Every finding on record at Northwoods Lodge

Based on record review and interview, the facility failed to notify the resident/resident's representative and Ombudsman in writing of the reason for the transfer/discharge to the hospital, convey the required information to the hospital and provide written bed hold notice at the time of transfer to the hospital for 4 of 4 sampled residents (Residents 34, 68, 18 and 66 ) when reviewed for hospitalization. These failures placed the residents at risk for lacking knowledge regarding their transfer, discharge rights and the right to hold their bed while in the hospital and diminished quality of life.Findings included .Resident 34 Review of the electronic health record (EHR) showed Resident 26 admitted to the facility on [DATE] with diagnoses that included left calf ulcer, heart failure and muscle weakness. Resident 34 was able to make needs known. Review of Resident 34's EHR showed hospitalization on 02/09/2026 and readmission to the facility on [DATE]. There was no documentation showing a bed hold was offered, a completed transfer discharge form or the required information was provided to the hospital at the time of transfer. Resident 68 Review of the EHR showed Resident 68 admitted to the facility on [DATE] with diagnoses that included diabetes (too much sugar in the blood) and chronic obstructive pulmonary disease (a lung disease that effects ability to breathe). Resident 68 was able to make needs known. Review of Resident 68's EHR showed a resident-initiated, against medical advice, discharge on [DATE]. The facility made contact with Resident 68 and they were able to verify their current address. The transfer discharge form was incomplete and not provided to the resident nor was the Ombudsman notified. During an interview on 03/13/2026 at 3:02 PM, Staff C, Patient Care Manager, stated the licensed nurse on duty at the time of transfer offered verbal bed holds but did not provide the resident/representative with a written copy. Staff C stated the facility did not complete the transfer/discharge form and notify the ombudsman for residents who left against medical advice. During an interview on 03/16/2026 at 8:10 AM, Staff B, Director of Nursing Services (DNS), stated they were unaware the transfer/discharge form was to be completed for all discharged residents to include those who left against medical advice. Staff B stated the facility only communicated bed holds verbally and did not provide residents with documentation explaining the bed hold. Staff B stated the lack of documentation showing if the hospital was provided with the required information at the time of transfer did not meet their expectations. Resident 18 Resident 18 was admitted to the facility on [DATE]. Review of the 02/01/2026 discharge MDS, showed the resident was transferred to acute care on 02/01/2026, return anticipated Review of Resident 18's EHR showed no documentation was present to show staff:a- Provided written notification to Resident 18 and/or their representative regarding the 02/01/2026 discharge.b- Sent required documents, called report, or otherwise conveyed the minimum required information to the receiving provider.c- Provided written notification to the Ombudsman. On 03/16/2026 at 9:53 AM, when asked if there was documentation to show the Ombudsman was notified of Resident 18's 02/01/2026 discharge, Staff H, Receptionist, said No. During an interview on 03/16/2026 at 12:42 PM, when asked if there was documentation to show staff provided written notification to Resident 18 and/or their representative or that staff sent required documents, called report, or otherwise conveyed required information to the receiving provider, Staff A, Administrator, indicated facility staff sent information with the resident in a packet at the time of discharge but acknowledged the resident's record had no documentation of what information, if any, had been sent. Staff A also confirmed there was no documentation that staff notified the resident or their representative in writing regarding the discharge. Resident 66 Resident 66 was admitted to the facility on [DATE]. Review of the 01/08/2026 Discharge MDS, showed the resident was transferred to acute care on 01/08/2026, return anticipatedReview of Resident 66s EHR showed no documentation was present to show staff:a- Provided written notification to Resident 66 and/or their representative regarding the 01/30/2026 discharge.b- Sent required documents, called report, or otherwise conveyed the minimum required information to the receiving provider.c- Provided written notification to the Ombudsman. On 03/16/2026 at 9:53 AM, when asked if there was documentation to show the ombudsman was notified of Resident 66's 01/08/2026 discharge, Staff H, Receptionist, said No. During an interview on 03/16/2026 at 12:42 PM Staff A, Administrator, said they could not find documentation that a written notice was provided to Resident 66 or their representative, or that indicated what documents and/or information was communicated to the receiving provider. Reference WAC 388-97-0120 (4)

Based on interview and record review the facility failed to ensure residents and/or resident representatives were provided education about COVID-19 vaccination, including risks, benefits and potential side effects for 4 of 5 sampled residents (Resident 2, 27, 54 and 16) reviewed for COVID-19 immunizations. Additionally, for facility staff the facility failed to annually screen and offer the COVID-19 vaccination (or provide information on where the vaccine could be obtained) and document if the vaccine was accepted/declined. These failures denied the residents and/or their representative and staff the right to make informed decisions.Findings included.Review of the facility policy, titled Coronavirus Disease (COVID-19) - Vaccination of Residents, revised June 2022, documented before the vaccine was offered, the resident was to be provided with education regarding the benefits, risks, and potential side effects associated with the vaccine. Under the section titled Documentation and Reporting, the policy documented the resident's medical record would include documentation that indicated the resident or resident representative was provided education regarding benefits and potential risks associated with the COVID-19 vaccine, to include samples of the educational materials used, the date the education took place and the name of the individual who received the education. Review of the facility policy, titled Coronavirus Disease (COVID-19) - Vaccination of Staff, revised June 2022, documented the COVID-19 vaccine education, documentation and reporting would be overseen by the facilities infection preventionist and coordinated by his or her designee. The policy went on to document that the vaccine may be offered and provided by the facility or indirectly offered, such as through an arrangement with a pharmacy partner, local health department, or other appropriate health entity. The policy documented staff members would be screened for contraindications to the vaccine, medical precautions and prior vaccination before being offered the vaccine.Lack of Resident COVID-19 Vaccine Education Resident 16 was admitted to the facility on [DATE], review of Resident 16's medical record showed no documentation to support that risks and benefits and/or education were provided to the resident and/or the resident's representative.Resident 2 was re-admitted to the facility on [DATE], review of Resident 2's medical record showed no documentation to support that risks and benefits and/or education were provided to the resident and/or the resident's representative.Resident 27 was admitted to the facility on [DATE], review of Resident 27's medical record showed no documentation to support that risks and benefits and/or education were provided to the resident and/or the resident's representative.Resident 54 was admitted to the facility on [DATE], review of Resident 54's medical record showed no documentation to support that risks and benefits and/or education were provided to the resident and/or the resident's representative.On 03/13/2026 at 2:34 PM, Staff E, Assistant Director or Nursing (ADON), confirmed there was no documentation Resident's 2, 27, 54, and 16 and/or their representative's had been provided education on the COVID-19 vaccination. Staff E said it did not meet her expectations, and she could see there needed to be some changes made. On 03/16/2026 at 9:30 AM, Staff A, Administrator, said residents' admission packet had information on vaccines, the admission nurse would go over previous vaccinations, and Staff E would do education as well. Staff A said Staff E monitored all vaccines in the building. When asked about the lack of documentation of education for the COVID-19 vaccination for residents, Staff A looked in the electronic health record and confirmed education had not been documented. Staff A said all the tools were present to document education that had been provided, and her expectation was that education be provided and documented.FAILURE TO ANNUALLY SCREEN/EDUCATE/OFFER/KEEP RECORD OF ACCEPTANCE OR DECLINATOIN OF COVID-19 VACCINATION FOR STAFFOn 03/11/2026 at 10:52 AM, Staff E, ADON, was asked if she had documentation that Staff was screened, educated, offered the COVID-19 vaccination and a record of staff's current COVID-19 vaccination status. Staff E said that was not something she did and she was not involved in the COVID-19 vaccination process.On 03/13/2026 at 2:05 PM, Staff A, Administrator, when asked who was responsible for ensuring staff were screened, educated and offered or provided information on where to obtain the COVID vaccination, Staff A said when staff were hired there was a page in the hiring packet on vaccinations and an area to document if they had received the COVID-19 vaccination or not. On 03/13/2026 at 2:20 PM, Staff A, when asked if staff were annually educated, screened and informed where they could receive the COVID-19 vaccine, Staff A said they had an All-Staff meeting in which COVID-19 vaccine was encouraged and education on the vaccine was reviewed. Staff would sign that they attended the meeting, Staff A said she had no documentation that staff signed annually that they were screened, educated, offered or informed where they could receive the vaccine and indicated no annual record was kept of staff acceptance or declination of the vaccine.On 03/16/2026 at 9:30 AM, Staff A, regarding the annual screening, educating, offering and documenting of the current COVID-19 vaccination status, Staff A said COVID-19 was discussed in the All-Staff meetings, but moving forward there should be a more formalized process.Reference WAC 388-97-1620(2)(b)(i)(ii)

Based on observation, interview and record review the facility failed to ensure a safe environment was maintained related to falls for 1 of 1 sampled resident (Resident 21) when reviewed for accident hazards. This failure placed the residents at risk for avoidable injuries and a diminished quality of life.Findings included.Review of the electronic health record (EHR) showed Resident 21 admitted to the facility on [DATE] with diagnoses that included severe protein malnutrition, right side paralysis due to a stroke and dysphagia (difficulty swallowing). Resident 21 was dependent on staff assistance for all activities of daily living.Review of the February 2026 incident log showed Resident 21 had an unwitnessed non-injury fall on 02/26/2026.Review of the facility incident report, dated 02/27/2026, showed the following interventions were in place at the time of the fall: fall mat, bed in lowest position and bed alarm. No new interventions or corrective measures were documented.Review of the March 2026 incident log showed Resident 21 had an unwitnessed non-injury fall on 03/03/2026.Review of the facility incident report, dated 03/03/2026, showed Resident 21 was found lying on the floor next to their bed. Documentation showed the bed alarm was not on and the bed was not in the lowest position at the time of the fall. Corrective measures taken were staff education and implementation of 15-minute checks.Observation on 03/12/2026, between 8:20 AM and 9:44 AM, showed one 15-minute check was completed.Observations on 03/09/2026 at 11:35 AM, 03/10/2026 at 9:35 AM, 03/11/2026 at 1:31 PM and 03/12/2026 at 8:20 AM showed two small thin mats on the floor at Resident 21's bed side.During an interview on 03/12/2026 at 12:52 PM, Staff O, Maintenance, stated that the two mats on the floor in Resident 21's room were concentrator floor mats used for oxygen tanks. Staff O stated that they would replace the floor mats with a fall mat if they could locate one in the facility.During an interview on 03/16/2026 at 8:20 AM, Staff B, Director of Nursing Services, stated that they did not have a fall mat in place because maintenance could not find one. The expectation was that central supply should have been notified to order the fall mat. Staff B stated that it did not meet their expectation that the fall interventions were not implemented. Reference WAC 388-97-1060 (3)(g)

Based on interview and record review the facility failed to ensure residents' records were complete and accurate for 2 of 2 residents (Residents 54 and 2) reviewed for accurate and complete records. Failure to maintain complete and accurate records placed residents at risk for unmet care needs and for a diminished quality of life. Findings included.Resident 54Review of the facility policy, titled Requesting, Refusing, and/or Discontinuing Care or Treatment, documented that if a resident refused care or treatment, the licensed nurse, Director of Nursing or designee would meet with the resident to determine why the resident was refusing care or treatment, try and address the residents' concerns and discuss alternative options; and discuss potential outcomes or consequences (positive and negative) of the resident's decision. Resident 54 was admitted to the facility on [DATE] with a diagnosis of dementia (loss of intellectual functioning). Review of the admission Medicare 5 Day Minimum Data Set, (MDS, an assessment tool) documented Resident 54 was moderately cognitively impaired and was dependent on others for showering/bathing. On 03/10/2026 at 11:46 AM, Resident 54 was observed in bed, with disheveled hair going in different directions.On 03/12/2026 at 12:16 PM, Resident 54's hair was observed to be oily in appearance and was sticking out on the sides. Resident 54 had a provider order, dated 02/23/2026, for showers scheduled on Monday, Wednesday and Friday on evening shift. The order instructed staff to document whether a shower was given and if not given staff were instructed to write a progress note on why the shower was not done and complete the Shower Refusal form. Staff were to document plus or minus sign to indicate if a shower was received, and write a progress note if not received every night shift on Monday, Wednesday and Friday. Review of Resident 54's shower record documented under type of bath received showed 10 different categories for staff to choose from as follows:a. Occupational Therapy provided the patient with a bath or shower todayb. Bed Bathc. Sponge bathd. Regular bathe. Showerf. Offered, but patient refusedg. Activity Did not Occurh. Resident Not Availablei. Resident Refusedj. Not applicableReview of Resident 54's shower record from 02/22/2026 through 03/11/2026 documented they had not had a shower since 02/25/2026, and the record did not indicate Resident 54 was offered and refused the missed showers, but that the Activity Did not Occur for six scheduled showers.02/22/2026- Not Applicable02/23/2026- Bed Bath02/25/2026- Shower02/27/2026- Activity Did not Occur03/02/2026- Activity Did not Occur03/04/2026- Activity Did not Occur03/06/2026- Activity Did not Occur03/09/2026- Activity Did not Occur03/11/2026- Activity Did not OccurOn 03/12/2026 at 12:43 PM, Staff M, Certified Nursing Assistant (CNA), said if a resident refused to shower or bathe, they would ask the resident again later and if resident was still not wanting to take a shower, he would alert his supervisor and fill out a refused shower form.On 03/12/2026 at 12:46 PM, Staff N, CNA, said if a resident refused a shower or bath, she would write a refusal form and write on the form what specifically the resident refused and ask the resident what the reason for refusal was and see if there was anything that could be done and then she and the nurse would sign the form. Staff N showed the refusal form binder. Review of the binder showed one refusal form, dated 02/27/2026, regarding shower/full bed bath refusal for Resident 54. On 03/12/2026 at 2:44 PM, Staff C, Patient Care Manager, said the expectation for documentation if a resident was refusing shower/bathing was for the CNA to reapproach and if resident still refused then let floor nurse know and then reapproach as a team, if after that the resident said no to both CNA and Nurse, then the nurse was to write a progress note and the CNA should do a refusal form and put it in the refusal binder. Staff C said the CNA was expected to also document in the electronic health record (shower record) the refusal as well. Regarding Resident 54's apparent lack of shower since 02/25/2026, Staff C said Resident 54 refused everything. Regarding the CNA documenting activity did not occur, Staff C confirmed this indicated the shower did not happen and said staff should have documented refusals. When asked if the lack of refusal forms for showers met her expectations, Staff C said no, she would see if she could locate additional refusal forms.On 03/16/2026, Staff A, Administrator, provided one additional refusal form relating to showers, dated 03/06/2026, for Resident 54, with no refusal forms provided for 03/02/2026, 03/04/2026, 03/09/2026, 03/11/2026. On 03/16/2026 at 11:01 AM, Staff B, Registered Nurse (RN)/ Director of Nursing Services (DNS), when asked what her expectations of staff were when a resident was refusing showers said, reapproach and ask resident if it was an issue with time preference or male vs female aide. Staff B said if the resident was still refusing to shower the CNA and nurse would reapproach the resident to determine if there was something else they could do to accommodate the resident. Regarding Resident 54 not having a documented shower for two weeks, Staff B said Resident 54 had been refusing care. Regarding CNA documenting activity did not occur, on 02/27, 03/02, 03/04, 03/06, 03/09 and 03/11/2026, Staff B said staff was documenting activity did not occur as opposed to refused, it looked like it had not been offered, and she thought it was incorrect documentation. When reviewing the order for staff to fill out a refusal form for refused showers, Staff B was told there were only two provided that pertained to showers, leaving four missing. Staff B said the forms were used for tracking if there were consistent refusals. When asked if staff should have filled out the refusal forms, Staff B said it was a way to communicate with the nurse so the CNA would not forget to let them know the resident had refused, to track refusals, and identify patterns. Staff B was asked how the facility was identifying the barriers to showering for Resident 54 who had not had a shower for over two weeks according to CNA documentation, Staff B said Resident 54 had behaviors and dementia. When asked if she had met with Resident 54 to determine why they were refusing showers, Staff B said she had not met with them on why they were refusing showers. When asked if the lack of correct/and or present documentation met her expectations, Staff B said no, not to the accuracy she would like. Resident 2Resident 2 re-admitted to the facility on [DATE]. The admission MDS, dated [DATE], documented Resident 2 was cognitively intact. On 03/09/2026 at 12:25 PM, Resident 2 said they watched television for activities, and that they were not sure what other activities were offered at the facility. When asked if staff from the activities department had come to see if they would like to participate in any of the activities offered, Resident 2 said no, they had never talked with anyone about activities and they would probably participate if they had been offered them. On 03/11/2026 at 2:32 PM, Staff L, Activity Professional Certified, said that all activities were done in the dining room and she offered arts and crafts, bingo, storytelling, painting, Sitter Cise (exercise), balloon toss, and a popcorn social on Tuesdays and Thursdays. Staff L said she posted an activity program calendar in Resident's rooms on the cork board and let them know the activities of the month and would tell them the times of activities were on the calendar, and she would also go into the room and let them know what was going on that day. When asked when attempts were made to include a resident or when contact was made with the resident regarding activities did, she document this, Staff L said yes, she would document it in a progress note. When asked if Resident 2 participated in activities offered at the facility, Staff L said she would go to Resident 2's room almost every day and Resident 2 would say no, they were ok. Staff L said she would offer one-to-one times with Resident 2 if they did not want to participate in group activities and sometimes, they would accept. When asked if there was any documentation of interactions with Resident 2 since their admission five weeks previous, Staff L looked in the electronic health record at progress notes and said she was unable to find any documentation of interactions with Resident 2.On 03/11/2026 at 3:31 PM, Staff B, Registered Nurse, RN/DNS, when told Resident 2 reported no one had talked with them about activities and they would probably participate if offered activities, and that Staff L was unable to provide any documentation that she had interacted with Resident 2 since admission, Staff B said she would think in over a month's time there would have been documentation that Staff L had interacted with Resident 2. Reference WAC 388-97-0940(1)(2)

.Based on interview and record review, the facility failed to develop and implement comprehensive person-centered care plans for 5 of 17 sample residents (Resident 16, 69, 74, 72 & 2) whose care plans were reviewed. Failure to develop and implement care plans that were individualized, and accurately reflected resident care needs related to constipation, target behaviors for psychotropic (drugs that affect behavior, mood, thoughts, or perception) medication use, activities, and weights monitoring, placed residents at risk for unidentified and/or unmet care needs and potential negative health outcomes.Findings included . Resident 16Resident 16 was admitted to the facility on [DATE]. Review of the 09/06/2025 admission MDS, showed the resident received an anticoagulant (medication that prevent or reduce blood clot formation) during the assessment period. Record review showed a 09/02/2025 order for Eliquis (an anticoagulant) twice daily for atrial fibrillation (a sustained heart rhythm disorder.) An anticoagulant therapy with Eliquis care plan, initiated 02/18/2026, documented the antidote to Eliquis was Vitamin K, and directed staff to have it on hand for emergencies. Review of Eliquis' manufacturer's insert showed the only recognized antidote was Andexxa (a recombinant protein used as an antidote to rapidly reverse the anticoagulation effects of apixaban) . On 03/16/2026 at 1:10 PM, Staff A, Administrator, confirmed Vitamin K was not an antidote to Eliquis and said the care plan was inaccurate Resident 69Resident 69 was admitted to the facility on [DATE]. Review of the 03/06/2026 admission Minimum Data Set (MDS, an assessment tool), showed the resident was cognitively impaired and had an active diagnosis of constipation. Review of the Daily Skilled Nursing Note Summaries from 03/01/2026 - 03/10/2026 showed they documented Resident 69 would have Daily assessment and monitoring of gastrointestinal (GI) function including bowel sounds, abdominal distension, and stool characteristics Review of the altered elimination due to bowel and bladder incontinence care plan, initiated 03/09/2026, showed the resident's active diagnosis of constipation was not addressed. Nor did the care plan interventions instruct staff to perform daily assessment and monitoring of Resident 69's GI function including bowel sounds, abdominal distension, and stool characteristics as documented in the resident's daily skilled nursing notes. On 03/16/2026 at 12:46 PM, Staff A, Administrator, said Resident 69's active diagnosis of constipation, and identified intervention(s) of daily GI function assessment and monitoring should have been addressed/incorporated into the residents bowel and bladder care plan. Resident 74Resident 74 was admitted to the facility on [DATE]. Review of the 02/16/2026 admission MDS, showed the resident was cognitively intact, had a diagnosis of heart failure and received diuretic medication (medications that help kidneys remove excess sodium and water from the body) during the assessment period. Record review showed a 02/11/2026 order for torsemide (a diuretic) daily for chronic heart failure, and a 02/12/2026 order to for daily weights. A heart failure care plan, initiated 02/11/2026, directed staff to obtain daily weights and report to the provider weight gains greater than 3 lbs. lbs. in 24-hours, or greater than 5 lbs. in a week. A renal insufficiency care plan, initiated 02/11/2026, directed staff to report to the provider a weight gain of greater than 2 lbs. in 24 hours. On 03/16/2026 at 12:34 PM, Staff A, Administrator, acknowledged the two care plans provided conflicting instruction to staff related to the amount of weight the resident could gain in 24 hours before provider notification was required. Staff A indicated the heart failure care plan was accurate and the renal insufficiency care plan needed to be revised. On 03/10/2026 at 11:59 AM, Resident 74 indicated they were not consistently provided bathing as scheduled. A skilled services care plan, initiated 02/11/2026, documented Resident 74 was to be showered three times a week on Monday, Wednesday and Friday, on evening shift. Review of Resident 74's bathing record showed for the two-week period of 02/25/2026 - 03/10/2026, staff offered/provided a shower on one of the resident's six scheduled shower days. On 03/16/2028 at 12:38 PM, when asked if Resident 74's plan of care for bathing type/frequency was implemented, Staff A, Administrator, said, No. Resident 72Resident 72 was admitted to the facility on [DATE]. On 03/10/2026 at 11:18 AM, Resident 72 said their showers were not always provided. A skilled services care plan, initiated 03/03/2026, showed Resident 72 was to be showered three times a week, on Monday, Wednesday and Friday on evening shift. Review of Resident 72's bathing record showed in the two-week period of 02/28/2026 - 03/13/2026, staff offered/provided a shower on two of the resident's six scheduled shower days. On 03/16/2028 at 12:39 PM, Staff A, Administrator, confirmed Resident 72's plan of care for bathing type/frequency was not consistently implemented. Resident 2Resident 2 re-admitted to the facility on [DATE]. The admission MDS, dated [DATE], documented Resident 2 was cognitively intact. On 03/09/2026 at 12:25 PM, Resident 2 said they watched television for activities, and that they were not sure what activities were offered at the facility. When asked if staff from the activities department had come to see if they would like to participate in activities, Resident 2 said no, they had never talked with anyone about activities and they would probably participate if they were offered activities. Resident 2 had an Activities & Enrichment Evaluation assessment completed on 02/06/2026, which indicated their activity interests. Review of Resident 2's activities care plan on 03/10/2026, showed the care plan had been entered that day, five weeks after admission to the facility. On 03/11/2026 at 2:32 PM, Staff L, Activity Professional Certified, said she would normally enter the activities care plan when she did the assessment. When asked about the activities care plan for Resident 2 being entered five weeks after admission, Staff L said this did not meet her expectations. On 03/11/2026 at 3:31 PM, Staff B, Director of Nursing Services, was asked if Resident 2's activities care plan should have been put in prior to five weeks after admission, said yes. Reference WAC 388-97-1020(1)(2)(a)(b)

Based on observation, interview and record review, the facility failed to consistently offer/provide showers and provide timely meal assistance to 3 of 3 Residents (Resident 72, 74 and 21) reviewed for activities of daily living (ADL). These failures placed dependent residents at risk for unmet care needs, poor hygiene and diminished quality of life.Findings included .Resident 72 Resident 72 was admitted to the facility on [DATE]. Review of the 03/05/2026 admission Minimum Data Set (MDS, an assessment tool), showed the resident was moderately cognitively impaired and decisions about bathing were Very Important. A skilled services care plan, initiated 03/03/2026, documented Resident 72 preferred showers three times a week on Monday, Wednesday and Friday, on evening shift. On 03/10/2026 at 11:18 AM, Resident 72 said they were not always provided their showers. Review of Resident 72's bathing record showed they received a shower on 03/04/2026 but were not offered/provided bathing again until 03/13/2026, nine days later. During an interview on 03/16/2026 at 12:35 PM, Staff A, Administrator, confirmed there was no documentation that Resident 72 was offered/provided bathing for nine days between 03/04/2026 - 03/13/2026, and that staff failed to offer/provide bathing in accordance with the resident's plan of care. Resident 74 Resident 74 was admitted to the facility on [DATE]. Review of the 02/16/2026 admission MDS, showed the resident was cognitively intact and decisions about bathing were Very Important. A skilled services care plan, initiated 02/11/2026, documented Resident 74 preferred showers three times a week on Monday, Wednesday and Friday, on evening shift. On 03/10/2026 at 11:59 AM, Resident 74 said when they changed rooms staff failed to provide bathing for over a week. Review of Resident 74's bathing record showed they received a shower on 02/24/2026 but was not offered/provided bathing again until 03/10/2026, 14 days later. During an interview on 03/16/2026 at 12:35 PM, Staff A, Administrator, confirmed there was no documentation of Resident 74 being offered/provided bathing for 14 days between 02/24/2026 - 03/10/2026, and that staff failed to offer/provide bathing in accordance with the resident's plan of care. Resident 21 Review of the electronic health record (EHR) showed Resident 21 admitted to the facility on [DATE] with diagnoses that included severe protein malnutrition, right side paralysis due to a stroke and dysphagia (swallowing difficulty). Resident 21 was dependent on staff assistance for all activities of daily living. Review of Resident 21's Care Plan, dated 02/21/2026, showed the following intervention Staff will provide assistance with meal consumption: Alternate small bites and sips. Use a teaspoon for eating. Do not use straws. Observation on 03/12/2026 at 8:20 AM, showed breakfast trays being passed out to resident rooms. Observation on 03/12/2026 at 9:21 AM, showed breakfast trays being picked up from resident rooms and the food cart taken back to the kitchen During an observation and interview on 03/12/2026 at 9:44 AM, Resident 21 was lying in bed in their gown and stated they did not receive breakfast. During an interview on 03/12/2026 at 9:44 AM, Staff J, Certified Nursing Assistant, stated they were assigned to Resident 21 but was unaware the resident did not receive breakfast and required feeding assistance. Staff J stated there was no meal tray on the cart for Resident 21. An observation on 03/12/2026 at 10:14 AM showed Resident 21 received a breakfast tray, two hours after initial tray pass. During an interview on 03/16/2026 at 8:38 AM, Staff B, Director of Nursing Services (DNS), stated the expectation was that staff were to be familiar with their assigned resident's plan of care and that residents' received that care timely. Reference WAC 388-97-1060 (2)(c)

Based on interview and record review, the facility failed to provide non-pharmacological interventions (NPI) prior to the use of as needed pain medications for 4 of 6 residents (Residents 30, 74, 5 and 2) when reviewed for unnecessary medication. This failure placed the residents at risk of receiving unneeded medications and a diminished quality of life.Findings included . Resident 30Review of the electronic health record (EHR) showed Resident 30 admitted to the facility on [DATE] with diagnoses to include high blood pressure, depression (mood disorder) and anxiety. Resident 30 was able to make needs known. Review of Resident 30's medication list showed a provider's order dated 02/24/2026 for acetaminophen (a pain medication) every four hours as needed (PRN) for pain. Review of Resident 30's medication list showed a provider's order, dated 02/27/2026, to offer non-pharmaceutical intervention prior to PRN medication administration 1) redirect, 2) 1:1, 3) activity, 4) return to room, 5) toilet, 6) give food, 7) give fluids, 8) change position, 9) adjust room temperature, 10) backrub 11) imagery. Review of Resident 30's March 2026 medication administration record (MAR) showed acetaminophen administered on March 1st, 3rd, 4th ,5th ,6th and 12th. There was no documentation that NPI's were offered/provided prior to the administration of the medication. During an interview on 03/13/2026 at 2:45 PM, Staff C, Patient Care Manager, stated nursing staff should have offered ice and repositioning prior to administering the as needed pain medication. Staff C stated the expectation was to document Resident 30's pain level and the interventions attempted and make sure the appropriate PRN medication is given for the pain level. During an interview on 03/16/2026 at 8:27 AM, Staff B, Director of Nursing Services, stated the expectation was for staff to offer and document NPI's prior to administering PRN pain medication. Resident 74Resident 74 was admitted to the facility on [DATE]. Review of the 02/16/2026 admission Minimum Data Set (MDS, an assessment tool), showed the resident was cognitively intact, had a diagnosis of heart failure and hypertension and received diuretic medication (medications that help kidneys remove excess sodium and water from the body through increased urine) during the assessment period. Record review showed Resident 74 had the following 02/11/2026 orders:a) Eplerenone one time a day for heart failure, Hold medication for a systolic blood pressure (SBP - top or first number of blood pressure reading) less than 110.b) Torsemide one time a day for heart failure, Hold medication for a SBP less than 110, Review of the February and March 2026 Medication Administration Record (MAR) showed on the following dates the medication was administered outside of the ordered parameters:Eplerenone:02/20/2026- BP= 105/63; medication was administered.03/8/2026- BP= 109/64; medication was administered.03/14/2026- BP= 107/64; medication was administered. Torsemide02/20/2026- BP= 105/63; medication was administered. During an interview on 03/16/2026 at 12:58 PM, Staff A, Administrator, said on the above referenced occasions the medication(s) should have been held, and acknowledged facility nurses administered the medication(s) outside of the physician ordered parameters. Resident 5Resident 5 was admitted to the facility on [DATE]. Review of the 02/19/2026 admission MDS, showed the resident had a diagnosis of heart failure and hypertension and received diuretic medication during the assessment period. Record review showed Resident 5 had a 02/17/2026 order for Metoprolol twice a day for atrial fibrillation, and a 02/14/2026 order that identified cardiac medication hold parameters: Hold for SBP less than 110 or a pulse less than 60, if not otherwise specified. Review of the February 2026 MAR showed on the following dates staff administered Resident 5's Metoprolol outside of the ordered parameters: 02/20/26 8pm dose- BP= 105/55, medication was administered. 02/25/26 8pm dose- BP= 97/63; Medication was administered.02/26/26 8pm dose- BP= 108/60; Medication was administered.02/27/26 8pm dose- BP= 101/63; Medication was administered. During an interview on 03/16/2026 at 12:58 PM, Staff A, Administrator, acknowledged on the above referenced occasions Resident 5's metoprolol should have been held, but confirmed facility nurse administered the medication outside of the physician ordered parameters. Resident 2 Resident 2 re-admitted to the facility on [DATE]. The admission MDS, dated [DATE], documented Resident 2 was cognitively intact. Resident 2 had a provider order, dated 02/11/2026, for acetaminophen to be given every 6 hours as needed for pain. Resident 2 had another provider order, dated 02/11/2026, for oxycodone (medication to relieve pain) to be given every 8 hours as needed for a pain level of 6-10/10 (pain scale based on 1-10, with 1 indicating no pain and 10 the highest level of pain). Review of Resident 2's MAR from 03/01/2026- 03/13/2026, showed they had an order for staff to document non-pharmacological interventions (NPI) for pain to 1. Lower back or 2. Bilateral legs. The NPIs were to include 1: repositioning, 2: removing lights and loud noises, or 3: pillows. Staff were to document the location of the pain and the interventions attempted. Review of the documentation showed no NPIs had been attempted. Resident 2's MAR from 03/01/2026- 03/13/2026, documented acetaminophen had been administered 13 times and oxycodone had been administered 15 times, with documentation that NPIs had been attempted. Further review of the MAR showed Resident 2 received oxycodone two times on 03/09/2026, with a pain level reported as 5/10, outside of the ordered parameters of 6-10/10. On 03/16/2026 at 11:23 AM, Staff B, DNS, confirmed that Resident 2 had ordered NPIs. When asked if NPIs had been attempted prior to administration of the acetaminophen and oxycodone, Staff B said NPIs were not connected to the orders for the pain medications and no NPIs had been attempted that she could see. Staff B confirmed the oxycodone had been given two times outside of the ordered parameters on 03/09/2026 and said this did not meet her expectations. Reference WAC 388-97-1060(3)(k)(i)

Based on interview and record review, the facility failed to provide the necessary care and services to maintain residents' highest practicable level of well-being for 1 of 6 sampled residents (Resident 69) reviewed for bowel management and for 1 of 2 sampled residents (Resident 74) reviewed for edema and/or weight monitoring. The failure to initiate bowel care in accordance with physician's orders and the facility's bowel protocol, and the failure to obtain and evaluate weights, and notify the provider of weight variances as ordered, placed residents at risk for delayed identification and treatment of fluid volume overload, and abdominal pain, nausea, and decreased appetite related to untreated constipation. Findings included .Bowel ManagementResidents 69Resident 69 was admitted to the facility on [DATE]. Review of the 03/06/2026 admission Minimum Data Set (MDS, an assessment tool), showed the resident was cognitively impaired and had an active diagnosis of constipation. On 03/10/2026 at 10:09 AM, Resident 69 reported they had a long history of constipation. Record review showed Resident 69 had the following 03/01/2026 as needed (PRN) bowel care orders:- Miralax 17 gram dissolved in four ounces of water every 24-hours PRN; Give first for bowel care.- Bisacodyl 5 milligrams one tablet every 24-hours PRN for constipation; Give second for bowel care if Miralax ineffective.- Bisacodyl 5 milligrams two tablets every 24-hours PRN for constipation; Give third for bowel care if Miralax and 5mg Bisacodyl ineffective.- Mineral Oil Enema rectally every 24-hours PRN for constipation; Give fourth for bowel care if Miralax and Bisacodyl 10mg ineffective.- Notify MD/NP if constipation persists for 4 days or more. Review of Resident 69's bowel record showed no documented bowel movement (BM) from 03/03/2026 - 03/06/2026 (4 days.) The March 2026 Medication and Treatment Administration Records (MAR/TAR) showed Resident 69 was not administered PRN bowel medication until 03/11/2026. Review of the Daily Skilled Nursing Note Summary from 03/01/2026 - 03/06/2026 showed they documented Management of Altered GI Function: Daily assessment and monitoring of GI function including bowel sounds, abdominal distension, and stool characteristics in each note, but there were no abdominal/bowel assessments documented. On 03/16/2026 at 12:32 PM, when asked if there was documentation to show staff performed an abdominal/bowel assessment and/or administered the resident PRN bowel medication when they went without a BM for four consecutive days from 03/03/2026 - 03/06/2026 Staff A, Administrator, said no. Edema Management/Weight Monitoring Resident 74Resident 74 was admitted to the facility on [DATE]. Review of the 02/16/2026 admission MDS, showed the resident was cognitively intact, had a diagnosis of heart failure and received diuretic medication (medications that help kidneys remove excess sodium and water from the body through increased urine) during the assessment period. Resident 74 had a 02/11/2026 order for torsemide (a diuretic) daily for chronic heart failure. A renal insufficiency care plan, initiated 02/11/2026, directed staff to monitor, document, and report to the provider: edema, weight gain of over two pounds (Lbs.) in a day.A heart failure care plan, initiated 02/11/2026, directed staff to obtain daily weights and report weight increases greater than three lbs. in a day or greater than five lbs. in a week. Record review showed a 02/12/2026 order to obtain daily weights related to heart failure.Review of the February 2026 TAR showed Resident 74 weighed the following:- 02/13/2026= 344.9 Lbs.- 02/14/2026= 352.2 (+7.3 Lbs. in 24 hours); Record review showed there was no documentation to show the provider was notified.- 02/18/2026 352.7 Lbs.- 02/19/2026= 339 Lbs. (-13.7 Lbs. in 24 hours), Record review showed there was no documentation to show the provider was notified.-02/22/2026= 320.8 Lbs.- 02/24/2026- 336.2 Lbs. (+ 15.4 Lbs. in 48-hours). Record review showed there was no documentation to show the provider was notified. On 03/16/2026 at 12:58 PM, when asked if there was documentation to show the provider was notified of Resident 74's weight variances of greater than two pounds in 24-hours Staff A, Administrator, stated, Not that I see. Reference WAC 388-97-1060 (1)

Based on observation, interview and record review, the facility failed to provide Physical Therapy (PT) and Occupational Therapy (OT) services according to the care plan for 2 of 4 residents (Resident 1 and Resident 2) reviewed for specialized rehabilitation services. This failure placed residents at risk for delayed progress towards goals, a longer stay at the facility, and a diminished quality of life. <Resident 1> Resident 1 admitted to the facility on [DATE] with diagnoses of left humerus (long bone in upper arm) fracture and left hip fracture. The admission Minimum Data Set (MDS, an assessment tool) dated 06/03/2025, showed Resident 1 was cognitively intact and needed limited assistance for Activities of Daily Living (ADL's). Resident 1 was admitted for PT and OT with a goal of improving function and returning to the community. A review of OT Evaluation and Plan of Treatment form, dated 06/02/2025, showed Resident 1 was to receive 5 sessions per week. A review of the treatment record showed they received services on 06/02/2025, 06/03/2025, 06/05/2025, and 06/09/2025. There were a total of 4 treatment days out of 8. <Resident 2> Resident 2 admitted to the facility on [DATE] with a diagnosis of hypercalcemia (too much calcium in the blood) which caused a decline in function. The admission MDS, dated [DATE], showed Resident 2 was cognitively intact and needed standby assistance for Activities of Daily Living (ADLs). Resident 2 was admitted for PT and OT with a goal of improving function and returning to the community. Resident 2 discharged against medical advice on 04/30/2025. On 06/09/2025 at 2:30 PM, Resident 1 said they were very disappointed with the lack of services from OT. Resident 1 said they had only received three sessions, four if you including the current morning, since admitting, and it was their understanding they would be receiving daily sessions. Resident 1 said they had a very uncomfortable hinged elbow brace in place until it was removed that day. Resident 1 said they went to a doctor's appointment on 06/06/2025 and were told the brace could be worn only at night. Resident 1 said they had gone to the nurse's station on Saturday, 06/07/2025, to ask about having the brace removed for the day, but were told there weren't any therapists available to assist. They were told by nursing staff that only the therapists could manipulate the brace. On 06/18/2025 at 1:20 PM, Resident 2 said they left the facility against medical advice due to insufficient services from PT. They said they completed a Concern/Grievance Form on 04/28/2025 about the lack of services. Resident 2 said they were told the lack of services was due to the holiday weekend and staffing issues. Resident 2 said they were told if they left, they would never be able to return to the facility again but decided to go home anyway. A review of the PT Evaluation and Plan of Treatment form, dated 04/21/2025, showed Resident 2 was to receive 6 sessions per week. Services were provided on 04/21/2025, 04/22/2024, 04/23/2025, 04/24/2025, and 04/29/2025. Resident 2 did not start services until 04/21/2025, 3 days after admission to the facility and received a total of 5 treatment days out of 11 days. On 06/25/2025 at 3:31 PM, Staff B, Rehabilitation Director, acknowledged the Evaluation and Treatment forms were part of the residents comprehensive care plan. They said the number of sessions needed for both PT and OT were determined after the initial assessment. Staff B said there had been two days of staff call outs for the week of 04/21/2025 and the week of 06/02/2025. They said these call offs affected both Resident 1 and Resident 2's treatment plans. When asked if there were PT and OT services on the weekend, Staff B said weekend staffing was limited. When asked if there was someone in Rehabilitation Services that nursing staff could call on weekends or after hours, Staff B stated, I guess that would be me. Staff B said their department did not get the order about Resident 1's brace until 06/09/2025. When asked if nursing could have removed the specialty brace without PT or OT present, Staff B said they could have. On 06/25/2025 at 4:14 PM, Staff C, Registered Nurse, said they would not be comfortable removing a specialty brace without having someone from OT or PT evaluate and assist. On 06/25/2025 at 4:50 PM, Staff A, Administrator, said the goal was for residents to receive the recommended services as outlined in their care plan, but that sometimes issues with staffing couldn't be helped. Staff A said the nursing staff should have removed the brace for Resident 1 as soon as the order was received. Reference WAC 388-97-1280(1)(a-b), (3)(a-b) .

Based on observation, interview, and record review, the facility failed to consistently implement measures to prevent development of avoidable pressure ulcers and to thoroughly assess, monitor and obtain timely treatment orders for pressure ulcers for 1 of 4 sampled residents (Resident 38) reviewed for pressure ulcers. Resident 38 experienced harm when they developed two avoidable pressure ulcers which required hospitalization for surgical intervention and intravenous (in the vein) antibiotics. Findings included . Resident 38 admitted to the facility on [DATE] with diagnoses of blastocystitis (an infection of the intestines caused by a parasite, may cause diarrhea), weakness, and polyneuropathy (damage to multiple nerves). The Admission Minimum Data Set (MDS), an assessment tool, dated 12/13/2024, showed Resident 38 was severely cognitively impaired and needed extensive assistance for positioning and transfers. Review of the facility's policy titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol, revised April 2018, showed, nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; b. Pain assessment; c. Resident's mobility status; d. Current treatments, including support surfaces. Review of the Admit Skin Evaluation form, dated 12/11/2024, showed Resident 38 had redness to their buttocks but no opened areas. The assessment did not document whether or not the redness was blanchable. The Braden Scale (a tool used to assess risk of pressure injury) documented on the same evaluation, showed a score of 9, indicating very high risk. The interventions on the form were: encouraged or assisted with repositioning and barrier cream. There were no identified skin impairment risks on the care plan or interventions. Review of nursing progress notes for Resident 38, dated 12/12/2024 and 12/13/2024, showed Resident 38 had red bottom and open area to the gluteal fold (crease in buttocks). Review of nursing progress notes, dated 12/14/2024 through 12/17/2024, documented no skin related concerns. Review of nursing progress notes, dated 12/19/2024, showed there was an open area on Resident 38's buttocks. Review of the weekly interdisciplinary team meeting note, dated 12/19/2024, showed, patient continues to have pain related to wound, but did not specify what wound. Review of the nursing progress notes, dated 12/19/2024 and 12/20/2024, showed no skin related concerns. Review of a nursing note, dated 12/21/2024, showed there was an open area to the coccyx (tailbone area) and left buttock. Review of the Weekly Skin Evaluation, dated 12/22/2024 at 9:09 PM, showed a Braden score of 12 which indicated high risk. The evaluation showed there was an open area to the coccyx, perineum (sensitive skin between the anus and the genitals) and left buttock. Interventions included: encouraged or assisted with repositioning, wheelchair cushion, nutritional interventions, barrier cream, physician and patient representative notified. Review of Electronic Health Record (EHR) from 12/11/2024 to 12/23/2024 did not show interventions or treatment for wound care or detailed descriptions, staging, or measurements of Resident 38's wounds. Review of a nursing progress note, dated 12/23/2024 at 2:30 PM, showed Staff C, Registered Nurse and Case Manager (CM), looked at wound, believes that the wound status needs a higher acuity, provider agreed. Resident 38 was transferred to the hospital later that same day. Hospital records for date of admission of 12/23/2024 showed the following: 12/23/2024 - Certified Wound Nurse evaluated and treated Resident 38 for three full-thickness wounds to the perianal area, coccyx and sacrum (area where lower spine and pelvis meet), of which the coccyx and sacral wounds appeared to be pressure injuries (unstageable). Measurements for the sacral wound were documented as, 4.7 cm [centimeter] length (larger of 2) by 1.3 cm by 0.8 cm. Photograph of wounds showed coccyx and sacral wounds somewhat conjoined. 12/24/2024 - Hospital Physician documented, pressure sacral decubitus [bedsore] stage III [full thickness loss of skin with fatty tissue visible] with acute infection. 12/27/2024 - Operative notes documented Resident 38 underwent surgical wound debridement [removal of dead tissue and deep cleaning] of sacral decubitus ulcer. Resident 38's EHR showed resident was readmitted to the facility on [DATE] with a new placement of a retention catheter (tube placed into the bladder for urine to drain) and antibiotic therapy. The care plan, dated 12/29/2024, showed to encourage off-loading or frequent shifting of position while in bed or chair. The Re-Admission MDS, dated [DATE], showed Resident 38 had a Stage 3 pressure ulcer. The section for skin and ulcer treatments were marked no for pressure reducing device in chair or a bed and turning and repositioning program. On 01/07/2025 at 10:35 AM, Resident 38 was observed lying on an air mattress. It had not been care planned and was not being monitored for correct settings. On 01/08/2025 at 11:11 AM, Staff C, CM, said prior to hospitalization , the wound(s) Resident 38 had were not pressure related. After reviewing the hospital notes, Staff C said it was a pressure ulcer. On 01/13/2024 at 10:33 AM, wound care was observed. Resident 38 had a large wound to the coccyx, a smaller wound to the left buttock, and another smaller wound to the right upper buttock. Resident 38 expressed pain and irritation with wound care. On 01/13/2025 at 2:41 PM, Staff A, Administrator, said the CM's were trained in wound management and would be the ones who assessed and documented on wounds. Reference WAC 388-97-1060(3)(b)

Based on observation, interview and record review, the facility failed to ensure intravenous (IV) access devices were assessed, maintained and monitored in accordance with professional standards of practice for 2 of 2 residents (Residents 33 & 103) reviewed for IV therapy. The failure to ensure IV orders included routine monitoring of IV insertion sites, flush orders, weekly changes of IV dressings and needleless injection caps, and initial and then weekly measurements of IV catheters external length and the residents arm circumferences, placed them at risk for loss of vascular access, infection, and other potential negative health outcomes. Findings included . <Facility Policy> Review of the facility's undated Central Venous Access Device (CVAD) Dressing Change policy showed for residents with Peripherally Inserted Central Catheters (PICCs), nurses would: a) Perform weekly PICC dressing changes and as needed if the dressing is soiled, wet or dislodged. b) Measure and document the PICC external length upon admission, weekly with dressing changes, and as needed. c) Measure and document upper arm circumference (10 cm above antecubital fossa) upon admit, with weekly dressing changes and as needed. d) Change needleless injection caps with weekly dressing changes, after blood draws and as needed. e) Assess vascular access insertion site upon admit, during dressing changes, at least every two hours during continuous therapy, and at least once per shift when not in use. The policy and procedure for midline (a type of IV catheter that is placed into a vein in the arm. It is longer than a standard IV and can stay in place for up to 29 days) maintenance and monitoring was requested but not provided. On 01/13/2025 at 12:37, Staff D, Resident Care Manager/Registered Nurse, said the policy and procedure was the same as the above CVAD policy. 1) Resident 33 admitted to the facility on [DATE]. Review of the Admission Minimum Data Set (MDS, an assessment tool), dated 12/16/2024, showed the resident was cognitively intact, had diagnoses of urinary tract infection, sepsis (a potentially life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs) and perinephric abscess (a collection of pus around one or both kidneys. It is caused by an infection that spreads from a urinary tract) and required IV medication during the assessment period. A 12/15/2024 nurses' note documented Resident 33 had a midline placed to their left upper arm. Record review showed Resident 33 received IV ertepenem (an antibiotic) from 12/13/2024 - 01/08/2025. Review of Resident 33's midline maintenance and monitoring orders showed a 12/26/2024 order for weeky midline dressing changes. There were no orders for or documentation to show the facility did the following during the resident's 27 days of IV antibiotic therapy: a) Measured and documented the midline external length upon inseriton, or with the weekly dressing changes. b) Measured and documented the upper arm circumference upon insertion, or with the weekly dressing changes. c) Changed the needleless injection caps weekly with the dressing changes. d) Assessed the midline insertion site during dressing changes, and at least once per shift when not in use. On 01/13/2025 at 12:55 PM, when asked if there was documentation to show the facility did the above required maintenance and monitoring of Resident 33's midline between 12/13/2024 - 01/08/2025 Staff C, Resident Care Manager/Registered Nurse, stated, No. 2) Resident 103 admitted to the facility on [DATE] with orders for IV cefepime every 12 hours for an infection related to cholelithiasis (gallstones). The 01/05/2025 hospital transfer orders showed Resident 103 had a PICC to the left upper arm. Review of the electronic health record (EHR) showed a 01/06/2025 order that directed staff to change the PICC dressing, measure arm circumference and external catheter length weekly. No documentation was found to show what the resident's arm circumference and external catheter length was upon admission. Review of January 2025 Medication Administration Record showed on 01/10/2025 staff signed they changed the PICC dressing, measured the arm circumference and external catheter length. However, no place was provided to record the resident's arm circumference or the external catheter length. Further review showed the nurse did not document the arm circumference or external catheter length in the EHR. On 01/13/2025 at 12:37 PM, when asked if there was any documentation to show the facility had measured Resident 103's arm circumference or external catheter length upon admission or anytime thereafter, Staff D stated, No, not that I see. Reference WAC 388-97-1060 (3)(j)(ii)

Based on observation, interview and record review, the facility failed to ensure residents were appropriate for the use of mobility bars, for 1 or 3 residents (Resident 103) reviewed for physical restraint, and to ensure prior to use of mobility bars that residents were evaluated for risk of entrapment and informed consent was obtained for 3 of 3 residents (Residents 103, 8 & 33) reviewed for physical restraint. This failure placed residents at risk for not knowing risks of mobility bars, accidents/harm/entrapment related to mobility bars, and a diminished quality of life. Findings included . Review of the document titled, Proper Use of Side Rails, dated December 2016, showed the facility was to assess for risk of entrapment, to add the assistive device to the resident's care plan, and was to obtain consent. The document also specified that side rails were only allowed if they were used to treat a medical symptom and assist with mobility or transfer of the resident. 1) Resident 103 was admitted to the facility on [DATE]. The Entry Minimum Data Set, as assessment tool, dated 01/05/2025, documented Resident 103 was cognitively intact. On 01/08/2025 at 10:20 AM, Resident 103 was observed laying in bed with bed mobility bars attached to the bed. When asked if the bed rails helped with mobility, Resident 103 demonstrated by attempting to turn and reach for the bedrails, but was unable to grab the bedrails, due to limited motion and the ability to grab the bed rails with their hands. On 01/09/2025, review of the Electronic Health Record (EHR), provided no documentation for bed mobility bars, including consent, orders, risk and benefits, assessments or care plan information. On 01/13/2025 at 11:40 AM, when shown the consent form and the order for the bed mobility bars, dated 01/10/2025 and asked if the consent and order should have been completed at the time the bedrails were installed, Staff Z, Rehabilitation Director, said yes. Staff Z said the process for assessing residents using bed rails as bed mobility bars could be completed by nursing or rehabilitation staff Staff Z said the process included determining what type of mobility bar would be used and what the resident's cognition was and if mobility bars would be appropriate. Staff Z said if the resident wanted bed mobility bars, they would have the resident sign a consent form. When asked how the facility was physically assessing if the bed rails would be considered a physical restraint, Staff Z stated, we're not. Staff Z said depending on the residents' cognition, the bed rails could be a restraint. When it was explained Resident 103 had limited repositioning capabilities and had difficulty reaching the bed rails behind them, Staff Z said staff would ask the resident to press the call light for assistance. When asked if the bed rails really assisted Resident 103, Staff Z did not answer the question directly, but instead said Resident 103 was assessed to be able to move independently and the bedrails would help with mobility. No assessment was provided documenting Resident 103 could use the bedrails. 50945 2) Resident 8 was admitted to the facility on [DATE]. During an observation and interview on 01/07/2025 at 10:38 AM, Resident 8 was seen with mobility bars on the upper sides of their bed. Resident 8 said they used their mobility bars for moving in bed. Review of the EHR on 01/09/2025, showed Resident 8 did not have an order, care plan, assessment, nor consent for the mobility bars. During an interview on 01/09/2025 at 12:29 PM, Staff C, Case Manager (CM), said after reviewing the EHR, said they could not find an order or care plan for Resident 8 and that there should have been. Staff C said they would need to track down the assessment done by the therapy department. Facility staff provided a document on 01/10/2025 titled, Assistive Device Consent for Resident 8. No signature by the resident was found and the date listed on the form was 01/10/2025. During an interview on 01/13/2025 at 12:00 PM, Staff A, Administrator, said an assessment and consent were needed to ensure mobility bars were not acting as a restraint. Staff A said the Assistive Device Consent did not have a risk of entrapment assessment and their expectation was for it to be completed, and the patient would have signed the form. 3) Resident 33 was admitted to the facility on [DATE]. During an observation and interview on 01/07/2025 at 2:21 PM, Resident 33 was seen with mobility bars on the upper sides of their bed. Resident 33 said they used the mobility bars for moving in bed, and the mobility bars did not prevent them from getting out of bed. Review of the EHR on 01/09/2025, showed Resident 33 did not have an order, care plan, assessment, nor consent for the mobility bars. During an interview on 01/09/2025 at 12:36 PM, Staff C, CM, after reviewing the EHR, said they could not find an order or care plan for mobility bars and there should have been. Documentation was requested for an assessment for the mobility bars. During a follow-up interview on 01/13/2025 at 10:35 AM, Staff C, CM, said Resident 33 did not have an assessment for mobility bars completed by therapy. During an interview on 01/13/2025 at 12:00 PM, Staff A, Administrator, when asked if it met expectations that Resident 33 had no care plan, no order, no assessment, and no consent, said this did not meet their expectations. Reference WAC 388-97-1060 (3)(g) -0230

Based on observation, interview and record review the facility failed to store, prepare and serve food to residents in accordance with professional standards for 1 of 1 kitchen and 2 of 2 unit refrigerators/freezers reviewed for food service safety. The failure to maintain documented refrigerator, freezer and dishwasher temperatures, prevent contamination of uncovered foods during transportation, to throw out expired foods and maintain sanitary conditions placed residents at risk of foodborne illness (caused by the ingestion of contaminated food or beverages), unsanitary conditions, and diminished quality of life. Findings included . <Food storage temperature logs> Review of the food storage temperature logs documented the following missing entry dates: Walk in refrigerator: [DATE] AM shift [DATE] PM shift Walk in Freezer: [DATE] AM shift [DATE] PM shift Kitchen refrigerator: [DATE] AM shift [DATE] PM shift Kitchen Freezer: [DATE] AM shift [DATE] PM shift Pantry Refrigerator/Freezer: [DATE] [DATE] Dining Room Refrigerator/Freezer: [DATE] [DATE] Review of the Dishwasher temperature logs documented the following missing entry dates: [DATE] Evening shift [DATE] Evening shift [DATE] Evening shift [DATE] Evening shift [DATE] Evening shift [DATE] Day Shift [DATE] Evening shift [DATE] Evening shift [DATE] Evening shift [DATE] Evening shift [DATE] Evening shift [DATE] Evening shift [DATE] Evening shift [DATE] Evening shift [DATE] Evening shift [DATE] Morning, Day & Evening shift [DATE] Evening shift [DATE] Day & Evening shift [DATE] Evening shift [DATE] Evening shift [DATE] Evening shift [DATE] Evening shift [DATE] Evening shift [DATE] Evening shift [DATE] Evening shift [DATE] Evening shift On [DATE] at 3:39 PM, when asked about the missing entries for the food storage temperature logs and dishwasher temperature logs, Staff U, Dietary Manager, said the dates should have been filled in. <Expired foods> On [DATE] at 11:11 AM, observation of the kitchen cart next to oven showed: Lea & [NAME] Worcestershire Sauce 1 gallon-best if used by [DATE] [NAME] Style Cooking Wine 1 gallon-best if used by [DATE]. 80%/20% Vegetable Olive Oil blend 1 gallon, had no use by date given. At 11:17AM, Staff U, Dietary Manager, said the staff check all foods everyday for expirations dates. When shown the multiple gallon containers of expired food, Staff U said those containers should have been removed from rotation. <Moldy container> On [DATE] at 11:30 AM, observation of the Walk in Refrigerator showed: Tartar sauce 1 gallon with no expiration date. Date on label documented Tartar sauce was received [DATE]. Observation of mold growing on the outside of container, 6 spots each about the size of a pencil eraser. At 11:35 AM, Staff U said the yellow label on the container was the date it was received from the distributor. Mold growing on the outside of the container was shown to Staff U. When asked if mold growing on the container was acceptable, Staff U said no. <Under covered foods during transportation> Observations of uncovered food being delivered to resident's rooms and/or dining room: On [DATE] at 1:04 PM, room [ROOM NUMBER], uncovered pudding. At 1:09 PM, room [ROOM NUMBER], uncovered lemon bar. At 1:14 PM, Dining room, uncovered salad and dessert. On [DATE] at 1:31 PM, Dining room, Jello/fruit on tray was uncovered. At 1:36 PM, meal tray being carried down dining room hallway included uncovered Jello/fruit. At 1:38 PM, another meal tray being carried down dining room hallway included uncovered Jello/fruit. On [DATE] at 12:53 PM, observation of uncovered foods that were placed on resident trays included pudding cup, diced peaches, vegetable salads and fruit salad. At 2:46 PM, Staff U, Dietary Manager, said they had never covered items like pudding cup, diced peaches, vegetable salads and fruit salad since they had been working there. When asked how they were preventing contamination of foods from the cart to the residents room/dining rooms with the uncovered foods, Staff U stated I can't guarantee non-contamination in the hallways. <Unsanitary conditions> On [DATE] at 11:54 AM, Staff W, Dietary Aide, dropped a pen on floor, then picked up pen and put it in their pants pocket. Staff W completed hand hygiene, but did not sanitize the pen. At 12:03 PM, Staff W pulled the same pen from their pocket, wrote on cup lids and then returned the pen back to their pocket. When asked about the non-sanitized pen that was retrieved from Staff W's pocket, Staff W said they did not clean the pen before using it again and should have. At 2:46 PM, the observation of the dropped pen without sanitizing it by Staff W was explained, Staff U said Staff W should have sanitized the pen before using it again or gotten a new pen. Reference WAC ,d+[DATE] -1100 (3), 2980

Based on observation, interview and record review, the facility failed to ensure transmission based precautions (TBPs, extra precautions to prevent spread of infection) were implemented consistently and as indicated for 3 of 3 sampled residents (Residents 105, 40,33) reviewed for aerosol generating procedures (AGPs, procedures that generate aerosols that could be infectious), 2 of 3 sampled residents (Residents 17 &33) reviewed for enhanced barrier precautions (EBPs, infection control precaution of wearing gown and gloves during high contact activities during resident care) and 1 of 2 sampled residents (Resident 38) reviewed for contact precautions (infection control precaution of wearing gown and gloves before room entry and while in room) observation. Additionally, the facility failed to ensure the Legionella Water Management Programs (LWMP) was updated to current industry standards, and that sharps containers were replaced when full. These failures placed residents at risk of cross-contamination, infection, complications, and a diminished quality of life. Findings included . <Aerosol Generating Procedures> Review of the facility policy titled Coronavirus Disease (COVID-19)-Aerosol Generating Procedures, dated December 2021, showed procedures considered to be AGPs were open suctioning of airways, sputum induction, and continuous positive airway pressure (CPAP, device that assists with breathing) machines. All employees that went into residents' rooms while on AGP precautions were to wear respirators (N-95 masks, protection against breathing in infectious particles), gloves, isolation gown or protective clothing, and eye protection. 1) Resident 105 was admitted to the facility on [DATE] and was on continuous AGP for suctioning. Review of Resident 105's progress notes showed a provider note on 12/31/2024 that stated, leave suction at bedside for oral secretion management, and a nursing note on 01/02/2025 stated patient has had the suction machine on 24 hours so that she can use it at will. During an observation on 01/08/2025 at 1:10 PM, there was no writing on the AGP sign outside of Resident 105's room to say when AGP was started, completed, ended, or that it was continuous. During an observation at 2:13 PM, Staff H, Certified Occupational Therapist Assistant, entered Resident 105's room without eye protection or a mask. At 2:27 PM, the resident's visitor entered the room and requested a mask. Staff H told the visitor the resident did not have anything respiratory related. During an observation at 2:32 PM, Staff I, Rehabilitation Technician, put on a surgical mask (no N-95), did not wear eye protection, and entered the room. During an interview at 2:55 PM, Staff D, Resident Care Manager (RCM), said they probably should have written continuously on the AGP sign. Staff D confirmed AGP precautions were not implemented until 01/07/2025, after the survey had started. During an interview on 01/13/2025 at 9:18 AM, Staff A, Administrator/Director of Nursing Services (DNS)/ Infection Preventionist (IP), said it did not meet expectations staff entered Resident 105's room unaware of the AGP continuous precautions, and there was no AGP signage until 01/07/2025. 2) Resident 40 was admitted to the facility on [DATE] and was on AGP precautions for CPAP usage at night. During an observation on 01/10/2025 at 6:26 AM, the AGP sign outside of Resident 40's room showed no writing to say when it was started, completed, or ended. At 8:23 AM, Staff J, Certified Nursing Assistant (CNA), entered Resident 40's room without a gown, N-95 mask, or gloves. During an interview at 8:28 AM, Staff J, said Resident 40 took off their CPAP before Staff J had gotten on duty, and staff did not need to wear additional protection. During an interview at 8:33 AM, Staff K, Registered Nurse, said they did not know what time Resident 40's CPAP came off. During an interview at 8:36 AM, Resident 40 said they did not know when they last used their CPAP machine, but that the CPAP was not used the previous night. During an interview at 8:39 AM, Staff J, CNA, said that the AGP sign outside of the resident's room should have been marked. During an interview at 8:43 AM, Staff L, CNA, said AGP is for when the CPAP is running and for 2 hours afterwards. Staff L explained that the nurse or the aid would be the only ones who would know when the CPAP machine was taken off. During an interview on 01/13/2025 at 9:18 AM, Staff A, Administrator/DNS/IP, said their expectation was for there to be clear communication between dayshift and nightshift staff, with signage filled out as applicable. 3) Resident 33 was admitted to the facility on [DATE] and had a CPAP machine for overnight. During observations on 01/07/2025 at 2:25 PM, 01/09/2025 at 9:32 AM, and 01/10/2025 at 8:50 AM, no AGP signage was found outside of Resident 33's room. During an interview on 01/10/2025 at 8:50 AM, Resident 33 said they used their CPAP every night, and had taken it off that morning after wearing it overnight. During an interview at 8:54 AM, Staff M, CNA, said Resident 33 was not on AGP precautions and they did not know when the resident took off their CPAP machine. During an interview at 9:00 AM, Staff N, Licensed Practical Nurse (LPN), said they were not told what time Resident 33's CPAP machine was taken off. <Enhanced Barrier Precautions> Review of the facility's policy titled Enhanced Barrier Precautions, dated August 2022, showed EBPs were indicated for residents that had wounds and/or indwelling medical devices (devices left inside the body for a period of time), and that EBPs were to remain for the duration of the resident's stay (or until resolution of wound and/or discontinuation of all indwelling devices). 1) Resident 17 was admitted to the facility on [DATE] and had a leg wound. During an observation on 01/08/2025 at 2:57 PM, Staff C examined Resident 17's exposed wound and asked them to go back into their room for a dressing change. There was no signage outside of Resident 17's room indicating they were on EBP. Observation on 01/08/2025 at 3:01 PM, showed Staff C, RCM, and Staff F, LPN, performed wound care, neither were wearing gowns. After wound care was performed and a new bandage was applied, Staff C, was observed to remove their gloves (did not perform hand hygiene), took a pen and marked the bandage with the date, then dropped the pen on the ground, picked up the pen and put the pen on the side table (did not perform hand hygiene). Staff C then touched the dressing while talking to Resident 17 and their visitor, touched the mobility bar, touched the bandage, touched Resident 17's leg, touched the bandage again, touched their own hair, touched the mobility bar again, touched their face with their left hand, touched their face with their right hand, touched their bangs and handed a green folder to Resident 17 and their visitor. Staff C then touched their own face again, touched the resident's right hand, touched their own face, touched Resident 17's right shoulder, touched their glasses, removed belongings from under Resident 17, cleaned up the room, and touched their own hair. During an interview on 01/08/2025 at 3:31 PM, Staff C, RCM, when asked why the EBP signage was removed before Resident 17 was discharged , said Resident 17 had no infection and the wound was surgical. When asked about what isolation precaution items were needed for wound care, Staff C said if it was a regular wound, then only gloves and hand washing. If wound was infected, then gown, gloves, and mask. When asked if hand hygiene should occur if you touched your face, Staff C said yes. During an interview on 01/09/2025 at 10:58 AM, Staff F, LPN, said gown and gloves should be worn for wound care, and it did not meet expectations they did not wear gowns during Resident 17's wound care. Staff F said it did not meet expectations that the signage was taken down before Resident 17 was discharged . During an interview on 01/13/2025, Staff A, Administrator/DNS/IP, said the observations of staff not wearing gowns during wound care for Resident 17 and the lack of hand hygiene observed after wound care, did not meet expectations. Staff A said the signage for EBP not being displayed did not meet expectations. 2) Resident 33 was admitted to the facility on [DATE]. During an observation on 01/07/2025, Resident 33 had a urinary catheter, intravenous device (IV), and a drain (indwelling medical device used to drain fluids from the body). During an observation and interview on 01/09/2025 at 9:28 AM, Resident 33 was observed to still have their IV and drain, but no longer had a catheter. Resident 33 said they were going home that day. During an observation at 9:32 AM, no signage was seen outside of Resident 33's door. During an interview at 10:58 AM, Staff F, LPN, said they did not see any signage outside of Resident 33's room and the IV had now been removed, but there should have been an EBP sign for their drain. During an observation and interview at 11:49 AM, Staff R, CNA removed a Hoyer lift (device for moving residents) from Resident 33's room. Staff R said they did not wear a gown in the room because there was no signage up on the wall. During an interview on 01/10/2025 at 8:54 AM, Staff M, CNA, said Resident 33 was no longer on EBP. When asked if Resident 33 still had a drain, Staff M said yes. During an interview at 9:00 AM, Staff N, LPN, said there was no signage and Resident 33 should have been on EBP for their drain. During an interview on 01/13/2025 at 9:18 AM, Staff A, Administrator/DNS/IP, said it did not meet expectations Resident 33 did not have signage up and staff did not know about the precautions. <Contact Precaution Room> Review of the facility policy titled Isolation- Categories of Transmission-Based Precautions, revised September 2022, showed Contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment 1) Resident 38 was admitted to the facility on [DATE]. During an observation and interview on 01/08/2025 at 1:43 PM, Staff M, CNA was observed to enter Resident 38's room with another CNA. The signage outside of the room said the resident was on contact precautions. The CNAs were observed to assist Resident 38 with moving from a wheelchair to the bed, using a Hoyer lift. During this observation, multiple items in the room were touched, including the resident, and then the Hoyer lift again. Staff M removed their gown and gloves, hand sanitized, and then touched the door to leave the room with the Hoyer lift. Staff M brought the Hoyer lift to the other end of the building, left the Hoyer lift (without wiping it with disinfectant), and then walked back to their assigned unit and said they were done. During this interview, Staff M said the signage outside of Resident 38's door said contact precautions, and Hoyer lifts were not included in items that needed to be wiped down after use in a contact room. During an interview on 01/08/2025 at 3:05 PM, Staff D, RCM, said the Hoyer lift should have been wiped down after being used in a contact room. During an interview on 01/13/2025 at 9:18 AM, Staff A, Administrator/DNS/IP, said the CNA was incorrect about not needing to wipe down the Hoyer lift after being in a contact room, and their expectation was for it to have been cleaned. <Legionella Water Management Program> According to the Centers for Disease Control and Prevention (CDC) document, Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings, dated 06/24/2021, Legionella is a bacterial contaminate in water systems that can cause pneumonia. Legionnaires' disease has been on the rise in the United States, so Legionella Water Management Programs (LWMP) are now industry standard for large buildings. Key points from the guidelines set forth by the CDC are: 1. Facilities need to actively identify and manage hazardous conditions that support growth and spread of Legionella 2. Examples of where Legionella can grow: a. Hot and cold water storage tanks b. Water heaters c. Water filters d. Faucets and faucet flow restrictors e. Showerheads and hoses f. Pipes, valves, and fittings g. Infrequently used eyewash stations h. Ice machines i. Medical devices including CPAP machines 3. The program's elements should be reviewed annually, when changes occur in regulations or guidelines, or when a major maintenance or water service changes. 4. The LWMP should have a team that includes someone with expertise in infection prevention and diseases, understands accreditation standards/licensing requirements, and risk/quality management staff. 5. Legionella grows best from 77 to 113 degrees Fahrenheit (F) and can still grow outside of this range 6. Residents with healthcare-associated pneumonia (bacterial infection of the lungs with an onset of greater than or equal to 48 hours after admission) should be tested for Legionnaires disease Review of the facility document titled Water Management Program for Building Water Systems Site Management Plan, dated 11/02/2017 and 2019, showed members of the program were Staff O, Environmental Service Director and one other maintenance staff member. Review of the LWMP diagram provided on 01/09/2025, undated and untitled, did not show where water was received from (water from outside of building). The cold water was shown to have started from the mechanical room and went to resident rooms, laundry and kitchen with no mention of gym or other areas in facility with water. The hot water from the water heaters (not shown on diagram) was drawn with a line with the words: Hot to resident rooms, hot out to Laundry and hot out to kitchen. Two of the three water heater lines had temperatures listed, one did not. The diagram did not show water leaving the areas listed as waste. The diagram did not identify where potentially hazardous conditions could occur. During an interview on 01/09/2025 at 8:03 AM, Staff O, Environmental Service Director, said they were the staff member in charge of the program, that one other maintenance member was a part of the team, but that the infection preventionist/administrator was not directly involved. During this interview, Staff O said the facility checked water temperatures once a week to make sure the temperature in resident rooms were no lower than 100 degrees F and no higher than 120 degrees F. When asked if that prevented Legionella from growing, Staff O said it did not. Staff O said they did not have a process for monitoring how long a room was empty for and ensuring faucets were flushed. During this interview, Staff O was able to verbalize, but was unable to show in writing/diagram, what interventions the facility would implement if control measures (what the facility does to limit growth/spread of Legionella) were not met and what would occur for a contingency response (such as construction). Staff O verbally said remediation should occur in these situations, then looked through the LWMP binder, and said they could not find the remediation steps in the binder, and it should have been there. During this interview, Staff O said the LWMP was reviewed once a year by them by reviewing sampled water Legionella test results. Staff O said they did not participate in QAPI (facility's quality assurance and performance improvement) related to Legionella. When asked if they could show how the facility documented and communicated all activities of the LWMP, Staff O said the only thing available was the sampled water Legionella test results. During a follow up phone interview on 01/09/2025 at 2:38 PM, Staff O said the LWMP had not identified ice machines as an area of growth for Legionella. After reviewing the facility's LWMP policy on other at-risk water systems, that included ice machines, Staff O mentioned the ice machines were cleaned and descaled every six months (the receipts were not readily available in the LWMP binder). During an interview on 01/10/2025 at 11:29 AM, Staff A, Administrator/DNS/IP, when asked their role in the LWMP said they were a member of the team, they understood the process and how it related to infection control, but maintenance was in charge of the testing. When asked for an example of how the facility would screen a resident for Legionnaires, Staff A said they could not provide an example, they had not had to screen because they had not had a scenario of when it would be applicable. When asked if the facility diagram showed where water from the drinking fountain was from (observed outside of the gym), Staff A said it did not. During this same interview at 11:29 AM, Staff P, Regional [NAME] President, said areas of concern at the facility for Legionella included CPAP machines with a water reservoir. Staff P said the facility diagram did not show areas of concern, only the standard way water came into the building and was distributed, and that they could identify areas of concern on the diagram. Staff P said the contingency plan should have been added to the LWMP binder. <Sharps Containers> During observations on 01/08/2025 at 3:00 PM and 01/09/2025 at 9:20 AM, room [ROOM NUMBER]'s sharps container (container for discarding sharp items) was full, with the flap up saying full. During observations on 01/07/2025 at 11:49 AM, 01/08/2025 at 3:54 PM, 01/09/2025 at 9:20 AM, and 01/10/2025 at 8:53 AM, room [ROOM NUMBER]'s sharps container was full. During observations on 01/08/2025 at 3:53 PM and on 01/09/2025 at 9:38 AM, room [ROOM NUMBER]'s sharps container was full. During an interview and observation on 01/09/2025 at 10:32 AM, Staff F, LPN, went into rooms [ROOM NUMBER], and confirmed the sharps containers were full. During an observation on 01/09/2025 at 11:32 AM, room [ROOM NUMBER]'s sharps container was full. During an observation on 01/10/2025 at 6:23 AM, room [ROOM NUMBER]'s sharps container was full. During an interview on 01/13/2025 at 9:18 AM, Staff A, Administrator/DNS/IP, said they expected staff to immediately address sharps containers being full when they became aware of it, and it did not meet expectations a sharps container was observed to still have been full after staff had been notified. Reference WAC 399-97-1320 (1)(a)(c), (2)(a)(b) 37044

Based on interview and record review, the facility failed to ensure the antibiotic stewardship program had an accurate and complete antibiotic line listing, with symptoms and McGeers Criteria (tool for infection surveillance and antibiotic stewardship, provided criteria to show if antibiotics were indicated) reviewed, and providers were updated on residents that did not meet criteria for antibiotic usage, for 3 of 3 residents (Resident 30, 354, & 355) reviewed for antibiotic line listing. This failure placed residents at risk of developing multi-drug resistant organisms, unidentified care needs, and a diminished quality of life. Findings included . During an interview on 01/08/2025 at 8:14 AM, Staff A, Administrator/Director of Nursing Services (DNS)/Infection Preventionist (IP), when asked to describe the antibiotic stewardship program, said they looked to see if the antibiotic use was appropriate/indicated, reviewed cultures as they resulted, and made sure the treatment/antibiotic was susceptible to the organism. Staff A said the facility was using McGeer Criteria. 1) Resident 30 was admitted to the facility on [DATE]. Review of Resident 30's Electronic Health Record (EHR), showed Resident 30 was prescribed Macrobid (an antibiotic) for a urinary tract infection (UTI) from 11/28/2024 to 12/07/2024. Review of Resident 30's progress notes showed on 11/21/2024 that Resident 30 had symptoms of fatigue, general unwellness, and dizziness. The bladder scanner showed possible urinary retention, so an in and out urinary catheterization (tube that goes into bladder to remove urine) was done, with one liter of urine removed from the bladder. A note on 11/22/2024 showed laboratory values, including a urinary analysis with culture and sensitivity, were ordered for dizziness, bladder distention and retention of urine for three days. An indwelling (device left inside the body for a period of time) urinary catheter was placed. Progress notes on 11/28/2024 showed Resident 30 had vaginal discharge with an odor, and later complained of pain in their vaginal area. One note said, I did a urine dip that resulted in positive leukocytes, protein, and blood. Called the on-call provider and was instructed to send a urine culture to test out for bacteria. Review of the EHR showed the urine sample sent to the laboratory on 11/22/2024 had a urinary analysis that did not indicate culture. The urine sample sent to the laboratory on 11/28/2024 was ran as a urinary analysis which did not indicate culture. The progress note above stated that the provider on 11/28/2024 instructed for a urine culture to be obtained, not a urinary analysis (it was already completed in the form of a urinary dip test). No urinary culture was obtained in the record before the antibiotic was started. Review of the November 2024 antibiotic line listing, showed Resident 30 had listed: a. admitted [DATE] b. Symptom onset date of 12/28/2024 c. Signs and symptoms- pain, urgency d. Antibiotic start date/end date- 11/28/2024 to 12/02/2024 e. Date of culture 11/28/2024 f. Organism on culture- not indicated g. Drug sensitivity- susceptible The symptom of urgency was not found in the EHR. Resident 30 had a urinary catheter on 12/28/2024. There was no culture ran on 11/28/2024, and therefore there was no organism found in order to determine the organism was susceptible to the antibiotic. Review of the December 2024 antibiotic line listing, showed Resident 30 had listed: a. admitted [DATE] b. Symptom onset date of 12/20/2024 c. Antibiotic start date/end date- 12/02/2024 to 12/07/2024 d. Signs and symptoms- urgency, frequency, burning e. Date of culture 12/21/2024 f. Organism on culture- not indicated g. Drug sensitivity- susceptible The symptom onset date of 12/20/2024 and the date of culture of 12/21/2024, were after antibiotics had finished on 12/07/2024. There was no organism listed to be able to determine if it was susceptible to the antibiotic. The symptoms of urgency and frequency were not found in the EHR, as symptoms for antibiotics being reordered. During an interview on 01/09/2025 at 9:40 AM, Resident 30, when asked when they have had a UTI while having a urinary catheter in place, if they develop increased urgency or the sensation of needing to urinate more, said no. During an interview on 01/13/2025 at 2:33 PM, Staff A, Administrator/DNS/IP, when asked how they knew Macrobid was the appropriate antibiotic for Resident 30, said they did not. When asked if there was a urine culture on 11/28/2024, Staff A said that the urinary analysis came back as not indicated for a culture, and there was no culture and sensitivity done. Staff A said that for the 12/21/2024 culture listed on the antibiotic line list, that this was done in error since the antibiotic ended on 12/07/2024. When asked how symptoms were obtained from Resident 30 with a urinary catheter in place, Staff A looked at the symptoms on the line list and said they would not think Resident 30 would be able to say frequency or urgency with a urinary catheter in place. When asked if either the 11/28/2024 or 12/02/2024 doses met McGeers Criteria, Staff A said no. Staff A said when it did not meet McGeers Criteria, that the provider should have been notified and it should have been documented. 2) Resident 354 was admitted to the facility from 11/01/2024 to 11/04/2024. Review of the EHR, showed Resident 354 on 11/04/2024 had a sputum culture that was sent to the laboratory, which was described to be mostly blood. Review of the November 2024 antibiotic line listing, showed Resident 354 had two lines listed, both documented that Resident 354: a. admitted [DATE] b. symptom onset date of 11/05/2024 c. sign and symptoms- per hospital d. date of culture- per hospital e. organism on culture- na (not applicable) f. drug sensitivity- susceptible Further review of the line listing for Resident 354 showed one antibiotic was started on 11/01/2024 and the second antibiotic was started on 11/12/2024. During an interview on 01/13/2025 at 2:33 PM, Staff A, Administrator/DNS/IP, when asked if Resident 354 met McGeer Criteria, said no they did not think Resident 354 met criteria. When asked what their symptoms were, Staff A said it looked like the antibiotic line listing should have included symptoms for the pneumonia (lung infection). When asked about the onset date of symptoms being after the resident had left the facility, Staff A said the onset date looked incorrect. When asked about the culture that said per hospital, if one was done before the start of the antibiotics and what the result was, Staff A said this was missing information. 3) Resident 355 was admitted from 10/02/2024 to 10/10/2024. Review of the October 2024 antibiotic line listing, showed Resident 355 had two lines listed, both documented that Resident 354: a. admitted [DATE] b. sign and symptoms- rosacea c. date of culture- N/A (not applicable) d. organism on culture- empty e. drug sensitivity- susceptible f. stop dates- N/A During an interview on 01/13/2025 at 2:33 PM, Staff A, Administrator/DNS/IP, when asked if Resident 355 met McGeer Criteria or if there was documentation of a conversation with the provider when criteria was not met, said no to both questions. When asked about how long Resident 355 was on antibiotics for, Staff A said Resident 355 was on antibiotics until discharge and it should have been updated on the antibiotic line list. During this interview, Staff A said without a culture they could not know if the organism was susceptible to the antibiotic, that the residents on the line listing that said, per hospital did not have any additional forms with symptoms listed and they should be listing the symptoms. Staff A said the examples listied during the interview did not meet expectations. No Associated WAC

Based on interview and record review, the facility failed to develop and implement a baseline care plan, within 48 hours of admission, that included instruction needed to properly care for 1 of 11 residents (Resident 105) reviewed for new admission. This failure placed residents at risk for unidentified and unmet needs, and other negative health outcomes. Findings included . Resident 105 admitted to the facility on [DATE] with orders for oral suctioning, which is an aerosol generating procedure (AGP/a procedure that creates respiratory particles that are small and light enough to remain suspended in air for long periods of time and that can travel past six feet from source and through surgical masks). Review of the baseline care plan showed it was not identified the resident required suctioning or AGP precautions. On 01/13/2025 at 11:01 AM, Staff D Resident Care Manager (RCM), said Resident 105's need for suctioning and AGP precautions should have been addressed on the baseline care plan. Resident 105 admitted with an order for NPO (nothing by mouth). Review of the baseline care plan showed the resident's NPO status was not identified. On 01/13/2025 at 11:01 AM, Staff D, RCM, said Resident 105's NPO status should have been on the baseline care plan. Review of Resident 105's baseline care plan showed no instruction was provided to staff on how to provide oral care to the resident given their NPO status (e.g. brush teeth with toothpaste, used moistened toothettes etc.), or who was to provide it (licensed staff, nurses' aides etc.). On 01/13/2025 at 11:01 AM, Staff D, RCM, said direction on how to provide oral care to resident 105 should have been on their baseline care plan. Reference WAC 388-97-1020(3)

Based on interview and record review, the facility failed to ensure residents and/or their representatives were offered the opportunity to participate in care conferences for 5 for 6 sampled residents (Resident 21, 156, 154, 40 & 25) reviewed for right to participate in planning care. This failure placed residents at risk of a diminished quality of life when not allowed to be involved in their long-term care needs. Findings included . 1) Resident 21 was admitted to the facility on [DATE]. The Admission Minimum Data Set (MDS, an assessment tool), dated 12/09/2024, documented Resident 21 was cognitively intact. On 01/07/2025 at 2:45 PM, Resident 21 said they had not had a care conference or any meeting to discuss their care while at the facility. The Electronic Health Record (EHR) documented Resident 21 had no care conference since being admitted . On 01/13/2025 at 10:01 AM, Staff A, Administrator, said no formal care conference was completed with Resident 21. Staff A said a care conference should have been completed. 42960 2) Resident 156 was admitted to the facility on [DATE]. The MDS 5-day scheduled assessment dated [DATE], documented Resident 156 was moderately cognitively impaired. On 01/07/2025 at 12:53 PM, Resident 156's representative said they had reached out to social services because they knew what they wanted for discharge and wanted to begin the process. A record review of the EHR showed Resident 156 had no care conferences since admission. On 01/10/2025 at 8:22 AM, Staff Y, Social Services Coordinator, said Resident 156's representative said they had reached out to her regarding discharge. A care conference was scheduled but Staff Y said she canceled it. On 01/13/2025 at 10:42 AM, Staff A, Administrator, said Resident 156 did not receive a care conference and her expectation would be for staff to document the rationale for why it was canceled. 3) Resident 154 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], documented Resident 154 was cognitively intact. On 01/07/2025 at 12:10 PM, Resident 154 said they had not been contacted by staff to set up a care conference to discuss care planning or schedule a care conference. A record review of the EHR showed a progress note on 01/09/2025 by Staff Y, Social Services Coordinator, documented patient was wondering about her discharge status, and Staff Y said she would update them today after a meeting where staff reviewed care planning. On 01/13/2025 at 10:42 AM, Staff A, Administrator, said Resident 154 did not have a care conference and this did not meet her expectations because Resident 154 initiated a meeting with social services to discuss discharge planning. 4) Resident 40 was admitted to the facility on [DATE]. The 5-day MDS, dated [DATE], documented Resident 40 was moderately cognitively impaired. On 01/07/2025 at 2:18 PM Resident 40 said that they had not had a care conference and staff had not talked to them about scheduling one. A record review of Resident 40's EHR showed a progress note on 01/09/2025 by Staff Y, Social Services Coordinator, said Resident 40 asked her to call their representative to set up a care conference. On 01/10/2025 at 8:22 AM, Staff Y, Social Services Coordinator, said Resident 40 asked me to set up a care conference after I talked to them yesterday. On 01/13/2025 at 10:42 AM, Staff A said Resident 40 has not had a care conference and this does not meet her expectation because Resident 40 initiated the process of setting up a care conference. Staff A said in the future they plan to offer to set up a care conference when they provide residents their base line care plan and document it in the EHR. 5) Resident 25 was admitted to the facility on [DATE]. The Admission MDS, dated [DATE], documented Resident 25 was severely cognitively impaired. On 01/07/2025 at 10:28 AM, Resident 25's representative said they had not had a care conference, and they had to talk to the case worker to find out what the plan for discharge was after being admitted to the facility for 12 days. A Review of Resident 25's EHR showed Resident 25 had not had a care conference since admission. On 01/09/2025 at 3:10 PM, Staff G, Resident Care Manager said Resident 25 did not have a care conference. Reference WAC 388-97-1020(2)(f)

Based on interview and record review, the facility failed to provide written bed hold notices at the time of transfer to the hospital for 2 of 2 sampled residents (40 and 30) reviewed for hospitalization . This failure placed the residents at risk for lack of knowledge regarding their right to hold their bed while in the hospital. Findings included . 1) Resident 40 was admitted to the facility on [DATE]. The 5-day Minimum Data Set (MDS, an assessment tool) dated 12/16/2024, documented Resident 40 was moderately cognitively impaired. A review of the Electronic Health Record (EHR) showed Resident 40 was transferred to the hospital on 12/21/2024 and returned to the facility on [DATE]. Resident 40's EHR did not show documentation that Resident 40 was offered and/or provided a bed hold notice at the time of transfer. On 01/09/2025 at 3:40 PM, Staff G, Resident Care Manager, said the bed hold policy was addressed when a resident was admitted to the facility and not when they are transferred to the hospital. On 01/09/2025 at 3:58 PM, Staff E, Admission Coordinator, said she did not have a bed hold notice for Resident 40. On 01/13/2025 at 10:42 AM, Staff A, Administrator, said she did not see a bed hold notice for Resident 40 and acknowledged it should have been done when Resident 40 was transferred to the hospital. 46793 2) Resident 30 was admitted to the facility on [DATE]. The 5 Day MDS, dated [DATE], documented Resident 30 was cognitively intact. Resident 30's EHR showed Resident 30 was transferred to the hospital on 11/12/2024 and returned to the facility on [DATE]. Resident 30's EHR did not show documentation that Resident 30 was offered and/or provided a bed hold notice at the time of transfer. On 01/10/2025 at 1:29 PM, Staff E, Admissions Coordinator, said the bed hold should have been sent with the resident at the time of transfer to the hospital. Staff E said they did not find a bed hold notice for Resident 30 and their should have been a bed hold notice. On 01/13/2025 at 10:01 AM, Staff A, Administrator, said the bed hold notices should be offered to the resident, when transferring to the hospital. Staff A said if the bed hold was not the EHR, then it was not completed. Staff A said a bed hold should have been offered. Reference WAC 388-97-0120 (4)

Based on interview and record review, the facility failed to provide a written transfer/discharge notice to the resident and/or their representative for 2 of 2 sampled residents (Residents 30 & 40), reviewed for hospitalization . This failure placed the resident and/or their representative at risk for not having an opportunity to make informed decisions about transfers/discharges. Findings included . 1) Resident 30 was admitted to the facility on [DATE]. The 5-Day Minimum Data Set (MDS, an assessment tool), dated 11/19/2024, documented Resident 30 was cognitively intact. Resident 30's Electronic Health Record (EHR) showed Resident 30 was transferred to the hospital on 11/12/2024 and returned to the facility on [DATE]. Resident 30's EHR did not show documentation that Resident 30 was offered and/or provided a transfer/discharge notice. On 01/10/2025 at 1:29 PM, Staff E, Admissions Coordinator, said the transfer notice should have been sent with the resident at the time of transfer to the hospital. Staff E said she was unable to determine if Resident 30 had a transfer notice sent with them to the hospital. On 01/13/2025 at 10:01 AM, Staff A, Administrator, said transfer notices should be completed in Point Click Care (PCC, Electronic Health Record system) and sent with the resident at the time of transfer. Staff A said if the transfer notice was not in PCC, then it was not completed. Staff A said a transfer notice should have been completed. 42960 2) Resident 40 was admitted to the facility on [DATE]. The 5-day MDS, dated [DATE], documented Resident 40 was moderately cognitively impaired. A review of the EHR showed Resident 40 was transferred to the hospital on 12/21/2024 and returned to the facility on [DATE]. Resident 40's EHR did not show documentation that Resident 40 was offered and/or provided a transfer/discharge notice. On 01/09/2025 at 3:40 PM, Staff G, Resident Care Manager, said she was not sure if the transfer notice was reviewed with Resident 40 and or their representative when they were sent to the hospital. Staff G said the transfer paperwork was sent with Resident 40 to the hospital and she did not have a copy or proof that it was provided. On 01/09/2025 at 3:58 PM Staff E, Admission Coordinator, said she did not have a transfer notice for Resident 40. On 01/13/2025 at 10:42 AM, Staff A, Administrator said she did not find a transfer notice for Resident 40 and said there was no documentation that it was completed. Reference WAC 388-97-0140 (1)(a)(b)(c)(i-iii)

Based on interview and record review, the facility failed to ensure resident choices regarding bathing type were honored for 1 of 4 sampled residents (Resident 103) reviewed for choices. The facility's failure to accommodate resident preferences related to type of bathing placed residents at risk for feelings of un-cleanliness, powerlessness, diminished self-worth, and a decreased quality of life. Findings included . Resident 103 was admitted to the facility on [DATE]. The Entry Minimum Data Set, an assessment tool, dated 01/05/2025, documented Resident 103 was cognitively intact, and required assistance with bathing and transfer. On 01/08/2025 at 9:25 AM, Resident 103 said they were told they could not have a shower and were told they could only receive a bed bath. Resident 103 stated, I want a shower. On 01/10/2025 at 6:23 AM, Resident 103 said they received a bed bath yesterday and was told they could not have a shower due to mobility. The Electronic Health Record documented Resident 103 was scheduled to receive showers on Tuesdays, Thursdays and Saturdays on evening shift. Resident 103 had received a bed bath on 01/07/2025 and 01/09/2025. On 01/10/2025 at 12:59 PM, when asked what would prevent a resident from receiving a bed bath instead of a shower, Staff D, Resident Care Manager, said if the resident needed a Hoyer lift, due to the Hoyer lift not fitting in the shower room, the resident would not receive a shower, but a bed bath instead. Staff D said physical therapy would assess a resident's ability to transfer and if the resident was not able to transfer, then they would receive a bed bath. On 01/13/2025 at 10:01 AM, Staff A, Administrator, said the only reason a resident would not receive a shower versus a bed bath would be resident preference or transfer status, meaning the resident was bed bound. Staff A said if the resident could be transferred to the shower chair, the resident should receive a shower per their preference. When asked if Resident 103 should have received a shower, Staff A said the expectation was the resident received a shower. Reference WAC 338-97-0900(1)-(4)

Based on observation, interview and record review, the facility failed to provide the assessed level of supervision required to ensure residents were free from avoidable accidents for 1 of 3 residents (Resident 1) reviewed for accident hazards. Additionally, the facility failed to document supervision for 2 of 2 residents (Residents 1 & 2) reviewed for accident hazards. Resident 1 experienced harm when they fell from bed and sustained a hip fracture, pain, and hospitalization . This failure placed residents at risk for injury and a diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, bipolar disorder (mental illness that can cause unusual shifts in mood, energy, activity levels, and concentration), and heart failure. The quarterly Minimum Data Set (MDS), dated [DATE], documented Resident 1 had severe cognitive impairment and required partial to moderate assistance from staff with activities of daily living (ADLs). The 06/28/2024 MDS documented Resident 1 had two falls with no injury during the assessment period. The MDS, dated [DATE], documented Resident 1 had two falls with no injury during the assessment period. The care plan, dated 06/28/2024, documented Resident 1 was at risk for falls due to a decline in the resident's function, decreased independence and having had ten falls. Interventions included that staff would ensure the resident's needs were met, furniture was locked, was not moved, and a clear pathway was maintained. A sensor alarm would be used in the resident's wheelchair and while in bed to alert staff of a potential fall. Resident 1 would have one-to-one supervision while up and in their wheelchair due to poor safety awareness and elopement risk. Resident 1's medical record showed Resident 1 had unexpected falls on 05/19/2024, 05/30/2024, 06/01/2024, twice on 06/02/2024, 06/03/2024, 06/08/2024, 06/12/2024, 07/05/2024, and 07/06/2024 (fall with major injury). The facility did not consistently identify the root cause of the falls, complete an assessment to identify a pattern in Resident 1's falls, or ensure interventions were implemented to prevent an unexpected fall. On 06/08/2024, Resident 1 was found sitting on the floor in her room. The sensor alarm was not attached to the resident. The NA (nursing assistant) was educated on the use of the sensor alarm and one-to-one supervision was implemented on 06/10/2024. Physician orders, dated 06/10/2024, showed orders for one-to-one supervision for Resident 1. Physician orders, dated 06/25/2024, showed updated orders for one-to-one supervision while the resident was up in their wheelchair due to poor safety awareness and elopement risk during all shifts. Progress notes, dated 07/01/2024, documented one-to-one continued for the shift. Progress notes, dated 07/05/2024, documented Resident 1 was on a one-to-one for safety. Progress notes, dated 07/06/2024, documented Resident 1 had sustained a fall at 1 AM and the nurse who responded documented her assessment which matched the fall investigation. When the resident was questioned as to why she was trying to get up, the resident said she was trying to see what everyone was doing outside and verbalized that her room was different, and it didn't feel like her home. The note showed the resident had been moved that same day to be in a room with another resident that required a one-to-one. The nurse documented Resident 1 had only been scheduled to have a one-to-one during the day and evening shifts but not on the night shift. Facility fall investigation, dated 07/06/2024, documented Resident 1 was found on the floor of their room at approximately 1:00 AM, was assessed for injuries and assisted back to bed. The investigation showed the nurse who responded to the fall noted the resident was on the floor, bare foot, the floor was wet, and the resident's sensor alarm was not on. An x-ray was ordered of the resident's hip, and they were transferred to the emergency room for right hip fracture. Contributing factors to the fall were noted as; the floor was wet, the resident recently changed rooms and was ambulating without assistance. The hospital History and Physical, dated 07/07/2024, documented Resident 1 had sustained a right hip fracture because of a fall. The resident's hip fracture did not require surgical intervention. On 09/05/2024 at 8:02 AM, Staff E, NA, said they were an agency NA. Staff E was Resident 1's primary care giver on the night the resident fell . Staff E said someone had called in shortly before the shift started and the shift was not covered, causing the staff to have to pick up additional residents. Staff E was assigned to Resident 1 and their roommate, who both required one-to-one supervision, and about ten other residents. A nurse told Staff E everything would be fine, and they would help them watch residents. Staff E said they were aware Resident 1 required a sensor alarm and knew it was on the resident at one point. Staff E did not have time to check to make sure the sensor alarm was still in place. Staff R was helping other resident's when Staff F, NA, found Resident 1 on the floor. Staff E said they were not asked to give a statement regarding contributing factors to Resident 1's fall. Staff E said they felt they were blamed for Resident 1 falling and Staff E was asked not to return to the facility. On 09/26/2024 at 11:45 AM, Staff G, NA, said they were an agency NA who worked the night of Resident 1's fall. Staff G said they remembered Resident 1 required one-to-one supervision due to a fall risk. Resident 1 had been recently moved from a room next to a nurses' station to another room at the end of the hall. Resident 1 was moved into a room with another resident who required one-to-one supervision. Staff G said, in all their experience, they had never seen a resident at risk for falls moved further from staffs' view. Staff G said it was too far to see in the room. Staff G said they were not involved in Resident 1's care the night of the fall, but did recall that staff called in and were not replaced and this increased everyone's workload. The staff caring for Resident 1 had two residents requiring one-to-one supervision and other residents to provide care. On 09/27/2024 at 10:01 AM, Staff F said they were an agency NA who worked the night of Resident 1's fall. Staff F said a staff member called in shortly before the shift started and no one was called in to cover the shift. Staff F said Staff E had two residents who required one-to-one supervision as well as other residents to assist. Staff F said normally the facility provided enough staff to cover the shift, but this was a unique night. Staff F said the number of staff were not enough to cover the one-to-one supervision needed for Resident 1 and their roommate. During the shift, Staff E was called out of Resident 1's room. Staff F heard someone yelling and found Resident 1 on the floor in their room. Staff F called the nurse, and they assisted the resident back into bed. Staff F said they were not asked to give statements regarding contributing factors to Resident 1's fall. Facility NAC (Nursing Assistant - Certified) Daily Sheet, dated 07/05/2025, documented one one-to-one for Staff I, NA. No staff call-ins were noted. No rooms were noted to be assigned to each NAs. Staff E did not have a resident with one-to-one supervision assigned to them. On 09/27/2024 at 2:30 PM, an observation was made of Resident 1's original room which was directly across from the nurses' station and would provide for visual checks of the resident. The room was surrounded by the community area, busy with staff and visitors. Observations of the room Resident 1 had been moved to the same day as the fall with injury. The room was near the end of a long hall. The room was separated from the community area and away from activity of the facility. At 2:58 PM, Staff H, NA, said residents at risk for falls were kept in a highly supervised area. Staff H said residents who were high fall risk required frequent visual checks. Staff H said sometimes residents required a sensor alarm to alert staff if they were attempting to self-transfer. At 3:04 PM, Staff D, Registered Nurse (RN), said normally they would keep a resident near the nurses' station if they were at risk for falls. They need to make frequent visual checks of these residents. They often use sensor alarms if someone was a fall risk to alert staff if the resident attempted to get up. Staff D said they were unsure why Resident 1 was moved to a room down the hall because the prior room was next to the nurses' station. Staff D said there was no standard form or means of documenting the assessment of a resident once they fall. They used a post-fall form which addressed only the current fall, but they were not evaluating the overall history and patterns of resident's falls. At 3:24 PM Staff C, RN, said they had no standard falls assessment form to use when they needed to re-assess a resident for fall risk. Staff C said they would use nursing judgement to complete an assessment. At 4:00 PM, Staff B, RN and Director of Nursing (DNS), said they did not comprehensively assess Resident 1's fall. Staff B said they did not implement interventions consistently. Staff B was unaware a staff called off on the night of Resident 1's fall. Staff B said the NAC Daily Sheet should reflect the assignments and any updates due to call-ins. Staff B said Resident 1 was moved to be in the same room as another resident who required a one-to-one. Staff B admitted there were times a staff member would not be able to watch both residents. Staff B said there was no regular form used for fall risk assessment after admission. <1:1 supervision> <Resident 1> Resident 1 was admitted to the facility on [DATE] with diagnoses of major depressive disorder, bipolar disorder, and heart failure. The quarterly MDS, dated [DATE], documented Resident 1 has severe cognitive impairment. Resident 1 required partial to moderate assistance from staff with activities of daily living (ADLs). The care plan, dated 06/28/2024, documented Resident 1 is at risk for falls due to a history of decline in function and independence and repeated falls. Interventions showed Resident 1 would have one-to-one supervision while up in their wheelchair due to poor safety awareness and elopement risk. Physician orders, dated 06/10/2024, showed orders for one-to-one supervision for Resident 1. Physician orders, dated 06/16/2024, showed orders for one-to-one supervision for fall prevention. The resident has poor safety awareness. Invite resident into community area for visual supervision. Staff to meet need of resident (toileting, comfort, etc.). Physician orders, dated 06/25/2024, showed updated orders for one-to-one supervision while the resident was up in their wheelchair due to poor safety awareness and elopement risk during all shifts. Progress notes, dated 07/01/2024, documented one-to-one continued for the shift. Progress notes, dated 07/05/2024, documented Resident 1 was on a one-to-one for safety. A review of the medical record showed no documentation of one-to-one supervision for Resident 1. <Resident 2> Resident 2 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD) and ischemic cardiomyopathy (the heart muscle cannot pump effectively due to lack of blood supply). The admission MDS, dated [DATE], documented Resident 2 had moderate cognitive impairment. Resident 2 required supervision with ADLs. Progress notes, dated 06/22/2024, documented staff had found the resident in the facility parking lot. Resident 2 said they wanted to leave and get out of here. A nurse from another unit brought the resident back to the nurses' station in a wheelchair and reported they had been found in the parking lot of the facility. Resident 2 had been seen ten minutes prior. Notifications were made and the resident was placed on a one-to-one. A review of the medical record showed no documentation of one-to-one supervision for Resident 2. On 09/27/2024 at 4:00 PM, Staff B said they did not document one-to-one supervision. Staff B said they could not show the one-to-one supervision intervention had been implemented for Resident 1 or Resident 2. Reference WAC 388-97-1060(3)(g)

Based on interview, observation and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice when a change of condition was not addressed timely for 1 of 3 residents (Resident 1) and when neurological (neuro) assessments were not consistently performed following unwitnessed falls for 3 of 3 residents (Resident 1, 2, and 3) reviewed for quality of care. Resident 1 experienced harm when they had to be emergently transferred to the hospital when they had a significant change in their baseline cognition and status following an unwitnessed fall. These failures placed residents at risk for medical complications, poor clinical outcomes, unmet care needs, pain, and a diminished quality of life. Findings included . Review of the facility policy, titled, Change in Resident's Condition or Status, revised May 2017, documented the nurse would notify the physician or physician on call when there was a change in the residents' physical, emotional, or mental condition. Review of the facility policy, titled Falls-Clinical Protocol, revised March 2018, documented residents would be assessed for fall risks. Nursing staff would assess, document and report changes in cognition or level of consciousness, neurological status, and pain. Review of the facility document, titled, Incident Report Licensed Nurse Checklist, undated, documented nurses were to initiate neuro checks for all residents that hit their head or any unwitnessed falls for patients that were not cognitively intact. The document included a page titled, [facility name] Neurological Record. The bottom of that document showed neuro checks were to be performed every 15 minutes times four, then every hour times four, then every shift for 72 hours. <Resident 1> Resident 1 was readmitted to the facility on [DATE] with diagnoses and problems including a lumbar compression fracture with recent surgical intervention, frequent falls and a baseline cognitive disorder. The Medicare 5-day Minimum Data Set (MDS), an assessment tool, dated 09/15/2022, documented Resident 1 was cognitively impaired. The care plan, initiated 09/08/2022, documented Resident 1 was alert and oriented to person, place, time, and situation. Per the care plan, Resident 1 had hearing and visual impairment and was at risk for falls. Review of a provider note, dated 09/19/2022 and untimed, documented Resident 1 was in no acute distress, their pain appeared well controlled, and the resident appeared comfortable. The resident had a urinalysis that showed signs of a urinary tract infection and an antibiotic was started. The resident also showed increased wheezing and coughing and a chest x-ray was ordered. Chest x-ray results were not found in the medical record or provided by the facility. Review of a daily skilled summary note, dated 9/19/2022 at 11:01 PM, documented, Resident 1 was more alert and less confused, oriented to person, no cognitive or behavior changes were noted, no changes to speech noted, cough and weakness were noted, Resident 1 reported severe pain, and the pain medication increased their ability to rest. Review of a daily skilled nursing note, dated 09/20/2022 at 8:15 PM by Staff D Licensed Practical Nurse (LPN), documented Resident 1 had increased confusion, was fearful, unaware of surroundings and situation, and staff were unable to reorient Resident 1. Resident 1 displayed jumbled speech and decreased oral intake of less than 50% of their food and fluids were offered. Documentation of provider notification of these assessed findings was not found in the medical record or provided by the facility. Review of a facility investigation report, dated 09/21/2022 at 4:06 PM, documented Resident 1 was found on the floor and reported he fell while using his walker, unassisted. The report documented when the resident was asked what happened, they said, I was just moving and felt like it. Resident 1 was assessed for injury, with no injuries noted and neurological assessments were initiated. Review of Resident 1's medical record showed neurological assessments were performed at 4:06 PM, 4:21 PM, 4:36 PM, 4:51 PM, 5:51 PM. Review of a daily skilled summary note, documented by Staff D, dated 09/21/2022 at 8:10 PM, showed Resident 1 called out loudly, repeatedly, was confused, disoriented and restless. Resident 1's speech was jumbled and unintelligible. Resident 1 was unable to tolerate repositioning without extreme pain even with two-person assist, and decreased oral intake of food and fluids eating less than 25% of food and fluids offered, rattled breathing and shortness of breath [SOB] noted at rest, worsened with lying flat, and disoriented, and severe pain continues this shift, now unable to tolerate efforts to reposition. Documentation of provider notification of these assessed findings was not found in the medical record or provided by the facility. Review of a neuro check summary, dated 09/21/2022 at 9:10 PM, documented Resident 1 was restless, lethargic, drowsy, unable to follow commands, and words were unintelligible. Documentation of provider notification of these assessed findings was not found in the medical record or provided by the facility. There were no clinical notes or neuro check summary notes in Resident 1's medical record between 09/21/2022 at 9:10 PM to 09/22/2022 at 6:17 PM, when a late entry note was made regarding the resident's condition at 8:45 AM on 09/22/2022. No additional documentation was provided by the facility. Reivew of a nursing note, dated 09/22/2022 at 6:17 PM, documented at 8:45 AM that morning Resident 1 had been found moaning loudly, unable to swallow or drink fluids, unable to follow simple commands and was transported to the emergency room (ER) for evaluation. Review of an ER Provider note, dated 09/22/2022 at 9:21 AM, documented the resident arrived at the ER for decreased mental ability/confusion. The resident was unable to voice any words and any movement caused them pain. The ER provider documented the emergency medical transport service staff received a limited report, as it was change of shift at the facility. Resident 1 was admitted to the intensive care unit based on the number of fractures and for severe sepsis. A hospital diagnostic imaging report, dated 09/22/2022 at 10:43 AM, documented Resident 1 was found to have multiple sternal (breastbone) fractures, multiple right upper rib fractures involving the first through fifth ribs, and new compression fracture deformities of C7, T1, T2, T3, T4 (Cervical and Thoracic vertebra) and a small, new right sided pleural effusion (excessive collection of fluid in the lungs). On 01/11/2024 at 3:40 PM, Staff C, Licensed Practical Nurse (LPN)/Resident Care Manager (RCM), said when staff find a resident on the floor, staff were to get help, make sure the resident was safe and allow the nursing staff to start their assessments on the resident, including neurological checks. Staff C said neuros were supposed to be completed every 15 minutes for one hour, then once an hour for four hours and then every shift for 72 hours. Staff C said if there were any concerns regarding the resident, they were documented in the medical record. Staff C said staff were to notify the Care Manager, the provider, and the family. At 3:55 PM, when asked about Resident 1's condition, Staff B, Registered Nurse (RN), Administrator in Training (AIT) and Director of Nursing Services (DNS) (with Staff A, Administrator, present for interview), said Resident 1 was admitted to the facility with a lumbar fracture. Staff B said the Resident was in a lot of pain and hollering out. Staff B said a Certified Nursing Assistant found Resident 1 on the floor on 09/21/2022. Staff B said Staff D, LPN, had stayed with Resident 1 all that night. Staff B said Staff D had first kept the medication cart outside Resident 1's room to keep a visual on them and then after Staff D had completed their medication pass to their assigned residents, Staff D was reported to have been in Resident 1's room all night. Staff B said Resident 1 was found non-responsive at 8:45 AM on 09/22/2022. When asked about Resident 1's neuro checks, Staff B said neuro checks were completed at 4:06 PM, 4:21 PM, 5:50 PM, and 9:10 PM. On 01/12/2024 at 10:45 AM, Staff B, RN/AIT/DNS (with Staff A, Administrator, present for interview), when asked why only four neuro checks were documented, Staff B said the staff member was sitting in the room with Resident 1 all night. When asked about staff documentation including assessments, neuro checks and progress notes regarding Resident 1, Staff B stated, unfortunately she was not charting what she needed to chart. When asked if neuro checks should have been completed, Staff B said Staff D had not done neuro checks because Resident 1 had no abnormalities in his baseline. On 02/12/2024, Collateral Contact 1 (CC1) said they visited Resident 1 every day and CC1 said after they left on the day Resident 1 fell (09/21/2022), they were called by the facility and informed Resident 1 fell and was found in front of the bathroom floor, but everything was fine. The following morning (09/22/2022), CC1 said they received a call that Resident 1 was non-responsive, and they were sending the resident to the hospital. On 03/28/2024 at 2:11 PM Staff B, RN/AIT/previous DNS, said residents who had unwitnessed falls would be assessed for injury and neuro assessments would be completed. Staff A said the suggested/recommended times for completion of neuros were every 15 minutes for four times, then every hour for four times and then every shift for 72 hours. Staff B said the LNs would be reassessing for injury during the neuro assessments. Staff B said she would expect LN staff to notify the provider if changes from baseline were noted. When asked if a resident was documented to have increased pain, lethargy, and confusion, would she expect the provider to be notified, Staff B responded, Yes. At 5:09 PM, Staff D, LPN, said when a resident had an unwitnessed fall, they were assessed for injury neuro checks were initiated. Staff D said neuro checks were to be performed every 15 minutes times four, then every hour times four, and then every shift for 72 hours. Staff D said changes to a resident that would cause her concern included, increased pain and decrease in cognition or function. Staff D said she would report these to the provider and the oncoming shift. Staff D said she recalled Resident 1 by name, and could recall some details of his stay, she recalled he had a fall (prior to the fall on 9/21/2022) and went to the hospital and readmitted back to the facility. Staff D recalled Resident 1 had confusion, back pain, and would call out as a baseline. Staff D could not recall notifying the provider for any concerns but said she may have through the secured electronic record. Staff D said she believed she had completed the neuros on Resident 1 and that this might have been done on paper and not transcribed to the electronic record. The facility did not provide any additional documentation regarding communication to a provider and or completion of additional neuro checks for Resident 1. <Resident 2> Resident 2 was admitted to the facility on [DATE]. The Admission MDS, dated [DATE], documented the resident was medically complex and cognitively impaired. The care plan, initiated on 03/11/2024, documented Resident 2 was at risk for falls. Review of a nursing note, dated 03/26/2024 at 6:33 AM, documented Resident 2 reported he had an unwitnessed fall in the bathroom the night before but had not told anyone until that morning and then they started neuro checks. Review of Resident 2's medical record showed the first neuro check was documented on 03/26/2024 at 12:52 PM, over six hours after Resident 1 informed facility staff of the fall. The next neuro check was at 4:07 PM. The last documented neuro check was documented on 03/27/2024 at 6:06 PM. Neuros were not completed every 15 minutes times four or every four hours times four. On 03/28/2024 at 11:42 AM, Resident 2 was observed laying on his back in bed with blankets over the lower half of his body. When asked about the fall on 03/08/2024, Resident 2 said he had fallen in the middle of the night, while using the bathroom. Resident 2 said he did not use the call light, nor did he call out for help, he pulled himself back into his wheelchair and returned to bed. Resident 2 said the next morning, during a dressing change, it was noted he had a large cherry blossom (red bruise) on the back of his right thigh. At this point, Resident 2 pulled off the blankets and pointed to the back of his right thigh. Resident 2 said that is when he informed staff about the fall. Resident 2 said the only thing staff had done was tell him to start wearing non-skid socks. <Resident 3> Resident 3 was admitted to the facility on [DATE]. The Admission MDS, dated [DATE], documented the resident was medically complex and cognitively impaired. The care plan initiated on 03/03/2024 documented Resident 3 was at risk for falls. Review of a nursing note, dated 03/08/2024 at 9:00 PM, documented Resident 3 had an unwitnessed fall in the bathroom and neuros were initiated. Review of Resident 3's medical record showed neuros were initiated on 03/09/2024 at 11:25 AM, over 14 hours after the fall with checks on/at 03/10/2024 at 3:37 AM, 03/10/2024 at 3:41 PM, 03/11/2024 at 3:09 AM, and 03/12/2024 at 2:15 AM. Neuros were not completed every 15 minutes times four or every four hours times four. On 03/28/2024 at 1:34 PM, Staff E, Registered Nurse, said when a resident was found on the floor the nurse was to complete a head-to-toe assessment for injuries and ask what happened. Once the initial assessment was completed, staff were to help the Resident back to bed if applicable and start neuro checks. Staff E said neuro checks were to be completed every 15 minutes for the first hour, then once an hour for four hours and then once a shift for 72 hours. Staff E said the facility staff were to notify the provider and family of the incident. Staff E showed a blank copy of Incident Report Licensed Nurse Checklist, and said staff will fill out the paper copy of the neuro checklist packet and when it was completed it was given to the Resident Care Manager. Staff E said everything was entered into the electronic health record. On 03/28/2024 at 2:45 PM, Staff A and Staff B were given until close of business 03/29/2024 to provide any additional documentation. The facility did not provide any additional documentation. Reference WAC 388-97-1060 (1)