited by Hospice care staff from 11/22/2025 – 03/19/2026. During an interview on 04/10/2026 at 11:04 PM, Staff L, Registered Nurse/Minimum Data Set Coordinator (RN/MDSC), stated Resident 56's significant change MDS dated [DATE] was coded No for Hospice care and should have been coded Yes. During an interview on 04/10/2026 at 11:10 AM, Staff A, Administrator, stated Resident 56's 12/04/2025 significant change MDS was coded No and was supposed to be coded Yes for Hospice care, and the MDS needed to be modified. <RESIDENT 62> Review of the 03/19/2026 admission Minimum Data Set (MDS) showed Resident 62 admitted to the facility on [DATE] with diagnoses that included a urinary tract infection and cancer. Resident 62 had an indwelling urine catheter. The MDS did not show a corresponding diagnosis or indication for use of the catheter. Review of the 03/16/2026 Post Acute and Transition of Care Orders showed Resident 62 had a standard urinary catheter due to urinary retention (inability to urinate). Review of the March 2026 Medication Administration Record (MAR) showed a physician order (PO) dated 03/17/2026 for the urinary catheter. The indication for use showed it was related to a tear in the aorta (the main artery that supplies blood to the body) and cancer. In an interview on 04/10/2026 at 1:25 PM, Staff Z, Registered Nurse-RN/MDS Coordinator, stated the indication for the use of the urinary catheter should have been clarified and assessed accurately on the MDS but was not. <RESIDENT 11> Review of the 03/11/2026 Admission/5-Day MDS showed Resident 11 was edentulous (had no natural teeth). Review of the 03/09/2026 nursing admission Assessment showed Resident 11 had no oral problems and was missing natural teeth (but not edentulous). During an observation and interview on 04/07/2026 at 11:28 AM, Resident 11 was observed to have some natural teeth present, but not all. During an interview on 04/10/2026 at 4:10 PM, Staff P, Licensed Practical Nurse-LPN/Unit Care Coordinator, stated the assessment should accurately reflect the resident's current status but did not. Reference WAC 388-97-1000(1)(a)(b)(4)(a).

Based on observation, interview, and record review, the facility failed to initiate new intervention and update the care plan for 1 of 3 sampled residents (Resident 20) reviewed for accidents. This failure placed the resident at risk of preventable falls, injuries, and a diminished quality of life Findings included .Review of the electronic health record (EHR) showed Resident 20 was admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (COPD, lung disease that makes breathing difficult due to damaged or inflamed airways), diabetes (high blood sugar), and hypothyroidism (condition where an underactive thyroid [endocrine gland that regulates metabolism] fails to produce enough hormones). Resident 20 was able to communicate their needs. Observation on 04/08/2026 at 9:32 AM showed Resident 20 sat in their bed with commode next to the bed. Resident 20 stated they had two falls because they slipped on the floor during transfers. Review of the second fall investigation dated 01/01/2026 showed Resident 20 had a fall due to self-transferring from commode to the bed. Investigation showed Resident 20 needed extensive assistance with transferring and Resident 20 had forgotten to put their nonskid socks on. Review of the investigation showed Resident 20 had previously used interventions in the summary of the fall. Review of care plan with focus area of fall, initiated 10/30/2025, revised on 12/26/2025 and 12/30/2025, showed Resident 20 did not have any new interventions initiated after the fall on 01/01/2026. During an interview on 04/10/2026 at 1:07 PM, Staff E, Regional Registered Nurse, stated the care plan for Resident 20 should have been updated and that did not meet expectations. Reference WAC 388-97-1020(2)(c)(d)

Based on observation, interview, and record review, the facility failed to ensure oral care was provided for 1 of 3 sampled residents (Resident 91) reviewed for activities of daily living. This failure placed the resident at risk for decreased self-worth, oral infection, and a diminished quality of life. Findings included .Review of the electronic health record (EHR) showed Resident 91 was admitted to the facility on [DATE] with diagnoses to include respiratory failure, pneumonia (infection of the lungs), asthma, and chronic obstructive pulmonary disease (COPD, lung disease that makes breathing difficult due to damaged or inflamed airways). Resident 91 was able to communicate their needs and required assistance with activities of daily living (ADL). Observation and interview on 04/07/2026 at 1:34 PM showed Resident 91 laid in bed. Resident 91 stated they had not brushed their teeth in the facility, and they did not have any oral care supplies. During an interview and observation on 04/08/2026 at 12:57 PM Resident 91 stated they still did not have any oral supplies. Observation of the sink area showed no oral care supplies. During an interview and observation on 04/09/2026 at 8:05 AM, Resident 91 stated that they could not brush their teeth. Observation showed a gray box on a nightstand out of reach of Resident 91 that had a new, unopened toothbrush and travel sized toothpaste that was not opened. During an interview on 04/09/2026 at 8:09 AM, Staff M, Certified Nursing Assistant (CNA), stated the process for oral care was to assist residents that could not perform the task, and set up and remind the ones that could perform oral care them self. Staff M stated they did not know about oral care of Resident 91 as they were not assigned to them. During an interview won 04/09/2026 at 8:12 AM, Staff O, Licensed Practical Nurse, stated the oral care supplies should be easily available and the staff were expected to assist residents with oral care. During an interview on 04/09/2026 at 8:13 AM, Staff N, CNA, stated they were assigned to the care of Resident 91 but did not remember if they had assisted with oral care. During an interview on 04/09/2026 at 8:34 AM, Staff B, Director of Nursing Services (DNS), stated the expectation was for staff to assist with oral care. Observation on 04/09/2026 at 8:39 AM, showed Staff B in Resident 91's room telling them they have seen them brush their teeth and Resident 91 stating No, you did not. During an interview on 04/09/2026 at 9:33 AM, Staff A, Administrator, stated the expectation was for oral care to be done every day per residents' preferences. Reference WAC 388-97-1060 (2) (b)

Based on observation, interview and record review, the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 3 sampled residents (Resident 91) reviewed for respiratory care. Failure to follow provider's order placed residents at risk of complications, potential negative outcomes and diminished quality of life Findings included .Review of the electronic health record (EHR) showed Resident 91 was admitted to the facility on [DATE] with diagnoses to include respiratory failure, pneumonia (lung infection), asthma, and chronic obstructive pulmonary disease (COPD, lung disease that makes breathing difficult due to damaged or inflamed airways). Resident 91 was able to communicate their needs. Observation and interview on 04/07/2026 at 1:01 PM and 1:34 PM showed Resident 91 laid in bed receiving oxygen (O2) set to 4 liters (L) per minute via a nasal canula (devise to deliver O2 through a tube into the nose) that was connected to an O2 concentrator (a device used to deliver O2 therapy). Observation on 04/09/2025 at 1:23 PM showed Resident 91 was receiving O2 at 3L via nasal cannula. Resident 91 stated they were unable to reach and adjust the liters of the O2 delivery. Review of the providers' orders dated 03/27/2026 showed Resident 91 had an order for Oxygen at 2L/minute via nasal cannula. During an interview on 04/09/2026 at 3:03 PM, Staff T, Registered Nurse, verified the O2 delivery rate was at 3L/min and stated the nursing report two days prior discussed how Resident 91 was desaturating (oxygen level below normal of 90%) and the O2 rate was increased. Staff T stated that the expectation was for the nurses to notify provider and obtain new orders. During a joint interview on 04/10/2026 at 12:21 PM, Staff A, Administrator, and Staff E, Regional Registered Nurse, stated the expectation was to follow oxygen orders. Reference WAC 388-97 -1060(3)(j)(iv)-(vi)

Based on interview and record review, the facility failed to act on and/or follow the consultant pharmacist's medication regimen review (MRR) recommendations in a timely manner for 1 of 5 sampled residents (Resident 15) reviewed for unnecessary medication use. This failure placed the resident at risk for receiving unnecessary medications, avoidable medication side effects, and a diminished quality of life. Findings included.Review of the electronic health record (EHR) showed Resident 15 admitted to the facility on [DATE] with diagnoses to include high blood pressure, diabetes (high blood sugar), and arthritis (conditions that cause pain, swelling, stiffness, and reduced movement in one or more joints). Resident 15 was able to make needs known. Review of the pharmacist consultation report recommendation, dated 03/23/2026, showed Resident 15 received as needed oxycodone (narcotic medication used to treat moderate to severe pain) one to three times a day; however, nonpharmacological interventions (NPI, health interventions/approaches used instead of medication) were not linked to the as needed oxycodone order. It showed, Please ensure nonpharmacological therapies are attempted prior to prn [as needed] oxycodone administration. Review of Resident 15's April 2026 medication administration records (MAR) from 04/01/2026 - 04/09/2026 showed an order dated 01/08/2026 to monitor and document pain level every shift and to attempt non-medication interventions prior to administering as needed pain medication with NPI interventions listed. Documentation showed Resident 15's pain level was documented; however, NPI was not. Review showed an order with a start date of 03/27/2026 for oxycodone one tablet every eight hours as needed for moderate to severe pain. Review showed Resident 15's pain levels documented and oxycodone was provided; however, there was no NPI linked to the order to ensure NPI was provided prior to being given the oxycodone per pharmacy recommendation. During an interview on 04/09/2026 at 4:57 PM, Staff E, Regional Registered Nurse, stated Resident 15's pharmacy recommendation on 03/23/2026 was not followed up on. Staff E stated that Resident 15 should have had specific NPIs linked to the oxycodone order and needed to be addressed per pharmacy recommendation. During an interview on 04/09/2026 at 5:02 PM, Staff A, Administrator, stated Resident 15's pharmacist consultation report dated 03/23/2026 was noted on 03/27/2026 by the nurse, and should have been linked per pharmacy recommendation, and this did not meet their expectations. Reference WAC 388-97-1300 (1)(c)(iv)

Based on observations, interviews, and record reviews, the facility failed to ensure their facility medication error rate was less than 5%. The facility's medication error rate was 12% for 2 of 5 residents (Resident 43 and 98) reviewed for medication error rate. These failures placed residents at risk for potentially significant medication errors, dehydration, inadequate pain management, and diminished quality of care/quality of life. Findings included. <RESIDENT 43>Review of the 02/18/2026 Significant Change minimum data set (MDS-assessment tool) showed Resident 43 admitted to the facility on [DATE] and had some problems with cognition. Resident 43 was hard of hearing and used hearing aids, vision impaired with the use of glasses, and was able understand others and was understood. Resident 43 was incontinent of bowel and bladder and required maximum assistance for toileting, bed mobility, and transfers.<Physician Order vs Medication Card Prescription label)During a medication administration observation on 04/10/2026 at 8:57 AM, Staff AA, Licensed Practical Nurse-LPN, showed the physicians order (PO) on the April 2026 medication administration record (MAR) for gabapentin 100mg, 1 capsule by mouth three times a day for nerve pain. The medication card prescription label showed 'gabapentin 100mg, 1 capsule by mouth one time a day'. The medication card did not match the order on the MAR and the card did not show the discrepancy in orders had been clarified. Staff AA placed one capsule in Resident 43's medication cup and administered the medication. In an interview on 04/10/2026 at 9:40 AM, Staff AA stated the medication card did not show the prescription order had been previously clarified by any of the nurses and they should have clarified the order prior to administration. Staff AA stated they were expected to note on the side of the card the date and time with their initial to show they verified which order to follow but that was not done.<Lidocaine patch removal>During a medication administration observation on 04/10/2026 at 9:15 AM, Staff AA lifted Resident 43's back of their shirt and observed a large white patch on Resident 43's lower back. Staff AA removed the patch, then placed a new lidocaine 4% patch on the same area of skin as the patch they removed. Staff AA stated the patch they removed was their lidocaine 4% patch that was placed yesterday morning. Review of the April 2026 MAR showed transcription of a PO dated 12/18/2025 for a lidocaine external patch 4%-apply to the back in the morning for pain, remove the patch at night. The transcribed hour for application of the lidocaine patch was scheduled for every morning at 9:00 AM. The transcribed hour for removal of the lidocaine patch was scheduled for every morning at 7:59 AM. The documentation showed that between 04/01/2026 and 04/10/2026, the same morning nurse documented both the removal of the old patch and placement of the new patch. In an interview on 04/10/2026 at 9:40 AM, Staff AA stated the lidocaine order directed the nurses to remove the patch in the evening, but the MAR transcription schedules showed to remove the patch in the morning an hour prior to application of the new patch. Staff AA stated this was an error and the patch should be removed in the evening, but it was not. <Failure to hold stool softener for loose stools>On 04/10/2026 at 9:10 AM, Staff AA showed the MAR PO for polyethylene glycole 3350 powder (stool softener) 17 grams mixed in eight ounces of water, by mouth twice a day for constipation and hold for loose stools. Staff AA took the cup of stool softener and the medications to Resident 43 and explained each of the medications. Staff AA asked Resident 43 Did you poop today? and Resident 43 stated yes. Staff AA administered both the stool softener and the gabapentin pill. Staff AA was not observed to have asked Resident 43 if they had any loose stool or diarrhea today. Staff AA left Resident 43's room.On 04/10/2026 at 9:23 AM, Resident 43 was asked if they had loose stool or diarrhea today and Resident 43 stated they did not know.In an interview on 4/10/2026 at 9:24 AM, Staff AA stated they determined if a resident had loose stools by asking the CNA's, asking the resident, and/or review of the 'alerts' list every morning on the Point Click Care (PCC-electronic health record system) dashboard. Staff AA stated they had not asked the CNAs about Resident 43's bowel consistency but asked Resident 43 if they had pooped. Staff AA stated they should have asked Resident 43 if they had loose stools/diarrhea but did not.On 04/10/2026 at 9:26 AM, Staff AA pulled up the alert list dashboard for 04/10/2026. Review of the list showed Resident 43 was not on the list for loose stool. A joint review of Resident 43's bowel record under the TASK tab in PCC showed they had a loose stool on 04/10/2026 at 5:18 AM. Staff AA stated they did not know they could pull up the bowel and bladder TASK responses in PCC. Staff AA acknowledged they did not look at the bowel record, identify Resident 43 had loose stool that morning, and should have held the stool softener, but did not.In an interview on 04/10/2026 at 1:10 PM, Staff G, LPN/Unit Care Coordinator, stated stool softener medications should be held after any episode of loose stool and monitored on alert for loose stool until resolved. To evaluate loose stools, the nurses are expected to include a review of the resident's bowel record daily under the TASK tab in PCC; Question 3, which shows the consistency of bowel movements. Staff G stated medication prescription labels should match the current medication orders and when they don't, the orders should be clarified and notated on the card (to the side of the prescription label) that the order was clarified and which order is correct until the card with the current order on the prescription label has arrived. <RESIDENT 98>Review of the 01/28/2026 Annual Comprehensive MDS showed Resident 98 admitted to the facility on [DATE], had short-term and long-term memory problems, was dependent on staff for assistance with toileting, bed mobility, and transfers. Diagnoses included cerebral palsy (a condition that affects a person's ability to move and control their muscles due to changes or damage in the brain during development before, during, and/or shortly after birth) and was incontinent of bowel and bladder.During a medication administration observation on 04/10/2026 at 10:29 AM, Staff H, LPN, showed a PO from the April 2026 MAR for Senna-Docusate sodium oral tablet 8.6mg - 50mg, one tabled two times a day for constipation. Staff H removed a bottle from the top drawer of the medication cart, placed a tablet in the medication cup, and the bottle read 'Senna 8.6mg'. The senna 8.6 mg was administered to Resident 98.In an interview on 04/10/2026 at 10:40 AM, Staff H provided the bottle they removed the senna 8.6 mg from and administered to Resident 98. Staff H re-read the PO listed in the MAR and realized they administered the wrong medication. Staff H stated they should have administered the senna with docusate sodium 8.6mg-50mg tablet but did not.Reference WAC: 388-97-1060 (3)(k)(ii).

Based on observations, interviews, and record review the facility failed to ensure intravenous (IV-administered into the veins) medications were properly labeled during administration for 3 of 3 residents (Residents 14, 104, and 125) reviewed for medication labeling and storage. The failure to ensure the medication bag was labeled with the date, time, and nurse initials at the time of administration placed residents at risk for significant medication errors, adverse effects, and diminished quality of care/quality of life.Findings included. <RESIDENT 104>Review of Resident 104's April 2026 Medication Administration Record (MAR) showed: A physician order (PO) dated 03/19/2026 for Cefepime 2Gm Intravenously every eight hours for infection. The transcription schedule showed the medication was to be administered at 6:00 AM, 2:00 PM, and 10:00 PM.A PO dated 03/27/2026 for Daptomycin 825 mg intravenously every 24 hours for infection. The transcribed schedule time on the MAR showed 24h. Review of the nurse's documentation showed the antibiotic medication was administered between 10:00 AM and 1:00 PM daily.A PO dated 03/22/2026 showed to hang a 250 ml bag of normal saline to use for priming the IV line and to flush 25ml of saline before and after the IV antibiotic medication administration and change the IV set daily. The MAR transcription schedule showed the 25 ml flush was to be administered four times a day, at 6:00 AM, 11:00 AM, 2:00 PM, and 10:00 PM.During observations on 04/07/2026 at 3:45 PM and, Resident 104's IV pole and IV solutions showed an empty 100ml bag of saline with a prescription label for Cefepime 2 Gm (an intravenous antibiotic medication) in 100ml solution, every eight hours. The second bag that was hanging was a 250ml bag of normal saline with no name on the bag, rate/time to infuse, date and time it was hung, when to discard unused amounts, and the nurse who hung the bag.During an observation on 04/10/2026 at 12:06 PM, Staff Q, Registered Nurse-RN, administered Resident 104's daily daptomycin antibiotic. Observation of the IV bag after administration began showed the bag did not indicate the date/time of the dose hung, the rate it should be hung, or the nurse who hung the dose.During an interview on 04/10/2026 at 12:10 PM, Staff Q was unsure what the facility's policy was regarding labeling of IV medications but felt that since they were the nurse that hung the medication, labeling the IV bag with the date/time/rate and nurse initials was not necessary. Similar findings for. <RESIDENT 14>During an observation on 04/07/2026 at 2:38 PM of Resident 14's IV pole and IV solutions showed an empty 100 milliliter (ml) bag of normal saline solution with a pharmacy prescription label that indicated the bag contained cefazolin 2 grams (GM)(an intravenous antibiotic medication) in the 100ml of saline to be administered IV over 60 minutes every eight hours. The empty bag did not include the date and time the dose was hung, or which nurse hung the medication. Additionally, a separate 250 ml IV solution of normal saline hung but did not indicate the name of the resident, the amount to infuse, the rate, when the bag was hung, and by which nurse, and when to discard the bag if not all the fluid was used. This IV bag had approximately 125 ml of solution remaining in the bag.During an observation on 04/10/2026 at 3:00 PM of Resident 14's IV pole and IV solutions showed the 100ml bag of saline that contained the cefazolin was empty. The IV bag did not indicate the date/time of the dose hung, or the nurse who administered the IV. Similarly, a second 250 ml bag of saline was hung but without the name of the resident, infusion rate, when to infuse, when the bag was hung, when to discard, and the nurse that hung the bag.Review of the April 2026 MAR showed the IV antibiotic medication was administered at 2:00 PM by Staff Q. <RESIDENT 125>Review of Resident 125's April 2026 MAR showed:A PO dated 03/23/2026 for cefazolin 2 Gm (IV antibiotic medication) intravenously every eight hours. The transcribed dose schedule was for 6:00 AM, 2:00 PM, and 10:00 PM.A PO dated 03/28/2026 showed to hang a 250 ml bag of normal saline to use for priming the IV line and to flush 25ml of saline before and after the IV antibiotic medication administration and change the IV set daily. The MAR transcription schedule showed the 25 ml flush was to be administered three times a day, at 6:00 AM, 2:00 PM, and 10:00 PM. During observations on 04/07/2026 at 9:50 AM and 04/08/2026 at 1:35 PM of Resident 125's IV Pole and IV solutions, the medication bag and the 250 ml saline solution were not dated/timed or initialed by the nurse that hung them. The Saline bag did not include the name of the resident, the rate of infusion, time of infusion, or when to discard if not used.An observation on 04/10/2026 at 2:25 PM of Resident 125's IV Pole and IV solutions showed an empty bag of the IV antibiotic and a bag of 250 ml normal saline with approximately 100 ml used. Both IV bags did not show the date/time of the dose administered, the nurse initials who hung the bag, and the Saline did not include the Resident's name.Review of Resident 125's April 2026 MAR showed the last IV antibiotic dose was administered by Staff Q at 2:00 PM.In an interview on 04/10/2026 at 4:00 PM, Staff P, LPN/Unit Care Coordinator, stated the professional standards for IV administration should be followed and all intravenous fluids/medications administered must be properly labeled with the Resident's name, the name of the medication if there was one added, the rate of infusion, the date and time of the dose that was hung, and initialed by the nurse that hung the dose. If the antibiotic IV medications did not indicate the date/time of the dose and the nurses' initials, then professional standards were not followed. Reference WAC: 388-97-1060 (3)(k); -1300(2).

Based on interview and record review, the facility failed to provide needed dental services for 1 of 3 sampled residents (Resident 17) when reviewed for dental services. This failure placed residents at risk for unmet needs, poor nutritional intake, and a decreased quality of life. Findings included.Review of the electronic health record (EHR) showed Resident 17 admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD, difficulty breathing) and diabetes (high blood sugar). The resident was able to make needs known. During an interview on 04/07/2026 at 10:06 AM, Resident 17 stated their dentures did not fit and they had seen a dentist three months ago for new dentures but had not heard anything further. Review of the EHR showed a form titled Dental Progress Note dated 02/05/2026 which recommended new upper and lower dentures and extractions for Resident 17. Review of a progress note dated 02/12/2026 showed Resident was seen by [outside dental provider]. Will need a referral out for x-rays, ex [extractions] FOR ALL LOWER TEETH. Referral and Transportation specialist is aware and working on it. During an interview on 04/09/2026 at 1:24 PM, Staff F, Central Supply/Transportation Specialist, stated they had not seen the recommendation for new dentures and Resident 17 was scheduled for a recall exam in one year. During an interview on 04/09/2026 at 1:27 PM, Staff G, Unit Care Coordinator, stated it was their expectation that transportation schedule the follow up and send them notice when it was done, but they had not received notice yet for Resident 17. During an interview on 04/09/2026 at 2:21 PM, Staff E, Regional Registered Nurse, stated it was their expectation Resident 17 be referred for dentures timely. Reference WAC 388-97 -1060(1)(3)(j)(vii)

Based on interview and record review, the facility failed to follow provider orders for laboratory blood work for 1 of 1 resident (Resident 1) reviewed for laboratory services. This failure placed the resident at risk for unidentified changes in condition and lack of, or delayed, medical intervention.Findings included . Review of the electronic medical record showed Resident 1 was admitted to the facility on [DATE] after surgical amputation of toes. The medical record showed that Resident 1 also had diagnoses to include diabetes and heart disease. Review of a document titled, After Visit Summary, dated 10/31/2025, showed Resident 1 had gone to an outpatient wound care center for follow up, and treatment of a dehiscence (opening/splitting apart) of their surgical foot wound. The After Visit Summary had orders for Resident 1 to have blood work drawn at the facility: c-reactive protein (CRP) and sed rate (ESR) - both laboratory tests are used to evaluate inflammation and infection in the body. Review of a facility physician's order, dated 10/31/2025, showed Resident 1's orders for CRP and ESR were transcribed onto the facility's orders to be completed. Review of Resident 1's laboratory results showed that a CRP and ESR was drawn on 12/10/2025 - 40 days after they were ordered. During interview on 12/17/2025 at 2:10 PM, Staff B, Director of Nursing Services, stated that Resident 1's lab work was not drawn on, or around, 10/31/2025 because the facility did not have a phlebotomist at that time, and the facility only had two nurses who knew how to draw blood. Staff B, DNS, stated that they tried to keep up with the orders for laboratory blood work, but Resident 1 was missed. WAC reference 388-97-1620(2)(b)(i)(ii).

Based on interview and record review, the facility failed to report an allegation of neglect for 1 of 3 sample residents (Resident 6) reviewed for neglect. This failure placed residents at risk for lack of regulatory oversight and on-going abuse and neglect.Findings included .Review of a public complaint sent to the State Agency, dated 12/09/2025, showed allegations of neglect related to Resident 6. The complaint showed allegations that Resident 6 was left in soiled adult diapers for long periods of time, and had developed open sores in their groin area; that staff were using incorrect treatment to treat/prevent Resident 6's skin impairments; and that Resident 6 had complained of left arm numbness and tingling, as well as nausea and vomiting (email noted these were signs of stroke), and symptoms were ignored by facility staff. The complaint showed that the contents of the allegation were copied (cc'd), via email, to Staff A, Administrator. Review of the facility incident report logs dated December 1, 2025, through December 17, 2025, did not show an allegation of neglect for Resident 6 was logged and/or reported to the State Agency. During interview on 12/17/2025 at 2:06 PM, Staff A stated that they had received an email copy of the allegations on 12/08/2025. Staff A stated that they had addressed the concerns with Resident 6 and Resident 6's concerned family members but had not reported the allegations to the State Agency. WAC reference 388-97-0640(5)(a).

Based on interview and record review, the facility failed to maintain accurate wound monitoring records for 1 of 1 resident (Resident 5) reviewed for medical records. This failure placed residents at risk for incomplete and inaccurate clinical information being presented to the interdisciplinary team, delays in care, prolonged stay, and a decreased quality of life.Findings included . Review of the admission Minimum Data Set assessment, dated 10/09/2025, showed Resident 5 admitted to the facility on [DATE] with a Stage 4 pressure ulcer (a full-thickness wound with extensive tissue loss, exposing muscle, tendons, ligaments or bone). Review of a facility document titled, NRSG: Admission/readmission Collection Tool - V 6, dated 10/07/2025, showed that Resident 5 had a Stage 4 pressure ulcer over their sacrum (a sheild-shaped bony structure located at the base of the spine, and between the two hip bones), with sacral bone exposed, measuring 3 centimeters (cm) by 2.2 cm by 1cm. Review of documents titled, Wound Observation Tool - V 4, on multiple dates, showed notes related to Resident 5's pressure ulcer to include location, stage, type and amount of drainage, wound measurements, condition of the tissue, status of the wound, and current treatment. Further review of the dates of Resident 5's Wound Observation Tools showed that the tool dated 10/14/2025 was entered into the medical record on 11/19/2025; the tools dated 10/21/2025, 10/28/2025, 11/04/2025, 11/11/2025 and 11/18/2025 were entered into the medical record on 11/20/2025. During an interview on 12/17/2025 at 2:10 PM, Staff B, Director of Nursing Services (DNS), stated that Resident 5's weekly wound documentation, via the Wound Observation Tools, were not completed on a weekly basis, as they should have been. Staff B, DNS, stated that they had entered all of the documentation into the electronic medical record, for dates 10/14/2025 through 11/18/2025, on 11/19/2025 and 11/20/205. When asked to produce the source of the data for the wound documentation, Staff B, DNS, was not able to provide documentation that was consistent with what was entered into the electronic medical record. During further interview on 12/17/2025 at 2:10 PM, Staff B, DNS, stated that everyone with a wound should have weekly wound documentation, in the form of a Wound Observation Tool document, and that they should be completed on a weekly basis, at the time of the wound assessment. Staff B, DNS, stated that they were behind in their documentation. WAC reference 388-97-1720(1)(a)(i)-(iv)(b).

Based on interview and record review, the facility failed to routinely monitor and assess the status of skin impairments for 2 of 3 residents (Residents 1 and 2) reviewed for pressure injuries. This failure placed the residents at risk for worsening of pressure wounds, lack of appropriate treatment, medical complications and a decreased quality of life.Findings included.Resident 1Review of the admission minimum data set (MDS, a required assessment tool), dated 06/18/2025, showed that Resident 1 admitted on [DATE] with diagnoses to include hip fracture with surgical repair, weakness, difficulty walking, and need for assistance with personal care. The MDS further showed that Resident 1 had a stage 1 pressure injury (the initial stage of a pressure ulcer, characterized by non-blanchable [does not fade or turn white when pressure is applied] redness of intact skin, usually over a bony prominence) over the sacrum (large triangular bone at the bottom of the spine).Review of the care plan, dated 06/16/2025, showed that Resident 1 was at risk for pressure related skin injury related to impaired mobility and incontinence (poor bladder and bowel control).Review of the facility document titled, Admission/readmission Collection Tool - V 6, dated 06/16/2025, showed that Resident 1 had non-blanchable redness to sacrum. There were no measurements documented.Review of the active and discontinued physician orders, on 07/09/2025, showed Resident 1 did not have a treatment or monitoring order for the stage 1 pressure injury over the sacrum.Review of the medical record showed no additional documentation, after Resident 1's admission date, to show that the stage 1 pressure injury had been monitored, and no documentation of it's worsening or improvement.Resident 2Review of the admission minimum data set (MDS, a required assessment tool), dated 05/23/2025, showed that Resident 2 was admitted on [DATE] with diagnoses to include dementia (a group of thinking and social symptoms that interferes with daily functioning), generalized muscle weakness, and need for assistance with personal care. The MDS further showed that Resident 2 had moisture-associated skin damage (MASD, skin inflammation and erosion caused by prolonged exposure to moisture such as urine) to the gluteal folds (the crease that separates the buttocks from the thighs).Review of the care plan, dated 05/20/2025, showed that Resident 2 was at risk for pressure related skin injury related to impaired mobility and incontinence.Review of a facility document titled, Admission/readmission Collection Tool - V 6, dated 05/20/2025, showed Resident 2 also had a small open area to their gluteal cleft (the deep [NAME] located between the buttocks).Review of a facility document titled, Wound Observation Tool - V 4, dated 05/21/2025, showed Resident 2's gluteal cleft open area measured 1.5 centimeters (cm) long by 1 cm wide.Review of the facility document titled, Weekly Skin Integrity Data Collection - V 2, dated 05/23/2025, showed Resident 2 had a Small size opening on the left gluteal cleft. There were no measurements documented.Review of the medical record showed no additional documentation, after 05/23/2025, to show that Resident 2's gluteal cleft open area had been monitored, and no documentation of it's worsening or improvement.During interview on 07/09/2025 at 3:36 PM, Staff A, Director of Nursing Services (DNS), stated there should have been orders for monitoring Resident 1 and 2's skin impairments, and there should have been assessments completed weekly, to include documentation of measurements and description of wound appearance. Staff A, DNS, further stated that it was their expectation that weekly assessments be completed until open areas heal, at which point there should be documentation that the areas were resolved. Reference WAC 388-97-1060 (3)(b).

Based on interview and record review, the facility failed to create a comprehensive care plan for 2 of 3 residents (Residents 1 and 2) reviewed for urinary incontinence. This failure placed the residents at risk for unmet needs, skin impairments, feelings of discomfort and a decreased quality of life.Findings included.Resident 1Review of the admission minimum data set (MDS, a required assessment tool), dated 06/18/2025, showed Resident 1 admitted on [DATE] with diagnoses to include hip fracture with surgical repair, weakness, difficulty walking, and need for assistance with personal care. The MDS showed Resident 1 was always incontinent (had lack of voluntary control) of bowel and bladder.Review of the comprehensive care plan, last reviewed 07/09/2025, showed incontinence was not listed, nor were goals or interventions in the care plan to address Resident 1's incontinence. Resident 2Review of the admission MDS, dated [DATE], showed Resident 2 admitted on [DATE] with diagnoses to include dementia (a group of thinking and social symptoms that interferes with daily functioning), overactive bladder, and need for assistance with personal care. The MDS showed Resident 2 was frequently incontinent of bladder.Review of a facility document titled, Admission/readmission Collection Tool - V 6, dated 05/20/2025, showed Resident 2 was incontinent of bladder.Review of the discharge MDS, dated [DATE], showed Resident 2 discharged from the facility on 06/02/2025.Review of the comprehensive care plan, last reviewed 07/09/2025, showed that Resident 2's incontinence was not included in their care plan until 06/02/2025, the date that Resident 2 discharged .During interview on 07/09/2025 at 3:36 PM, Staff A, Director of Nursing Services (DNS), stated that Residents 1 and 2 should have had care plans in place for incontinence as soon as the need for care in that area was identified - via the admission nursing assessment and/or the MDS.Reference WAC 388-97-1020(1), (2)(a)(b).

Based on interview and record review, the facility failed to ensure 1 of 3 residents (Resident 1) reviewed for anticoagulant (anticlotting) therapy was free of significant medication error. This failure resulted in harm to Resident 1 who was symptomatic with severe unrelieved chest pain that required emergent transfer to the hospital and hospitalization for myocardial infarction (heart attack). Findings included . According to the American Heart Association's article titled A Patient's Guide to Taking Warfarin, dated 11/17/2022, Warfarin (brand name Coumadin) is a prescription medication used to prevent harmful blood clots from forming or growing larger .Harmful blood clots can cause a heart attack, stroke, deep vein thrombosis (DVT, blood clot in a deep vein) or pulmonary embolism (PE, blood clot in the lungs). Review of the facility policy and procedures titled, Coumadin (Warfarin sodium) Therapy, dated 08/25/2022, showed that residents receiving Coumadin were monitored for side effects and received clotting tests prothrombin time (PT) and the International Normalization Ratio (INR) to determine therapeutic dosing. The policy further indicated that the facility must ensure that its residents were free of any significant medication errors. Review of the policy and procedures titled, Anticoagulation/Coumadin Drug Meeting, dated 08/25/2022, showed that residents receiving anticoagulation therapy were to be reviewed to ensure correct dosage and adequate monitoring. The policy and procedures indicated that the facility was expected to review the electronic medication administration record (eMAR), physician order, PT/INR Coumadin flowsheet and care plan. According to the policy and procedures, the expectation was for facility to review that the PT/INR Coumadin flowsheet was current with the PT/INR results, current dose, physician notification, dose change and the next date for PT/INR. The nurse was expected to review the eMAR to ensure new orders had been transcribed. Review of Resident 1's admission Minimum Data Set (MDS, a required assessment tool) dated 12/08/2022, showed that Resident 1 admitted on [DATE] with diagnoses to include heart attack, coronary artery disease (CAD, damage in the heart's major blood vessels), chest pain, DVT, PE and long-term use of anticoagulant medication. The MDS showed Resident 1 was cognitively intact and able to make needs known. Review of Resident 1's progress note dated 12/19/2022, showed that Resident 1 complained of severe chest pain unrelieved by Nitroglycerin (medication to treat chest pain caused by CAD). According to the progress note, Resident 1 cried while in severe pain and described pain as the same chest pain as with previous heart attacks. The progress note further showed that the licensed nurse called 911 to transfer the resident to the hospital. In an interview on 01/06/2023 at 3:20 PM, Resident 1 stated they readmitted back yesterday (01/05/2023) from the hospital after having a heart attack. According to the resident, the chest pain they experienced was the same as their first two heart attacks. Resident 1 stated that they underwent coronary artery bypass graft (surgical procedure to treat CAD) before and had been on long-term anticoagulant for [AGE] years. The resident further stated that when they transferred to the hospital, the doctors told their spouse that the facility did not reorder the Coumadin and that the anticoagulant medication was not administered for several days. Review of the physician's progress note dated 01/06/2023 at 7:53 AM, showed Resident 1 readmitted to the facility on [DATE], after being admitted to the hospital on 12/19/2022 for which the resident was ruled in for myocardial infarction. Review of Resident 1's PT/INR/Coumadin flowsheet for December 2022, showed on 12/05/2022 INR result was 2.5, the physician was notified, there was no change to the current Coumadin dose and the next INR was scheduled 12/12/2022. Review of the 12/12/2022 entry showed INR result of 2.4, the physician notified of the result, no changes to the coumadin dose of the resident and a repeat INR on 12/13/2022. Review of the entry for 12/13/2022, showed no documentation of the INR result, dose of Coumadin, if physician was notified and if dose was changed. The next INR box was left blank. Review of Resident 1's physician order summary report dated December 2022, showed that the physician ordered for Coumadin 10 milligrams (mg) by mouth one time a day every Monday, Wednesday and Friday and Coumadin 5 mg by mouth one time a day every Tuesday, Thursday, Saturday and Sunday with a start date of 12/05/2022 and end date 12/11/2022. The physician summary report also showed a 12/02/2022 order for PT/INR with an end date of 12/05/2022. Review of the physician order report showed no order entered for PT/INR for 12/12/2022 and 12/13/2022 and no order entry to continue with the same dose of Coumadin starting 12/12/2022. Review of Resident 1's eMAR from 12/01/2022 through 12/19/2022, showed that Resident 1 did not receive Coumadin from 12/12/2022 to 12/19/2022. In an interview on 01/06/2023 at 4:00 PM, Staff C, Licensed Practical Nurse (LPN), stated that the expectation was for the nurse to notify the physician or nurse practitioner of the PT/INR result; complete the PT/INR/Coumadin flowsheet; enter the order of the Coumadin dose in the computer and the next scheduled PT/INR as ordered by the physician. In an interview on 01/06/2023 at 4:15 PM, Staff D, Registered Nurse/Staff Development Coordinator (RN/SDC), stated that they helped with the investigation about Resident 1's Coumadin issue. According to Staff D, RN/SDC, the nurse notified the doctor of the INR result, received orders to continue with the same dose of Coumadin and to repeat PT/INR on 12/13/2023; however, forgot to transcribe the order of Coumadin and next PT/INR in the computer. In an interview on 01/18/2023 at 12:04 PM, Staff B, Director of Nursing Services (DNS) stated that nurses were expected to review the PT/INR Coumadin flowsheet and make sure that the physician or nurse practitioner was notified of the PT/INR result. The nurses were also expected to check that whatever was in the PT/INR/Coumadin flowsheet matched the orders in the eMAR. The DNS further stated that the process should have been followed and the error could have been avoided. Reference WAC 388-97-1060(3)(k)(iii)

Based on interview and record review, the facility failed to ensure necessary care and services were provided following a fall incident for 1 of 4 residents (Resident 1) reviewed for injury of unknown origin and falls. This failure resulted in delayed identification of a significant injury, delayed treatment, hospitalization , inability of the resident to maximize participation in therapy and a diminished quality of life. Findings included . Refer to F658 and F689 for additional information Review of the facility's policy and procedures titled, Incident and Reportable Event Management, revised 06/17/2022, showed that if an event occurs, the facility will determine what happened, provide care and document the injury, conduct an interview, investigate why the event occurred, and evaluate interventions being used to minimize the potential for recurrence. Review of Resident 1's admission Minimum Data Set (MDS, a required assessment tool) dated 06/10/2022, showed that Resident 1 admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS further showed that the resident had severe cognitive impairment and required one to two-person extensive assistance with activities of daily living. Review of Resident 1's care plan initiated 06/03/2022, showed that the facility identified Resident 1 as a risk for falls due to weakness. The care plan goal was for the resident not to sustain serious injury requiring hospitalization . Review of the facility investigation report for an injury of unknown origin dated 06/22/2022, showed that on 06/20/2022 therapy staff reported swelling of Resident 1's left knee during an interdisciplinary team care conference. The physician evaluated Resident 1 on 06/21/2022 and ordered a left knee x-ray that was completed on 06/22/2022. Further review of the facility investigation report showed nursing staff interviews conducted on 06/28/2022 indicated that Resident 1 had a fall incident on 06/05/2022. In a phone interview on 07/08/2022 at 3:36 PM, Staff C, Nursing Assistant Registered (NAR), stated that she worked the night shift on 06/05/2022 and while providing care to Resident 1's roommate heard some commotion from Resident 1's side of the room behind the drawn curtain. When Staff C, NAR, checked what was going on, she found Resident 1 sitting on the fall mat on the floor next to the bed and immediately alerted the nurse. Staff C, NAR, stated that the licensed nurse assessed the resident for injuries, and none was found. Staff C, NAR, further stated that together with the licensed nurse, both assisted Resident 1 back to bed using the gait belt. Staff C, NAR, also stated that Resident 1 denied having pain the night when the incident happened. Staff C, NAR, remembered that Resident 1 indicated having pain to the legs and asked for pain medication a few days after the incident occurred. In an interview on 07/14/2022 at 1:18 PM, Staff D, Registered Nurse (RN), stated that after a fall incident, the facility expected staff to assess the resident's vital signs, check range of motion and evaluate for injuries. Staff D, RN, further stated that staff was to notify the Director of Nursing Services (DNS), provider and family, write an incident report and place the resident on alert monitoring for at least 72 hours. According to Staff D, RN, licensed nurses were expected to document the alert monitoring in the progress notes. Review of Resident 1's progress notes dated 06/05/2022 through 06/08/2022, showed no documentation detailing the fall incident that happened on 06/05/2022. There was no documentation that showed staff monitored Resident 1 for latent injuries. Review of Resident 1's left knee x-ray result dated 06/22/2022 showed that Resident 1 had a prior left total knee replacement and that there was an acute periprosthetic fracture (broken bone that occurred around the knee replacement implant). Review of Resident 1's transfer form dated 06/23/2022 at 8:20 AM, showed that the facility transferred Resident 1 to the hospital due to the abnormal x-ray result for further evaluation and treatment. In an interview on 07/14/2022 at 1:30 PM, Staff E, Physical Therapy Assistant (PTA), stated that Resident 1 received therapy services. According to Staff E, PTA, Resident 1 was able to move and exercise arms and lower legs while sitting in the wheelchair and when it came to standing and holding on to the parallel bars or to stand up for ambulation, Resident 1 refused and gestured having difficulty and pain with the left leg. Staff E, PTA, further stated that physical therapy was not aware of a fall incident until later when x-ray result showed a fracture and Resident 1 was transferred to the hospital for further evaluation and treatment. In an interview on 07/14/2022 at 2:30 PM, Staff B, DNS, stated that the expectation was for staff to notify the DNS of any incident, continue with alert monitoring, conduct proper assessment and documentation. According to Staff B, DNS, facility staff did not provide the necessary care and services for Resident 1 following a fall incident. In an interview on 07/14/2022 at 3:00 PM, Staff A, Executive Director, stated that the expectation from staff was to follow the standards of practice following an incident, which included timely reporting, conducting a fall incident investigation, assessing and monitoring for injuries, reviewing and revising the care plan as indicated. Reference WAC 388-97-1060(1)

Based on interview and record review the facility failed to ensure residents were free of significant medication errors for one of three residents (#1) reviewed for admission medication errors. This error resulted in Resident #1's high blood pressure not being treated and her being sent to the emergency room with high blood pressure. Findings included . Resident #1 was no longer in the facility. Review of Resident #1's record showed he/she admitted to the facility on [DATE] after being hospitalized . Record review of Resident #1's Minimum Data Set (MDS) assessments dated 9/9/19 showed his/her list of active medical [DIAGNOSES REDACTED]. Review of Resident #1's hospital discharge records showed physician orders [REDACTED]. Review of Resident #1's facility medical record showed admission orders [REDACTED]. In an interview on 10/18/19 at 11:10 AM, Staff B, Director of Nursing, DON, reported the admission nurse transcribed the order for Losartan incorrectly, writing it to be given one time only instead on one time daily as indicated in the hospital orders. Staff B, DNS, reported Resident #1 received Losartan one time on 9/2/19 during her stay in the facility from 9/2/19 to 9/17/19, when she was sent to the emergency room . Review of Resident #1's medical record showed his/her blood pressures were higher than normal range on seven different days; 9/9/19- 185/87 9/10/19- 168/90 9/12/19- 180/96 9/13/19- 182/116 9/15/19- 186/99 9/17/19- 208/88 Further review of Resident #1's record showed nursing progress notes dated 9/13/19 in which the nurse identified the resident had elevated blood pressure and was dizzy. Staff spoke with the resident's family who reported the resident had a history of [REDACTED].#1 started taking at he time of admit. Progress notes dated 9/14/19 indicated Resident #1 had refused her anti-smoking medication and reported her head is a lot clearer. Progress note dated 9/15/19 again indicated Resident #1 had high blood pressure. The note indicated Resident #1 requested to have the physician review her medications and determine if adjustments should be made. The nurse printed the blood pressure list and notified the physician who ordered [MEDICATION NAME] (a medication to treat high blood pressure) to be given one time daily. Progress notes dated 9/17/19 at 7:01 AM indicated Resident #1 had complained of a headache, however her blood pressure was at baseline and not high at the time. A progress note written three hours later on 9/17/19 at 9:58 AM, indicated Resident #1 again complained of a headache. A nursing progress note documented three hours later at 9:58 AM, indicated Resident #1 had complained of a headache, inability to sleep and had developed a dry cough. The note also indicated the physician had written a new order the day before on 9/16/19 for [MEDICATION NAME], another medication used to treat high blood pressure. An hour later at 11:17 AM, a nursing progress noted indicated Resident #1's headache had not yet resolved. A nursing note twelve minutes later at 11:29 AM, indicated Resident #1's blood pressure was elevated and the nurse practitioner had wrote an order to double the dose of high blood pressure medication. Vitals signs documented at noon indicated Resident #1's blood pressure was now 208/88 and an ambulance was called to transport her to the emergency room . There was no documentation to show that staff had identified Resident #1 had not been receiving her ordered high blood pressure medications since the day she admitted to the facility on [DATE]. Review of the Resident #1's emergency room record showed Resident #1 was admitted to the hospital after having [MEDICAL CONDITION] activity in the emergency room associated with a hypertensive (high blood pressure) emergency and a new stroke. WAC Rference 388-97-1060(3)(k)(iii)

Based on interview and record review it was determined that the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 3 Sampled Residents (#1) reviewed for falls. This failure resulted in a fall which sent him/her to the emergency room for treatment. Findings include: Resident #1 was no longer in the facility. FOLLOWING THE CARE PLAN: Review of Resident #1's medical record revealed a fall assessments completed in November 2013 and in February 2014. Both fall assessments indicated Resident #1 was at risk for falls. Review of Resident #1's care plan entitled "fall" dated 5/9/14 revealed he/she had been identified as being at risk for falls. The care plan included interventions to avoid risk of falls/injuries. The interventions included Resident #1 needed 2 people to assist her in transferring. Additional interventions included reinforcing safety awareness and educating the resident on the need for assistance. Review of Resident #1's care plan entitled "Activities of Daily Living" dated 5/15/13 indicated he/she needed assistance with mobility due to weakness. Interventions listed on the care plan included "provide the amount of assistance/supervision that is needed." During an interview on 6/5/14 at 12:35 p.m. Staff F reported Resident #1's care plan directed 2 people to assist her with care because he/she had been having episodes of weakness in his/her legs. Review of a facility incident investigation revealed Resident #1 fell in his/her room while being assisted by a staff member on 5/11/14. In a statement dated 5/12/14 Staff C reported he/she had reviewed care directives at the beginning of her shift and she was aware that Resident #1 was supposed to have 2 people assist him/her in transferring. Further review of the facility's investigation revealed while Staff C was in Resident #1's room, the resident requested assistance in changing her brief and getting into bed. Staff C told Resident #1 that she needed to get additional staff for assistance, but Resident #1 reported she did not want to wait. Staff C then reported she assisted the resident to a standing position and began to clean him/her and get ready for bed. While assisting with changing Resident #1's brief, the resident became unsteady and fell forward, hitting her face on the floor. Further review of the facility's fall investigation revealed the call light in Resident #1's room had not been turned on in effort to summons assistance. Review of a statement dated 5/12/14 revealed Staff D reported she was in a nearby Resident #1's room and heard the noise of the fall. Staff D did not report being asked for assistance or seeing a call light on indicating the need for assistance. Review of a form entitled "Suspension Pending Investigation Form" revealed a second statement dated 5/12/14 written by Staff C. In the statement Staff C reported when Resident #1 did not want to wait for her to get an additional staff member she should have done it anyway. Further review of the same form revealed a statement dated 5/12/14 written by Staff D. Staff D indicated Resident #1's care plan was not followed by having 1 c.n.a. (certified nursing assistant) assisting and the POC (plan of care) required 2 people. During an interview on 6/5/14 at 1:15 p.m. Staff D reported she was working near Resident #1's room at the time she fell . Staff D confirmed that Staff C was the only staff member in the room assisting Resident #1. During an interview on 6/5/14 at 1:05 p.m. Staff B confirmed Staff C had not followed the care plan when providing care to Resident #1. Review of hospital records indicated Resident #1's fall resulted in a head injury. Staff C failed to follow Resident #1's care plan. Resident #1 fell and sustained a head injury while being transferred by a single staff member instead of the 2 staff directed in the care plan. Resident #1 was diagnosed at the hospital with an intracranial bleed (bleeding under the skull) and a subdural hematoma (accumulation of blood on the surface of the brain) as a result of her uncontrolled fall.

Based on interview and record review the facility failed to assess and implement measures to protect skin from breakdown for 1 of 6 Sampled Residents (# 1). This failure resulted in breakdown of skin integrity in the form of deep tissue injury and pressure ulcer. Findings include: Record review of hospital records revealed hospital photos and documentation from the wound care consultant indicating Resident #1 presented to the hospital on [DATE] with an unstagable pressure ulcer on the right heel measuring 4.5 x 6 cm with deep tissue injury (damage to tissue below the skin's surface form prolonged pressure), an unstagable left heel pressure ulcer measuring 4.5 x 6 cm with deep tissue injury and a Stage II pressure ulcer (Partial thickness loss of dermis (vascular inner layer of the skin) presenting as a shallow open ulcer with a red pink wound bed, without slough(dead tissue)) on the sacrum measuring 6.5 x 10 cm described as red, moist and macerated (skin softened and usually white form prolonged exposure to moisture). The hospital photographs revealed dark, reddened skin from sacrum to perineum (area from scrotum to rectum). Record review revealed Resident #1 admitted to the facility on [DATE] with blanchable (temporarily turns white with pressure applied indicating a vascular source), reddened area on both heels and redness on buttocks. Statement faxed by Staff B dated 03/29/12 indicated on 03/03/12, the day after admission, a shower aide reported Resident #1's heels were sore and red. Staff B indicated in her statement the resident had "underlying damage" to the heels. The nurse initiated Skin Prep (a liquid film applied to intact skin to reduce friction when removing tape) and heel protectors. The statement indicated knowledge of the potential for breakdown but failed to follow-up by notifying the physician of the potential skin breakdown or the discomfort of the heels. or monitoring the integrity of the skin for improvement or decline. Progress notes for Resident #1 revealed the resident was determined to have an organism causing loose stools and diarrhea upon admission. Documentation revealed the resident had frequent bouts of loose stool, indicating the skin in the rectal area was at risk for breakdown due to the acid and digestive enzymes contained in the stool. Interview with Staff G on 03/22/12 at 2:45 p.m. revealed Resident #1 had an order for [REDACTED]. During subsequent interview on 03/27/11 at 4:25 p.m. Staff G said Resident #1 had an intestinal organism causing diarrhea. Interview with Staff R on 03/27/12 at 2:15 p.m. revealed Resident #1 required two people to assist him with ADLs (activities of daily living) and the resident did not refuse assistance with care. Staff R indicated the buttocks of Resident #1 was reddened; Staff R said she thought the licensed staff provided treatment to the buttocks because of the redness. Interview with Staff S on 03/27/12 at 4:10 p.m. revealed the condition of resident ' s skin in annotated on the weekly skin assessments. All skin discrepancies, even areas receiving treatment was documented on the weekly skin assessments. Staff S admitted the condition of Resident #1's heels and buttocks should have been documented on the weekly skin assessment sheets. Review of weekly skin assessment dated [DATE] revealed Resident #1 had redness on "groin area" and "peg tube site". There was no mention of the reddened heels annotated on admission. Record review of weekly skin assessment for Resident #1 dated 03/13/12 revealed redness on the groin area and buttocks. Review of the resident's TAR (treatment records) revealed the resident received skin prep on both heels three times daily. Record review of the resident's Daily Care Guide (individualized instructions for care) revealed no mention of care for the resident's skin. Review of the resident's care plan revealed no guidance to staff for skin care. Resident #1 admitted with reddened, blanchable areas to heels and buttocks. The staff applied skin prep to the resident's heels daily but did not document the condition of the heels. The resident had an organism causing loose stool and although staff reported noticing redness of the buttocks the buttocks was not monitored and the physician was not notified. The resident presented to the hospital with altered skin integrity the facility was not monitoring or aware of. .