Every finding on record at Orchard Park Health Care & Rehab Center

Based on interview and record review, the facility failed to provide the required care planned supervision to prevent accidents for 2 of 4 sample residents (Resident 2 & 5) reviewed for accidents/hazards. The facility failed to assess safety risks, provide adequate resident supervision, and implement fall and elopement care plans (CP). Resident 2, who had a history of falling, experienced harm when they fell out of bed and fractured their nose, requiring hospitalization, due to fall prevention interventions not being implemented. These failures placed the residents at a potential risk of harm related to avoidable incidents. Findings included .Review of the facility's Fall Management policy, dated 05/26/2021 showed residents would be assessed for fall risk upon admission to the facility. Residents determined to be at risk for falls would receive appropriate interventions to reduce the risk and minimize injury. The facility would communicate residents fall risk status to caregivers, develop/revise a resident-centered CP. If a resident fell, the facility would assess the resident, document the incident in the clinical record and update/revise the CP to reflect new interventions, notify the appropriate parties, and the IDT would review the resident after the fall.Review of the facility's Leave of Absence without Notice (LAWN) policy, dated 01/16/2026, showed Elopement occurred when a resident left the facility premises or a safe area without notice/authorization (such as a physician's order for discharge or leave of absence). The Interdisciplinary Team (IDT) would evaluate residents on admission, quarterly, and with a significant change in condition to determine level of risk for LAWN and initiate a resident-centered care plan (CP) with interventions to provide a least restrictive environment. <RESIDENT 2>Review of the 07/15/2026 Minimum Data Set (MDS - an assessment tool) showed Resident 2 had Non-Alzheimer's Dementia, an anxiety disorder, and severe cognitive impairment. Resident 2 required substantial/maximal assistance with bed mobility and transfers and had no falls since the prior assessment (04/16/2026).Review of the 04/16/2026 MDS, showed Resident 2 had two non-injury falls since the prior assessment (01/20/2026).Review of the Fall Care Plan revised 04/07/2026 showed Resident 2 had an actual fall with no injury related to poor balance, functional status, cognitive limitations, usual positioning habits, and slipped out of bed. Interventions included to keep the bed low at all times and ensure placement of a floor mat on left side of bed to help reduce risk of injury with falls, monitor/document/report for 72 hours for pain, bruises, change in mental status, new onset confusion, and/or agitation. Additional interventions were added on: 03/16/2026 for a bolster sheet on top of the bed to help define bed perimeter and reduce risk of falls; on 04/07/2026 -Resident 2 was moved to a room closer to nurses the station to allow for closer supervision and timely response to needs; and on 06/08/2026 to change their brief every 2-3 hours. Review of the Risk for Falls CP initiated on 02/23/2026 showed Resident 2 was at risk related to their habit of lying on their side on the edge of the bed and intermittent restlessness. The listed goals were that Resident 2 would be safely positioned in bed; their positioning needs would be anticipated and supported to reduce the incidence of lying on their side so close to the edge of the bed. Interventions included a bolster sheet applied to their specialty mattress to help define bed perimeters and reduce risk of falls.Review of the Interdisciplinary (IDT) Care Conference note dated 02/18/2026 at 8:41 PM showed the IDT met to review Resident 2's fall from bed that occurred on 02/18/2026 at 6:30 AM. IDT recommended a low bed, a fall mat on the floor on left side of bed and collaborated with hospice for Low Air Loss Mattress (LALM) with bolster to define bed boundaries.Review of IDT Care Conference note dated 03/09/2026 at 5:19 PM showed the IDT met to review Resident 2's fall that occurred on 03/08/2026 at 12:00 AM when Resident 2 was found on the floor on the left side of the bed after reportedly attempting to reach for personal items located on the bedside table. IDT recommended Resident 2 to be up in wheelchair when wanting to do some coloring.Review of Nurse Progress note dated 03/14/2026 at 10:41 PM showed Resident 2 fell, was found on the mat on their left side, and head was toward the sink.Review of an IDT post fall care conference note dated 03/14/2026 showed the team met to review the unwitnessed fall on 03/14/2026 in which Resident 2 was found on the floor next to the bed without injury. The resident had reported pain earlier in the day, received prescribed pain medication, and was observed attempting to get out of bed and dangling legs over the left side of the bed. IDT recommended LAL with bolsters to define bed boundaries.Review of a Device Informed Consent dated 03/16/2026 showed Resident 2's representative granted permission to use Bolster Sheet to help define bed perimeters and reduce risk of falls.Review of a Nurse Progress Note dated 04/07/2026 showed Resident 2 had an unwitnessed, non-injury fall at 1:20 AM. The bed was lowered, bed brakes were locked, and the call light was within reach.Review of the IDT post fall care conference note dated 04/07/2026 showed the team reviewed Resident 2's fall that occurred on 04/07/2026 at TIME where Resident 2 experienced the fall from bed. The team recommended moving Resident 2 to a room closer to the nurse station to allow for closer supervision and staff reinforced frequent rounding and monitoring. Repositioning protocols were reviewed to maintain Resident 2 in midline position with pillows between knees and proper support and the CP was updated to prevent recurrence.Review of a Nurse Progress Note dated 06/07/2026 at 3:54 PM showed Resident 2 fell around 8:20 AM.Review of the facility's Incident Investigation dated 06/07/2026 showed Resident 2 was found on the floor, on the left side of the bed, the bed was in a low position and the brakes were locked. Resident 2 was found to be incontinent of a bowel movement, and their incontinence brief was found undone. The planned post-fall intervention was to change Resident 2's briefs every 2-3 hours.During an interview on 08/06/2026 at 3:53 PM, when asked what interventions were put in place to prevent reoccurrence, Staff B, Director of Nursing, stated scheduled incontinence care, and to continue frequent monitoring and prompt response to resident's needs.Review of the Nurse Progress Note dated 08/02/2026 at 11:44 PM showed Resident 2 was heard yelling out at 10:35 PM. The nurse went into the room to find Resident 2 lying face down on the floor on the left side of the bed, wrapped in blankets and a sheet. A pool of clotted blood was found under their face. Resident 2 was assessed and put back into bed. Resident 2 had a bruise on the left eye/eyebrow that measured 3 centimeters (cm) by 4 cm and a swollen nose (4 cm by 4 cm). A fall mat was placed on the left side of the bed. Resident 2's Responsible Party (RP2) was notified and agreed to fall mats on the left and right side of the bed.Review of the facility's Fall Investigation dated 08/02/2026 showed Resident 2 was found on the floor, swollen and bleeding nose and a bruise to the left eye/eyebrow. Resident 2 had removed a dry brief and their shirt. The fall was initially associated with no injury or a minor injury.Review of a physician's order dated 08/02/2026 at 11:07 PM showed orders for fall mats to each side of the bed every shift, and to monitor the bruising and swollen nose.Review of the Hospice Nurse Visit progress note dated 08/03/2026 showed Resident 2 had significant bruising and swelling of their left eye, ear, and nose. The Nurse felt Resident 2's nose may be broken. Facility staff reported to the nurse that Resident 2 fell out of bed the night prior (08/02/2026). The nurse educated staff on fall prevention to include bed in the lowest setting and fall mats on both sides of the bed on the floor. The documentation showed Resident 2 was supposed to be discharged from hospice that day (08/03/2026), but due to recent fall and injury they would remain on hospice for now.During an interview on 08/07/2026 at 1:47 PM, Collateral Contact 4 (CC4), Hospice Nurse, said the facility staff had notified the triage line in the middle of the night and reported Resident 2 had a fall with a bruise, so CC4 went to see Resident 2. CC4 stated Resident 2's nose looked broken, it was crooked and the bruising was well spread on their face. CC4 noted that to have caused that much damage the bed must have been in a high position when Resident 2 fell out of bed. CC4 stated they told Resident 4's Responsible Party that it looked very concerned and asked if they wanted to send the resident out to the hospital to be evaluated.Review of a Nurse Progress Note dated 08/05/2026 at 6:02 PM showed Resident 2's Responsible Party requested Resident 2 be sent to the Emergency Department and Resident 2 left the facility around 5:55 PM.Review of 08/05/2026 Emergency Department to Hospital admission records showed Resident 2 had raccoon eyes (dark bruises around both eyes), left conjunctiva injection (the clear tissue over the white of left eye had swollen, red, or bloodshot vessels).Review of a 08/05/2026 CT scan showed Resident 2 sustained a comminuted (broke into three or more pieces) fracture of the bilateral nasal bones, with moderate medial angulation (the bone on the left side of the nose bent inward toward the center of the face) the left nasal bone. Mildly angulated fracture of the anterior nasal septum (a sharp angular break in the cartilage or bone partition dividing the nasal cavities, typically caused by direct facial trauma). During an observation and interview at the hospital on [DATE] at 12:16 PM Resident 2's face was observed with red and black discolorations around both of their eyes (racoon eyes), their nose was swollen, and their left cheek was discolored. Resident 2 stated they had fallen out of bed and they hurt nose.During an interview on 08/06/2026 at 1:17 PM, RP2 stated they were called by the facility after Resident 2 fell and informed Resident 2 fell out of bed and had a 'little bruise under their eye'. RP2 stated they went to visit Resident 2 the day before (08/05/2026) and when Resident 2 turned their head towards [them], Resident 2's eyes were bruised, and their nose was obviously visibly broken. RP2 stated Resident 2 fell out of bed a lot and [they] asked for mats on the floor months ago. RP2 stated when the bed was in the low position it was like 6 inches off the floor and the injury Resident 2 sustained was from blunt force.During an interview on 08/06/2026 at 3:19 PM, Staff L, Registered Nurse, stated Resident 2 ripped the bolster sheet in the past and they would change it and then within one week Resident 2 would rip it again.During an observation of the bolster sheet on Resident 2's LAL mattress on 08/06/2026 at 3:19 PM showed the Bolster Sheet was torn on the left side at the head of the mattress and did not stay in place like the other bolstered edges and made the bed surface unstable. In an interview at that time, Staff B, Director of Nursing, agreed the Bolster Sheet was not implemented safely, as they were ripped and not functioning. When asked how they thought the resident sustained a fracture if the bed was in the low position as planned, Staff B stated the air mattress was thick, and the head of the bed may have been up.<RESIDENT 5>Review of the Nursing admission assessment dated [DATE] showed that Resident 5 was confused, oriented to person only, exhibited behaviors including non-compliance, confused, poor safety judgement, forgetful, and anxious. The documentation showed that family reported Resident 5 had left different places AMA (Against Medical Advice). Resident 5 was risk for falls due to disorientation, poor safety judgement, impaired balance, predisposing disease or injury, an unsteady gait, and medications. Upon arrival, Resident 5 was agitated, wanted to get out of bed, and when they saw family leaving, wanted to go with them. Resident 5's family was concerned about Resident 5 leaving AMA like they had in previous places.Review of the Leave of Absence Without Notice (LAWN-elopement) Evaluation Form, dated 07/24/2026, showed Resident 5 had impaired cognition, was able to ambulate or demonstrate mobility independently, had a history of exhibiting exit-seeking behavior, was expressing desire to go home, and was determined to be at risk LAWN. The documentation showed Resident 5's CP re was reviewed and updated by the IDT to address all applicable considerations supported by resident specific interventions.Review of the 07/24/2026 CP showed Resident 5 was at risk for falls/injury, with a goal that the resident would not experience a fall or fall with injury. Interventions included directives to staff to remind Resident 5 to use call light when attempting to ambulate or transfer. The documentation did not show directives to staff to monitor Resident 5. The 07/27/2026 Baseline CP listed an intervention to assist with transfers and ambulation as needed, keep their area clutter-free and well-lit. The CP did not provide documentation to show the facility developed a CP for their elopement (LAWN) risk with interventions for supervision and safety to prevent elopement.Review of a Nurse Progress Note dated 07/27/2026 at 10:18 AM showed Resident 5's family took Resident 5 out of the facility AMA. Nursing was unable to assess Resident 5 due to their AMA discharge. Review of the facility incident reporting log showed Resident 5 discharged from the facility AMA on 07/27/2026 at 9:30 AM.During an interview on 08/06/2026 at 11:05 AM, Resident 5's Responsible Party (RP5) who was with Resident 5, stated Resident 5 was unable to be interviewed due to their cognitive deficits, but they were safe, and living with RP5 until an alternative solution was found. RP5 stated their sibling (RPS5) went to the facility to visit Resident 5 on 07/27/2026 and called RP5 almost in tears. RPS5 told RP5 that they went to Resident 5's room and they were not in the room. RPS5 saw three staff members cleaning the room who told RPS5 that there were no residents staying in that room. Concerned, RPS5 went to the nurse station to inquire about the whereabouts of Resident 5. The person they spoke to at the nurse station told them Resident 5 was in their room (the same room RPS5 had just left where three staff told them no residents were in that room). RPS5 told them they were not in their room and repeated what the three staff members told RPS5. The nurse, RPS5, and other staff began looking for Resident 5, looking in all the rooms, and could not find Resident 5. RPS5 told RP5 the situation became one of obvious panic as they did not know where Resident 5 was and RPS5 was upset that no one knew where Resident 5 was. Because Resident 5 was not found inside the facility, they began searching outside the facility. A resident told RPS5 they saw a resident go out the door from the [NAME] dining room area. RPS5 went through the [NAME] dining room door that opened out into a small courtyard area. They found feet sticking out from under a chain link fence, behind a tall wood divider. RPS5 went around the wood fence divider and found Resident 5 lying on the ground with their feet wedged under the chain-link fence. The staff had no idea how long Resident 5 had been trapped under the fence or how long they were outside in the heat. RPS5 placed Resident 5 in their care and took Resident 5 out of the facility. During an interview on 08/04/2026 at 7:25 AM, RPS5 stated Resident was a fall risk, wander risk and had little sense of reality so they assumed the staff would take some precautions, but they did not. The entire staff and [I] searched up and down the facility until a resident pointed outside and sure enough there was Resident 5; they had fallen, was trapped underneath the chain link fence, hurt and screaming for someone to save them. When Resident 5 saw my face, they started crying and begged me not to make them stay there.During an interview on 08/06/2026 at 4:05 PM Staff B stated Resident 5's family came to the facility to take Resident 5 to an appointment that day. They found Resident 5 outside the west dining room, in the resident garden, back yard activity area, behind a fence. They were upset, put Resident 5 in a wheelchair and went straight to the parking lot, loaded the resident in the car, left the wheelchair at the front, and they were gone. Staff B stated there was an incident report for the AMA discharge.REFERENCE WAC: 388-97-1060(3)(g)

Based on observation, interview, and record review, the facility failed to ensure 2 of 3 residents (Residents 1 & 4) reviewed, received the necessary care and services in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. The facility failed to ensure Resident 1, and Resident 4 had wheelchairs which fit properly and were in good repair. These failures placed Resident 1 and Resident 4 at risk skin breakdown, accidents/hazards, uncomfortable positioning, and diminished quality of life. Resident 1 experienced psychosocial harm, anger, and frustration when the facility failed to submit all required documentation timely to the Durable Medical Equipment (DME) company who fitted Resident 1 for a custom wheelchair which led to the cancellation of their custom wheelchair, impeded their ability to be more independent, ability to tolerate sitting out of bed for longer periods of time (including meals, activities, and going outside for fresh air), and delayed discharge planning.Findings included.<RESIDENT 1>Review of the 06/17/2026 Quarterly Minimum Data Set (MDS-assessment tool) showed Resident 1 had moderate cognitive impairment, had functional limitations in range of motion of their right upper extremity and right lower extremity, and required substantial staff assistance to push their wheelchair up to 150 feet. Resident 1's diagnoses included a stroke with right- sided hemiparesis (weakness of the right side of the body effecting both the arm and leg) and depression. Resident 1 had no recent falls, did not receive any specialized therapy services during the period of observation, and no restorative nursing care was coded.Review of the Activities of Daily Living (ADL) care plan (CP) revised on 10/07/2025 showed Resident 1 had limited self-care performance due to right sided weakness from their stroke and limitations with mobility. A 01/20/2026 intervention showed Resident 1 required one person to assist with the use of a tilt-n-space (TNS) wheelchair (a specialized wheelchair where the entire seat and back rest tilt backwards together as a solid unit where the angles of the user's hips and knees do not change and main benefits include improved posture and comfort, safe shifting of body weight for pressure relief to prevent skin breakdown, slide prevention by changing the center of gravity to lower risk of falling forward out of their chair, help with breathing and digestion, and relieve fatigue). A 09/30/2025 intervention showed Resident 1 required two staff to transfer with the use of a mechanical lift.Review of the Actual Witnessed fall CP revised on 02/11/2026 showed Resident 1 sustained a witnessed fall due to weakness and malfunction of their wheelchair brake. An intervention dated 02/11/2026 showed the wheelchair brakes were fixed and properly functioning. Two interventions dated 01/28/2026 directed staff to remind Resident 1 to not lean forward to pick stuff up off the floor while in their wheelchair and to encourage Resident 1 to be out in a highly visualized area like the nurse station while up in their wheelchair.During an observation and interview on 08/19/2026 at 10:30 AM, when asked about their discharge plan, Resident 1 angrily stated in a loud voice I don't have one! I have been here over six months, and I still can't do anything for myself. I was moving into a place with my kid and had a stroke in the doorway. I never made it past the doorway. I want to get back home but I can't walk, and I can't move around in this wheelchair by myself. When asked if the facility staff treated them with dignity and respect Resident 1 stated, No! They don't answer your questions, and they just put you in the wheelchair and set you somewhere out of 'their' way like luggage. They want me up in that chair for meals or, at least one meal, a day. They get me up around 2:00 PM and then I sit there until after dinner. I have to complain and yell to get put back in bed. This wheelchair I have does not fit me properly - it's too small, as soon as I get in it, I start sliding out of it, it's too narrow in the hips, and I can't tolerate sitting up for as long as they want me to. Resident 1 stated When I try to push the chair myself, I just go in circles to the right because of my bad right arm. Resident 1's voice became physically upset and stated in a loud, firm tone, I was fitted for a special wheelchair about six months ago and I still have not received the chair! When I ask the staff about my new chair they all say they will check on it but never come back and tell me anything! I am going to die before I get that chair, and these people don't give a shit!In an interview on 08/19/2026 at 11:40 AM, Staff F, Rehabilitation Director, stated they did not know the status of Resident 1's special wheelchair. Staff F stated they provided the Named DME company with the required documents to submit to Resident 1's insurance but it took a long time for the whole process. When asked if therapy staff documented their assessments of residents they treated to ensure their wheelchairs fit properly and were in good repair, Staff F stated they did not have a specific wheelchair evaluation and that any documentation would be in their progress notes or therapy evaluations. Staff F stated Resident 1 was on caseload currently under their Medicare B benefit and was seen three times per week. Staff F stated they did not keep copies of any of the documents they provided to the Named DME and was unsure when Resident 1's wheelchair process started. Resident 1's therapy documentation regarding any wheelchair evaluations, fittings, or concerns was requested as well as their current reason for treatment.Review of the Occupational Therapy (OT) Evaluation, dated 07/29/2026 and signed by the physician on 07/31/2026, showed the reason for referral was due to compromised physical exertion level during exercise, decline in functional mobility and strength, and reduced dynamic balance. Resident 1 had severe impairment of range of motion to the right upper extremity observed on 04/27/2026. The documentation showed Resident 1 received prior therapy and at the end of therapy was able to stand with a vertical bar with maximum assistance of two people.Review of the 08/13/2026 physician order showed OT was to evaluate and treat for worsening of hand contractures and decline in hand mobility and strength. Further review of the physician orders did not provide documentation to show the facility received an order for a custom wheelchair fitting or therapy orders for wheelchair management.During an interview on 08/19/2026 at 1:49 PM Collateral Contact 1 (CC1), Named DME Company representative, stated their account representative, CC2, was involved in Resident 1's wheelchair process and reviewed all of CC2's notes. CC1 stated they started an order for Resident 1 on 02/11/2026 and their representative went to the facility and obtained the measurements and fitting for Resident 1. CC2's account notes showed Resident 1 was recommended to receive a custom fit manual Tilt in Space wheelchair with a one-arm drive (a wheelchair customization that allows a person with limited function or strength in one upper limb to propel, steer, and brake the chair entirely from a single side). CC1 stated their insurance (Medicaid) required a list of specific documents to justify the need for the custom chair that included (but not limited to): a signed physician's order, a functional mobility assessment completed by a physical or occupational therapist, and a doctor visit within 60 days. According to CC2's notes, the documents they received from the facility were incomplete; the physician order was not signed by a physician and the functional necessity form was not provided. CC2's notes showed they went to the facility on [DATE] and dropped off the remaining documents that needed completion or correction. A note by CC2 on 06/01/2026 showed they had not received the requested documents, and they were due to expire on 06/22/2026 (they must be within 60 days of the order). On 06/12/2026, CC2 sent an email to Staff F to remind them of the pending order expiration and request for the documents which included a signed physician order for the custom wheelchair, and justification for the height adjustable arm rest, solid seat, anti-tippers, and head rest hardware. CC1 stated nothing was ever received and the wheelchair order had to be canceled.During an interview on 08/19/2026 at 2:21 PM, Staff F stated they provided all the information that was required for Resident 1's custom wheelchair but was unable to find any copies of the documents. Staff F stated they last time they talked to CC2 was either the end of May or June of 2026. Staff F was not aware the wheelchair was cancelled because of lack of appropriate documentation. Staff F stated Resident 1 asked them about two weeks prior what the status of the wheelchair was but they did not contact the Named DME company or CC2 to inquire about the wheelchair status. Staff F stated the DME company had an online portal, but they had never used it before. Staff F stated they were not sure if they received an email from CC2 but would review their email account. No further information was provided.During an observation and interview on 08/19/2026 at 2:42 PM with Staff F and Staff G, Physical Therapy Assistant (PTA), Staff F notified Resident 1 that they would have to start the paperwork process for their custom wheelchair over again. Resident 1 loudly replied OH Shit! This is all a scam! Forget it!! Staff F stated, I gave them everything they needed so I am not sure why, but the order was canceled. Resident 1 yelled Goddammit now I got to wait another 60 months, I am going to be dead before I get a chair that fits me! Resident 1 explained to Staff G what was wrong with the wheelchair they currently had. After Staff G measured the current wheelchair and Resident 1 for an idea of fit, Staff G stated the wheelchair was about an inch too low and the width was about right but the only way to tell for sure was to see Resident 1 sitting in the wheelchair. Resident 1 had gained a significant amount of weight due to snacking since they were fitted for the wheelchair in February and would need a completely new fitting. During an interview on 08/19/2026 at 3:05 pm, Resident 1 stated I am frustrated and goddamn pissed! These people can't do anything right!<RESIDENT 4>Review of the 08/04/2026 MDS showed Resident 4 was alert and oriented, used a walker and a wheelchair, and was independent with wheelchair mobility.Review of the Edema CP revised 04/27/2021 listed interventions to elevate legs as tolerated when sitting, encourage to elevate lower extremities, and remind resident to elevate feet. A 06/17/2028 CP showed Resident 4 enjoyed being active and occupied. They liked to go to church and would like to go out to eat with friends. They went to Library twice a week. They are currently taken out regularly by an agency that works with Developmental Disabilities Administration to promote socialization and community engagement outside of facility.On 08/11/2026 the provider that takes Resident 4 out of the facility reported that the facility had not fixed Resident 4's wheelchair and the Non-Emergency Medical Transportation (NEMT) company would not be able to transport Resident 4 due to safety concerns. They requested the wheelchair brakes be adjusted April 28, 2026, May 14, 2926, June 11, 2026 and on June 29th were told the brakes were unrepairable by facility staff. Additionally, Resident 4's leg rests were not able to support the resident's legs, the leg rests drop and drag onto the floor or the pavement preventing Resident 4 from moving the wheelchair easily, which is both a health and safety issue.On 08/19/2026 at 9:39 AM, Resident 4 was observed seated in a wheelchair in which the foot pedals touched the ground. The right foot pedal fell down if raised. Resident 4 said, They can't fix the foot pedals. The tire tread was worn down flat. A new wheelchair was observed in the doorway of the resident's room. Resident 4 stated they were not using the new wheelchair yet because there were no foot pedals and they also needed a cushion. A third wheelchair was observed in Resident 4's room, with foot pedals. Resident 4 stated, They won't take me in that one, its too wide.During an interview on 08/19/2026 at 9:53 AM, Staff F stated they gave Resident 4 a new wheelchair the week prior. Staff F stated they offered another wheelchair previously, but Resident 4 refused to use it.Review of the resident's record showed no documentation regarding the status of Resident 4's wheelchair, no documentation that Resident 4 refused to use the new wheelchair or when it was provided.REFERENCE WAC: 388-97-1060(1)

Based on interview and record review, the facility failed to protect the resident's right to be free from abuse for 4 of 6 residents (Resident 3, 4, 12 & 13) reviewed for resident-to-resident abuse. Resident 3 experienced physical abuse when they were hit in multiple locations on their body by Resident 6. Resident 4, 12 & 13 experienced verbal abuse when they expressed feeling uncomfortable from Resident 6's verbal and non-verbal behaviors. These failures placed the residents at risk of further abuse, physical injury, psychosocial harm and emotional distress.Findings included.Review of the facility's Abuse Prohibition Policy, dated 10/25/2024, showed Sexual Abuse is a non-consensual sexual contact of any type by another person and included, but was not limited to, sexual harassment or sexual assault. Physical Abuse included hitting, slapping, pinching, kicking, etc. Mental Abuse included, but is not limited to, humiliation, harassment, and threats of punishment or deprivation. Mental abuse could occur through either verbal or nonverbal conduct which caused or had the potential to cause the victim to experience humiliation, intimidation, fear, shame, agitation, or degradation.According to the policy, actions to prevent abuse included identifying, correcting, and intervening in situations in which abuse is more likely to occur, and staff would identify events such as suspicious bruising of patients, occurrences, patterns and trends that may constitute abuse. <RESIDENT 6>Review of the 04/27/2026 Annual Minimum Data Set (MDS - an assessment tool) showed Resident 6 was assessed to have severe cognitive impairment, no adverse behaviors, and was independent with walking.Review of the Care Plan (CP) showed Resident 6 had a psychosocial well-being problem related to resident-to-resident altercations, initiated on 09/30/2025 and revised on 10/30/2025. A 10/13/2025 intervention directed staff to remove residents to a calm safe environment when conflict arose. On 07/13/2026 the CP was revised to keep Resident 6 separated from residents they were known to target whenever possible, especially in common areas and during activities. Further review showed on 07/13/2026 the CP was updated to show Resident 6 was at risk for or demonstrated resident-to-resident aggression, placing self and others at risk for injury.On 07/15/2026 the facility was cited F600 for failure to protect two residents from abuse when they experienced physical and verbal abuse from Resident 6 during two separate resident-to-resident altercations (on 07/13/2026 and 07/15/2026). <RESIDENTs 3 & 4 vs. RESIDENT 6>Review of Resident 3's Quarterly MDS dated [DATE] showed they re-admitted to the facility on [DATE], they were alert and had no problems with memory recall. Resident 3 required a wheelchair for mobility and staff assistance for activities of daily living. Review of the 08/07/2026 Police Department Incident Report showed Resident 3 stated she was in the library of the facility when she was struck in her crotch, breasts and back of her head by Resident 6 with a book. The responding officer did not see any obvious signs of injury on Resident 3's head, however, Resident 3 continually requested an ambulance to take them to the emergency room because the back of their head hurt. Staff advised the officer that Resident 3 was seen by the facility doctor who reported all vitals were stable. The staff advised they would continue to work with Resident 3 about their complaint of injury.Review of a Nurse Progress Note, dated 08/07/2026 at 7:28 PM, showed Resident 3 complained of excruciating pain to both upper breast, center back of head, and groin. The pain was described as aching, and their pain severity was a 10 (on a scale of 1-10-where 1 equaled no to minimal pain and 10 equaled most severe pain).Review of the Nurse Progress Note, dated 08/10/2026 at 6:39 PM, showed Staff I, Unit Manager, spoke to Resident 3 regarding bruises found on their right arm. Resident 3 reported the bruises were from the 08/07/2026 incident where Resident 6 struck [them] multiple times on the right forearm with a Bible. Resident 3's statement was documented and appropriate management were notified of the injury.During an interview on 08/19/2026 at 10:07 AM, Staff H, Unit Manager, stated on 08/07/2026 while walking down the hall they observed Resident 6 standing at the doorway to the library, facing the hallway. Staff H stated they walked toward the area to observe who else was in the library to ensure no other residents were in the vicinity due to Resident 6's prior history of altercations. Staff H stated they observed Resident 3 seated in the middle of the library who called out to [them], pointing at Resident 6, and yelled Resident 6 touched their 'boob' and 'crotch', and then Resident 3 stated Resident 6 took a book and hit [them] with it. Staff H moved Resident 3 to the Unit Manager's office and called the police. Resident 6 was placed on one-to-one supervision to ensure all the residents were safe.During an interview on 08/19/2026 at 2:42 PM, Staff D, Assistant Director of Nursing, stated they interviewed Resident 3 following the incident on 08/07/2026. Staff D stated Resident 3 was alert, oriented, and able to describe what occurred. Staff D was asked about their internal investigation of the incident and if there was any reason to suspect the incident had not occurred as Resident 3 described, Staff D stated they did not find any witnesses and when they attempted to interview Resident 6, [they] would not say anything, they just stared at Staff D during the attempted interview. Staff D stated Resident 3 reported to them they were in the library watching TV when Resident 6 entered the library, walked over to Resident 3 and them on the head, chest and crotch. Resident 3 asked for help from Staff H, who intervened. Staff D stated they asked Resident 3 why they thought it happened and they did not know the reason. Staff D stated Resident 3 was wheelchair bound and unable to wheel fast. The facility initiated one-on-one supervision of Resident 6 immediately after the incident because both residents resided on the same wing. Staff D stated when the police arrived, Resident 3 told them the same thing they reported to Staff D and stated they experienced pain on the back of their head where they were hit with the book. Staff D did not observe bruising at that time. The physician was notified and instructed staff to give Resident 3 Tylenol and to continue to monitor.During an interview on 08/19/2026 at 3:05 PM, Resident 11 (Resident 3's roommate at the time of the incident) stated that Resident 3 told them [they] were hit on the breast with a Bible, that's what she said, she didn't change that story so it must be true. Resident 3 also told Resident 11 they got hit in the crotch with the book and in the back of the head. Resident 11 stated Resident 3 was crying and visibly upset about the incident. During an interview on 08/19/2026 at 9:39 AM, Resident 4 stated Resident 3 told them about an incident in the library, where Resident 6 was targeting them and Resident 3 told Resident 6 'Don't grab me, keep your hands to yourself.' When Resident 4 was asked if they had problems with any other residents, Resident 4 stated yes and stated that Resident 6 pointed their finger at them which they perceived to be a threatening gesture and stated, [they] are going to attack me!During an interview on 08/19/2026 at 2:22 PM, Staff B, Director of Nursing, stated although there were no witnesses, Resident 3 was alert and oriented and they believed Resident 3's recollection of the event. Following the incident Resident 6 was placed on one-to-one monitoring and has been ever since the incident occurred.During an interview on 08/20/2026 at 2:47 PM, Resident 3 stated they returned home on [DATE]. Resident 3 stated the event occurred in the library, they were alone, and Resident 6 came into the library toward them, and then hit them with a Bible multiple times including their head, breast, and groin areas. When asked how it made them feel, Resident 3 replied Mad! Resident 3 stated Resident 6 had bothered them before, Morning, Noon and Night. Resident 3 stated they told staff, who did nothing about it. <RESIDENTs 12 & 13 vs. RESIDENT 6>During an observation on 08/19/2026 at 3:15 PM, Resident 6 was observed in the hall outside of the Activity room on the East unit while a group activity was in progress, yelling into the room Fucking Whore!.During an interview on 08/19/2026 at 3:16 PM, Staff J, Activity Director, stated Resident 6 was in the doorway of the activity area, silently staring at the female residents (Resident 12 & Resident 13) and they complained about feeling uncomfortable. Staff J was in the process of moving Resident 12 and Resident 13 out of reach/view of Resident 6 when Resident 6 yelled the profanities. Resident 6's 1-on-1 monitor was standing behind Resident 6 observing the interaction but did not intervene or provide an intervention.During an interview on 08/19/2026 at 3:17 PM, Resident 12 stated There [Resident 6] is again, out there., pointing to Resident 6 who was standing in the hallway, looking in the room through the doorway. CC3, a teenage visitor of another resident, walked over toward the doorway and stood between Resident 12 and the doorway where Resident 6 stood. CC3 stated, I'll stand here and block the view.During an observation on 08/19/2026 at 3:18 PM, Resident 6 returned to the activity room doorway with their 1-on-1 staff member standing behind them, standing still, staring at Resident 12 and 13 who were talking with the investigator, without saying anything. Resident 6 was positioned behind Resident 12. CC3 again positioned themselves between Resident 12 and Resident 6. Resident 12 was aware that Resident 6 was standing in the doorway again and appeared very nervous and anxious and asked, Are you watching him? Resident 12 was informed that Resident 6 was being monitored and CC3 was standing between them and Resident 6. Resident 6 stated, Oh good.During an observation on 08/19/2026 at 3:20 PM, Resident 6 sat down in a chair in the activity room and began to watch TV. Resident 12 requested to be removed from the group activity. Resident 12 was visibly restless and verbalized their nervousness and distress that Resident 6 was in the room. Staff J assisted Resident 12 out of the activity room, and they were unable to finish participating in the group activity.During an interview on 08/19/2026 at 5:04 PM, Staff K, Certified Nursing Assistant (CNA), who was assigned as Resident 6's 1-to-1 monitor, stated Resident 6 was watching Resident 12 and Resident 13. Staff K said that Staff J wanted to move Resident 12 & 13 because they are afraid of Resident 6, which made Resident 6 very mad. Staff K stated it was easier to move them than redirect Resident 6.REFERENCE WAC: 388-97-0640(1).

Based on observations, interviews, and record reviews, the facility to implement their abuse prohibition policy; to identify, investigate, and implement measures to protect other residents and prevent recurrence for 6 of 8 Residents (Resident 12, 6, 13, 38, 9, & 23) reviewed for abuse, misappropriation, and resident-to-resident altercations. Resident 12 experienced psychological harm including intense fear and worsening of night terrors that affected their sleep patterns, requiring medication changes, when the facility failed to identify, report, investigate, and implement adequate safety measures after an alleged misappropriation of Resident 12's belongings by Resident 6 on 07/24/2026. This failure led to a resident-to-resident verbal altercation between Resident 12, Resident 12's spouse, and Resident 6 on 07/29/2026 in the front parking lot of the facility. During this altercation Resident 12 was called derogatory names and verbally threatened by Resident 6 out of anger because of the 07/24/2026 misappropriation allegation. These failures placed all residents at risk for abuse, misappropriation, resident-to-resident altercations, and a diminished quality of life. Findings included. <POLICY> Review of the facility's SNF Clinic Abuse Prohibition Administrative policy, revised 10/25/2024, showed the facility's Executive Director was responsible for operationalizing abuse policy and procedures and defined the following: >Verbal abuse as any use of oral, written, or gestured language that willfully included disparaging and /or derogatory terms to patients or their families, or within hearing distance of residents (regardless of age, ability to comprehend, or disability). >Misappropriation of patient property as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a patient's belongings or money without the patient's consent. Exploitation was defined as the act/process of taking advantage of a resident for personal gain using manipulation, intimidation, threats, and/or coercion. The facility would train their staff of their reporting obligations annually and as needed to include appropriate interventions to deal with aggressive and/or catastrophic reactions of patients, how to report their knowledge of allegations without fear of reprisal, what constitutes abuse and misappropriation of resident property, dementia management and resident abuse prevention, and understanding the behavioral symptoms of a patient that could increase the risk of abuse, and how to respond. The facility would implement actions to prevent recurrence including identifying, correcting, and intervening in situations where abuse was more likely to occur. If the alleged violation was a resident-to-resident event, the resident who was the aggressor would be removed from the situation, and an investigation would be completed. The facility would provide adequate supervision when the risk of resident-to-resident altercations were likely. The facility was responsible for identifying residents who had a history of disruptive or intrusive interactions. The facility would notify local Law Enforcement when required. The facility would initiate an investigation within 2 hours of the allegation or event to rule out whether abuse occurred, extend, causative factors, and intervention to prevent further injury or event. The event would be thoroughly documented and include witness interviews. The center would protect patients from further harm, provide a safe environment and assign a social services staff member to follow up with and monitor the residents' reactions. <Resident 12 vs. Resident 6- Misappropriation and Resident-to-Resident Altercation> <RESIDENT 12> Review of the 07/16/2026 admission Minimum Data Set (MDS-assessment tool) showed Resident 12 admitted to the facility on [DATE], had an intellectual disability, and had no cognitive deficits, behaviors, or rejections of care. Resident 12 had frequent symptoms of depression and trouble with sleeping. Resident 12's diagnoses included a catheter associated infection, cerebral palsy, anxiety, depression. Resident 12 was assessed to require staff assistance for Activities of Daily Living (ADLs). Review of Resident 12's Mood care plan (CP), dated 07/15/2026, showed they were at risk for distress or fluctuating moods related to sadness, depression, fear, and anxiety. The 07/15/2026 dated interventions included referral to behavioral health specialists, observe lab reports, observe for pain and effectiveness of current interventions and attempt non-drug interventions (none were listed), and observe for signs of worsening sadness/depression/anxiety/fear/anger/agitation and determine the psychosocial cause for their symptoms, encourage them to seek staff support for distressed mood, refocus on something positive, and provide an environment that was conducive to the resident's ability to get adequate sleep and maintain their preferred awake/sleep cycle, allow time to express feelings, and Social Services visits to provide support as needed. Review of Resident 12's Past Trauma CP, showed they experienced intrusive thoughts of disturbing memories, images of stressful past experiences, and negative feelings of traumatic past events as a child that included verbal and physical abuse. The 07/15/2026 dated interventions showed: Resident 12's triggers were loud voices yelling at them, demeaning behaviors, and sudden movements perceived as threats and/or feeling threatened; encourage them to identify personal trauma and triggers and take steps to eliminate or minimize them; keep noise level as low as possible-be sensitive; offer sufficient notice and prepare patient when changes are necessary; maintain good consistent communication; and respect concerns and questions. <MISAPPROPRIATION> Review of a concern submitted anonymously to the State Agency (SA) on 07/27/2026 showed Resident 6 was found going through Resident 12's (their roommate) belongings while Resident 12 slept. Some of Resident 12's belongings were found in Resident 6's hands and retrieved. Resident 12 was also missing other property. After the event, Resident 6 was moved to another room, and the reporter was concerned that the facility did not properly handle the allegation. Review of Resident 12's active CP did not provide documentation to show a CP problem with interventions were developed and implemented for their risk of potential psychosocial harm related to the alleged misappropriation. Review of an Assessment Progress Note, dated 07/24/2026 at 3:21 PM, showed Resident 12 was expected to move to another room because their roommate was accused of looking into their belongings on 07/24/2026. Review of the facility's Reporting Log did not show an allegation of misappropriation was reported or investigated for 07/24/2026. Review of an Order Progress Note, dated 07/31/2026 at 1:41 PM, showed the provider made an increase in Resident 12's medication for nightmares and was placed on alert. Further review of Resident 12's progress notes did not provide documentation to show the facility monitored Resident 12's mood after the 07/24/2026 allegation of misappropriation. During an interview on 07/30/2026 at 2:49 PM, Staff A, Administrator, stated they had bought replacement items for the items Resident 12 was missing, (which were sitting on Staff A's desk). Staff A stated they did not report the alleged misappropriation to the SA or Law Enforcement, and did not ensure an investigation was conducted, but they should have. During an interview on 08/05/2026 at 9:31 AM, Staff B, Director of Nursing Services, stated they did not have an investigation for misappropriation regarding Resident 6 and Resident 12 but believed the 07/24/2026 incident was handled as a grievance because no one could prove that Resident 6 took Resident 12's items, and Staff A already replaced the items. Staff B stated the word, stolen was not used, the items were missing. Staff B stated when they discussed the grievance in standup, they were told the missing items were taken care of. During an interview on 08/05/2026 at 10:12 AM, when asked why the incident was handled as a grievance, rather than an incident of abuse, Staff D, Social Services Director, stated when they talked to Resident 12, they expressed they wanted to be moved to the other end of the hall and wanted their items replaced. Staff D stated that they felt it was resolved. <RESIDENT TO RESIDENT VERBAL ALTERCATION> During an interview on 07/30/2026 at 9:20 AM, Staff Z, Receptionist, stated Resident 6 was involved with an altercation with Resident 12 during the afternoon of 07/29/2026. Staff Z stated once they were notified of the altercation, they reported the altercation to a supervisor, and summoned assistance from Social Services and Nursing to intervene. In an interview on 07/30/2026 at 10:45 AM, Staff G, Admissions Director, stated Resident 12 and their significant other came into their office to talk with them after the altercation on 07/29/2026 with Resident 6. Staff G stated Resident 12 was very upset about the incident and expressed their fear and safety concerns regarding Resident 6 and their criminal history. Review of the facility's DSHS Reporting Log for July 2026 did not provide documentation to show reporting or an investigation was conducted for the resident-to-resident altercation between Resident 12 and Resident 6 on 07/29/2026. During an interview on 07/30/2026 at 2:49 PM, Staff A stated Resident 6 had not had any altercations with any other residents but did have an altercation with a Resident 12's spouse, which was also witnessed by Resident 12. When asked if they interviewed all parties involved, Staff A stated Resident 12 spoke on behalf of their spouse, who stated they wanted to apologize. Staff A stated an investigation was not conducted but should have been. During an interview on 08/05/2026 at 9:31 AM, Staff B stated they heard that Resident 6 had an argument in the parking lot with Resident 12's wife on 07/29/2026. Staff B stated they were informed by Staff A about the altercation and that social services staff were involved. Staff B stated they did not have an investigation of the resident-to-resident altercation to provide to the SA. During an interview on 08/05/2026 at 1:06 PM, Resident 12 stated they did not recall any staff interviewing them after they were missing their personal items or after the altercation that occurred on 07/29/2026. Resident 12 stated they felt unsafe with a Level III Sex Offender residing in the facility and felt very unsafe with Resident 6 in the facility, whether they were supervised or not. Resident 12 stated the facility had women conducting Resident 6's constant supervision and they were very worried about their safety as well. Resident 12 stated although they moved to the other side of the facility, they were fearful Resident 6 could retaliate against them, and it was affecting their sleep (due to persistent night terrors). During an interview on 08/07/2026 at 10:14 AM, CC3 stated Resident 6 had been going into Resident 12's room stealing snacks, and Resident 12's spouse has had it. CC3 stated they arrived at the facility and saw Resident 12's spouse yelling at Resident 6 and they stepped out of their car and intervened, I told them they couldn't talk to each other that way. They were yelling at each other, and Resident 6 was verbally abusive. CC3 stated Resident 6 also threatened Resident 12; called Resident 12 a 'F'***, B***, Liar' and that he was going to get them. When Resident 6 heard CC3's tone of voice, Resident 6 went inside the facility. Then four facility staff came outside. <RESIDENT 6> <ADMISSION> Review of Resident 6's hospitalist progress note, dated 06/17/2026, showed Resident 6 was taken to the emergency room by a County Jail staff after Resident 6 reportedly was lying on a table when another prisoner drug Resident 6 off the table, causing them to fall onto their back. Resident 6's injury resulted in loss of sensation from the neck down. Further review of Resident 6's clinical record did not show a hospital discharge summary. Review of the 06/30/2026 admission MDS showed Resident 6 admitted to the facility on [DATE]. Resident 6 was assessed to have no cognitive deficits, behaviors, or rejection of care. Resident 6 diagnoses included a traumatic spinal cord dysfunction, an affective mood disorder (a mental health condition that causes intense, ongoing disruption in a person's emotional state and instead of normal daily ups and downs, this disorder involves daily fluctuations of extreme sadness, overwhelming highs, or unpredictable shifts that make it hard to live a normal life), and a history of substance abuse. Resident 6 required staff assistance for activities of daily living (ADLs). Resident 6's discharge goal was to remain in the facility, and no active discharge planning was in place. Review of Resident 6's ADL CP, revised 07/02/2026, showed Resident 6 had improved since their admission assessment and now required supervision with ambulation, hygiene, toilet use, transfers, and was able to eat independently. Review of the Leave of Absence without Notice (LAWN) CP, revised 07/17/2026, showed Resident 6 was at risk for LAWN due to: [blank]. The CP problem showed X PLEASE CONTACT OFFICER [COLLATERAL CONTACT 2 (CC2)] WITH [County name] COUNTY IF THIS RESIDENT LEAVES THE FACILITY (I.E. ELOPES, DISCHARGES, LEAVES AGAINST MEDICAL ADVICE) AT [CC2'S PHONE NUMBER]. The CP interventions all dated 07/02/2026 directed staff to: observe for risk factors of exit seeking behavior and adjust care delivery, encourage to engage in services and establishment of an appropriate discharge plan, encourage preferred activities, allow time to express feelings, personalize room, familiarize them to their belongings, listen to resident/and try to calm them, redirect from exit seeking at doorways. Review of a Psychiatric Follow-up progress note, dated 07/14/2026 at 12:00 PM, showed Resident 6 had a complex psychiatric history including bipolar disorder (predominately depressive episodes with mood swings), Post Traumatic Stress Disorder (PTST) from gang violence exposure, anxiety disorders, and possible antisocial personality disorder. Resident 6 was currently experiencing mild depression related to their current situation, daily anxiety with difficulty relaxing, irritability, mood swings, restlessness, fidgeting, and daily concentration difficulties. Resident 6 was currently on an anti-psychotic medication and was previously on an anti-depressant (Effexor) which was discontinued but Resident 6 was asked to re-start. The provider ordered labs and requested an AIMS (Abnormal Involuntary Movement Scale) be completed. The documentation showed the following BEHAVIORAL INTERVENTIONS: Utilize cognitive behavioral techniques to identify and challenge maladaptive thought patterns contributing to anxiety and mood instability. Implement grounding techniques (i.e. sensory awareness, present-moment focus) to reduce anxiety and restlessness. Introduce relaxation strategies including deep breathing and brief structured rest periods to improve ability to tolerate stillness. Encourage behavioral activation through engagement in structured, low-demand activities (i.e. music, TV, routine-based tasks). Provided psychoeducation on the connection between thoughts, behaviors, and emotional regulation. Reinforced development of daily structure to improve mood stability and reduce irritability. Supported use of copying strategies for managing environmental stressors within current living situation. Encouraged self-monitoring of mood, anxiety, and triggers to increase insight and early identification of symptom escalation. Promoted continued abstinence from substances and utilization of health coping alternatives. Review of Resident 6's active Comprehensive CP showed the facility failed to provide a CP problem or interventions that were recommended by the Psychiatrist. During an interview on 07/29/2026 at 2:00 PM, Staff Y, Licensed Practical Nurse (LPN), stated Resident 6 was known to ambulate about the facility independently, was non-compliant with wearing their neck brace they were ordered to wear by their physician, and required repeated directives to stay out of other resident's rooms, to not push residents down the hallway in their wheelchairs, or unwanted touching of residents on the head and shoulders. Staff Y stated they believed the facility management was aware of Resident 6's behaviors- entering resident's rooms uninvited and going through resident's personal property. Staff Y stated they documented resident behaviors in the progress notes when residents had behaviors. Staff Y was unsure what Resident 6's CP directed staff to do to keep residents safe, but they watched them as best they could during their shift. Staff Y stated Resident 6 was not on 1:1 supervision and just became aware they were required to contact CC2 in the event Resident 6 eloped or discharged against medical advice. During an interview on 07/30/2026 at 11:26 AM, Resident 13 stated they witnessed Resident 6 walk into Resident 38's room and Staff L, Certified Nursing Assistant (CNA), yelled at Resident 6 to get out of Resident 38's room. During an interview on 07/30/2026 at 10:55 AM, Staff D, stated Resident 6 was at the facility for rehabilitation following a neck injury until they were cleared by their surgeon of their neck brace. Staff D stated they became aware of Resident 6's legal problems several weeks prior and they documented a progress note of the conversation. They could not remember the day but knew they made a progress note that day. Staff D stated they were directed by CC2 to notify [CC2] if Resident 6 discharged or left the facility. Staff D stated they were aware Resident 6 left the facility without notice a couple weeks prior when Resident 6 went out to lunch with another resident. When asked if Staff D was aware of the reason CC2 wanted to be notified if Resident 6 left, Staff D stated they did not ask and recently became aware they were a Level III Sex Offender. When Staff D was asked what interventions were implemented to ensure the safety of other residents after they had knowledge of Resident 6's criminal background, Staff D replied, I thought they were leaving today but they are unable because they are still ordered to wear the neck brace. Staff D stated they were notified of an altercation that occurred in the front parking lot area with Residents 6 and 12 and they just had a phone meeting with CC2 and the Social Services team regarding Resident 6. After the conversation, they decided to place Resident 6 on 1:1 monitoring and were on their way to update Staff A regarding their plan to place Resident 6 on a 1:1. Staff D stated they were not aware that Resident 6 was going into other residents' rooms. Staff D stated they received a grievance that Resident 6 was going through Resident 12's personal effects while Resident 12 was sleeping but was unsure if the allegation was reported to the SA or if an investigation was conducted. Staff D stated they would have thought if there was substantiated misappropriation of personal property it would have been reported. The interview ended so Staff D could update the Administrator and implement their plan. Review of a Social Service Progress Note, dated 07/16/2026 at 1:45 PM, showed Staff D, spoke with CC2 and that CC2 needed to be notified if Resident 6 left the facility because they were on probation with a warrant. The note ended with CC2's contact information. The documentation did not provide any other pertinent information or plan for CP updates. During an interview on 08/06/2026 at 10:00 AM, CC2 stated they contacted the facility around the middle of July, after they were able to track down where Resident 6 was. CC2 stated they informed the facility regarding Resident 6's risk for re-offending, their Level III Sex Offense history including failure to register, safety concerns for the other residents due to Resident 6's history of violence and criminal activity. CC2 stated Resident 6 had a felony no-bail nationwide warrant for their arrest and their discharge plan was back to jail after they were medically cleared of their neck brace. During an interview on 07/30/2026 at 11:35 AM, Staff L, stated they witnessed Resident 6 enter residents' rooms without invitation on several occasions, and when that occurred, they told Resident 6 they could not go into other residents' rooms, or push residents in wheelchairs, and/or touch their hair. Staff L stated Resident 6 was non-compliant and must be told repeatedly not to do such things. Staff L stated they notified their supervisor after each encounter, and Staff A and Social Services were also made aware. During an interview on 07/30/2026 at 11:43 AM, with Staff L, Resident 6 (with a female CNA walking behind them) approached the surveyor and Staff L in the [NAME] dining room, yelling loudly, pointing their finger at the surveyor. Resident 6 stated You need to fix this! Staff N, Social Services Assistant, came into my room and told me that the State has required me to be on 1:1 monitoring. I am not going to stay here if that's the case! Resident 6 was asked to step back and calm down in a quiet manner, which Resident 6 did. Resident 6 was informed that the surveyor did not tell the facility what interventions to implement regarding their care and services. <Resident Screening> Review of Resident 6's electronic clinical record did not provide documentation to show a Sex Offender Registration search was conducted prior to Resident 6 admitting to the facility. In an interview on 07/29/2026 at 9:30 AM, Staff G, stated the facility policy for all admissions was to run their name through the National Sex Offender Public Website (NSOPW) search prior to a resident's admission. Staff G stated their practice was to also do a Washington State Search. Staff G stated approximately a week after Resident 6 admitted to the facility, they were notified by another staff member that Resident 6 was a Level III registered sex offender. After Staff G investigated how a registered sex offender made it through their admission vetting process, they found that their assistant (who was no longer employed by the facility) did not run a NSOPW or Washington State Sex Offender search. Once the Admissions Assistant finally ran the search, they confirmed Resident 6 was in fact a Level III Registered Sex Offender. Staff G stated they notified Staff A, Administrator, immediately after they had knowledge of Resident 6's status and how it was missed during admission. Surveyors conducted an audit on 07/30/2026 at 12:33 PM which showed NSOPW were not in the clinical records for 23 of 62 residents reviewed. During an interview 07/30/2026 at 2:49 PM, when asked if they had ensured an audit was conducted of current residents to ensure the NSOPW were done at admission, Staff A stated no. <ELOPEMENT #1> Review of a Nurse Progress Note dated 07/20/2026 at 6:12 PM showed Resident 6 was found down the street by Staff A. Resident 6 was transported back to the facility. Resident 6 appeared drowsy but was responsive. The physician was notified and they educated Resident 6 regarding their probation requirements, and they were not permitted to leave the facility without prior authorization, for which Resident 6 verbalized understanding of those requirements. CC2 was also notified. <ELOPEMENT #2>Review of a Nurse Progress Note, dated 07/23/2026 at 12:15 PM, showed they were notified by Staff A that Resident 6 eloped. Review of a Nurse Progress Note, dated 07/23/2026 at 12:47 PM, showed the nurse was notified Resident 6 had eloped. The documentation showed after Resident 6 was administered their noon pain medication they left the facility with another resident. The other resident was contacted by phone and confirmed they were with Resident 6 and would return within four hours. Notifications went out to the Director of Nursing, Resident 6's emergency contact, and the physician. During an interview on 07/30/2026 at 9:20 AM, Staff Z stated they were made aware of the special requirements required for Resident 6 if they eloped the day prior (07/29/2026 just after lunch) after Resident 6 was involved in an altercation outside in the front smoking area. During an interview on 07/30/2026 at 2:49 PM, Staff A stated the facility did not have a policy on admitting Registered Sex Offenders, it was determined on a case-by-case basis. Staff A stated they were notified of Resident 6's Sex Offender status after Resident 6 admitted but could not remember what day. Staff A stated they did not notify the other residents and family members of the facility that a Level III Registered Sex Offender was admitted to the facility because they did not want to create a panic. Staff A stated they spoke with CC2 almost daily and that directives given from CC2 was to monitor Resident 6 closely, do not provoke Resident 6 due to the history of a temper, and do not engage with Resident 6. Staff A stated they did not ensure a safety plan and/or behavior management plan was developed and updated after Resident 6 was identified as a Registered Sex Offender with a violent history, after they left the facility without authorization twice, after they were alleged to have stolen their roommates personal effects, or immediately after a resident-to-resident altercation with the same person they were accused of stealing from. <RESIDENT 38> Review of the 05/28/2026 5-Day MDS showed Resident 38 admitted to the facility on [DATE], had no cognitive deficits, behaviors, or rejection of care. Resident 38 experienced symptoms of depression and required staff assistance for ADL cares. During an interview on 07/30/2026 at 11:26 AM, Resident 13 stated they witnessed Resident 6 walk into Resident 38's room and Staff L, CNA, yelled at Resident 6 to get out of Resident 38's room. In an interview on 07/30/2026 at 11:26 AM, Resident 38 stated that Resident 6 came walking into their room (unable to remember the date) and walked straight to Resident 38's closet and started going through their belongings. Resident 38 yelled at Resident 6 Get Out, That's My stuff!. Resident 6 closed the closet, turned around, and left the room without saying anything. Resident 38 stated they did not feel safe with Resident 6 just coming into their room uninvited and stated, Makes it hard to relax and go to sleep. Resident 38 stated they notified facility staff but did not know what was done about it. Resident 38 stated that no facility staff had talked to them after they notified staff. Review of Resident 38's electronic clinical record did not provide documentation to show facility staff addressed Resident 38's concern regarding Resident 6 attempting to go through their belongings. <RESIDENT 9 vs RESIDENT 23> <RESIDENT 9> Review of the 05/04/2026 Quarterly MDS showed Resident 9 was alert and oriented, able to make needs known, and exhibited no behaviors. During an interview on 07/29/2026 at 11:08 AM, Resident 1 stated the prior evening (07/28/2026), [they] and Resident 9 returned to their room after dinner and found another resident in Resident 9's room going through their personal items. Resident 9 yelled out to get them out of their room. A nurse came and intervened and got the resident out. During an interview on 07/29/2026 at 11:42 AM, Resident 9 stated Resident 23 was their roommate and when they found Resident 23 going through their personal items, they yelled at them to leave their stuff alone. Resident 9 stated Resident 23 frequently woke Resident 9 up during the night and [they] tell Resident 23 not to bother [them] when they are trying to sleep. Resident 9 stated they try to help Resident 23 and tell them to get off their bed. Resident 9 stated [Resident 23] Gets mad at me - they cursed loudly and got mad at me when I try to help them. Review of Resident 9's electronic clinical did not provide documentation to show the facility identified, investigated, or developed/implemented/revised a CP to address Resident 9's roommate concerns. During an interview on 08/05/2026 at 1:06 PM, Staff T, Registered Nurse (RN) stated Resident 23 was very confused and went through Resident 9's personal items, picking up their stuff. Staff T stated they stopped and redirected Resident 23. Staff T said Resident 9 had requested a different roommate. During an interview on 08/05/2026 at 9:54 AM, Staff D, Social Services Director, stated Resident 9 had come to them and stated they did not favor their roommate. Staff D stated they offered to move them (Resident 9), but they declined as they like their room. When asked why they did not move Resident 23, who was moved into Resident 9's room, Staff D stated the nursing staff said they were a high fall risk and had to stay in that room. When informed of the 07/28/2026 incident, Staff D stated they were not aware and had previously told Resident 9 to return and chat if there were further problems. <RESIDENT 23> Review of the 06/30/2026 admission MDS showed Resident 23 was assessed with severe cognitive impairment and exhibited no behaviors. During an interview on 08/05/2026 at 1:06 PM, Staff T stated Resident 23 was very confused and went through Resident 9's personal items, picking up their stuff. Staff T stated they stopped and redirected Resident 23. Review of Resident 23's electronic clinical record did not provide documentation to show the facility identified, investigated, or developed/implemented/revised a CP to address Resident 23's rummaging behaviors. During an interview on 08/05/2026 at 9:54 AM, Staff D, stated they did not consider moving Resident 23 to a more appropriate room because Resident 23 was told by nursing they were a high fall risk. Staff D stated they were not aware of the incident on 07/28/2026. During the exit interview on 08/05/2026 at 2:45 PM, both Staff A and Staff B stated they had not previously heard anything about incidents involving Resident 9 and Resident 23. Refer to F609 REFERENCE WAC: 399-97-0640(6)(a)(b).

Based on observation, interview and record review, the facility failed to provide care and services in a manner that maintained and promoted dignity for 10 of 10 sampled Residents (Resident 12, 8, 13, 1, 5, 4, 3, 7, 17 & 21) reviewed for resident rights. The facility failed to ensure staff spoke in the English language in common areas and while providing personal care for 8 of 10 sampled residents (Residents 12, 8, 13, 7, 5, 4, 3, & 21) and failed to answer call lights timely for 5 of 10 sampled residents (Residents 1, 17, 8, 12 & 13). These failures detracted from a homelike environment, placed residents at risk of feeling excluded and/or frustrated, diminished self-worth, unmet care needs, and diminished quality of life.Resident 12 experienced psychosocial harm and humiliation when the facility moved them to a room that did not have a functioning toilet and they were forced to defecate on a pad instead of using a toilet for their bowel movements.Findings included .Review of the facility Dignity policy, revised October 2025, showed the facility would treat each resident with dignity and respect in a manner that promoted or enhanced their sense of well-being, feelings of self-worth and self-esteem.<RESIDENT 12>Review of the 07/16/2026 admission Minimum Data Set (MDS-assessment tool) showed Resident 12 had no cognitive deficits, behaviors, or rejection of care. Resident 12 had limited functional range of motion of both legs and used an electric wheelchair for mobility. Resident 12 required substantial/maximal staff assistance for toileting hygiene and supervision with toilet transfers. Resident 12 had a foley catheter and was always incontinent of bowel but not on a bowel program. Resident diagnoses included neurogenic bladder, recent urinary tract infection, cerebral palsy, anxiety, and depression.Review of Resident 12's Activities of Daily Living (ADL) Care Plan (CP), revised 07/15/2026, showed Resident 12 required one person assistance for toilet use.Review of the Comprehensive CP showed Resident 12 experienced symptoms of Post Traumatic Stress Disorder (PTSD) and a problem revised 07/15/2026 showed Resident 12 was at risk of was experiencing adjustment issues due to changes in their customary routine, difficulty accepting nursing home placement, loss of status and/or freedom associated with transition, and loss of social support network. An intervention revised on 07/15/2026 directed staff to review Resident 12's ADL status for impact on their social environment and provide ADL assistance as needed to increase social involvement and to provide them with opportunities for choice during care to maintain sense of control. The CP did not show a problem or interventions to address Resident 12's bowel incontinence or a bowel program.Review of Resident 12's census showed they moved to a room on the other side of the facility on 07/29/2026.During an observation on 07/30/2026 at 10:43 AM, Resident 12 was not observed in their room. Resident 12's breakfast tray was lying on their unmade bed, next to a set of clothing on a hanger. On the floor, next to the bathroom door, was a covered garbage can. On top of the garbage can lid was a grey wash basin with a detached foley catheter drainage bag. The drainage bag had 300 milliliters (mls) of urine in the bag that was not drained. The bag was not secured in a clean storage bag. The bathroom door was open halfway and on the outside of the door was a pink sign taped to the door that read Out of Order, Maintenance in progress, signed by someone, and dated 1/10/24. Inside the bathroom was a toilet that was removed from the floor and set along the wall under the toilet paper holder. There were various screws and tools scattered on the floor. In the floor where the toilet should have been, there was dusty, old black debris on the floor and around the toilet drain hole. Stuffed inside the drain hole was a disposable brief.During an observation and interview on 07/30/2026 at 10:49 AM, Staff R, Certified Nursing Assistant (CNA), was observed walking down the hall toward Resident 12's room, carrying linen, with their persona phone in their pocket while it was playing music that could be heard by everyone. When asked where Resident 12 was, they stated What room number?. Staff R stated they only knew residents by their room number, not by their name. Staff R then said they believed Room [Resident 12] went to work but was not sure. Staff R did not know how Resident 12 used the bathroom.During an interview on 07/30/2026 at 10:55 AM, Staff D, Social Services Director, stated Resident 12 went back to work but was not sure who all was notified.During an interview on 07/30/2026 at 2:45 PM, Staff A, Administrator, was not aware of any resident rooms that did not have intact functioning toilets. The facility's maintenance log was requested but was not provided.During an interview on 08/05/2026 at 1:06 PM, Resident 12 stated they used the toilet for bowel movements when they had a toilet that worked. Resident 12 stated they were moved to another room on 07/29/2026 but the facility did not ensure the bathroom toilet was intact and/or functioning. Resident 12 stated they had to use a disposable pad to have a bowel movement after they moved to the new room. Resident 12 stated the nurse changed their foley drainage bag to a leg bag in the mornings when they went to work. Resident 12 stated they used the toilet for bowel movements while they were at work. Resident 12 stated they told their nurse they needed a room with a functioning toilet, but nothing was done about it. Resident 12 stated they felt humiliated when they were forced to have their bowel movements on a pad instead of the toilet.During an interview on 08/05/2026 at 11:50 AM, Staff F, Maintenance Director, stated the resident previously in the room did not use the toilet. Staff F stated the staff must have put Resident 12 in the room not realizing the toilet was not fixed yet. Staff F stated Resident 12 would have to be relocated.During an interview on 08/05/2026 at 2:04 PM, Staff B, Director of Nursing, stated Resident 12 should never have been put in that room without a functioning toilet and they would ensure Resident 12 was placed in an appropriate room. Staff B stated they expected the staff to address residents by their preferred name, not room numbers.<LANUGUAGE OTHER THAN ENGLISH><RESIDENT 12>During an interview on 08/05/2026 at 1:06 PM, Resident 12 stated staff routinely spoke in languages other than English in resident rooms and hallways. Resident 12 stated it was very inappropriate and unwelcoming for staff to speak other than English when the residents spoke English.<RESIDENT 8>During an interview on 07/29/2026 at 10:15 AM, when asked if staff spoke in a language other than English while providing care and around residents, Resident 8 stated Absolutely. Resident 8 stated they have heard Swahili, Spanish, and some other Asian language spoke in the facility. Resident 8 stated they have asked staff to speak English when they started speaking in other languages in their room, but the staff just looked at them and continued to speak the other language, and one just left the room without finishing their care.<RESIDENT 13>During an interview on 07/29/2026 at 2:08 PM, Resident 13 stated they observed staff speaking in languages other than English Always. Resident 13 stated they should not be speaking in any language except English while at work and during care. Resident 13 recalled an incident where they needed help, and they were trying to get a CNA's attention who was walking down the hall with their personal phone on their ear, speaking in another language. Once they got the CNA's attention, the CNA gestured to [them] to wait a minute, stating I am on a call, one minute. Resident 13 stated I have never seen anything like it. Resident 13 stated they have witnessed CNAs with their earbuds in, holding phone conversations in their native language, while they were working. Resident 13 stated it very undignified.<RESIDENT 7>During an interview on 07/29/2026 at 1:35 PM, Resident 7 stated they noticed staff talked to each other in resident rooms and hallways in a native language they believed to be of African origin. Resident 7 stated they preferred staff spoke in English.<RESIDENT 5>During an interview on 07/29/2026 at 10:09 AM, when asked if they heard staff speaking in other languages, Resident 5 stated, Yes, and I don't like it. Resident 5 recalled they had a difficult time when they were moved from a private room to a smaller room, they couldn't turn the light off, there was no television, and three nursing assistants were all speaking Swahili and laughing at me. Resident 5 stated the next couple of days they didn't say anything to anyone.<RESIDENT 4>During an interview on 07/29/2026 at 10:54 AM, Resident 4 stated they sometimes heard staff talking in other languages, I don't understand what they're saying. It's frustrating.<RESIDENT 3>During an interview on 07/29/2026 at 10:38 AM, Resident 3 stated the staff speak other languages, not to them, but in the hallways.<RESIDENT 21>During an interview on 07/29/2026 at 1:45 PM, Resident 21 stated they heard staff speaking in their native language. Resident 21 stated, Personally, I don't like it.During an observation on 07/30/2026 at 1:57 PM, staff were heard speaking loudly, in a language other than English, in the hallway outside room [ROOM NUMBER].During an interview on 08/05/2026 at 9:15 AM, Staff B, Director of Nursing, stated the expectation was for staff to speak English in resident care areas. Staff B stated they remind staff to whisper to each other, not to talk loudly.<DELAYED CALL LIGHT RESPONSE><RESIDENT 1>During an observation and interview on 07/29/2026 at 11:07 AM, Resident 1 was observed to push their call light button for assistance because they wanted to get up to attend an activity next door that started at 12:00 PM. When asked if staff answered their call light timely, Resident 1 laughed and then stated, Most of the time. When they're short staffed it's hard. At 11:35 AM the investigator looked out into the hallway to verify the call light was on and visible. The only staff observed was the nurse on the medication cart. At 11:39 AM, Staff M, CNA, answered the call light. In an interview at that time, Staff M stated they were in and out of resident rooms, and there was another CNA and nurse in the hallway that could have answered the light. <RESIDENT 17>In a written statement dated 07/02/2026, Resident 17 wrote, There were times during the night when I had a bowel movement and had to sit in my own waste for hours waiting for someone to come. I would ring for assistance, and would be told someone was coming, and then no one would arrive. Those hours felt endless. Sitting there unable to clean myself was degrading and heartbreaking. No human being should have to experience that, especially when they are completely dependent on others for help.<RESIDENT 8>During an interview on 07/29/2026 at 10:15 AM, Resident 8 stated staff did not answer their call light timely and reported their longest wait time to be around 40 minutes. Resident 8 stated there were times when staff would sneak into their room without saying anything, shut off the call light, then leave the room without checking on them. <RESIDENT 12>During an interview on 08/05/2026 at 1:06 PM, Resident 12 stated their call light was hardly ever answered timely.<RESIDENT 13>During an interview on 07/29/2026 at 2:08 PM, Resident 13 stated their call light was not answered timely on a routine basis, and the longest wait time was over an hour.Review of the Resident Council Meeting minutes, dated July 7, 2026, showed nine residents were present. The residents reported long delays in call light response for bathroom assistance. Some residents reported their wait was around 90 minutes, worse in [NAME] Hall, and majority on the night shift.REFERENCE WAC: 388-97-0860(1)(a).

Based on observation, interview, and record review, the facility failed to ensure menus were followed for 7 of 18 residents (Residents 27, 29, 8, 31, 5, 1 & 34) reviewed for food and nutrition services. Failure to follow the menu as directed, and provide accurate portion sizes, placed residents at risk for not having their food choices honored, dissatisfaction with meals, unmet nutritional needs, and a diminished quality of life. Findings included .<RESIDENT 27>Review of the physician diet orders dated 11/01/2025 showed Resident 27 was on a Carbohydrate Controlled (CCD), No Added Salt diet with Regular texture, thin liquid consistency, and low potassium diet (no orange juice--substitute cranberry juice for orange juice and substitute rice with gravy instead of mashed potatoes when available) for regular diet.Review of the 05/12/2026 Dietary Profile showed Resident 27 disliked tomatoes.During an observation on 07/29/2026 at 1:23 PM of Resident 27's lunch tray showed a hamburger patty in a bun, with no mayonnaise, no mustard, and no lettuce. Resident 27 stated, It's bare. Resident 27 stated they liked catsup and mustard.During an interview on 07/30/2026 at 10:39 AM, Staff K, Food Service Director, stated Resident 27 had themselves on a low potassium diet so they did not receive tomatoes. Staff K stated Resident 27 should have been served mayonnaise or mustard with the burger.<RESIDENT 29>Review of the physician diet orders dated 04/29/2025 showed Resident 29 was on a fortified Regular diet with Regular texture and thin liquid consistency. During an observation and interview on 07/29/2026 at 1:28 PM, Resident 29's tray card showed they were on a fortified diet and were to receive Mashed Potatoes and Gravy (MP & G) served with a #8 scoop. The tray card also indicated that the resident was to receive white cake with jelly topping. Resident 29's lunch tray was observed without MP & G, without white cake, and instead they were served chocolate ice cream.During an interview on 07/30/2026 at 10:39 AM, Staff K stated all fortified diets get served MP & G, unless the resident was on a controlled carbohydrate diet, then they substitute with something else. Staff K stated Resident 29 was at the end of the tray line so they may have run out of cake and they did not have any alternatives for the white cake.<RESIDENT 8>Review of the physician diet orders dated 04/29/2025 showed Resident 8 was on a Regular diet, Regular texture, thin liquid consistency, and request for larger portions for each meal (three times a day).Review of the Dietary Profile dated 07/15/2026, showed Resident 8 requested Double portions.During an interview on 07/29/2026 at 10:15 AM, Resident 8 stated their food was generally cold, their milk was usually warm, and they regularly did not receive the food items they were ordered to receive. Resident 8 kept their tray tickets with notes when they did not receive what they were supposed to receive. Resident 8 stated they were supposed to receive double portions because they were a big guy. Resident 8 stated they get upset when it continues to happen daily, and when they sent staff to the kitchen to retrieve the items that were missing, they often never came back with the food items. Resident 8 stated I don't know how they can screw it up because what I am supposed to get is written in detail on the tray ticket.Review of Resident 8's meal tray ticket for the Tuesday 07/28/2026 evening meal showed Resident 8 was on a Regular diet, Regular Texture, and thin liquid consistency. For this meal, Resident 8 explained what they were supposed to receive compared to what they actually received as follows: two servings of Fried Chicken-they only received two tiny wings with no meat on them, two servings with #8 scoop of Au Gratin potatoes-they only received one small scoop, two servings of seasoned peas- they got peas but they were not seasoned, two rolls with margarine-they received one roll and no margarine, two #8 scoops of peaches-they received one small cup of peaches, two #8 scoops of ice cream-they did not receive any ice cream, and 16 ounces of milk (two small portioned milk cartons with eight ounces each)- they received on eight ounce carton of milk that was warm.Review of Resident 8's tray ticket for breakfast on Wednesday 07/29/2026 showed Resident 8 was to receive double portions of each food item but received: one orange juice, one six-ounce oatmeal, sausage/egg/cheese biscuit- received two, hashbrowns-received two scoops but they were very dry, one coffee and one warm whole milk. Resident 8 stated they asked the staff to retrieve the missing milk, coffee, and oatmeal but they had not come back, and it had been over an hour.During an interview on 07/30/2026 at 11:19 AM, Staff K stated Resident 8 has double portion everything. The kitchen staff were doing good beforehand, but Resident 8 recently complained they were not getting two drinks. Staff K stated they had previously scheduled training for kitchen staff reviewing double portions. Staff K stated portion sizes served in the facility were different than what we would serve at home.<RESIDENT 31>Review of the 04/21/2026 Minimum Data Set (MDS - an assessment tool), showed Resident 31 had no natural teeth or toot fragments (edentulous).Review of the physician diet order dated 04/29/2025 showed Resident 31 was on a Regular diet with Regular texture and thin liquid consistency, per resident request LARGER portions for each meal (three times a day) on trays.During an observation and interview on 07/29/2026 at 1:35 PM, Resident 31's tray card showed they were on a regular texture diet. There was a large amount of corn observed on their plate. In an interview at that time, Resident 31 stated they could not eat the corn because they couldn't chew it.During an interview on 07/30/2026 at 10:39 AM, Staff K stated Resident 31 was on a regular diet and had not complained about any issues with chewing. Staff K stated they could substitute with creamed corn. Staff K looked in Resident 31's record and noted the last dietary profile was dated 05/09/2024 and should have been reviewed every 90 days but was not.<RESIDENT 5>Review of the physician diet orders dated 05/25/2026 showed Resident 5 was on a Cardiac (Low fat, Low Cholesterol, 2-gram sodium) diet with Easy- to- Chew texture and thin liquid consistency.Review of the Dietary Profile dated 07/11/2026 showed Resident 5 liked brown sugar with cream of wheat and did not want pork for religious reasons.During an observation and interview on 07/29/2026 at 10:09 AM Resident 5 stated for their breakfast meal they were served oatmeal instead of cream of wheat which they notified the facility of that preference. Resident 5 was on a kosher diet and received lots of grilled cheese sandwiches. Resident 5 stated they once received a pork patty with their eggs, so then they could not eat the eggs either. Resident 5 stated they understood they did not have a kosher kitchen but expected some accommodation for their preferred food preferences.During an interview on 07/30/2026 at 11:19 AM, Staff K stated the tray card listed cream of wheat and Resident 5 should have gotten cream of wheat. Staff K stated they knew Resident 5 did not eat pork but did not realize it was religious reasons. Staff K acknowledged that pork should not be put on Resident 5's tray.<RESIDENT 1>Review of the physician diet orders dated 01/23/2026 showed Resident 1 was on a CCD diet with Easy- to- Chew texture and thin liquid consistency. Portions ordered were Regular portions for Breakfast and Dinner, Large portions for Lunch.Review of the Nutrition Care Plan dated 06/24/2026 showed staff were to honor food preferences within the meal plan and provide diet as ordered.During an interview on 07/29/2026 at 11:08 AM, Resident 1 stated they sometimes were served food they could not eat, such as salad, broccoli, and corn, because their medical condition inhibited their ability to digest high fiber foods. Resident 1 stated corn blocked their ostomy stoma.Review of Resident 1's 07/29/2026 tray card did not show the higher fiber foods on their dislike list.During an interview on 07/30/2026 at 11:19 AM, Staff K stated Resident 1 was to receive food that was Easy to Chew so they should not be served lettuce as it can't be smashed with a fork.<RESIDENT 34>The 07/29/2026 lunch meal listed garlic bread.On 07/29/2026 at 1:40 PM, Resident 34 stated what they were served was a roll, not garlic bread.During an interview on 07/30/2026 at 10:39 AM, Staff K stated the menu listed garlic bread, but they did not have the ability to order garlic bread so the roll should have been brushed with garlic butter. Staff K stated on 07/30/2026 lunch menu listed breadsticks, but they can't order those either, so they serve rolls. Staff K stated they were not listed on the substitution log, and they could not change the menu without IT support.REFERENCE: WAC 388-97-1160(1)(a)(b)

Based on observation, interview, and record review the facility failed to report to the State Agency (SA) and/or local Law Enforcement alleged violations for 4 of 5 Residents (Residents 6, 12, 9 & 23) reviewed for elopements, misappropriation, and resident-to-resident altercations. These failures placed residents at risk for accidents, continued abuse and/or misappropriation, potential ongoing resident-to-resident altercations, and diminished quality of life.Findings included.<POLICY>Review of the facility's SNF Clinic Abuse Prohibition Administrative policy, revised 10/25/2024, showed the facility's Executive Director was responsible for operationalizing abuse policy and procedures and defined the following:>Verbal abuse as any use of oral, written, or gestured language that willfully included disparaging and /or derogatory terms to patients or their families, or within hearing distance of residents (regardless of age, ability to comprehend, or disability). >Misappropriation of patient property as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a patient's belongings or money without the patient's consent. Exploitation was defined as the act/process of taking advantage of a resident for personal gain using manipulation, intimidation, threats, and/or coercion.The facility would train their staff of their reporting obligations annually and as needed to include appropriate interventions to deal with aggressive and/or catastrophic reactions of patients, how to report their knowledge of allegations without fear of reprisal, what constitutes abuse and misappropriation of resident property, dementia management and resident abuse prevention, and understanding the behavioral symptoms of patient that could increase the risk of abuse, and how to respond. The facility would report suspected or alleged abuse or misappropriation to the SA no later than 2 hours after the allegation was made and notify local Law Enforcement as when required. Failure to report within the required timeframes would result in disciplinary action up to and including termination.<RESIDENT 6 vs. RESIDENT 12-MISAPPROPRIATION AND RESIDENT-TO-RESIDENT ALTERCATION><RESIDENT 6-ELOPEMENTS> Review of the Leave of Absence without Notice (LAWN) CP, revised 07/17/2026, showed Resident 6 was at risk for LAWN.Review of Resident 6's electronic clinical record showed Resident 6 left the facility without notice on 07/20/2026 and 07/23/2026. Resident 6 was also moved to another room on 07/24/2026 due to allegations of stealing from and going through their roommates' personal items.During an interview on 07/30/2026 at 9:20 AM, Staff Z, Receptionist, stated Resident 6 was involved in an altercation with Resident 12 during the afternoon of 07/29/2026. Staff Z stated they summoned assistance from Social Services and Nursing to intervene. Review of the July 2026 Reporting Log did not provide documentation to show the facility reported the two elopements, the alleged misappropriation, or the resident-to-resident altercation. During an interview on 07/30/2026 at 2:49 PM with Staff A, Administrator, when asked if they should have reported Resident 6's two elopements, Staff A, Administrator, stated yes. When asked why they did not, Staff A stated Resident 6 signed themselves out of the facility and facility staff notified the police and Resident 6's parole officer. Staff A stated they did not report the misappropriation as required to the SA or local law enforcement, but they replaced the missing items. Staff A stated the altercation that occurred with Residents 6 and 12's spouse did not involve Resident 12, so it was not reported as a resident-to-resident altercation but confirmed Resident 12 was present for the altercation.During an interview on 08/05/2026 at 9:31 AM, Staff B, DNS, stated they had heard from Staff A that Resident 6 had an argument in the parking lot with Resident 12's wife. When asked why they did not report the incident, Staff B stated Staff A stated they did not have to, because the incident was with a wife. Resident 6 was alert, oriented and able to stand up for themselves, so they didn't think they would have psychological harm.During an interview on 08/05/2026 at 10:12 AM, when asked why the incident was handled as a grievance, rather than an incident of abuse, Staff D, Social Services Director, stated when they talked to Resident 12, they expressed they wanted to be moved to the other end of the hall and wanted their items replaced. Staff D stated they felt it was resolved. When asked why Resident 12's grievance was not reported to the SA or Law Enforcement, Staff D, stated, I don't make the decisions on reporting.<RESIDENT 9 vs RESIDENT 23>During an interview on 07/29/2026 at 11:08 AM, Resident 1 stated the prior evening, they and Resident 9 were returning to their rooms after dinner and another resident was in Resident 9's room tossing their stuff. Resident 9 yelled out to get them out of their room. A nurse came and intervened and got the resident out. During an interview on 07/29/2026 at 11:42 AM, Resident 9 stated they told Resident 23 to leave their stuff alone, that it did not belong to them. Resident 9 stated Resident 23 was their roommate and went through their stuff.During an interview on 08/05/2026 at 1:06 PM, Staff T, Registered Nurse (RN), stated Resident 23 was so confused, they went through Resident 9's stuff, picking up his stuff. Staff T stated they stopped and redirected Resident 23. Staff T was aware Resident 9 wanted a different roommate. When asked if they had reported the incident, Staff T stated Resident 9 told everybody.Review of the facility's Reporting Log for July 2026 and August 2026 did not provide documentation to show the incident was reported.Refer to F610 - Investigate/Prevent/Correct Alleged Violation.REFERENCE WAC: 399-97-0640(5)(a)

Based on interview and record review, the facility failed to promptly resolve grievances for 4 of 6 Residents (Residents 36, 2, 11 & 34) and Resident Council reviewed for grievances. Failure to timely resolve grievances placed the residents at risk for a diminished quality of life.Findings included.Review of the undated facility Grievances/Concern policy showed all residents and/or their representatives may voice grievances and the facility will investigate, document, and follow up with them.<RESIDENT 36>During an interview on 07/09/2026 at 11:52 AM, Resident 36's representative stated after Resident 36 discharged from the facility [they] went to the facility to get their clothes and found several new clothing items that were missing including: a shirt that said World's Greatest Grandpa on it, a Star Wars shirt, two pajama bottoms, two V-neck zipper pull over sweaters, and a pair of slip-on tennis shoes.During an interview on 07/15/2026 at 5:24 PM, Staff A, Administrator and Staff B, Director of Nursing, were provided with a list with the missing items to be processed as a grievance.Review of the July 2026 Grievance Log on 07/30/2026 did not provide documentation to show the facility initiated or completed a grievance for Resident 36's missing items.During an interview on 08/05/2026 at 9:54 AM, Staff D, Social Services Director, stated they had not received a grievance for Resident 36 missing clothes.<RESIDENT 2>Review of Resident 2's electronic clinical record showed they were admitted to the facility in July 2026.During an interview on 07/29/2026 at 4:05 PM, Resident 2's Responsible Party (RP2) stated they were in the facility every day for four to five hours. RP2 stated they submitted a written list of questions into Staff U, Resident Care Manager (RCM)'s, box. RP2 stated they did not receive a response from Staff U, so they went to social services for assistance, on 07/29/2026. RP2 shared the issues they had with Social Services, including, but not limited to, missing clothing. RP2 stated they labeled all of Resident 2's clothes and previously observed two distinct items worn by Resident 2's roommate. Resident 2's spouse stated they put a sign up in Resident 2's room that [they] would do the laundry, they put the clothes in a bag, and then the bag of clothes was gone. RP2 stated they were able to look in laundry and found a couple of Resident 2's missing items. RP2 was provided with a grievance form at that time.Review of the July 2026 Grievance Log showed only one entry for Resident 2, received and resolved on 07/31/2026.Review of the Grievance dated 07/31/2026, showed the summary of the Grievance was written as *See attached questions and concerns left in Unit Manager's in box outside his office on Tuesday 28 July. No response as of Friday 31 July. Actions taken were documented as- see attached care conference notes, spouse was happy with all plans moving forward.During an interview on 08/05/2026 at 9:54 AM, Staff D, Social Services Director, stated they received a grievance in July for Resident 2, a list of items Resident 2's spouse wanted addressed. Staff D stated they had a care conference with them the same day, a plan was made, and the grievance was resolved. During an interview on 08/05/2026 at 11:39 AM, RP2 confirmed they had a care conference, but the facility had not gotten back to them regarding when and how they planned to address the list of concerns discussed.During an interview on 08/05/2026 at 12:31 PM, Staff U stated a list of concerns from RP2 were received on Friday (07/31/2026) or Monday (08/03/2026). Staff U stated they were no longer the RCM for that unit, so they believed a charge nurse was supposed to follow up.During an interview on 08/05/2026 at 12:39 PM, Staff V, LPN, stated they usually worked on the floor but were helping on their days off because there was no RCM for that unit. Staff V stated they were not aware of a list of questions, concerns or tasks for Resident 2.During an interview on 08/05/2026 at 12:47 PM, Staff W, RCM, stated they thought Social Services had a list, but they did not get a list of concerns for Resident 2.<RESIDENT 11>During an interview on 07/27/2026 at 9:25 AM, Resident 11 stated when they discharged the money they had in their facility trust fund was supposed to be returned to them. Resident 11 stated they asked repeatedly for their money to be returned but the facility refused.During an interview on 07/29/2026 at 1:45 PM, Staff I, Business Office Assistant, stated they told Resident 11 they had to let consulting staff know Resident 11 discharged so they could get a check written. When Staff I was asked when they notified the appropriate people, Staff I stated they did not notify anyone that Resident 11 discharged and requested their trust fund balance. <RESIDENT 34>During an interview on 07/29/2026 at 1:40 PM, Resident 34 stated they were not allergic to milk, they preferred to drink milk, and they ate ice cream. Resident 34 stated they asked the facility staff to have the allergy removed from their tray card but were told it was in the computer, so they had to follow it.During an interview on 07/30/2026 at 10:39 AM, Staff K, Food Services Director, stated if an allergy is listed in the resident's record, then they must follow it. Staff K stated they had asked nursing staff to do a risk and benefits waiver with Resident 34 multiple times. Staff K stated they asked Resident 34 to ask a nurse. Staff K stated they had also posted on clinical communications on 07/20/2026 for it to be addressed.Review of the facility's Grievance Log for July 2026 did not show a grievance was submitted for Resident 34 regarding correction of their allergies.<RESIDENT COUNCIL>During an interview on 08/05/2026 at 10:40 AM, Staff X, Activity Assistant, stated they just had their August 2026 Resident Council meeting. Staff X stated the residents had concerns about the menus not matching the food on the tray or what they wanted. Staff K, Food Service Director, was present at the meeting and addressed the residents' concerns at that time. The resident council also voiced concerns about staffing which Staff X conveyed to nursing in the morning meeting.Review of the July 2026 Resident Council meeting minutes showed under the heading of Old Business: written, Tickets sometimes do not match what is on the tray. During an interview on 08/05/2026 at 10:40 AM, Staff X stated Staff K was also at that meeting and addressed the concerns during the meeting. Review of the July 2026 Resident Council meeting minutes showed under the New Business was written, Sometimes it takes long for assistance to the bathroom, Wait maybe an hour and a half to get to room (West) majority during night shift. During an interview on 08/05/2026 at 10:40 AM, Staff X said they usually notified nursing as there was not much they could do. When asked if they had filled out any Grievances on behalf of the Resident Council, Staff X stated they had not.Review of the July 2026 Grievance Log showed no entries for the Resident Council concerns.During an interview on 08/05/2026 at 9:54 AM, Staff D stated they had become responsible for processing Grievances in May 2026 and didn't have any kitchen related Grievances for a while. Staff D stated if someone brought an issue to them, they would have likely turned it into a Grievance and noted that 90% of the Grievances were filled out by staff on behalf of residents, not by the residents themselves.Refer to F-569 Notice and Conveyance of Personal FundsREFERENCE WAC: 388-97-0460 (1)(2).

Based on observation, interview, and record review the facility failed to provide quality care and services for 2 of 3 Residents (Resident 8 & 5) reviewed for non-pressure wound care. The failure to monitor wounds and follow physician orders for wound care placed residents at risk for delayed healing, infections, potential pain, and diminished quality of care. Findings included .<RESIDENT 8>Review of the 07/19/2026 admission Minimum Data Set (MDS - an assessment tool) showed Resident 8 had no cognitive deficits, behaviors, or refusals of care. Resident 8's diagnoses included a major infection with a Multidrug-Resistant Organism (MDRO), skin infection of the lower extremities, bone infection of the right foot and ankle, and diabetes. Resident 8 had non-pressure ulcers of the foot that required application of dressings.Review of the 07/13/2026 skin breakdown Care Plan (CP) showed staff were to provide wound treatment as ordered.Review of the 07/13/2026 hospital Nursing Transfer Summary showed Resident 8 had open wounds on the right and left great toes that were to be cleansed daily (at 5:00 AM) with betadine, covered with gauze, then secured in place. Resident 8 also had redness to both buttocks and wounds to the scrotal area.Review of the 07/13/2026 hospital Provider Orders-Nursing Home Transfer showed Wound Care orders included keeping the wounds clean, redress with a clean bandage daily after cleaning the area, monitoring the wounds often for signs of infection, and wearing shoes to prevent injuries to the feet.Review of the July 2026 and August 2026 Treatment Administration Record (TAR) showed a physician order dated 07/13/2026 for twice daily wound care for groin redness: wash the area with warm water and soap, pat dry, apply barrier ointment cream. The documentation showed the treatment was administered twice daily from 07/13/2026 through 08/05/2026. A wound treatment physician order dated 07/14/2026 for both great toes gave directives to cleanse the wounds with wound cleanser, pat dry, apply betadine, cover with gauze, secure with kerlix, and change the dressing every other day (not daily as directed by the hospital physician). The documentation showed the wound care was documented as provided to both toes on 07/14/2026, 07/16/2026, 07/18/2026, 07/20/2026, 07/22/2026, 07/24/2026, 07/26/2026, and 07/28/2026. The treatment order was discontinued on 07/29/2026. A new wound care physician order was entered on 07/30/2026 to paint both toes with betadine and leave open to air every other day and signed as performed on 07/30/2026. That physician order was discontinued on 07/31/2026. A new wound care physician order was entered on 07/31/2026 for wound care to both toes: paint with betadine and cover with a dry dressing as needed for soiled dressing. There were no as needed treatments signed for as completed. The August 2026 TAR showed a wound care order dated 08/01/2026 for wound care of both toes: paint with betadine and cover with a dry dressing every Tuesday, Thursday, and Saturday. The documentation showed the treatment was administered on 08/01/2026 (Saturday) and 08/04/2026 (Tuesday).During an observation and interview on 07/29/2026 at 10:50 AM, Resident 8 stated they did not receive daily wound care for their toes as ordered by their Infectious Disease Specialist and Podiatrist. Resident 8 recalled 3-4 dressing changes since they were admitted on [DATE] for their toes. Resident 8 stated the facility physician came to evaluate them yesterday, 07/28/2026, and removed the dressings on their toes. After the physician was done, the nurse rubbed some antibiotic ointment on the toes and then said they would return to dress the toes but never came back. When they told the nurse on duty that their dressings were never reapplied after their doctor visit, they were told by the nurse [the nurse] did not have time right now and they would notify the oncoming shift in the morning. Resident 8 stated they were still waiting for someone to dress their toes as the dressing had been off for 24 hours. Resident 8 stated their wounds drained at times, but they were more concerned about losing their toes to amputation. Resident 8's toes were observed to be open to air under their bedding, and a slight bit of dry drainage was noted on the bedding. When asked if staff performed their wound care for their groin and buttocks, Resident 8 stated hell no.In an interview on 07/29/2026 at 2:00 PM, Staff Y, Licensed Practical Nurse (LPN), stated the wound nurse changed dressings for the residents that required wound care. Staff Y stated in the absence of a wound nurse for the day, the nurses on the carts were responsible for their residents' dressings and wound care. Staff Y was unsure when the wound nurse planned to change Resident 8's dressing.During an observation and interview on 07/30/2026 at 1:13 PM, Resident 8 still had no dressings applied to their toes. Resident 8 confirmed they had not been redressed since after their doctor's visit on 07/28/2026. During an observation and interview on 08/05/2026 at 12:03 PM, Resident 8 stated they did not have their dressings changed and they were undressed under their socks. Resident 8's feet were observed to have socks on them with no dressing on the toes. <RESIDENT 5>Review of the 5-Day admission MDS showed Resident 5 admitted to the facility on [DATE]. Resident 5 had no cognitive deficits, no behaviors, and no rejection of care. Resident 5 required staff assistance for ADLs (Activities of Daily Living) and diagnoses included a heart rhythm problem and liver failure. Resident 5 admitted with a vascular ulcer and required non-surgical dressings other than to their feet.Review of the Skin Risk CP revised on 07/21/2026 showed Resident 5 had a chronic venous stasis ulcer on the right lower leg. Staff were directed to provide wound care as ordered.Review of Resident 5's July 2026 TAR showed a physician order dated 07/22/2026 for wound care treatment of the right lower leg vascular wound: cleanse with wound cleanser, pat dry, apply xeroform (medical gauze dressing), apply calcium alginate (medical gel which promotes healing), cover with rolled gauze, and secure with tape. The dressing was scheduled to be changed every other day, on even numbered days. The documentation showed the wound care was not provided on Sunday, 07/26/2026.During an observation and interview on 07/29/2026 at 10:09 AM, Resident 5 stated they did not get their leg dressings changed on Sundays.In an interview on 08/05/2026 at 11:55 AM, Staff B, Director of Nursing, stated it was their expectation that the nurses followed all physician orders for wound care, that wounds were monitored daily for signs of infection, and dressings were checked every shift to ensure they were clean, dry, and intact. REFERENCE WAC: 388-97-1060 (1)

Based on interview and record review, the facility failed to ensure resident trust funds were refunded within 30 days following discharge for 1 of 3 Residents (Resident 11) reviewed for transfer of resident funds. This failure placed the residents at risk for loss of funds and the interest accumulated.Findings included .During an interview on 07/27/2026 at 9:25 AM, Resident 11 stated they had approximately $300.00 left in their trust fund account when they discharged . Resident 11 stated they asked repeatedly for their money to be returned but the facility refused.Review of Resident 11's electronic clinical record showed they were discharged from the facility on 06/18/2026.Review of the Resident Fund Management Services Balances as of 07/29/2026 showed Resident 11 had a balance of $280.00 in the trust fund.During an interview on 07/29/2026 at 1:45 PM, Staff I, Business Office Assistant, stated at the time of Resident 11's discharge, they did not have a Business Office Manager and they told Resident 11 they had to let consulting staff know of their discharge and trust fund balance in order to have a check written to Resident 11 to refund their money. During an interview on 07/29/2026 at 1:45 PM, Staff H, Business Office Manager, stated they started in that position on 07/10/2026 and had not processed any trust fund refunds since then. Staff H reviewed documentation and verified Resident 11 did not but should have received their funds within 30 days of discharge.REFERENCE WAC: 388-97-0340 (5)

Based on observation and interviews, the facility failed to ensure a safe, functional, and clean environment for 2 of 10 residents (Residents 12 & 8) reviewed for a homelike environment. The failure to ensure safe, functioning toilets in bathrooms for residents who required the use of toilets placed the residents at risk for unmet care needs, infections, skin breakdown, falls / adverse events, humiliation, and diminished quality of life.Findings included .<RESIDENT 12>During an observation of Resident 12's room on 07/30/2026 at 10:43 AM, on the floor, next to the bathroom door, was a covered garbage can. On top of the garbage can lid was a grey wash basin with a detached foley catheter drainage bag. The drainage bag had 300 milliliters (mls) of urine in the bag that was not drained. The bathroom door was open halfway and on the outside of the door was a pink sign taped to the door that read Out of Order, Maintenance in progress, signed by someone, and dated 1/10/24 (two years and seven months ago). Inside the bathroom was a toilet that was removed from the floor and set along the wall under the toilet paper holder. There were various screws and tools scattered on the floor. In the floor where the toilet should have been, there was black grime buildup covered with dust surrounding the drain hole. Stuffed inside the drain hole was a disposable brief.During an interview on 07/30/2026 at 2:49 PM, Staff A, Administrator, was asked if they were aware of any toilets in resident rooms that were non-functional or in need of repair and Staff A stated No. Staff A stated the facility maintenance requests were submitted electronically to TELS (a specialized building management and operations platform designed for healthcare facilities to centralize asset management, regulatory compliance, routine/preventative maintenance, life safety checks, and repair services into one digital system). The TELS maintenance request reports for July 2026 were requested but no further information was provided. During an interview on 08/05/2026 at 1:06 PM, Resident 12 stated they were moved to another room on 07/29/2026 but the facility did not ensure the bathroom toilet was intact and/or functioning. Resident 12 stated they told their nurse they needed a room with a functioning toilet, but nothing was done about it.During an interview on 08/05/2026 at 11:50 AM, Staff F, Maintenance Director, looked in the bathroom, saw the toilet and stated they had to get a plumber to fix it.During an interview on 08/05/2026 at 11:55 AM, Staff B, Director of Nursing, observed the condition of Resident 12's bathroom, stated they were never notified the bathroom/toilet was not functional, and Resident 12 should never have been moved into that room. Staff B stated they would address the situation immediately.<RESIDENT 8>During an observation and interview on 07/29/2026 at 11:18 AM, Resident 8 stated they notified several nurses and the maintenance assistant that their toilet was wobbly and moved. Resident 8 stated they were able to hold on to the handrails next to the toilet but felt the toilet should be repaired, especially after they left and another resident moved in. During observation, with minimal pushing force on the top upper area of the tank (next to the toilet handle) toward the wall behind the toilet, when pushed, caused the entire toilet to detach from the floor approximately an inch, making the toilet unstable.During an interview on 08/05/2026 at 11:50 AM, Staff F, Maintenance Director, stated they did not have an open work order in TELS for the toilet in Resident 8's room. At 12:00 PM, when the toilet was observed, Staff F stated a previous resident had turned the toilet sideways which the Maintenance Assistant repaired a while ago. Staff F acknowledged there was something wrong with the toilet and it needed to be repaired.Refer to F550 Dignity.REFERENCE WAC: 388-97-0880.

Based on observation, interview and record review, the facility failed to ensure intravenous (IV) services were provided in accordance with professional standards of practice for 2 of 4 residents (Residents 8 & 18) reviewed for IV therapy. The failure to provide Peripherally Inserted Central Catheter (PICC- a long, thin tube that's inserted through a vein in the upper arm and extended into the larger veins near the heart) care including monitoring, maintenance (including changing needleless injection caps), sterile PICC dressing changes weekly, measuring external length to verify the line had not migrated, and arm circumference to monitor for potential serious complications placed the residents at risk for adverse events, loss of vascular access, infection, pain, and diminished quality of care.Findings included .<PICC MANUFACTURERS RECOMMENDATIONS>Review of the undated BD PowerPICC Provena SOLO manufacturer's brochure showed they were designed to not require heparin for flushing after IV medication administration and flushed with 10 milliliters (ml) of Normal Saline (NS) using push-pause (pulsatile) technique (injecting saline with a 10 ml or larger syringe using quick, forceful start-and-stop pulses of 1-3 mls), the catheters were 55 cm long, trimmable, and clearly marked every centimeter (cm) on the catheter body to show length after trimming. The PICC line dressing procedure required sterile technique and required to be changed weekly. The PICC came with a needless end cap that should be scrubbed with an alcohol pad for 15 seconds prior to each access of the IV line and changed weekly during the sterile dressing changes.<RESIDENT 8>Review of the 07/19/2026 admission Minimum Data Set (MDS - an assessment tool) showed Resident 8 had no cognitive deficits, behaviors, or refusals of care. Resident 8's diagnoses included a major infection with a Multidrug-Resistant Organism (MDRO), skin infection of the lower extremities, bone infection of the right foot and ankle, and diabetes. Resident 8 received IV antibiotic therapy.Review of the 07/13/2026 IV therapy care plan (CP) showed staff were required to change the PICC dressing and perform IV flushes per facility policy and as needed, monitor the IV site for symptoms of infiltration or complications (i.e. pain at the site, redness, fever, poorly functioning IV, red streak traveling down/up the arm from the PICC site, foul/smelly drainage, or swelling), monitor for a venous air embolism (a dangerous condition where one or more air bubbles enter the vein and block the flow of oxygenated blood to vital organs like the brain, heart, or lungs, which can lead to a stroke, heart attack, or death), distended neck veins, gurgling noises, chest pain, symptoms of blood/air in the lungs, allergic reactions to the medications, and fluid volume overload.Review of the hospital After Visit Summary dated 07/13/2026 showed Resident 8 admitted to the facility with a PICC that was inserted on 07/07/2026 at 1:01 PM. Resident 8 was ordered to receive two strong IV antibiotics daily for six weeks for skin and bone infections.Review of Resident 8's hospital documentation and electronic medical record at the facility did not provide documentation from the hospital regarding the PICC placement procedure on 07/07/2026, placement verification, external catheter length after placement and/or amount trimmed during the procedure to establish a baseline for monitoring.Review of the Nurse Progress Notes, the July 2026 Medication and Treatment Administration Records (MAR/TARs), and August 2026 MAR/TARs showed:<Antibiotic Administration and Flushes>>A physician order dated 07/13/2026 for IV Vancomycin (antibiotic) 1.5-0.9 gram (GM)/250 milliliters (ml) Sodium Chloride solution-administer 1.5 GM every 12 hours for bone infection for six weeks, scheduled at 9:00 AM and 11:00 PM. On 07/30/2026, the scheduled times were changed to 7:00 AM and 7:00 PM.>A physician order dated 07/13/2026 for 10 milliliter (ml) Normal Saline (NS) IV flushes intravenously every 12 hours for SASH/SAS (a universal IV administration protocol that stands for S-Saline, A-Administer, S-Saline, H-Heparin-or SAS which does not require heparin) technique BEFORE IV medication administration, scheduled at 9:00 AM and 11:00 PM and a physician order dated 07/13/2026 for 10 ml NS IV flush every 12 hours for SASH/SAS technique AFTER IV medication administration, also scheduled at 9:00 AM and 11:00 PM. The physician order did not indicate whether heparin was required for their specific PICC maintenance and the documentation did not show the facility changed the flush times on 07/30/2026 (to 7:00 AM and 7:00 PM) to correspond with the time change of the antibiotic administration.>A physician order dated 07/14/2026 for IV Ceftriaxone (antibiotic) 2GM intravenously in the morning for bone infection for six weeks, scheduled at 5:00 AM. The documentation did not show a physician order for the 10 ml NS IV flushes before and after the administration of the Ceftriaxone medication at 5:00 AM every day. <PICC Monitoring and Maintenance>>A physician order dated 07/14/2026 at 8:00 AM that read: IV left upper arm, change catheter site transparent dressing. Indicate external catheter length and upper arm circumference (10 cm above the elbow). Notify provider if the external length had changed since last measurement, every day shift Tuesday weekly. The task schedule showed three required entries: CIR (circumference above the elbow), EXT (external catheter length), and DAY 4 (where the nurses initialed the task was completed). The documentation showed on 07/14/2026, 07/21/2026, and 07/28/2026 similar findings that the circumference equaled NA, the external length equaled NA, and in the Day 4 box was a check mark with the nurse initials. The documentation did not show the facility measured the exterior catheter length or the upper arm circumference on admission and weekly.>A physician order dated 07/13/2026 to observe the IV site routinely for signs of infiltration (when fluid/medication leaks out of the vein and into the soft tissue under the skin) at a frequency based on therapy and resident condition. Document in PN (progress notes) at least every shift before and after administration of intermittent medications. The scheduled showed requirement for two entries: +/- and Day 1, +/- and Eve 1, and +/- Night. The documentation showed no omissions for each shift from 07/13/2026 to 07/31/2026 and all entries for each shift included a - except for 07/23/2026 Night shift (+) and 07/25/2026 Day shift (0). The transcribed order did not indicate what +/- referred to.>Review of the nurse progress notes from 07/13/2026 through 08/05/2026 did not show documentation each shift of the IV administration, PICC access condition, or Resident 8's tolerance/reactions to the treatment.During an observation and interview on 07/29/2026 at 10:15 AM Resident 8 stated they did not think the facility cared for their PICC appropriately. Resident 8 lifted their left arm up and showed they had a single lumen (one access) purple 18 gauge/3 ml PowerPICC that was inserted in the hospital on [DATE]. The PICC dressing was dirty, not intact on all sides of the square dressing, and had a buildup of dark red matter around the entry site of the catheter. The date on the PICC dressing, written in black sharpie ink, said 7/13/26. Resident 8 stated it had not been changed since they were admitted to the facility on [DATE].During an interview on 07/29/2026 at 12:20 PM, Staff J, Licensed Practical Nurse-LPN /Infection Preventionist, stated as part of their Infection Control Program, they monitored the care and maintenance of IVs in the facility. Staff J stated they routinely/randomly audited to monitor for IV dressing changes, condition of the access device to ensure the dressing was changed weekly, that the IV tubing and bags were changed and dated, and whether they were still required (if their antibiotic was completed). Staff J stated the facility expectation was that PICC line dressings were changed using sterile technique weekly (including the access cap), the external catheter and upper arm circumference were measured to monitor for PICC placement and infiltration, that the appropriate flushes were used for the specific catheter device before and after each medication administration, and documented appropriately on the MAR/TAR. Staff J was not aware of any PICC dressings that were not changed timely and stated, There are a lot of things to catch.During an interview on 07/29/2026 at 2:00 PM, Staff Y, Licensed Practical Nurse-LPN, stated they flushed the PICC with 10 ml of NS before and after each antibiotic administration, which they received three total IV administrations daily. Staff Y stated they monitored the dressing daily with each administration. Staff Y stated that when the PICC dressings were changed, the external length of the catheter and upper arm circumference were measured to ensure the PICC was in place and not moved. They had not administered Resident 8's morning Vancomycin yet because Resident 8 had a lab draw that morning and they were waiting for the pharmacy to dose the Vancomycin based on lab results. Staff Y looked at the MAR and stated Resident 8's PICC dressing was changed on 07/28/2026.During an observation on 07/30/2026 at 1:13 PM Resident 8 still had the same PICC dressing dated 07/13/2026.Review of the August 2026 MAR/TAR documentation showed on 08/01/2026 Resident 8 did not receive their 5:00 AM dose of IV Ceftriaxone, there remained no physician orders for SAS flushes for the Ceftriaxone, and their PICC line dressing was finally changed (19 days after the last dressing change).During an observation on 08/05/2026 at 11:45 AM with Staff B, Director of Nursing, Resident 8's PICC dressing showed a handwritten date of 08/02/2026 (20 days after the last dressing change).<RESIDENT 18>According to the 06/30/2026 admission MDS, Resident 18 did not have IV access, including a PICC line, at admission or while a resident.Review of the Care Plan initiated 06/26/2026 showed no mention of IV access or maintenance.Review of the 06/26/2026 Hospital Discharge Orders and Nursing Home Transfer, showed Resident 18 had temporary IV access, a PICC line with order for care and maintenance.Review of the Skin Condition Sheet, dated 06/26/2026, showed Resident 18 had a PICC line with three lumens, an external catheter 1 cm, incompetence 28 cm at admission.Review of the June 2026 and July 2026 TARs showed orders for staff to flush left upper arm PICC lines with Normal Saline (NS) every week on Saturday dayshift for patency Staff documented it was done as ordered on 06/27/2026 and 07/04/2026. There were no additional directives or care including changing of the dressing, site monitoring, or measuring of the external catheter length.During an interview on 08/05/2026 at 11:55 AM Staff B stated the PICC dressings must be changed (including changing the needless access cap) with sterile technique weekly and monitor every shift, a responsibility of the nurses on the cart. The nurses on the cart must also flush the PICC with the appropriate solutions (according to their PICC manufacturer's recommendations) before and after each IV-medication administration but did not.REFERENCE WAC: 388-97-1060 (3)(j)(ii).

Based on observation, interview, and record review, the facility failed to provide medically related social service interventions that addressed refusal of care for 4 of 4 residents (Resident 12, 3, 15, 7) reviewed for care and services. Failure to have a process for resident refusals, identify, and find ways to support residents' needs related to refusals placed residents at risk for unmet care needs, and a decreased quality of life.Findings included .Review of the facility Activities of Daily Living (ADLs) Policy, revised March 2018, showed that residents would be provided with care and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition demonstrated that diminishing ADLs were unavoidable. Unavoidable decline could occur if the residents refused care and treatment. The residents and/or representatives were informed of the risk and benefits of the proposed care or treatment; and they were offered alternative interventions to minimize further decline; and the refusal and information are documented in the resident's clinical record. If a resident resisted or refused care, staff would attempt to identify the underlying cause of the behavior and consider approaching the resident in a different way or at a different time or having another staff member speak with the resident.During an interview on 07/15/2026 at 12:10 PM, Staff G, Social Services Designee, stated they were notified of refusals from their supervisor after the daily clinical meeting. They then interviewed the residents, asked what the reasons for the refusals were, wrote a progress note, and communicated back to their supervisor (Staff E, Social Services Director).<RESIDENT 12>Review of the 06/29/2026 5-day Minimum Data Set (MDS - an assessment tool) showed Resident 12 had highly impaired vision, did not talk, was cognitively impaired, usually understood others, and did not reject care.Review of the 07/02/2026 Care Plan (CP) showed interventions to provide medically related social services as ordered/indicated. Refusals were not addressed on the CP.Review of the Medication Administration Record (MAR) for July 2026 showed Resident 12 refused medications offered 07/10/2026 at 1:00 PM, and 07/12/2026 at 9:00 PM.Review of the Treatment Administration Record (TAR) for July 2026 showed Resident 12 refused treatments offered on 07/11/2026 at 8:00 AM, and 07/12/2026 at 8:00 PM.Review of a progress note dated 07/09/2026 at 1:18 PM, showed Resident 12 refused medications on 07/09/2026 and provider was notified.Review of a Nurse Progress Note, dated 07/01/2026 at 5:04 AM, showed the resident was on alert for signs of hypoglycemia (low blood sugar) due to refusing eating or eating low percentage of food offered. Further review of progress notes showed the resident was seen by the Registered Dietician on 07/01/2026 but did not document an attempt to identify the underlying cause of the refusals.On 07/14/2026 at 3:20 PM, Resident 12 was observed with soiled nails with black debris underneath. Resident 12 was observed with a long beard and indicated they would like it trimmed. Although Resident 12 was non-verbal, they were able to nod, shake head no, and used hand gestures to communicate and make needs known.During an interview on 07/14/2026 at 3:25 PM, Staff BB, Certified Nursing Assistant (CNA), said they had seen nurses try to care for Resident 12's nails, but the resident didn't like it.During an interview on 07/14/2026 at 3:27 PM, when asked who maintained Resident 12's nails, Staff W, Registered Nurse (RN), stated mostly restorative staff or nurses, but Resident 12 did not want them to touch anything. Staff W stated earlier that day the lab technician couldn't draw blood. Staff W stated Resident 12 had refused more in the last month, but they did not know why. When asked if they reported the refusals to social services, Staff W stated, I think everybody knows and added that they did report to the doctor the medication refusals.During an interview on 07/15/2026 at 12:10 PM, Staff G said they thought they spoke to Resident 12 once that they could remember. Staff G was unable to find an associated progress note and added that if they did talk to them, they didn't document it.<RESIDENT 3>Review of the 04/16/2026 CP showed Resident 3 required one-staff assistance with bathing/showering. The documentation showed Resident 3 did not have a CP or interventions to address refusal of bathing. Review of the East Shower Book showed Shower Sheets for Resident 3 with refusal to bathe on 06/02/2026, 06/05/2026, 06/08/2026, 06/09/2026, and 06/12/2026. Review of the progress notes showed a Nurses Progress Note dated 06/02/2026 at 3:08 PM where Resident 3 was offered a shower twice during the shift but refused both attempts and an Alert Note dated 06/08/2026 at 3:26 PM, that showed Resident 3 refused their shower despite encouragement and assistance offered by the shower aide. The Licensed Nurse (LN) educated Resident 3 on the importance of personal hygiene; however, the resident continued to refuse the shower.During an interview on 07/14/2026 at 11:33 AM, Staff E stated resident refusals were brought to social services in the daily clinical meeting. The social services designee would then follow up with the resident to see why they refused and documented their findings in the progress notes. During an interview on 07/15/2026 at 12:10 PM, Staff G stated they did not recall speaking to Resident 3 about refusals, and they were not aware of Resident 3 refusing care.<RESIDENT 15>Review of the 06/30/2026 admission MDS showed Resident 15 had no cognitive impairment, behaviors, or rejection of cares. Resident 15 required substantial/maximum assistance for toileting hygiene and was dependent on staff for toilet transfers. Resident 15 was frequently incontinent of bowel and did not have a toileting program.Review of Resident 15's Comprehensive CP on 07/15/2026 did not provide documentation to show the facility developed a CP for bowel incontinence/management or medically related social services with interventions to address refusals of care.Review of Resident 15's July 2026 MAR showed a physician order, dated 07/01/2026, for the rectal bowel stimulant medication daily and scheduled for administration at 8:00 AM. The documentation showed the medication was refused on 07/01/2026, 07/02/2026, 07/03/2026, 07/08/2026, 07/14/2026, and 07/15/2026.Review of Resident 15's progress notes, from 06/24/2026-07/15/2026, did not provide documentation to show the facility assessed Resident 15 related to bowel medication refusals or required bowel program/regime. The documentation did not show that the physician was notified of medication refusals or that nursing monitored their bowel status.In an interview on 07/15/2026 at 11:05 AM, Resident 15 stated they were aware that their clinical record showed they refused their rectal stimulant medication on multiple occasions, but they did not refuse. Resident 15 stated staff brought the medication during breakfast while they were trying to eat and asked the nurses to return after [they] were finished. Resident 15 said it was very important to them to get that medication to decrease their frustrations regarding bowel incontinence and hygiene concerns. <RESIDENT 7>Review of the Annual MDS assessment dated [DATE] showed Resident 7 was assessed to have severe cognitive impairment, exhibited no behaviors, and had no rejection of care. According to the MDS, Resident 7 required set-up assistance with bathing, dressing, and personal hygiene. Review of the 09/09/2025 CP showed Resident 7 refused skin checks at times. The documentation did not show a CP or interventions to address refusals. Review of a Psychiatric Follow-up progress note, dated 06/30/2026, showed Resident 7 consistently refused medications and care. On 07/15/2026 at 11:01 AM, Resident 7 was observed standing outside their room, leaning against the medication cart. At 11:08 AM, Staff P, RN, offered Resident 7 medications which they refused. During an interview at that time, when asked how they knew Resident 7 refused, Staff P stated that Resident 7 had asked them to fool around. Staff P stated the previous day, they offered Resident 7 a snack, and Resident 7 stated You are the snack I want. During an interview on 07/15/2026 at 12:10 PM, Staff G stated they had not addressed Resident 7's refusals. Staff E stated they did have Behavioral Health Services that followed Resident 7 for all their behaviors.During an interview on 07/15/2026 at 12:10 PM, Staff E stated the facility had a clinical tool they filled out daily with everything they needed to follow up on. Staff E reviewed the form and identified there was not a specific place on the tool for refusals but there was a note of a resident refusal under the nursing section, however it was not about the four sampled residents.REFERENCE WAC: 388-97-0960(1)

Based on observation, interview and record review the facility failed to ensure appropriate dementia related care and services were provided to 4 of 4 residents (Residents 14, 7, 16, & 13) reviewed for dementia related behaviors. The failure to develop and/or implement resident-centered dementia care plans (CP) with purposeful diversional activities and behavioral interventions to address resident's care needs who had dementia with behavioral disturbances, exit-seeking behaviors, and/or required 1:1 supervision. These failures placed the residents at risk for a diminished quality of life/quality of care, decline in mood, increased social isolation, boredom induced restlessness/anxiety/behaviors, and accidents/hazards (falls, elopement, and resident-to-resident altercations). Findings included .<POLICY>Review of the facility's Dementia-Clinical Protocol policy, undated, showed that the facility and the physician would evaluate the resident for dementia, the neurological cause of the dementia, and determine/differentiate other potential diagnoses such as delirium (confusion or altered mental status caused by other medical causes/medications side effects). For residents who were confirmed to have dementia, the Interdisciplinary team (IDT) would develop a resident-centered CP. Certified Nursing Assistants (CNAs) would receive initial training in the care of residents with dementia and related behaviors and ongoing education at least annually. The facility would strive to optimize familiarity through consistent staff-resident assignments. Direct care staff would assist the resident in completing supervised activities and tasks of daily living (bathing, mealtime assistance, therapeutic and recreational activities). The IDT would identify and document the residents' condition and level of support needed during CP development and revisions would be made as changes arose. Progressive or persistent worsening of symptoms and increase need for staff support would be reported to the IDT. The physician would order appropriate interventions to address significant behavioral and psychiatric symptoms; medications would be targeted to specific symptoms, would be used at the lowest effective doses for the shortest time possible unless clinical rationale determined otherwise. If a psychiatric consultant was called to help manage behavioral symptoms, the IDT would retain an active role by reviewing and implementing the consultant's recommendations, addressing issues that could affect mood, cognition or function, monitoring complications related to treatment, and evaluation the resident's response.<RESIDENT 14>Review of the 06/11/2026 admission Minimum Data Set (MDS - an assessment tool), showed Resident 14 had severe cognitive impairment and diagnoses included Non-Alzheimer's Dementia, arthritis, and neuropathy (severe nerve pain). Resident 14 had difficulty understanding others, impaired vision, exhibited verbal behavioral symptoms directed at others (threatening, screaming at, cursing at) daily, which significantly interfered with the resident's care and their participation in activities or social interactions. Resident 14's behaviors significantly intruded on the privacy or activities of others and significantly disrupted their care and/or living environments. Resident 14's interview for activity preferences showed it was very important to [them] to listen to music they liked, go outside for fresh air, participate in religious practices, and do their favorite activities, and did not include family (or close friend) to assist in providing insight on past-time activities/preferences they would enjoy.Review of the 06/08/2026 Activity Care Plan (CP), showed Resident 14 had little or no activity involvement related to behavioral issues: self-isolation, socially inappropriate disruptive behaviors, poor adjustment to the facility, and desire not to participate in activities. Interventions listed included providing Resident 14 with activity materials and showing their resident-centered activity preferences including watching TV, particularly the Hallmark channel, cooking channel, animal planet, and nature shows. The CP did not include interventions to address Resident 14's activities that were important to them during as assessed during their MDS activities interview: provision of music, religious based activities, or getting some fresh air. Further review of the CP showed interventions which would not be effective for a resident with severe cognitive impairment including: Explain to the resident the importance of social interaction, provide activity calendar monthly, leisure activity time, advise resident to request pain medication before pain becomes severe, educate resident regarding other meds/food that could affect anticoagulation (blood thinning) action.Review of a Psychiatry Follow Up note, dated 06/23/2026, showed staff reported Resident 14 exhibited frequent medication seeking behavior, particularly requesting unscheduled pain medication, and demonstrated agitation with verbal outbursts including screaming, help me. Resident 14 showed decreased appetite and was easily distracted during meals. Resident 14 occasionally exhibited rare episodes of possible visual hallucinations and demonstrated aggressive behavior approximately 60 percent of the time, primarily verbal rather than physical. The plan included medication changes and directives to staff to document behaviors for proper medication adjustments.Review of a Cardiology Follow up Note, dated 06/29/2026, showed Resident 14 continued to require 1:1 supervision due to severe behavioral disturbances (agitation, verbal/physical aggression, disorientation), and was dependent with all activities of daily living (ADLs).Review of a Psychotropic Medication Management (PMM) Interdisciplinary Care Conference Note dated 07/07/2026 showed Resident 14's targeted behaviors were yelling and cussing out staff. Causative diagnoses listed included Dementia with behavioral disturbance, Bipolar II disorder, Depressive Disorder and Anxiety. Interventions listed included psychotropic medications and non-pharmacological intervention of 1:1 supervision 24/7.Review of the June 2026 and July 2026 Behavior Monitoring showed staff monitored for episodes of agitation behavior manifestation, episodes of anxiousness, restlessness, and episodes of being combative, agitation.During an observation on 07/13/2026 at 11:10 AM, Resident 14's door was observed shut. After request to enter, Resident 14 was observed lying in bed, sleeping. Resident 14's 1:1 staff member was observed seated next to the bed in a chair watching TV. Observation of their room showed no personal effects and no in-room activity items.During observations on 07/13/2026 at 12:30 PM, 1:15 PM, 2:10 PM, and 4:06 PM Resident 14's room door remained closed.During an observation on 07/14/2026 at 9:45 AM and 11:06 AM, Resident 14 was observed in their room with the door shut, in the dark, with the shades closed, asleep in their bed, and their 1:1 not engaging them with normal morning activities. During an observation on 07/14/2026 at 2:06 PM, Resident 14 was observed in a large wheelchair leaning to their right side, trying to self-propel down the hallway. Resident 14's 1:1 staff monitor, walking behind them, looking at their personal phone as they walked. The staff member was not engaging with Resident 14.During an observation on 07/14/2026 at 3:35 PM, Resident 14 was observed yelling Get Away! at a male staff member, Staff EE, Certified Nursing Assistant (CNA). When Staff EE did not allow Resident 14 space, Resident 14 attempted to self-propel in their wheelchair, out of their room, and away from Staff EE. During an interview on 07/14/2026 at 3:51 PM, Staff EE stated they had worked with Resident 14 before, but the resident slept the whole time.During an interview on 07/14/2026 at 3:38 PM, Collateral Contact 2 (CC2) stated Resident 14 was not comfortable with male staff in the past. CC2 stated that Resident 14 would yell out when they were in pain but did not believe the staff understood that as their pain indicator. CC2 stated they felt Resident 14 needed more diversional engagement and stimulation with activities they enjoyed including Christian based TV programs/music. On 07/15/2026 at 1:10 PM, Resident 14 was observed asleep in bed. The TV was playing sports. A doll was observed on the bedside cabinet, not within the resident's reach.During an interview on 07/15/2026 at 1:10 PM, Staff T, CNA, stated they had seen Resident 14 slap peoples' butts, call people the 'B word', call them 'Hos' and other names. Staff T said the behaviors were exhibited towards both staff and other residents. Staff T stated Resident 14 liked dolls, candy, and coffee. When asked why the resident's room door was always shut, Staff T stated they were not too sure, but Resident 14 was asleep, and it was loud in the hallway.<RESIDENT 7>Review of the 04/27/2026 Annual MDS showed Resident 7 met a serious mental illness, was assessed with moderately impaired cognition, had no behaviors, and no rejection of care. Resident 7's activity interview showed their favorite activities and religious based activities were very important to them. Resident 7's diagnoses included Wernicke's encephalopathy (a serious brain disorder caused by lack of vitamin B1-often due to prolonged long-term heavy drinking and poor nutrition that causes cognitive decline and balance problems like dementia), repeated falls, and depression. Resident 7 required set-up/supervision of ADLs and ambulated independently.Review of Resident 7's Cognitive Decline CP dated 06/03/2025 showed their cognitive function was impaired due to dementia, memory loss, and impaired decision making. The listed interventions included monitoring for cognitive changes, medication side effects, pain, and decline in ADL abilities. Additional interventions included evaluating behavioral symptoms for underlying causes (unmet care needs), breakdown tasks, providing consistent, trusted caregiver, structured daily routine, calm/soothing environment.Review of Resident 7's Activity CP revised on 10/30/2026 showed they kept engaged with activities independently and would need visits from activity staff for social support. Interventions included: Activities would conduct weekly visits, allow choices for daily decision making, they would like pet visits (especially dogs), liked socializing, going outside for walks, people watching, and fishing.Review of Resident 7's Fall CP, revised 07/10/2026, showed Resident 7 had severe cognitive impairment, decreased safety awareness, and impaired judgement. Interventions included providing frequent safety checks to monitor resident's location, positioning, comfort, and need for assistance due to impaired cognition and inability to consistently call for help, reinforce use of call light, and educate resident on requesting assistance before attempting mobility, provide reminders as tolerated due to cognitive impairment.Review of Resident 7's Skin CP dated 12/11/2025 showed they were at risk for skin breakdown related to refusal to take a shower and non-compliance with weekly body checks. Listed interventions did not show approaches staff could take in the event of resident refusals, other than continue to encourage.Review of Resident 7's ADL CP dated 05/08/2026 showed they had self-care performance problems related to dementia and limited mobility. The personal hygiene/oral care intervention revised 06/08/2025 showed they required partial-moderate assistance standing at the sink and was dependent on staff for bathing.Review of Resident 7's Psycho-Social well-being CP revised 10/30/2025 showed they were at risk due to resident-to-resident altercations.Review of a Provider note dated 06/22/2026 showed Resident 7 had advanced dementia with multiple chronic comorbidities (simultaneous presence of two or more distinct medical or psychological conditions).Review of the July 2026 Behavior Monitoring showed for an antidepressant staff were directed to monitor episodes of blank (the 06/04/2026 order failed to specify a behavior manifestation). An additional monitor was for inappropriate sexual behaviors towards other residents or staff which was implemented 04/14/2026.An observation on 07/13/2026 at 10:30 AM showed Resident 7 standing in the doorway of their room, leaning against the left door frame. Their hair was long, uncombed, and unkempt. They had long, shaggy facial hair. Their nails were long. They had no shoes on and no non-skid footwear.During an observation on 07/13/2026 at 10:50 AM, Resident 7 was in the East nurse station area walking, yelling curse words at staff after they intervened to stop a resident-to-resident physical altercation from escalating with another resident. Resident 7 was trembling with anger and yelling profanities. In the same area were four direct care nursing staff plus Staff C, Nurse Consultant. Staff C was providing directions for one of the staff members to provide redirection for Resident 7. The other three nursing staff were observed smiling/giggling and talking to each other while they watched the episode unfold. This reaction from the staff increased Resident 7's anger and paranoia. The staff member that received direction from Staff C was eventually able to redirect Resident 7 to their room without further incident.Review of a 07/13/2026 Nurses Note showed Resident 7 was involved in a physical and verbal altercation with another resident. Resident 7 called the other resident names, threatened to beat them up, and hit them on their head.During an observation on 07/13/2026 at 12:55 PM, Resident 7 was observed lying on top of a bottom sheet on their mattress and appeared to be asleep. Resident 7 had no pillow, top sheet, blanket on their bed, and no bedding in their closet or on the other bed in the room. Resident 7's pant legs exposed both their shins which had lots of scattered scabbed areas. There were no personal items in their room except for their care products. No activity items were observed in their room. On Resident 7's bedside table was their lunch tray, covered with a lid, and their meal was untouched.An observation on 07/14/2026 at 12:48 PM showed Resident 7 lying on their bed, with only a bottom sheet on the mattress, and appeared to be asleep. Resident 7 did not have a pillow or top sheet/blanket on them, on the bed, or observed anywhere in the room. During an observation on 07/15/2026 at 8:39 AM, Resident 7 was observed lying on a bottom sheet on their mattress and appeared to be sleeping. Resident 7 had no bedding on them or in their room.During an observation and interview on 07/15/2026 at 10:30 AM, Resident 7 was observed standing in the doorway of their room, leaning up against the door frame. Resident 7's hair was uncombed, long, and unkempt. They were wearing the same clothing were observed to wear the day before, on 07/14/2026. They did not have shoes on or non-skid footwear on their feet. When asked if staff assisted them with combing their hair Resident 7 shook their head no. When asked if they would let staff comb their hair and shave them, Resident 7 shook their head yes. When asked if they preferred to sleep in bed without a pillow or bedding, Resident 7 shook their head no. When asked if they would like a pillow and blankets for their bed, Resident 7 shook their head yes.During an observation on 07/15/2026 at 11:01 AM, showed Resident 7 standing outside their room, with socks on, leaning against the med cart. No staff were observed to intervene until 11:08 AM when Staff P, Registered Nurse (RN), offered Resident 7 medications, which they refused. In an interview on 07/15/2026 at 11:09 AM, Staff P stated Resident 7 asked Staff P if they wanted to fool around. Staff P stated Resident 7 often exhibited behaviors such as sticking out their tongue, making crude noises, and sexually inappropriate comments. Staff P was not aware Resident 7 did not have bedding. On 07/15/2026 at 11:14 AM, Resident 7 was observed to walk over to the nurses' station, rummage through the nourishment bin and took three boxes of cookies and other items before returning to their room. At 11:17 AM, Resident 7 walked back out of their room, eating cookies and was standing in the hallway in front of the nurses' station.During an observation on 07/15/2026 at 1:45 PM, Resident 7 was observed in the front entrance sitting area, lying on the couch with their eyes closed, one leg on the couch and the other leg hanging off the couch. Resident 7 did not have shoes on and wore socks without non-skid. Resident 7's hair was uncombed and appeared unkempt. There were two other people sitting in sitting area.<RESIDENT 16>Similar findings for Resident 16. Review of the 06/17/2026 admission MDS showed Resident 16 admitted to the facility on [DATE]. Resident 16 had moderate difficulty hearing, wore corrective lenses, had no cognitive decline, no behaviors, and no rejection of care, but showed their current behavior status, care rejection, and/or wandering was worse than from their prior assessment. Resident 16's activity/preference interview showed choice of their bedtime, family involvement, doing their favorite activities, and going outside for fresh air when the weather was good were very important to them. Resident 16 required assistance for all ADLS. Resident 16's diagnoses included severe liver damage and non-Alzheimer's dementia, and a traumatic brain injury. Resident 16 had a history of falls before admission and after admission to the facility.Review of Resident 16's Wandering/Elopement Risk CP dated 06/21/2026 showed Resident 16 was at risk for elopement and interventions included: a WanderGaurd device (alarm device that goes off if the WanderGaurd comes to close to designated exits) placed on the back of their wheelchair, identify triggers/patterns to exit seeking, and engage Resident 16 in purposeful activities.Review of Resident 16's Leave of Absence without Notice (LAWN) CP revised 06/22/2026 showed they had history of one or more attempts to LAWN since admission to the facility or previous stays at other facilities. An intervention dated 06/18/2026 showed Resident 16 was on 1:1 supervision and an intervention dated 06/18/2026 showed staff were to encourage participation in activities of preference and as diversional techniques.Review of Resident 16's Behavior CP showed Resident 16 exhibited physical behaviors that included scooting around in their wheelchair in a fast, reckless manner.Review of Resident 16's Activity CP showed interventions that included: encouraging and facilitate activity preferences, enjoyed reading materials (educational and mysteries), music (soft music, country music), keeping up with the news, crossword puzzles/games, looking out the window, naps, praying, TV, and religious activities.Review of a Nurse Progress note dated 07/01/2026 at 7:13 AM showed Resident 16 was restless, getting out of bed and resistant to redirection. Resident 16 was assisted to their wheelchair and at 1:30 AM was found entering another resident's room. At 3:00 AM, Resident 16 was back in bed, and their roommate complained that Resident 16 was touching their personal belongings. The nurse continued safety checks but did not indicate Resident was monitored 1:1 as the CP indicated. Review of the facility's Daily Staffing Assignment dated 07/01/2026 did not show Resident 16 had a 1:1 assigned to them on the schedule.Review of a Nurse Progress Note dated 07/07/2026 at 6:37 PM, Resident 16 had behaviors that were difficult to redirect, was exit seeking and after redirection became angry at staff and was wanting to fall out of the wheelchair but was intercepted by three staff members. Resident 16 was yelling profanity and was taken back to their room. The documentation did not indicate what happened after that event, what interventions were attempted and which interventions were effective at redirection.Review of a Nurse Progress Note dated 07/09/2026 at 5:03 PM showed Resident 16 engaged in self-harming behaviors when they became agitated that included hitting the bedside table despite verbal redirection and advising them to stop. The provider was notified. The documentation did not indicate what precipitated the behavior or what interventions were attempted, or the resident's response to the interventions. The documentation also did not show the responsible party was notified or if a skin evaluation was done to determine if injury occurred. Review of an initial psychiatric provider progress note dated 07/14/2026 at 1:45 PM showed Resident 16 was restless during their evaluation and diagnoses included major depressive disorder, chronic Post Traumatic Stress Disorder (PTSD), Dementia with behavioral disturbance, alcoholic cirrhosis of the liver. The provider ordered to increase their antipsychotic medication and provide BEHAVIORAL INTERVENTIONS: maintain 1:1 supervision for safety and redirection given persistent restlessness and exit-seeking behaviors, frequent verbal redirection and reassurance using simple, clear communication; avoid confrontation, address unmet needs including sleep disruption, establish structured daily routine to reduce confusion and anxiety, including a consistent sleep/wake schedule, reduce daytime oversleeping, encourage safe opportunities to go outside with 1:1 supervision to reduce exit-seeking behaviors, and provide individualized, simple activities appropriate to cognitive level, and provide ongoing staff education on dementia-related behaviors and de-escalation techniques.During intermittent observations on 07/13/2026 at 11:45 AM and 3:05 PM, 07/14/2026 at 9:01 AM and 2:10 PM, and 07/15/2026 at 9:12 AM and 1:10 PM Resident 16's door was observed to be shut, Resident 16 was in their room asleep, and the 1:1 monitoring staff were not engaging in activities that Resident 16 preferred and/or ADLS. The monitoring staff sat in the chair watching the resident. <RESIDENT 13>Review of the 06/24/2026 admission Minimum Data Set (MDS-assessment tool) showed Resident 13 admitted to the facility 06/18/2026, with slightly impaired cognition and no wandering behaviors. Resident 13 required the use of a walker and wheelchair for mobility and partial/moderate staff assistance to transfers. Resident 13s diagnoses included a spine fracture and Traumatic Brain Injury (TBI). Review of Resident 13s Comprehensive CP, printed 07/15/2026, did not provide CP problems, goals, or interventions to support impaired cognition with behavioral disturbances or risk for elopement.Review of Resident 13s clinical record did not provide documentation to show the facility assessed their risk for elopement.Review of a Progress Note on 06/20/2026 at 12:47 PM, showed Resident 13 was noted to be impulsive with poor safety awareness. Seen putting on their pants, when asked where they were going, Resident 13 said, 'that's none of your business.' When the nurse told them there were no doctor's order for discharge, Resident 13 said, 'he is not my doctor anymore. When asked who was going to pick them up, Resident 13 said My [RP]. The nurse called the RP and notified them of the resident's behavior. The nurse notified the physician and was given an order for medication for anxiety to be administered.Review of a 06/25/2026 Physician Progress Note showed that Resident 13 had been refusing medications, was agitated, and demanding to leave and go home. Resident 13 contacted their Responsible Party and other acquaintances to get a ride home. Resident 13 said they just wanted to go home and have their spouse by their side. Resident 13's wife was admitted to a memory care unit and Resident 13's Responsible Party was trying to find appropriate memory care placement for Resident 13.Review of a Nurse Progress Note dated 06/27/2026 at 1:45 AM showed at approximately 12:45 AM, Resident 13 was unable to be located in the facility or on the facility premises; they eloped.During an interview on 07/14/2026 at 11:32 AM, Staff E, Social Services Director, stated behaviors were discussed in clinicals, and audits of psychotropic medications were done to ensure behaviors were identified and nursing had orders for behavior monitoring. For residents who exhibit behaviors without medications, and/or diagnoses, they are referred to Behavioral Health Services (BHS).Refer to F600.Refer to F677.Refer to F689.Refer to F745.REFERENCE WAC: 388-97-1060 (1), -1040 (1) (a, b).

Based on observation, interview and record review, the facility failed to have sufficient staff to provide necessary care and services for 7 of 8 Residents (8, 12, 18, 1, 15, 22, & 9) reviewed for Activities of Daily Living (ADL). The facility had insufficient staff to ensure residents received assistance with showers and nail care in accordance with established clinical standards, care plans, and preferences. These failures placed residents at risk for unmet care needs and negative outcomes.Findings included.<Resident 8>Review of the East Shower Schedule showed Resident 8 was scheduled to receive showers on Wednesdays and Saturdays on the day shift. Review of Resident 8's Documentation Survey Report from 06/19/2026 through 07/13/2026 they bathed on five days when they should have had seven. During an observation and interview 07/13/2026 at 11:15 AM, Resident 8 was observed to have long nails with dark debris under the nails, and their hair appeared to be oily with dry, flaky scalp. Resident 8 stated they did not recall how many baths they had since admission to the facility but stated, Not as many as were planned. Resident 8 stated they planned to have two showers per week but that did not occur during their stay because they went to dialysis during the day on Tuesdays, Thursdays, and Saturdays and their second scheduled shower day for the week was scheduled during their dialysis treatment. Resident 8 stated they had asked nursing staff to have their nails trimmed, but no one ever trimmed them. Resident 8 stated I finally got a shower today, for the week, but I am discharging home today.<Resident 12>Review of Resident 12's bathing record from 06/23/2026 through 07/15/2026 showed they received three baths in 22 days. As of 07/15/2026, they had not received a bath in 12 days. During an observation and interview on 07/14/2026 at 3:20 PM, Resident 12 was observed with dark matter under their nails and had long facial hair. Resident 12 indicated they would like their beard trimmed. <Resident 18>Review of the East Shower Schedule, undated, showed Resident 18 was scheduled for a shower on Wednesdays and Saturdays in the evening. Review of Resident 18s bathing record from 06/19/2026 through 07/15/2026 showed bathing events documented on nine days (out of 26 days), some were documented on consecutive days. During an observation of an interaction between Staff CC, Certified Nursing Assistant (CNA), shower aid, and Resident 18 on 07/14/2026 at 11:15 AM, Resident 18 asked Staff CC if they could receive a shower that morning because they did not receive their scheduled shower on Saturday (07/11/2026) or their requested shower on Monday (07/13/2026-to make-up for the missed Saturday shower). Staff CC replied to Resident 18 saying they were not on the bath schedule for that day. Resident 18 was observed to have very long hair that appeared slightly matted, oily, and not combed through. In an interview on 07/15/2026 at 9:45 AM, Resident 18 stated they were scheduled to receive a shower twice weekly on Wednesdays and Saturdays. Resident 18 stated they did not receive their scheduled shower on Saturday 07/11/2026. Resident 18 stated when they asked about their shower on Saturday, they were told by their CNA that the facility did not provide showers on the weekends. Resident 18 stated they had never received showers on consecutive days and confirmed they did not receive a shower on three of the days that were documented in their clinical record.<Resident 1>Review of the undated East Shower Schedule showed that Resident 1 was scheduled for bathing on Tuesdays and Fridays. Review of Resident 1s bathing record from 06/19/2026 through 07/15/2026 (26 days) showed five showers/bed baths documented as provided. In an observation and interview on 07/13/2026 at 11:12 AM, Resident 1 was observed to have long nails with dark matter under the nails and a noticeable odor of urine. <Resident 15>Review of the undated East Shower Schedule showed Resident 15 was scheduled for showers on Monday and Thursday evenings. Review of Resident 15's bathing record from 06/24/2026-07/15/2026 (21 days) showed seven bathing events documented as provided; one tub bath, four showers, and two bed baths. During an interview on 07/15/2026 at 11:05 AM, when asked if there was sufficient staff to meet their care needs, Resident 15 stated no and that they did not receive their bathing as planned. During an observation and interview on 07/15/2026 at 11:06 AM, Resident 15 stated they had not received a shower since admission to the facility on [DATE]. Resident 15 stated they were scheduled for showers on Mondays and Thursdays but had never been in the shower room. Resident 15 stated they received several bed baths, but they didn't feel clean after bed baths. Resident 15 stated Staff CC told [them] that bed baths were easier and quicker, so they only provided bed baths and not always on their scheduled bathing day.<Resident 22>Review of Resident 22's bathing record from 06/19/2026-07/15/2026 (22 days) showed bathing events documented as provided on six days, the last day was 07/09/2026.During an observation on 07/13/2026 at 10:40 AM, Resident 22 was observed to be disheveled in appearance, with uncombed hair, and very long facial hair.Review of Resident 22s bathing record from 06/22/2026-07/14/2026 (24 days) showed bathing events documented as provided on eight days. <Resident 9>Review of the undated East Shower Scheule showed Resident 9 was scheduled for bathing on Tuesdays and Fridays during the day.On 07/14/2026 at 9:30 AM, Resident 9 was observed with long nails with black debris underneath. The resident had long hair and a long beard.On Tuesday 07/14/2026 at 11:01 AM, Staff V, CNA, stated they did not have a shower aid that day, so they gave Resident 9 a bed bath. Staff V stated, He's clean, see. When asked about Resident 9's nails, Staff V stated they would check to see if the resident was diabetic and if not, they sat with residents, put their nails in a water soak, and cut them, if they're not too busy. At 11:06 AM, Staff V stated they did not take Resident 9 to the shower, they gave them a bed bath instead and did not check to see if they were diabetic. <STAFFING>Review of the Facility Assessment Tool, updated 06/25/2026, showed the average daily census was 127 residents and the total number of Certified Nursing Assistants (CNAs) needed ranged from 35-40.Review of facility's Daily Posted Staffing records showed the following: on 06/22/2026 the census was 124 and there were 26 CNAs scheduled, on 06/29/2026 the census was 133 and there were 26 CNAs scheduled, on 07/06/2026 the census was 132 and 25 CNAs were scheduled, and 07/10/2026 the census was 131 and 30 CNAs were scheduled.Review of the [NAME] Daily Shower Schedules showed:On 06/23/2026, 23 showers were scheduled and two were documented as done, on 06/24/2026, 20 showers were scheduled and five were documented as done, on 06/26/2026, 23 showers were scheduled and none were documented as done, on 06/27/2026, 21 showers were scheduled and none were documented as done, on 06/29/2026, 21 showers were scheduled and four were documented as done, on 06/30/2026, 23 showers were scheduled and none were documented as done, and on 07/15/2026, 21 showers were scheduled and none were documented as done.Review of facility's Daily Staffing Assignment sheets showed the following:>06/19/2026- Shower aid scheduled for East Wing Day shift, but none on [NAME] Wing or South Wing. >06/20/2026- Saturday, no shower aids scheduled for the facility.>06/21/2026-Sunday, no shower aids scheduled for the facility.>06/23/2026-Shower aid scheduled for East Wing Day shift, but none on [NAME] Wing or South Wing. >06/24/2026- Shower aid scheduled for East Wing Day shift, but none on [NAME] Wing or South Wing. >06/25/2026 - Shower aid scheduled for East Hall Day Shift, [NAME] Hall Days shift, and [NAME] Hall evening shift. No shower aid scheduled for South (Day/Eve) or East and [NAME] Evening shifts.>06/26/2026- Shower aid scheduled for [NAME] Hall Day shift but none for East and South days, and no shower aids for any hall on evening shift.>06/27/2026 -Saturday, no shower aids scheduled for the facility.>06/28/2026 -Sunday, no shower aids scheduled for the facility.>06/29/2026- Shower aid scheduled for East Hall Day Shift, [NAME] Hall Days shift, and [NAME] Hall evening shift. No shower aid scheduled for South (Day/Eve) or East and [NAME] Evening shifts.>06/30/2026- Shower aid scheduled for East Hall Day Shift, [NAME] Hall Days shift, and [NAME] Hall evening shift. No shower aid scheduled for South (Day/Eve) or East and [NAME] Evening shifts.>07/01/2026- Shower aid scheduled for the East Wing Day shift, one for [NAME] Wing Day shift, and one for [NAME] Wing Evening Shift.On 07/14/2026 at 11:08 AM the [NAME] Shower book was reviewed and showed there were no skin sheets for 07/05/2026, 07/06/2026, 07/09/2026, 07/10/2026, 07/13/2026 and none for 07/14/2026. In an interview on 07/14/2026 at that time, Staff V, CNA, stated there was no shower aid on 07/13/2026 and 07/14/2026, and the shower aid fills those sheets out. When asked if the CNAs fill them out when they give showers, Staff V stated no, just the assigned shower aid.During an interview on 07/14/2026 at 11:04 AM, Staff CC, CNA, stated there was no shower aid scheduled so the CNAs were doing their own showers.In an interview on 07/15/2026 at 8:25 AM, Staff CC stated they were the shower aid on most days, but they were pulled to the floor yesterday (07/14/2026) and had to work a run (a section of designated residents the CNA was assigned to be responsible for all their care). Staff CC stated when that occurred, which was quite often, then the showers were the responsibility of the CNA assigned to that resident. Staff CC stated they were the designated shower aid that day (07/15/2026) and they would not be able to provide all the showers that were scheduled during their shift and that the evening shift CNA would have to give the showers that were left over.In an interview on 07/15/2026 at 3:15 PM, Staff B, Director of Nursing, stated they were just getting familiar with the facility but recognized that their facility system for providing showers was not functioning the way it should and they were in the process of analyzing their data to correct the situation. Staff BB stated it was their expectation that the facility had enough staff scheduled to meet the care needs of the residents and the residents should have had the bathing they required but did not.Refer to F677.REFERENCE WAC: 388-97-1080(1).

Based on interview and record review, the facility failed to provide the required care planned supervision to prevent accidents for 4 of 5 sample residents (Resident 1, 14, 13 & 20) reviewed for accidents/hazards. The facility failed to assess safety risks, provide adequate resident supervision, develop/implement/revise fall and elopement care plans (CP), and conduct thorough accident investigations to determine the circumstances of resident accidents and revise CPs to prevent reoccurrence for 2 of 2 residents (Resident 1 & 14) reviewed for falls and 2 of 3 residents (Resident 13 & 20) reviewed for elopement. These failures placed the residents at a potential risk of harm related to avoidable incidents.Findings included .<ELOPEMENT>POLICY Review of the facility's Leave of Absence without Notice (LAWN) policy, dated 01/16/2026, showed Elopement occurred when a resident left the facility premises or a safe area without notice/authorization (such as a physician's order for discharge or leave of absence). The Interdisciplinary Team (IDT) would evaluate residents on admission, quarterly, and with a significant change in condition to determine level of risk for LAWN and initiate a resident-centered care plan with interventions to provide a least restrictive environment. <RESIDENT 13><BEFORE admission TO THE FACILITY>Review of a hospital Trauma note dated 06/12/2026 showed Resident 13 was confused and was trying to leave against medical advice during the night but was redirectable.Review of a hospital Psychiatric Progress Note dated 06/17/2026 showed Resident 13 continued to have altered mental status and confusion and was referred to psychiatry by the neurologist due to mood, memory deficits and medication management. The psychiatrist noted that Resident 13 was confused, irritable, restless, impulsive, pulled out IV lines, refused assessments, insisted on leaving, was unsteady with ambulation, was poorly redirectable, had a Code Gray (an emergency alert that signals a combative, aggressive, or violent person) called, and was placed in restraints. Resident 13 was assessed to have poor insight into their condition and poor safety awareness. Resident 13's Responsible Party (RP) reported that since Resident 13's spouse was admitted into a memory care unit, Resident 13 showed an accelerated decline in memory, mood/personality, and behavior; making unsafe safety and financial decisions, taking their spouse home from the memory unit, multiple car accidents, and had their driver's license revoked. Resident 13 reported difficulty sleeping and awakening frequently in the night. The documentation showed their plan included the standard geriatric interventions to manage cognitive impairment with behavioral disturbance including relaxation techniques, orientation cues, correction of sensory deficits, normalization of the sleep/wake cycle, creating a behavioral care plan with known triggers and soothers, and consideration for placement near the nurse station for regular checks and staff interaction to help minimize boredom induced behavioral problems and anxiety.<AFTER admission TO THE FACILITY >Review of the 06/24/2026 admission Minimum Data Set (MDS-assessment tool) showed Resident 13 admitted to the facility 06/18/2026, with slightly impaired cognition and no wandering behaviors. Resident 13 required the use of a walker and wheelchair for mobility and partial/moderate staff assistance to transfers. Resident 13's diagnoses included a spine fracture and Traumatic Brain Injury (TBI). Review of Resident 13's Comprehensive CP, printed 07/15/2026, did not provide CP problems, goals, or interventions to support impaired cognition with behavioral disturbances or risk for elopement.Review of the Nursing admission assessment dated [DATE] under the section LAWN (Leave of Absence Without Notice) showed the resident could not ambulate or demonstrate mobility (locomotion) independently, with or without the use of a mobility device (e.g. wheelchair, walker). The assessment did not indicate whether Resident 13 was at risk for elopement.Review of a 06/19/2026 Physician admission Note showed that Resident 13 admitted to the facility after a hospital stay following a ground level fall with fracture and head injury. According to the admission note, Resident 13 was quite anxious and wanted to go home. Resident 13 was quite confused, unable to provide any significant history about their falls, but did admit they had fallen multiple times. Resident 13's son reported that the night before, Resident 13 slept with their shoes on and their car keys in their pocket because they wanted to leave as soon as possible. Resident 13 had significant confusion and impulsive behaviors during the hospital stay, requiring physical restraints. Son reported that Resident 13 had multiple falls and cognition has been declining over the past couple of years.Review of Resident 13's clinical record did not provide documentation to show the facility assessed their risk for elopement.Review of a Progress Note on 06/20/2026 at 12:47 PM, showed Resident 13 was noted to be impulsive with poor safety awareness. Seen putting on their pants, when asked where they were going, Resident 13 said, 'that's none of your business.' When the nurse told them there was no doctor's order for discharge, Resident 13 said, he is not my doctor anymore. When asked who was going to pick them up, Resident 13 said My [RP]. The nurse called the RP and notified them of the resident's behavior. The nurse notified the physician and was given an order for medication for anxiety to be administered.Review of a 06/25/2026 Physician Progress Note showed that Resident 13 had been refusing medications, was agitated, and demanding to leave and go home. Resident 13 contacted their Responsible Party and other acquaintances to get a ride home. Resident 13 said they just wanted to go home and have their spouse by their side. Resident 13's wife was admitted to a memory care unit and Resident 13's Responsible Party was trying to find appropriate memory care placement for Resident 13.Review of a Nurse Progress Note dated 06/27/2026 at 1:45 AM showed at approximately 12:45 AM, the nurse was off the unit looking for oxygen equipment for another resident. Upon return to the unit (time unspecified), two CNAs were observed stationed at opposite ends of the hall. During rounds, Resident 13 was not found in their room and was noted to be missing from the unit. The nurse immediately initiated a Code Pink (facility code for missing resident). Staff began searching the unit and surrounding areas, calling out for the resident. A thorough search was conducted for approximately 30 minutes; however, the resident was not located. After confirming the resident was not in the facility, the nurse notified the family, physician, and 911 for assistance. Staff continued attempts to contact Resident 13 by phone. Approximately 20 minutes later, Resident 13 answered the phone and stated they were not returning to the facility due to dissatisfaction with the facility's processes. Resident 13 said they were at their home. The provider was notified and advised to have AMA (Against Medical Advice) paperwork prepared.Review of the 06/27/2026 Discharge Return Not Anticipated Assessment MDS showed Resident 13 had an unplanned discharge to the community. According to this MDS, Resident 13 did not exhibit wandering behaviors in the prior 7 days.Review of the June 2026 Incident Reporting Log showed a 06/27/2026 entry at 1:45 AM-Against Medical Advice Discharge. The reporting log did not show an entry on 06/27/2026 for a missing resident/elopement for Resident 13. Review of the facility's Incident Report/Investigation dated 06/27/2026 showed Resident 13 exited the facility through the south dining room patio door that staff left unlocked for another resident. The facility responded by locking the patio door permanently for all residents' safety and conducting an elopement drill on the night shift; performed 07/03/2026. During an interview on 07/09/2026 at 11:52 AM, Resident 13's RP stated when they awoke on 06/28/2026, they had calls from Resident 13's house so they called back and Resident 13 answered the phone. Resident 13's RP went to Resident 13's house and found them sitting on the couch in the dark in soiled and dirty pajamas. The temperature was 80 degrees Fahrenheit. There was a message on Resident 13's cell phone from a Taxicab on 06/28/2026 at 2:00 AM, asking where Resident 13 was. Resident 13's RP stated they called the facility and asked where Resident 13 was and was told the facility did not know. Resident 13's RP stated Resident 13 could barely walk or use a walker and somehow, they got out of the facility without anyone knowing during the middle of the night.During an interview on 07/15/2026 at 1:56 PM, Staff B, Director of Nursing, stated Resident 13 was alert, oriented, and knew what they were doing, as they were not cognitively impaired.In an interview on 07/15/2026 at 3:12 PM, Staff B was unable to locate an evaluation of Resident 13's elopement risk in the clinical record and stated an evaluation should have been completed during admission and after Resident 13 demonstrated exit seeking behaviors but was not.<RESIDENT 20> Review of Resident 20's 04/24/2026 Quarterly Assessment MDS showed Resident 20 had difficulty making themselves understood and understanding others, had severe cognitive impairment, and going outside to get fresh air when the weather permitted was very important to them. Resident 20 was independent with dressing, transfers, and ambulation without mobility devices. Resident 20's diagnoses included a stroke with alteration in ability to speak, depression, and history of alcohol dependence.Review of Resident 20's Activity CP, revised 12/11/2025, showed it was very important for Resident 20 to go outside when the weather was good but required supervision because they were at risk for elopement.Review of Resident 20's Elopement risk CP, revised 06/30/2026, showed Resident 20 was at risk of LAWN due to aimlessly wandering, cognitive impairment, trying to exit the facility through windows, and exiting the facility through the south dining room side door to stand on the sidewalk or parking lot, then return inside the facility without leaving the premises. A revision dated 06/29/2026 showed Resident 20 will walk up the hill on the side of the parking lot to get some fresh air, attempts were made to redirect them to a safer residential common area on the premises, but [they] preferred to go out in the parking lot. The CP goal revised 06/22/2026 showed they would not attempt to exit the facility without an escort. Interventions dated 10/12/2025 included: observing for exit seeking behavior, placement in the Elopement Book, monitoring their location with visual checks during routine care, encouraging participation in activities, personalization of their room with familiar items, and providing diversional activities/objects.Review of Resident 20's physician orders did not show the physician authorized Resident 20 to exit the facility/premises independently, without an escort.Review of a Nurse Progress Note dated 02/17/2026 at 6:17 PM showed Resident 20 was under one-to-one supervision due to an elopement incident and was located safely. The clinical record did not show a LAWN re-evaluation was completed or revisions were made to the CP.Review of a Nurse Progress Note dated 03/18/2026 showed Resident 20 was on one-to-one supervision due to an elopement event where they were found out on the main street.Review of a LAWN Evaluation dated 03/18/2026 showed Resident 20 was at risk for elopement due to: cognitive impairment, poor safety awareness, ambulated independently, was unable to consent for themselves, had history of exit-seeking, substance abuse, expressed desire to go home, and wandering in and out of the facility. The IDT determined Resident 20's elopement risk was high due to actively exit seeking behaviors and wandering, agitation with redirection, and refusal to wear the facility wander alert system. The evaluation did not indicate a recent elopement event. Resident 20 was placed on one-to-one supervision and re-evaluate in 72 hours. Review of Resident 20's CP did not provide documentation to show the CP was revised/updated. Review of the clinical record did not show a re-evaluation after 72 hours.Review of a LAWN Evaluation dated 06/22/2026 showed Resident 20 had severe cognitive impairment, safety awareness was a concern, the resident had a history of exit-seeking behaviors and wandering in or out of the facility, out the South Hall dining room French doors and out to the parking lot, but did not wander outside the parking lot. The evaluation did not show the physician provided an order approving Resident 20 to exit the facility independently. The determination was that Resident 20 was at risk for LAWN. IDT interventions included CP review and revision, resident education on out on pass policy, and assistance with discharge planning.Review of a Tele-Health Psychiatric Follow up note dated 06/23/2026 at 9:30 AM by a Nurse Practitioner located in [NAME], Texas showed Resident 20 had multiple chronic illnesses with severe exacerbation and progression, including severe expressive aphasia, severe cognitive impairment, vascular dementia with severe behavioral disturbances (yelling, agitation, breaking windows, and elopement risk), restlessness, disorganized speech, and disorientation. Resident 20 was awake, alert, but significantly confused and communicated in a disorganized manner, pacing in their room during the telehealth visit. The provider documented instructions for behavioral interventions that included continuing close observation of wandering, restlessness, yelling, anger, agitation, and maintain elopement precautions due to wandering and cognitive impairment. The provider documented on physical exam Resident 20 appeared disheveled, would not make eye contact, showed impulsivity, was anxious, irritable, had impaired judgement, and oriented to person only.Review of a Nurse Progress Note dated 06/27/2026 at 8:00 PM showed when the nurse arrived at the facility, they were notified that the south hall dining room French doors were locked and Resident 20 was very upset because they were approved to use those doors to go in and out of the facility as they desired. Despite redirection, Resident 20 unlocked the doors and went outside. Resident 20 returned to their room without incident and then the nurse placed Resident 20 on 15-minute checks to monitor.Review of a Nurse Progress Note dated 06/29/2026 at 1:47 PM showed Resident 20 was upset that they were unable to exit the facility through the south hall dining room French doors, so they exited the facility through the alarmed egress door and was unable to get back into the facility. Resident 20 was redirected to the front door exit but was still upset and broke their knife in half during lunch.Review of a Nurse Progress Note dated 07/01/2026 at 3:51 AM showed Resident 20 was allowed to walk out the front entrance without an escort to get fresh air. Resident 20 appropriately notified the nurse when wanting to go outside and returned to the facility without incident. The documentation did not show the facility followed Resident 20s elopement CP to ensure they had an escort.Review of a Nurse Progress Note dated 07/02/2026 at 5:49 AM showed Resident 20 was compliant with using the main entrance when leaving the facility and upon returning and appropriately notified staff when leaving the facility without an escort.During an interview on 07/15/2026 at 11:20 AM, Staff J, Maintenance Director, showed an exit door on the South Hall with exit lights which was considered an egress door, triggered with an alarm, used for emergency exit and entrance only. Nearby were two sets of double doors that led onto a cement patio and the front parking lot. Staff J stated the sets of double doors were not considered fire exits and were the doors Resident 13 and Resident 20 exited the building from. Staff J stated Resident 20 was very determined to get out. Staff J stated they put wood across the double doors to the patio to secure them shut and Resident 20 busted them out. Since then, Staff J screwed metal angles across the double doors so they are no longer able to open/close. During an interview on 07/15/2026 at 3:15 PM, Staff B (a newly hired Director of Nursing) stated they were aware Resident 20 went out the South Hall French doors independently but was not yet familiar with Resident 20's complete history or care needs. Staff B stated they expected the staff to follow the Residents CP but did not.<FALLS><Policy>Review of the facility's Fall Management policy, dated 05/26/2021 showed residents would be assessed for fall risk upon admission to the facility. Residents determined to be at risk for falls would receive appropriate interventions to reduce the risk and minimize injury. The facility would communicate residents fall risk status to caregivers, develop/revise a resident-centered CP. If a resident fell, the facility would assess the resident, document the incident in the clinical record and update/revise the CP to reflect new interventions, notify the appropriate parties, and the IDT would review the resident after the fall.<RESIDENT 14> Review of the 06/11/2026 admission MDS showed Resident 14 admitted to the facility on [DATE] and had severe cognitive impairment. Resident 14 was assessed to require substantial/maximal assistance with bed mobility, transfers, and supervision with wheelchair mobility. Resident 14's diagnoses included dementia with behavioral disturbances, falls, arthritis, and neuropathy (painful nerve damage that disrupts the communication lines between your brain, spinal cord, and rest of the body). Resident 14 had falls prior to admission and after admission to the facility. Review of the Fall Risk CP, revised 07/10/2026, showed Resident 14 was at risk for falls/injury due to exit-seeking behavior, unsafe attempts to self-transfer, unsafe wheelchair positioning due to poor trunk control, impaired safety awareness, and cognitive impairment. Multiple fall interventions dated 06/07/2026 included: adjustment of bed height accordingly; assessment for mental status changes, pain and report to physician; assist with getting out of bed with the use of using standard, walker, rolling walker, quad cane, straight cane, no device, standard pivot transfer, slide board; assist with ambulation, clutter free environment. Interventions dated 07/10/2026 included directions to staff to ensure Resident 14 was safely positioned in their wheelchair with appropriate support and to monitor/provide redirection for unsafe leaning, attempts to self-transfer, or exit-seeking behaviors. Review of a facility fall investigation dated 06/06/2026 showed Resident 14 had a witnessed fall where they fell forward out of their wheelchair and hit their head. Resident 14 was transferred to the emergency department and cleared of any significant injury, then returned to the facility the same day. The updated fall interventions included the interventions initiated on admission, as the witnessed fall occurred on the same day as their admission to the facility.Review of Resident 14's Fall CP showed an intervention created 06/11/2026 that showed 1:1 supervision was initiated on 06/08/2026.Review of a Nurse Progress Note dated 06/20/2026 at 11:50 PM showed Resident 14 had an unwitnessed fall. Resident 14's 1:1 CNA monitor was in the hallway on their phone. When the CNA returned to the resident's room, they found Resident 14 on the floor. The nurse assessed Resident 14 for injury and initiated neurological monitoring. The documentation showed that Resident 14's Fall CP was not followed for 1:1 supervision.Review of the facility's fall investigation report dated 06/20/2026 at 8:00 PM showed Resident 14 had a non-injury fall because they rolled out of bed. A staff interview on 06/20/2026 showed Resident 14 had a 1:1 caregiver who was out in the hallway on their cell phone when Resident 14 fell out of bed. The Incident Summary showed Resident 14 was observed on the floor next to their bed after rolling out of bed. Despite continuous observation, the event occurred suddenly, and staff were unable to intervene before Resident 14 rolled from the bed to the floor. The root cause analysis/conclusion showed the investigation did not show neglect, abuse, staff misconduct, equipment malfunction or failure to follow the CP occurred. Based on their available evidence, the event was consistent with an accidental, non-injury fall related to cognitive impairment and unpredictable movement during sleep. Abuse and neglect were unsubstantiated. The post-fall interventions included continuing 1:1 supervision, evaluating bed safety, maintaining close distance to the resident when sleeping, and monitoring sleep patterns.During an interview on 07/14/2026 at 3:15 PM, Staff D, Assistant Director of Nursing-ADON, stated the staff member that was providing 1:1 supervision was just outside Resident 14's door, on their phone, but was about three feet from the resident, according to the CNA statement. Staff D stated the caregiver should not have been on their phone-distracted and should have been observing the resident according to the CP but did not.Review of Resident 14's Fall CP did not show any CP revisions or additional interventions dated 06/20/2026. The documentation did not show interventions to evaluate bed safety, maintaining close distance to Resident 14 during sleep, or monitoring of sleep patterns.Review of the Nurse Progress Notes did not provide documentation to show that post-fall monitoring occurred by the licensed nurses.During an interview on 07/14/2026 at 3:15 PM, Staff D stated after an incident, residents were placed on Alert Charting that appears on the PCC (Point Click Care electronic documentation system) and after the required time, the resident is removed from alert charting. Staff D confirmed there was no way to print a report to show residents were placed on alert charting, but licensed staff were required to monitor residents after falls for 72 hours, each shift, for potential injuries or other effects after the fall as well as updating the CP. Staff D was not aware that post-fall monitoring did not occur after the fall but stated it was part of their investigation process when reviewing/conducting a fall investigation. After reviewing Resident 14s clinical record, Staff D stated that post-fall monitoring and CP updating should have occurred but did not.Review of a Nurse Progress Note dated 06/27/2026 at 6:48 PM showed Resident 14 experienced another unwitnessed fall and was found lying on the floor between the bed and their wheelchair, trying to self-transfer. The nurse assessed Resident 14 and initiated neurological monitoring. The documentation showed that appropriate notifications were made and Resident 14 remained on 1:1 monitoring.Review of the facility's witnessed fall investigation dated 06/27/2026 at 1:30 PM showed Resident 14 was under the supervision of a 1:1 caregiver when Resident 14 attempted to self-transfer. Re-directional intervention from the caregiver was implemented to intercept the unsafe transfer and additional support was called. Resident 14 became increasingly agitated, cursing at the staff members and pushing them away. Despite the redirection and additional assistance to intervene, Resident 14 fell to the floor. They ruled out abuse/neglect or staff misconduct. The investigation did not include staff/witness statements or post-fall monitoring by licensed nursing staff.Review of Resident 14's Fall CP did not provide documentation to show the CP had been reviewed, revised, or updated after the 06/27/2026 fall.Review of an Alert Note dated 06/29/2026 at 2:33 PM showed Resident 14 moved to a room closer to the nurse station. The documentation did not show why the room change was made. In an interview on 07/14/2026 at 3:15 PM, Staff D, Assistant Director of Nursing, stated Resident 14 admitted from the hospital after a stay at a previous long-term care facility where they were on 1:1 supervision, so Resident 14 was on 1:1 supervision upon admission.<RESIDENT 1>Review of the 05/22/2026 admission Assessment MDS showed Resident 1 admitted to the facility on [DATE], was assessed with moderate cognitive impairment, no behaviors, and no rejections of care. Resident 1 was always incontinent of bowel and bladder and required substantial, maximal assistance with toileting and transfers, and dependent with ambulation. Resident 1s diagnoses included a stroke, arthritis, multiple rib fractures, anxiety, abnormal walking pattern, and need for assistance with personal care. Resident 1 had no falls prior to admission and sustained two or more non-injury falls since admission to the facility. This MDS did not indicate Resident 1 had dementia.Review of Resident 1's Fall CP revised 06/01/2026 showed they were at risk for falls due to a traumatic brain injury, abdominal distention, itching, agitation/impulsivity, and low iron in the blood. The interventions dated 05/11/2026 included: to assess for mental status changes or pain; two person assist to get out of bed using standard walker, rolling walker, quad cane, straight cane, no device, standard pivot transfer, slide board; monitor and assist with toileting needs; medication evaluation as needed; therapy evaluation and treatment. The CP interventions showed they were not person-centered and did not provide interventions to address their identified fall risk factors.Review of Resident 1's Fall CP and progress notes showed the following:>FALL #1: Review of a Nurse Progress Note dated 05/12/2026 at 3:15 PM showed Resident 1 fell on the floor and was found next to their bed yelling HELP! HELP!. Review of the Fall CP showed an intervention update dated 05/12/2026: Toileting frequently as needed.>FALL #2: Review of a Nurse Progress Note-SBAR dated 05/13/2026 at 6:29 PM showed Resident 1 fell from bed while trying to reach for their phone. Review of the Fall CP did not provide documentation to show a CP intervention was added on the day of the fall. The fall CP showed a delayed update dated 05/19/2026 (six days after the first fall, initiated 05/13/2026): Provide grabber for hard-to-reach objects to prevent bending over. The documentation showed Resident 1 fell twice (Fall # 3 and Fall # 4) between Fall #2 and the day the CP was updated on 05/19/2026 with a new intervention to prevent further falls.>FALL #3: Review of a Nurse Progress Note dated 05/17/2026 at 6:29 AM showed Resident 1 was found on the floor on the right side of their bed and their call light cord pulled out from the wall. Resident 1 stated they were looking for their phone when they slid from the bed. Their phone was located on their nightstand on their left side of the bed. Review of the Fall CP showed no CP updates on the day of the fall. The documentation showed this was Resident 1's second fall trying to reach for their phone and an appropriate intervention to prevent recurrence was not added to the CP until 05/19/2026.>FALL #4: Review of a Nurse Progress Note-SBAR dated 05/19/2026 at 10:45 PM showed Resident 1 was found on the floor next to their bed. Resident 1 reported they slid off the bed after trying to self-transfer because they were trying to get to 7-11 to get their bowling card. Review of the Fall CP showed two CP interventions: Fall mat(s), if indicated and when Resident 1 was in bed, place all personal items within reach. The documentation did not provide directions to staff on which side of the bed to place the fall mat or when it was supposed to be in place.>FALL #5: Review of the Fall CP showed Resident 1 fell on [DATE] but the CP showed no updated interventions on the day of the fall. Review of the Progress Notes did not show a progress note that detailed the events of a fall on 05/22/2026.>FALL #6: A Nurse Progress Note dated 05/23/2026 at 1:39 AM showed Resident 1 was found on the floor next to their bed. Review of the Fall CP did not show a CP intervention was added on 05/23/2026.>FALL #7: A Nurse Progress Note dated 05/25/2026 at 4:10 PM showed Resident 1 was found sitting on the floor next to their bed at 3:55 AM and stated they were trying to get up for the day. Review of the Fall CP did not provide documentation to show a CP intervention was implemented after the fall. >Review of the Fall CP showed a delayed CP intervention update dated 05/25/2026 (initiated 05/23/2026): urinalysis asap to rule out urinary tract infection due to multiple falls- Resident 1 was refusing and had increased agitation during straight catheterization (a method of urine collection to ensure a sterile sample is obtained).>FALL #8: A Nurse Progress Note dated 05/29/2026 at 2:08 PM showed Resident 1 was found sitting on the floor next to their bed. Resident 1 stated they were trying to reach their vaping device which was later found near the sink and confiscated. Review of the CP showed two new interventions dated 05/29/2026: orthostatic blood pressures for three days and concave/perimeter mattress.>FALL #9: A Nurse Progress Note dated 05/30/2026 at 9:58 AM showed Resident 1 was found sitting on the floor next to their bed yelling for help. The nurse noted Resident 1 experienced recurrent falls and their last fall was on 05/29/2026. Resident 1 said they were attempting to put their pants on and fell off the bed. Review of the Fall CP did not show a CP intervention update was added on 05/30/2026.>Review of the Fall CP showed a delayed CP intervention update dated 06/01/2026 that showed it was initiated 05/19/2026. The CP showed the CP update was 12 days after their fall on 05/19/2026. The intervention showed: Lab work to rule out infection or change of condition related to falls.>Review of the Fall CP showed a delayed CP intervention update dated 06/08/2026 (with an initiation date 10 days prior on 05/29/2026): Medication review by pharmacy due to multiple falls.>Review of the Fall CP showed a new CP intervention added on 06/01/2026: Room move to a room across from the nurse station for closer monitoring.>FALL #10: Review of a Nurse Progress Note dated 06/18/2026 at 5:44 PM showed Resident 1 had a witnessed fall outside. A new CP intervention was added on 06/18/2026 (initiated the same day): Educate spouse/family to not leave Resident 1 unattended when they left after visits. Enforce education about safety.>FALL #11: Review of a Nurse Progress Note dated 06/25/2026 at 12:11 PM showed Resident 1 was found on the floor next to their bed after an attempt to self-transfer. Review of the facility's fall investigation dated 06/25/2026 at 12:00 showed new interventions would include anticipate resident needs and safety, Post Fall Rehab Screen, ensure the wheelchair was properly positioned and brakes engaged when not in use, and reinforce education with the resident on using the call light and requesting staff assistance before all transfers. Review of the Fall CP did not show that any of the interventions described in the investigation were updated to the CP.Review of the Fall CP showed a delayed CP intervention update dated 06/29/2026: Anticipate care needs and safety.During an observation and interview on 07/13/2026 at 11:12 AM, Resident 1 was observed lying in bed with regular socks on (not non-skid) and a fall mat on the floor on their right side of the bed. There was strong urine odor noted in their room. Resident 1 stated they had not had any falls since admission.During an observation on 07/15/2026 at 8:30 AM, Resident 1 was observed seated in their wheelchair in the doorway of their room. Resident 1 wore regular black socks, no shoes or non-skid footwear. Their reacher/grabber was not observed to be in their room. At 8:45 AM, Resident 1 was observed at the East nurse station, hanging on to the counter while standing, with no non-skid footwear, and unlocked wheelchair brakes. Staff in the area did not recognize or respond to Resident 1's unsafe attempts to stand without assistance.In an interview on 07/15/2026 at 2:30 PM, Staff B, Director of Nursing, stated it was their expectation that when a resident fell, licensed staff were expected to update the clinical record and CP with an appropriate intervention as soon as safely possible, document the event and findings, place the resident on alert charting every shift for 72 hours at a minimum to m[TRUNCATED]

Based on observations, interviews, and record reviews the facility failed to ensure 7 of 8 Residents (Residents 8, 12, 18, 1, 15, 22 & 9) who were unable to perform Activities of Daily Living (ADLs-including oral care, grooming, personal hygiene, toileting, and good nutrition) received the care and services they required. This failure placed residents at risk for unmet care needs, skin breakdown, infections, and undignified quality of life. Findings included . <POLICY> Review of the facility's Activities of Daily Living (ADLs), Supporting policy, revised 2018, showed the staff would ensure residents who were unable to independently perform ADLs would be provided the necessary services and care they were assessed to require (and according to their care plan (CP)), including assistance with: hygiene (bathing, dressing, grooming, and oral care), mobility (transfer, ambulation, and walking), toileting (staff would do round prior to all meals to ensure that ADL care needs were met), dining, and communication (speech, language and any functional communication systems). The resident's response to care interventions would be monitored, evaluated, and revised appropriately. Review of the facility's CNA Shower Sheet, undated, showed the form was to be completed for all baths/showers provided. The sheet showed the date, resident, and room number, a body graph for accurate description of abnormal skin findings, and staff were to circle the tasks they provided during that bathing event. The choices included: shower, hair washed (unless they went to the salon regularly-then no hair wash), shave, nails trimmed (toes and fingernails-Not if Diabetic!), their weight, and any observed skin abnormalities. The tasked options did not include tub bath or bed bath performed. The form also showed that if the residents refused their scheduled bath the CNA must get the nurse to speak with the resident and any bed baths provided must be approved by the nurse. <RESIDENT 8> Review of the 06/25/2026 Significant Change in Status Minimum Data Set (MDS-assessment tool) showed Resident 8 re-admitted to the facility on [DATE], had no cognition problems, and no behaviors or rejection of care. Resident 8 required maximum bathing assistance, moderate assistance with bathing transfers, and was incontinent of bowel and bladder. Resident 8 diagnoses included heart failure, diabetes, arthritis, seizure disorder, and kidney failure that required hemodialysis (an outpatient procedure where the blood is removed from the body so that the toxins can be filtered from the blood, then the blood is replaced) three times a week. Review of the 06/25/2026 ADL Care Plan (CP) showed Resident 8 was dependent on staff to provide bathing. The CP did not provide documentation to show their resident-centered preferences for bathing including weekly schedule, type of bathing they preferred, or time of day. Review of the East Shower Schedule showed Resident 8 was scheduled to receive showers on Wednesdays and Saturdays on the day shift. Review of Resident 8's Documentation Survey Report from 06/19/2026 through 07/13/2026 showed a bed bath documented on 06/27/2026 and showers documented 06/30/2026, 07/04/2026, 07/06/2026, and 07/13/2026. The documentation showed Resident 8 had areas of their skin that were reddened on 07/06/2026 and 07/13/2026. Review of a Shower Sheet dated 06/17/2026 showed Resident 8 received a shower and hair wash, but their nails were not trimmed, and was signed by Staff CC, Certified Nursing Assistant (CNA)/Bath Aid. Review of the June and July 2026 Treatment Administration Record (TAR) did not show licensed staff provided diabetic nail care and monitoring. Review of Resident 8s clinical record did not provide documentation to show the CNA Shower Sheets were completed with each shower provided. During an observation and interview 07/13/2026 at 11:15 AM, Resident 8 was observed to have long nails with dark debris under the nails, and their hair appeared to be oily with dry, flaky scalp. Resident 8 stated they did not recall how many baths they had since admission to the facility but stated, Not as many as were planned. Resident 8 stated they planned to have two showers per week but that did not occur during their stay because they went to dialysis during the day on Tuesdays, Thursdays, and Saturdays and their second scheduled shower day for the week was scheduled during their dialysis treatment. Resident 8 stated they had asked nursing staff to have their nails trimmed, but no one ever trimmed them. Resident 8 stated I finally got a shower today, for the week, but I am discharging home today.<RESIDENT 12> Review of the 06/29/2026 5-Day MDS showed Resident 12 re-admitted to the facility on [DATE]. Resident 12 was unable to speak but was able to express themselves in a manner that others could usually understand and they usually were able to understand others. Resident 12 had severely impaired vision and severely impaired cognition. Resident 12 was assessed to have no behavior or rejections of care. Resident 12 was dependent on staff for bathing, transfers, hygiene, toileting, and was incontinent of bowel and bladder. Resident 12s diagnoses included a stroke with inability to speak or safely swallow and hemiplegia (loss of movement of one side of the body), kidney failure that required hemodialysis three times per week, a major infection, and diabetes. Resident 12 admitted to the facility with a surgical wound and Moisture Associated Skin Damage (MASD-skin impairment caused by excessive exposure to moisture from incontinence, perspiration, or other drainage). Review of Resident 12s ADL CP, dated 04/08/2025, showed Resident 12 was dependent on staff to provide a bath but did not indicate their resident-centered preferences for bathing or who was responsible for providing nail care. Review of the [NAME] Shower Book on 07/15/2026 11:30 AM showed a [NAME] Daily Shower Schedule, dated Monday 06/29/2026 that showed Resident 12 was scheduled to receive a shower on the day shift and it was not documented as provided. The [NAME] Shower Schedule process appeared to be different than the East Shower Schedule process.Review of Resident 12s bathing record from 06/23/2026 through 07/15/2026 showed they received a shower on 06/24/2026, 07/02/2026 (eight days later), and a bed bath on 07/03/2026. The documentation showed Resident 12 had not received a bath in 12 days. 12 days as of 07/15/2026. Review of Resident 12s clinical record did not provide documentation to show the CNA Shower Sheets were completed with each shower provided. During an observation and interview on 07/14/2026 at 3:20 PM, Resident 12 was observed with dark matter under their nails and had long facial hair. Resident 12 indicated they would like their beard trimmed. During an interview on 07/14/2026 at 3:25 PM, Staff BB, CNA, stated they did not know who was responsible to trim Resident 12's beard. Staff BB stated the nurses were responsible for trimming Resident 12's nails. Staff BB stated they had shower aids some days, but if they did not and it was Resident 12's shower day then they gave them a bed bath. Review of Resident 12s June and July 2026 TAR did not provide documentation to show that licensed nurses performed/offered and monitored weekly diabetic nail care. In an interview on 07/14/2026 at 3:27 PM, Staff W, Registered Nurse (RN), stated the restorative CNA or licensed nurses were responsible for providing and cleaning nails but Resident 12 had a history of refusing care. <RESIDENT 18> Review of the 05/11/2026 Quarterly MDS showed Resident 18 admitted to the facility on [DATE]. Resident 18 had no problems with their cognition, no behaviors, and no rejection of care. Resident 18 required a wheelchair for mobility, moderate staff assistance for bathing and set-up/supervision for transfers. Resident 18s ability to transfer in the shower was not assessed. Resident 18 was incontinent of bowel and bladder and diagnoses included: surgical aftercare for osteoarthritis of the right knee, diabetes, anxiety, depression, generalized weakness, and need for assistance with personal care. Review of Resident 18s ADL CP, dated 02/03/2026, showed they required one person for staff assistance with bathing. The CP did not indicate Resident 18s resident-centered shower preferences. Review of the East Shower Schedule, undated, showed Resident 18 was scheduled for a shower on Wednesdays and Saturdays in the evening. Review of Resident 18s bathing record from 06/19/2026 through 07/15/2026 showed a bed bath documented on 06/23/2026 and 06/26/2026. Showers were documented on 06/30/2026, 07/01/2026, 07/04/2026, 07/05/2026, and 07/06/2026. The documentation showed Resident 18 was not available on Saturday 07/11/2026, a shower was documented on 07/13/2026, and bed bath was documented 07/14/2026. Review of Resident 18s clinical record did not provide documentation of the CNA Shower Sheets from showers documented as provided. Review of Resident 18s June and July 2026 TARs did not provide documentation to show that weekly diabetic nail care was provided or monitored by licensed nursing staff. Review of the Shower Book at the nurse station showed two CNA Shower Sheets: One dated 07/01/2026 and signed by Staff CC that indicated a shower and hair wash were provided and one dated 07/08/2026, signed by Staff CC, that a shower and hair wash were provided. During an observation of an interaction between Staff CC and Resident 18 on 07/14/2026 at 11:15 AM, Resident 18 asked Staff CC if they could receive a shower that morning because they did not receive their scheduled shower on Saturday (07/11/2026) or their requested shower on Monday (07/13/2026-to make-up for the missed Saturday shower). Staff CC replied to Resident 18 saying they were not on the bath schedule for that day. Resident 18 was observed to have very long hair that appeared slightly matted, oily, and not combed through. In an interview on 07/15/2026 at 9:45 AM, Resident 18 stated they still had not received the shower they requested on 07/14/2026 at 11:15 AM. Resident 18 stated they were scheduled to receive a shower twice weekly on Wednesdays and Saturdays. Resident 18 stated they did not receive their scheduled shower on Saturday 07/11/2026. Resident 18 stated when they asked about their shower on Saturday, they were told by their CNA that the facility did not provide showers on the weekends. They requested a shower on Monday, 07/13/2026, to make up for their missed Saturday shower but did not receive one. On 07/14/2026 they again requested a shower and was told it was not their scheduled shower day. Resident18 stated they requested to receive their shower at 11:00 AM on 07/15/2026 but was not optimistic that they would get their shower. Resident 18 stated they had skin problems that worsened when they didn't get to adequately bathe. Resident 18 showed their skin problem that appeared red and irritated. Resident 18 stated the facility provided treatment for the skin problem, but routine bathing helped prevent it from worsening. Resident 18 stated they had never received showers or bed baths on consecutive days while at the facility, as the documentation on the bathing record reflected, and confirmed they did not receive showers on 07/13/2026 or 07/14/2026. <RESIDENT 1> Review of the 05/22/2026 admission Assessment MDS showed Resident 1 was assessed with moderate cognitive impairment, no behaviors, and no rejections of care. Resident 1 was always incontinent of bowel and bladder and required substantial, maximal assistance with shower/bathing, dressing, and personal hygiene. Review of Resident 1's ADL CP, dated 05/11/2026, showed a bathing intervention dated 05/19/2026 that Resident 1 was totally dependent on staff to provide a bath and as necessary and to provide a sponge bath when a full bath or shower could not be tolerated. The CP did not indicate their resident-centered bathing preferences or who was responsible to provide nail care.Review of the undated East Shower Schedule showed that Resident 1 was scheduled for bathing on Tuesdays and Fridays. Review of Resident 1s bathing record from 06/19/2026 through 07/15/2026 showed a shower documented on 06/22/2026, 06/23/2026, 06/28/2026, 06/29/2026, and a bed bath on 07/05/2026. There were no documented refusals. Review of the shower book at the nurse station on 07/14/2026 at 11:22 AM showed CNA Shower Sheets for Resident 1 on: 06/02/2026 -shower and hair wash, no nail care or shave; 06/05/2026-shower, hair wash, no nail care or shave; 06/09/2026-Refused bathing; 06/12/2026-shower and hair wash, no nail care or shave; 06/16/2026-bed bath, no hair wash, nail care or shave; and 07/08/2026-shower, hair wash, no nail care or shave. No other shower sheets were in the binder for Resident 1. Review of Resident 1s clinical record did not provide documentation to show the shower sheets were completed, that refusals of care were addressed, or that additional showers and nail care were provided. In an observation and interview on 07/13/2026 at 11:12 AM, Resident 1 was observed to have long nails with dark matter under the nails and a noticeable odor of urine. <RESIDENT 15> Review of the 06/30/2026 admission MDS showed Resident 15 admitted to the facility on [DATE]. Resident 15 had no problems with their cognition, no behaviors, and no rejection of care. Resident 15's daily preferences interview showed it was very important to them to choose how they took baths (whether it was a shower, tub bath, bed bath, or sponge bath). Resident 15 required a wheelchair for mobility, was dependent on staff for bathing and transfers, was incontinent of bowel, and had a urinary catheter. Resident 15's diagnoses included: new traumatic spinal cord injury with paraplegia (inability to move parts of the body below the spinal cord injury site), traumatic brain injury, catheter associated urinary tract infection in the previous 30 days, other multiple fractures, and awaiting admission to inpatient rehabilitation. Review of Resident 15's ADL CP, dated 06/24/2026, showed they required one person staff assistance for bathing/showering. The CP did not indicate Resident 15s resident-centered bathing preferences or weekly schedule. Review of the undated East Shower Schedule showed Resident 15 was scheduled for showers on Monday and Thursday evenings. Review of Resident 15's bathing record from 06/24/2026-07/15/2026 showed: a tub bath documented on 06/27/2026; a shower documented on 06/30/2026; a bed bath on 07/01/2026; showers on 07/04/2026, 07/05/2026, 07/06/2026, and 07/13/2026.During an observation and interview on 07/15/2026 at 11:06 AM, Resident 15 stated they did had not received a shower since admission to the facility on [DATE]. Resident 15 stated they were scheduled for showers on Mondays and Thursdays but had never been in the shower room. Resident 15 stated they received several bed baths, but they don't feel clean after bed baths. Resident 15 stated Staff CC told [them] that bed baths were easier and quicker, so they only provided bed baths and not always on their scheduled bathing day. Resident 15 stated they were able to keep up on their own fingernail care, but they had requested toenail care several times, but the care had not yet been provided. Resident 15's toenails were observed to be long and in need of care. <RESIDENT 22> Review of the 06/06/2026 Comprehensive Assessment MDS showed Resident 22 admitted [DATE], severe cognitive impairment, no behaviors, and no rejections of care. Resident 22 was dependent on staff for shower/bathing/transfers and required moderate/partial assistance with personal hygiene. Resident 22 was incontinent of bowel/bladder and diagnoses included respiratory failure, diabetes, dementia, and vision problems.Review of Resident 22's ADL CP, revised 11/07/2023, showed: an intervention revised 08/06/2021 that Resident 22 required extensive assistance for personal hygiene/grooming and an intervention revised 08/06/2021 that Resident 22 required extensive assistance of one person for bathing. The CP showed it was not updated/revised to reflect the most recent 06/06/2026 Comprehensive Assessment and did not indicate their assigned shower schedule/preferences or who was responsible for nail care/trimming.Review of Resident 22's Diabetic CP, revised 10/16/2020, showed an intervention dated 11/15/2018 directing licensed nurses to perform a daily diabetic foot check, observe feet/toes for impairments and observe toenails for shape, length, and color. The CP did not address toenail care/trimming. Review of the [NAME] Shower Book showed a [NAME] Daily Shower Schedule, dated Monday 06/29/2026, showed Resident 22's room/bed was scheduled for a shower during the day. The documentation showed no shower was provided.Review of Resident 22's bathing record from 06/19/2026-07/15/2026 showed the following: a bed bath documented 06/19/2026 and 06/20/2026; showers on 06/22/2026, 06/24/2026, and 07/02/2026; a bed bath on 07/09/2026, the last documented shower/bath.During an observation on 07/13/2026 at 10:40 AM, Resident 22 was observed seated in their wheelchair in the front entrance hallway, outside the day room. Resident 22 wore a purple top that was soiled and had a large amount of loose white hair on both the front and back of the top and small visible stains/debris on their pants. They were wearing socks with no shoes. Their hair was not combed, and they had a clump of hair that was matted together tightly (about the size of a silver dollar) on the back of their head. Resident 22 had what appeared to be residual food in the creases around their mouth and they had long white chin hairs on their chin and upper lip that were approximately half an inch long.During a three-minute observation on 07/13/2026 at 1:05 PM, Resident 22 was observed to be in the same physical condition as they were observed to be at 10:40 AM. Four staff walked by them and not a single one acknowledged them or recognized their unkempt condition.<RESIDENT 9> Review of the 06/28/2026 admission MDS showed Resident 9 admitted to the facility on [DATE] with severe cognitive impairment, rarely understood others, did not talk, and was not able to make daily decisions. Resident 9 had no behaviors or rejections of care. They were assessed to be dependent on staff for showering, lower body dressing, hygiene.Review of the ADL CP, dated 06/22/2026, showed Resident 9 required two staff to assist with bathing/showering and as necessary and preferred baths but did not indicate their assigned shower schedule. Review of the undated East Shower Scheule showed Resident 9 was scheduled for bathing on Tuesdays and Fridays during the day. Review of Bathing point of care documentation for 06/22/2026-07/14/2026 showed Tuesday 06/23/2026 was Not Applicable, Friday 06/26/2026 was Not Applicable, a bed bath was documented on 06/27/2026, a shower on 06/30/2026, a bed bath 07/01/2026, 07/02/2026, Friday 07/03/2026 was Not Applicable, a shower 07/04/2026, 07/05/2026, a bed bath 07/06/2026, Tuesday 07/07/2026 was Not Applicable, Friday 07/10/2026 was Not Applicable, and a bed bath was documented on 07/13/2026, six days after the last documented bathing event. On 07/14/2026 at 9:30 AM, Resident 9 was observed with long nails with black debris underneath. The resident had long hair and a long beard. Resident 9 was unable to answer questions asked as they made vocalizations which were heard but not understood. On Tuesday 07/14/2026 at 11:01 AM, Staff V, CNA, stated they did not have a shower aid that day, so they gave Resident 9 a bed bath. Staff V stated, He's clean, see. When asked about Resident 9's nails, Staff V stated they would check to see if the resident was diabetic and if not, they sat with residents, put their nails in a water soak, and cut them, if they're not too busy. At 11:06 AM, Staff V stated they did not take Resident 9 to the shower, they gave them a bed bath instead and did not check to see if they were diabetic. In an interview on 07/15/2026 at 8:25 AM, Staff CC, CNA/ shower aid, stated when they performed showers, they only provided the shower and shave but not nail care. Nail care was the responsibility of their assigned CNA (or the nurse if the resident was a diabetic). Staff CC stated the showers were scheduled by room assignment not by specified preferences. Staff CC provided the shower assignment schedule that showed each resident was scheduled two showers per week, based on the bed they occupied. Staff CC stated after the shower was provided, they completed the Shower Sheet and placed it in the shower book for the nurse to review at the end of their shift. In an interview on 07/15/2026 at 3:15 PM, Staff B, Director of Nursing, stated the facility provided showers seven days a week by the designated bath aid if there was one for that day and if they did not have a designated bath aid, the CNAs were still responsible to provide the residents bathing according to their preferences and/or as scheduled, including shaving and nail care if needed, and should be documented in the clinical record. Staff B confirmed that if the resident had diabetes, the licensed nurses were responsible to monitor and trim their fingernails due to risk for infection. Licensed Nurses were responsible for toenail monitoring, care, and trimming (if their condition allowed and did not require the podiatrist to trim), the CNAs were responsible to trim nails for the residents who were not diabetics, and the resident's CP should specify responsibilities correctly but did not.Refer to F725. Refer to F745. REFERENCE WAC: 388-97-1060 (2)(c).

Based on observations, interviews, and record reviews the facility failed to develop and implement an effective discharge planning process that focused on residents' discharge goals and preparation of residents for discharge and failed to develop and implement comprehensive discharge care plans for 4 of 5 residents (Residents 2, 4, 3 & 5) reviewed for discharge planning. These failures placed residents at risk of a diminished quality of life, depleting valuable Medicare coverage days, unnecessarily extended length of stay and/or feeling they were being held against their will.Findings included.<RESIDENT 2> Review of the 04/27/2026 admission Minimum Data Set (MDS - an assessment tool) showed Resident 2 admitted to the facility on [DATE], was assessed to have moderate cognitive impairment, and required substantial assistance with bed mobility and transfers. Resident 2 received Occupational Therapy (OT), Physical Therapy (PT), and Resident 2's plan was to discharge to the community. According to this MDS, active discharge planning had been initiated for Resident 2 to return to the community. Review of the 04/24/2026 Comprehensive Care Plan (CP), last revised on 07/08/2026, did not provide documentation to show a discharge plan had been initiated. Review of the 04/24/2026 Activities of Daily Living (ADL) CP showed Resident 2 was non-ambulatory, required substantial/max assist with bed mobility and personal hygiene, was dependent on staff for dressing, and required a 2-person mechanical lift transfer. An intervention with the same date gave directives for PT/OT to evaluate and treat according to the physician orders. Review of the 04/21/2026 CP showed Resident 2 had a chronic indwelling urinary catheter. Review of Case Management Note dated 04/22/2026 showed that Resident 2 desired to return home to their apartment where they previously lived Independently with a paid caregiver's assistance. A 04/28/2026 note showed Resident 2 was taking steps with therapy and their goal remained to be able to climb up three steps to enter their home. Review of Resident 2's PT Encounter Notes showed therapy began stair-step training on 05/13/2026. On 05/31/2026 Resident 2 ambulated with a walker 100 feet, 70 feet, 120 feet, and 100 feet with staff following behind with wheelchair and with emphasis on stride length, ambulation posture, and negotiating obstacles. Resident 2 practiced four steps up and down with handrail assist, modified independence (Mod I-ability to safely complete a physical task or mobility maneuver independently but requires the use of an assistive device, adaptive equipment, or additional time to complete the task). Review of a PT Encounter Note dated 06/01/2026 showed Resident 2's functional status with skilled interventions were Mod-I with bed mobility, transfers, ambulation with a walker, stairs, and wheelchair mobility. Resident 2's safety awareness was intact. Review of an OT-ADL Training Functional Status as a Result of Skilled Interventions note dated 06/17/2026 showed Resident 2 was assessed as Mod-I with personal hygiene, toileting, and dressing. Review of a PT Encounter Note dated 06/30/2026 showed they discussed with Resident 2 the plan of care and new goals to optimize independence and safety to return home. Review of a Medicare Recertification dated 07/12/2026, showed it was signed by the provider on 07/10/2026 and certified the need for continued daily skilled therapy and nursing care including wound care for redness and Indwelling catheter although Resident 2 had met their discharge goals with therapy for returning home independently and did not have nursing care needs that required seven days per week of skilled nursing services. During an interview on 07/13/2026 at 11:19 AM, Resident 2 stated they wanted to discharge from the facility as soon as possible, but the facility staff said they were not ready yet. Resident 2 stated they planned to discharge home to their apartment and only had to climb three steps. Resident 2 stated prior to admission they used a walker and/or cane and walked one-mile round trip to the grocery store three times a week. Resident 2 stated they were doing steps and walking in 150 feet therapy, and up to 410 feet outside. Resident 2 stated the therapist said they wanted [them] to be better with walking before discharge. When asked what their barriers to discharge were to discharge, Resident 2 stated they felt they were ready for discharge, they just needed the facility to say when they could discharge so they could get their caregiver scheduled. Resident 2 stated they had been asking to discharge for the past two or three weeks. During an interview on 07/13/2026 at 1:28 PM, Staff O, Director of Rehabilitation, stated they believed Resident 2 was discharging real soon, last week they were able to walk 90 feet. Initially they needed to do stairs, then they wanted to walk to grocery store with a four wheeled walker. Staff O stated they held a progress meeting on 06/13/2026 to recommend discharge, but Resident 2 still had stairs and a further distance to walk. During an interview on 07/14/2026 at 12:02 PM, Staff F, Social Services Designee, stated they had a care conference with Resident 2, three to four weeks ago and therapy reported they needed one more week to work on stairs, and that was the last had heard. <RESIDENT 4>Review of the 05/26/2026 Significant Change in Status / 5-day MDS showed Resident 4 readmitted to the facility on [DATE]. Resident 4 was alert, oriented, and required set-up assistance with oral hygiene, partial/moderate assistance with toileting hygiene, dressing and transfers, and required supervision for bed mobility. According to this MDS there was no information regarding Resident 4's overall goal for discharge, but active discharge planning was already occurring for the resident to return to the community. During an interview on 07/13/2026 at 1:21 PM, Resident 4 stated they wanted to go home. When asked what their barriers to discharge were, Resident 4 stated they did not know and they had been asking the staff the same questions. Resident 4 stated they had 3 steps to climb to enter their home, which they achieved, and they could dress themselves and use the bathroom independently. Resident 4 stated their adult child lived with them and they also had a caregiver. Resident 4 stated PT told social services they were ready to discharge a couple of weeks ago. During an interview on 07/13/2026 at 1:28 PM, Staff O stated Resident 4 had difficulty maintaining their oxygen saturation at the beginning of their stay and they were currently working on increasing activity tolerance and lower body dressing, and PT was working on functional transfers. Resident 4 currently ambulated 75 feet with contact guard assistance (CGA-a safety measure where the therapist keeps one or two hands on the patient-often a gait belt-to help with balance, the patient performs 100% of the physical effort, and the therapist provides zero assistance only steadying support in case the resident lost their balance) required for the last 15 feet. Resident 4's goal was to ambulate 150 feet. <RESIDENT 3>Review of the 04/26/2026 admission MDS showed Resident 3 admitted to the facility on [DATE], had no cognitive impairment, required supervision with bed mobility, partial/moderate assistance with oral hygiene, lower body dressing, and transfers, set up with upper body dressing, substantial/maximal assistance with toileting hygiene, showering, and personal hygiene. Resident 3 received PT, OT, and Speech-Language Pathology (SLP) at least 15 minutes a day on one or more days in the last 7 days. According to this MDS, Resident 3's overall goal for discharge was to remain in the facility and no active discharge planning had been initiated to return to the community. Review of the resident's 04/23/2026 Comprehensive CP did not provide documentation to show a CP had been initiated for discharge planning. According to the CP, Resident 3 required PT related to impaired bed mobility, impaired gait, and impaired transfers. Listed goals included the resident will would perform bed mobility with Modified Independence, would increase gait ability on flat surfaces, ambulate 150 feet with a two-wheeled walker and supervision, and increase only require supervision with transfers.Review of an Interdisciplinary Care Conference dated 04/21/2026 showed Resident 3's original discharge goal was to return to the community, but during the conversation, Resident 3 decided they would remain in the facility long-term as Resident 3 felt they were too sick to return to living in their van. Review of a 04/28/2026 Case Management Assessment note showed the Resident 3 intended to stay at the facility as a long-term care resident once skilled services ended. Review of PT Treatment Encounter Notes showed on Resident 3 performed transfers from bed to wheelchair with Mod-I on 05/19/2026. On 06/09/2026 Resident 3 ambulated 150 feet using four-wheeled walker (4WW) with Stand By Assist (SBA- a safety level where the caregiver stands close to supervise the task, ready to step in instantly if the resident lost their balance). On 06/10/2026 Resident 3 participated in bed mobility training and was assessed as Mod-I. On 07/13/2026 Resident 3 performed bed mobility and transfers with Mod-I, ambulated using 4WW with SBA, and was independent with WC mobility. During an observation and interview on 07/13/2026 at 11:32 AM, Resident 3 was dressed, wearing tennis shoes. Resident 3 stated they planned to stay at the facility for awhile and noted the facility changed their insurance so they could stay longer. Resident 3 stated prior to admission they lived in their van. Resident 3 stated they were currently receiving therapy for walking and stuff. During an interview on 07/13/2026 at 1:28 PM, Staff O stated Resident 3 was on PT caseload for ambulation and safe transfers and OT for upper and lower body dressing, toileting, and safely gathering items for ADL tasks. During an interview on 07/14/2026 at 12:02 PM, Staff F stated Resident 3 had no current discharge plan and they were still receiving skilled therapy services. <RESIDENT 5> Review of the 05/27/2026 admission MDS showed Resident 5 admitted to the facility on [DATE], had no cognitive impairment, and was able to communicate clearly. Resident 5 was assessed during the first three days of their stay to require set-up assistance with oral hygiene, toileting hygiene, dressing upper body, and personal hygiene, supervision with showers, dressing lower body, and walking 10 feet, and was independent with bed mobility and transfers. Resident 5 received PT and OT for at least 15 minutes a day on one or more day in the prior 7 days of the observation period. According to this MDS, Resident 5's overall goal was to discharge the community, and active discharge planning was already initiated for the residents to return to the community. Review of the 06/01/2026 CP showed Resident 5's discharge plan was to an Assisted Living Facility. The CP did not show status updates documented. The OT CP revised 06/11/2026 showed Resident 5 required OT related to decreased balance and coordination, decreased strength and endurance, impaired functional mobility and impaired ADL skills. The goals listed were that Resident 5 would perform lower body dressing independently, toilet self with modified independence, and increase functional transfers to modified independence. Review of OT ADL Training Note dated 06/24/2026 showed Resident 5 was intermittently refusing participation and was mostly independent. Resident 5 ambulated with a FWW or walking stick, and no assistive device required when ambulating in their room. OT did not discharge Resident 5 from skilled OT services until 07/07/2026. Review of the PT Evaluation dated 06/12/2026, showed Resident 5 was assessed as independent with bed mobility, transfers, modified independent with ambulation, and SBA to pick up an object. According to the evaluation, Skilled PT services were warranted to address mobility deficits, improve balance and strength, enhance safety with functional activities, and maximize independence while reducing risk of rehospitalization. A 06/23/2026 PT note showed Resident 5 ambulated the facility hallway with and without assistive devices for community distances. Review of a 06/25/2026 PT note showed Resident 5 actively participated in skilled interventions but refused group therapy and did not like therapy because they could do the exercises on their own. Skilled PT was discontinued on 07/07/2026 and Resident 5 would remain in the facility long term care. On 07/14/2026 at 9:54 AM, Resident 5 was observed ambulating independently with a walker. Resident 5 was fully dressed, groomed, and wearing tennis shoes. Resident 5's left foot was in a boot. Resident 5 stated they were at the facility for their leg, that they had a titanium plate in their leg, and their leg gave out. Resident 5 stated they were receiving PT and OT. During an interview on 07/15/2026 at 9:51 AM, Resident 5 stated they did not have a place to live, and they wanted to keep the single private room they had in the facility. Resident 5 stated they were able to dress themselves, Of course, went to the bathroom, All alone, and ambulated independently. When asked about the use of a walker, Resident 5 stated it was not permanent and they were trying not to use it. Resident 5 stated they were receiving therapy, covered by their insurance. During an interview on 07/15/2026 at 5:24 PM, Staff B, Director of Nursing, stated they discussed in their clinical meeting that Resident 5 needed to discharge, but they were Medicaid Pending, homeless, with no place to go. During an interview on 07/15/2026 at 5:24 PM, Staff A, Administrator, stated that Resident 5 was on the list for a DSHS (Department of Social & Health Services) Assessment for placement. During an interview on 07/13/2026 at 2:29 PM, Staff N, Internal Case Manager, stated they managed the residents that received care and services under the Managed Medicaid and HMOs (Health Maintenance Organization, a type of Medicare Advantage Plan). Staff N stated they did not manage the residents under Traditional/Medicare A insurance. Staff N stated social services were responsible for the coordination of discharges. During an interview on 07/14/2026 at 11:32 AM, Staff E, Social Services Director, stated they did not attend the facility's Utilization Review or Interdisciplinary Team Meetings, and stated Staff F was the discharge planner. During an interview on 07/14/2026 at 12:02 PM, Staff F, stated they attended Utilization Review meetings and held discharge care conferences. Staff F stated when they heard about someone being ready for discharge, they coordinated the set-up of home health services, appointments, and initiated a discharge packet they provided to the nurse manager. When asked how they knew what factors and disciplines (nursing and/or therapy) were [NAME] a resident's stay, Staff F stated they did not know. Staff F stated residents under the traditional Medicare A were reviewed by the business office, but since the Business Office Manager quit three weeks prior no one was doing them. REFERENCE WAC: 388-97-0080

Based on interviews and record reviews, the facility failed to protect 5 of 5 residents' rights to Medicare benefits. The facility disenrolled five (Residents 1, 2, 3, 4 & 10) beneficiaries from Medicare Managed Health Plans without their request, consent, knowledge and/or complete understanding. The facility failed to develop written policies and procedures regarding the process of assisting beneficiaries with changing their health care coverage, including the circumstances under which the facility could assist a beneficiary with a plan change, and the need to obtain an attestation signed by the facility staff member that assisted with the change in enrollment, attesting that the beneficiary or representative requested the change. Failure of the facility placed residents at risk of non-coverage, increased cost out of pocket, and caused undue stress to residents and/or resident representatives and placed 24 Managed Medicare residents at risk of the facility disenrolling them without their request, consent knowledge or complete understanding.Findings included.A facility policy and procedure regarding how staff assist beneficiaries with insurance coverage changes was requested on 07/13/2026 at 10:41 AM and none was provided.During an interview on 07/13/2026 at 11:56 AM, Staff C, Nurse Consultant stated that based on their conversation with the Administrator, the facility did not have such a policy.<RESIDENT 1>Review of the Census List showed Resident 1 admitted to the facility 05/11/2026 on Managed Medicare and transitioned to Traditional Medicare effective 06/01/2026.Review of a Facility Attestation, (to be used if Resident's Authorized Representative requests assistance with healthcare insurance coverage changes) dated 05/26/2026 showed Staff DD, Regional Social Worker, assisted Resident 1's spouse with the change in enrollment from Wellcare Medicare to Medicare. Staff DD signed attesting that the Resident's Authorized Representative requested the change and that the Resident's Authorized Representative received and understood the information contained in the Information Sheet for Residents. Any and all assistance provided assisting the Resident's Authorized Representative to review or make healthcare insurance coverage decisions, including disenrollment and enrollment in a Medicare health plan or Original Medicare, was in compliance with Policy on Resident Insurance Coverage and Changes. The form did not contain a signature of acknowledgement from the Resident's Authorized Representative.A Facility Attestation (to be used if Resident requests assistance with healthcare insurance coverage changes) was completed by Staff E, Social Services Director, attesting they assisted Resident 1 with the change in enrollment from WellCare to Medicare on 05/26/2026. The form did not contain a signature of acknowledgement from the Resident.During an interview on 07/13/2026 at 11:10 AM, Resident 1 was not aware of any changes made to their insurance and asked the investigator to speak with their Representative.During an interview on 07/13/2026 at 12:56 PM, Resident 1's Representative (R1R) stated they were not aware of or remember any discussions regarding changing Resident 1's insurance.<RESIDENT 2>Review of the Census List showed Resident 2 admitted to the facility 04/21/2026 on Managed Medicare and transitioned to Traditional Medicare effective 05/01/2026.During an interview on 07/13/2026 at 11:19 AM, Resident 2 stated a guy came in and talked to them about changing over their insurance, saying it would be better for them. Resident 2 said they were told nothing would change, and Resident 2 told them if they did, they could not afford it. When asked if they had provided anything in writing, Resident 2 stated they got something in the mail informing them that they dropped their insurance.<RESIDENT 3>Review of the Census List showed Resident 2 admitted to the facility 04/20/2026 on Managed Medicare and transitioned to Traditional Medicare effective 05/01/2026.Review of Resident 3's record showed no Notice of Medicare Non-Coverage ( NOMNC), no progress notes regarding the change request and no consent.During an interview on 07/13/2026 at 11:32 AM, Resident 3 stated that they previously lived in their van and the facility changed their insurance so they could stay in the facility longer. Resident 3 stated a while ago; some lady talked to them because they wanted to change their insurance. Resident 3 stated the facility staff initiated the conversation.<RESIDENT 4>Review of the Census List showed Resident 4 admitted to the facility 04/29/2026 on Managed Medicare and transitioned to Traditional Medicare effective 05/01/2026.During an interview on 07/13/2026 at 1:21 PM, when asked if they requested their insurance to be changed, Resident 4 responded, No, why would I? Resident 4 denied signing any documents consenting to having their insurance changed.<RESIDENT 10>Review of the Census List showed Resident 10 admitted to the facility 04/21/2026 on Managed Medicare and transitioned to Traditional Medicare effective 05/01/2026.During an interview on 07/15/2026 at 2:36 PM, Resident 10's Representative (R10R), stated, I have no idea how that happened, I've already changed it back. Resident 10 will be back on their Managed Medicare plan effective 08/01/2026. R10R stated they asked around and nobody knows who did it. I was shocked!During an interview on 07/14/2026 at 11:32 AM, Staff E stated that Staff DD told the facility staff that if a resident got a NOMNC (Notice of Medicare Non Coverage) and was concerned about going home, didn't feel stable, they could appeal the NOMNC, apply for Medicaid, or switch to Medicare A and get therapy longer. Staff E there was a paper the resident would sign that Medical Records was uploading and an associated progress note. Staff E stated they did the first few in May 2026 (with the change effective June 1st) with Staff DD who were providing the training. Staff E stated they had not done any in subsequent months, and did not know who, if anyone, was doing them.During an interview on 07/14/2026 at 12:02 PM, Staff F, Social Services Designee, stated that Staff DD provided them with training that if residents needed to be skilled longer to transfer their insurance over to Traditional Medicare. Staff F stated they had not done so or been involved in that practice.During an interview on 07/15/2026 at 4:18 PM, Staff A, Administrator, stated the procedure was if a resident was issued a NOMNC, the staff were to educate the residents on their options. They have three options; 1) apply for Medicaid, 2) appeal the insurance decision, 3) Transition to traditional Medicare. Staff A stated their understanding was that the residents and families signed consent forms when they switched (their insurance). Staff A stated, I tell them not to influence or push the residents. We are not insurance agents.Review of Resident 2, Resident 3, Resident 4 and Resident 10's record showed no consent forms, or other documentation to support the beneficiary or representative requested the change.During an interview on 07/14/2026 at 12:57 PM, Staff M, Health Information, stated they previously uploaded all the documentation of residents' insurance changes they received.REFERENCE WAC: 388-97-0040(2), -1780(1)(2), -0180(4)(c).

Based on interview and record review, the facility failed to ensure 5 of 5 residents (Residents 1, 2, 3, 4 & 10) reviewed for insurance disenrollment were informed of the risks/benefits, options, and alternative changes in their insurance, in ways that were easy for the residents and/or the residents' representative to understand. The facility failed to develop written policies and procedures regarding the process of assisting beneficiaries with changing their health care coverage, including the need to obtain a document signed by the beneficiary or representative that acknowledges that the specific information regarding the impact of a change in coverage was provided to them orally and in writing, and that they understood the information. Failure of the facility placed residents at risk of non-coverage, increased cost out of pocket, and caused undue stress to residents and/or resident representatives and placed 24 Managed Medicare residents at risk of the facility disenrolling them without their request, consent knowledge or complete understanding.Findings included.Review of the undated notice of Long-Term Care Resident Rights in the facility admission Agreement Packet showed the facility must inform each resident in writing in a language the resident or his or her representative understands changes in the availability or the charges for services, items, or activities. In addition, the resident has the right to manage his or her financial affairs.<RESIDENT 1>Review of the Census List showed Resident 1 admitted to the facility 05/11/2026 on Managed Medicare and transitioned to Traditional Medicare effective 06/01/2026.Review of a Facility Attestation, (to be used if Resident's Authorized Representative requests assistance with healthcare insurance coverage changes), dated 05/26/2026, showed Staff DD, Corporate Social Worker, assisted Resident 1's spouse with the change in enrollment from Wellcare Medicare to Medicare. Staff DD signed attesting that the Resident's Authorized Representative received and understood the information contained in the Information Sheet for Residents. The form did not contain a signature of acknowledgement from the Resident's Authorized Representative.During an interview on 07/13/2026 at 11:10 AM, Resident 1 was not aware of any changes made to their insurance and asked the investigator to speak with their Representative.During an interview on 07/13/2026 at 12:56 PM, Resident 1's Representative (R1R) stated they were not aware of or remember any discussions regarding changing Resident 1's insurance. R1R did not recall receiving any information in writing and stated they were not aware of what those changes entailed.<RESIDENT 2>Review of the Census List showed Resident 2 admitted to the facility 04/21/2026 on Managed Medicare and transitioned to Traditional Medicare effective 05/01/2026.During an interview on 07/13/2026 at 11:19 AM, Resident 2 stated they were not aware their insurance was changed and asked, what does that mean? Resident 2 stated with their Medicare Advantage plan everything was covered, but now that they were put on Traditional Medicare they will end up owing money. Resident 2 stated they got something in the mail informing them that they dropped their insurance. Under Managed Medicare they had coverage for their specialists and doctors and now they are getting letters that they need to do this and do that, etc.<RESIDENT 3>Review of the Census List showed Resident 3 admitted to the facility 04/20/2026 on Managed Medicare and transitioned to Traditional Medicare effective 05/01/2026.During an interview on 07/13/2026 at 11:32 AM, Resident 3 stated they did not receive anything in writing prior to their insurance being changed. Resident 3 did not recall being informed of the benefit or potential consequences of the change, other than they would be able to stay in the facility longer.Review of Resident 3's record showed no Notice of Medicare Non-Coverage (NOMNC), no progress notes regarding the change and no consent form.<RESIDENT 4>Review of the Census List showed Resident 4 admitted to the facility 04/29/2026 on Managed Medicare and transitioned to Traditional Medicare effective 05/01/2026.During an interview on 07/13/2026 at 1:21 PM, Resident 4 stated they were not aware their insurance was changed.Review of Resident 4's record showed no NOMNC, no progress note regarding the change and no consent form.<RESIDENT 10>Review of the Census List showed Resident 10 admitted to the facility 04/21/2026 on Managed Medicare and transitioned to Traditional Medicare effective 05/01/2026.During an interview on 07/15/2026 at 2:36 PM, Resident 10's Representative (R10R), stated they had no idea how Resident 10's insurance was changed. R10R stated no one talked to them before changing Resident 10's insurance, and Resident 10 did not understand it. R10R explained they went to a pharmacy to pick up medications, and they were told that Resident 10's Managed Medicare was cancelled and transitioned to Medicare A on 05/01/2026. They also lost their Case Manager and representative with the changes. They started getting a bunch of stuff in the mail, people were charging Resident 10 money. They received a bill for $1,894.00, but it doesn't say from where, but the insurance paid zero.During an interview on 07/13/2026 at 2:29 PM, Staff N, Internal Case Manager, stated they follow the residents on Managed insurances for the duration of their stay with that insurance. Staff N sends the insurance company weekly reports as requested. When the insurance company says the resident no longer meets the criteria for coverage and they issue a NOMNC, they communicate that to the resident or resident's responsible party. Staff N stated they advise them they have three options; 1) discharge, 2) stay in the facility with coverage by a different payor (Medicaid, Private.), 3) appeal the insurance decision. Staff N stated that if the resident requested an alternate payor, the business office assisted them. Staff N stated the facility currently had 24 residents under managed care.During an interview on 07/15/2026 at 4:18 PM, Staff A, Administrator, stated the procedure was if a resident was issued a NOMNC, the staff were to educate the residents on their options. If the residents had more questions they could call the insurance company. Staff A stated, It is ultimately the resident's decision on what they want to do. When asked if they provided anything to the residents in writing, Staff A stated the notice from their insurance company, the NOMNC explained why it was being issued. When asked if the staff explained the pros and cons of changing their insurance, Staff A stated, no as they were no insurance agents. When asked who would assist the residents back on their Managed Medicare plan prior to discharge, Staff A stated they did not know.REFERENCE WAC: 388-97-0260, -0300(3)(a).

Based on observation, interview, and record review, the facility failed to prevent abuse of 1 of 6 residents (Resident 7) reviewed for resident to resident altercations. Resident 7 experienced psychological harm, evidenced by change in social behaviors, isolating to their room and expressed changes in a trauma assessment, when the facility failed to provide adequate supervision, effective interventions to assure safety, and evaluate the effectiveness of current interventions to prevent further abuse. In addition, staff failed to adequately monitor and prevent Resident 151 from expressing aggressive behavior towards residents. These failures placed residents at risk for sexual and physical abuse, psychological harm, feeling uncomfortable and unsafe.Findings included .Review of facility provided policy titled SNF Clinic Abuse Prohibition, dated 10/25/2024, showed staff would take action to prevent abuse by identifying, correcting and intervening in situations in which abuse is more likely to occur. If the suspected abuse is resident to resident, the resident who has in anyway threatened or attacked another will be removed from the setting or situation and an investigation will be completed. The facility will provide adequate supervision when the risk of resident to resident altercation is suspected. The facility is responsible for identifying residents who have a history of disruptive or intrusive interactions or who exhibit other behaviors that make them more likely to be involved in an altercation. The facility will protect residents from further harm during an investigation by providing a safe environment.Review of Resident 7's electronic health record (EHR) showed they admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (a lung disease that effects ability to breathe) and post-traumatic stress disorder (mental health condition that's caused by an extremely stressful or terrifying event - either being part of it or witnessing it). Resident 7 was able to make needs known. Review of Resident 7's answers on a trauma questionnaire, dated 12/26/2025, showed:Have you felt numb or detached from people, activities, or your surroundings: NoHave you had a nightmare about event(s) or thought about the event(s) when you did not want to: NoHave you tried hard not to think about the event(s) or went out of your way to avoid situations that reminded you of the event(s): YesHave you been constantly on guard, watchful, or easily startled: NoIs there anything we should be aware of that makes you feel worse: Does not indicate-states she has dealt with it.Additional Comments: Resident reports history of being abused from childhood through adulthood. She was physically and sexually abused as a child. She had domestic violence assaults and reports she was traded and trafficked for drug and money.Review of Resident 151's EHR showed they admitted to the facility on [DATE] with diagnoses that included above the knee amputation and psychoactive substance dependance. Resident 151 was able to make his needs known.Review of Resident 151's EHR showed an acute care note, dated 05/21/2026, documenting Resident 151 was an active user of methamphetamine and marijuana three times per week.<First Incident>Review of Resident 7's progress note, dated 03/08/2026, read, Patient said to this writer that they're afraid of going to sleep because they worry about a resident who lives in room [identified as Resident 151] comes to shake them awake. When this writer came along with another nurse to [Resident 151] to make sure that it will not happen, the resident admitted they went to the room and woke the resident up. Resident [151] was educated about patient safety and respect and encouraged to meet other resident at a nursing station or lobby area. Continue to monitor.Review of the March 2026 incident log and March 2026 grievance log did not show an entry related to the concern documented in the progress note.During an interview on 05/22/2026 at 11:02 AM, Resident 7 stated Resident 151 would come to their room late at night and shake them awake. Resident 7 stated they reported it to the nurse because they were scared. Resident 7 stated, I've been sexually assaulted, was in an abusive marriage and I don't like being touched. Resident 7 stated facility management came and talked to them about it the next day.During an interview on 05/22/2026 at 10:14 AM, Staff H, Social Service Director (SSD), stated they were unaware of the situation. Staff H stated based on the allegation and Resident 7's past trauma, the social service department should have conducted a trauma assessment and put Resident 7 on alert to monitor any negative psychological social outcomes.During an interview on 05/22/2026 at 10:43 AM, Staff A, Administrator, stated Resident 7 was interviewed the day after the concern was documented. Staff A stated the nurse who documented Resident 7's concern should have reported it to the state if they confirmed that Resident 7 was scared. Staff A stated a trauma assessment should have been completed.Review of Resident 7's EHR did not show an investigation was conducted, no monitoring for negative psychological social outcomes related to the incident, no trauma assessment was completed and no care plan interventions to promote sense of security.<Second Incident>During an interview on 05/22/2026 at 11:02 AM, Resident 7 reported they were not friends with Resident 151 anymore because they were a former addict and when they were out in the smoking shed, Resident 151 blew methamphetamine smoke in their face. Resident 7 said when they got mad about it, Resident 151 blocked them from leaving with their wheelchair, trapping them in the smoking shed. Resident 7 said Resident 151 also pulled out his penis and started pleasuring himself in front of them. Resident 7 said they tried to stay away from him; the meth makes [Resident 151] that way. Resident 7 said she reported the incident to the receptionist but the did not work there anymore. On 05/22/2026 at 1:27 PM, the above information was reported to the facility Administrator by The Department staff.Review of Resident 7's answers on the trauma questionnaire, dated 05/22/2026, related to the allegation reported to the surveyor showed the following:Have you felt numb or detached from people, activities, or your surroundings: Yes (change from previous)Have you had a nightmare about event(s) or thought about the event(s) when you did not want to: Yes (change from previous)Have you tried hard not to think about the event(s) or went out of your way to avoid situations that reminded you of the event(s): YesHave you been constantly on guard, watchful, or easily startled: Yes (change from previous)Is there anything we should be aware of that makes you feel worse: Feeling trapped.Additional Comments: Resident says this situation with Resident 151 had triggered past childhood trauma about being molested, Resident 7 was trying to avoid further contact [with Resident 151] so the situation did not escalate. Review of Resident 7's telehealth visit, dated 05/22/2026, showed the chief complaint as inappropriate sexual abuse and diagnosis as adult sexual abuse, suspected.Review of the facility investigation, dated 05/22/2026, showed interventions included a separation plan that was implemented to avoid contact between the residents to include alternate smoking area or times and Resident 7 was to have one-to-one supervision for safety (although industry standard is to place one-to-one supervision on the perpetrator instead of the victim). Resident 151 was placed on alert status with increased monitoring and behavior risk.Review of Resident 151's nurse progress notes showed a late entry on 05/22/2026 to describe the allegations in the smoke shed. The notes did not include any documentation of implementation of a behavior based monitoring regarding the incident.Review of Resident 7's nurse progress note, dated 05/23/2026 at 09:39 PM, showed Resident 7 was on alert for psychosocial harm and had a one-to-one with staff. Review of Resident 7's EHR showed this was the second and last nurse progress note regarding alert monitoring and implementation of an intervention.Observations on 05/26/2026 at 9:00 AM and 11:40 AM and 06/01/2026 at 2:49 PM showed Resident 7 without staff supervision.During an interview on 06/01/2026 at 2:49 PM, Resident 7 stated they were not receiving one-to-one supervision. Resident 7 stated they felt depressed due to losing friends who asked why they told on Resident 151. Resident 7 stated they had been leaving the smoking area when Resident 151 attempted to make eye contact with them in the past few days. Resident 7 was teary-eyed and stated they are considering discharge to avoid any further problems.During an interview on 06/01/2026 at 4:13 PM, Resident 151 said, The allegation is total bulls**t. Resident 151 stated the facility hadn't restricted him from having contact with Resident 7 or told him he had to smoke elsewhere or at a different time and if they did, he would not listen. Resident 151 stated they had been in the smoke shed with Resident 7 recently and Resident 7 just leaves because they're chicken s**t, every time they see me, they leave. Resident 151 said if the facility told him he had to smoke at a different time or in a different place he would tell them bullshit, he knows his rights, plus [Administrator] won't say anything to him because he doesn't have the balls to and doesn't have a clue what's going on in the facility. Resident 151 said he's never wanted to hit a female but after the allegation he was this close.Observation on 06/01/2025 at 4:20 PM, showed Resident 7 walking in from the smoking area. Resident 7 stated they had to cut their smoke break short due to Resident 151's presence in the smoking area. Resident 7 stated I don't want any problems; I'm just going back to my room. During an interview on 06/01/2026 at 4:23 PM, Saff B, Director of Nursing, stated due to lack of staff, the one-on-one supervision for safety of Resident 7 had not been consistent. Staff B stated it did not meet their expectations that Resident 7 was still subjected to Resident 151 during smoke breaks and that the interventions had not been implemented. Staff B was asked why the one-to-one was not on Resident 151 and how the facility planned to keep other residents safe, Staff B said they were not. Staff B stated the facility had a hard time dealing with Resident 151 and their aggressive behaviors towards staff. Staff B stated the facility had not implemented the intervention to monitor/document Resident 151's behaviors and that did not meet expectations.Review of Resident 151's progress note, dated 06/02/2026, showed during a scheduled smoke break, Resident 151 was observed engaging in inappropriate interactions with another resident. Staff intervened and redirected the resident; however, the resident became verbally agitated, yelling and using abusive language toward staff. Reference WAC 388-97-0640(1)

Based on interview and record review, the facility failed to provide food that accommodated a documented food allergy for 1 of 3 residents (Resident 1) reviewed for dietary services. Resident 1 experienced harm when the resident was served food which contained an ingredient to which they were allergic, and the resident required medical intervention and monitoring. This failure placed other residents at risk for allergic reaction and medical complications. Findings included. Resident 1 was admitted to the facility on [DATE], was alert and oriented, and was their own responsible party.Review of Resident 1's Electronic Medical Record (EHR) showed that Resident 1 was admitted to the facility on [DATE], was alert and oriented, and was their own responsible party. The EHR further showed Resident 1 had allergies to multiple medications, as well as to onions and latex. Review of Resident 1's record showed that the allergies were listed throughout the resident's chart, including the Resident Profile created on admission, Medication Administration Record and Treatment Administration Records for April 2026 and May 2026.Review of Resident 1's admission diet order, dated 04/20/2026, documented Resident 1 was to receive a cardiac diet (diet to manage heart health) with regular texture and thin liquids, and at the top of the form stated the resident's allergies as onion and latex.Review of the Order Summary noted Resident 1's allergy to onions was documented on 04/20/2026, the date of admission to the facility.Review of a Nutritional Assessment by the facility's Registered Dietitian, dated 04/23/2026, documented Resident 1's allergy to onions and recommended large protein portions.Review of Resident 1's Care Plan created 04/20/2026 and revised 04/23/2026, showed to include large portions of protein to promote wound healing, noted that Resident 1 was at nutrition risk due to multiple diagnoses, but did not include interventions regarding the resident's documented allergy to onions.Record Review on 04/23/2026 at 12:05 PM, a Dietary Profile showed that Staff C, the Dietary Manager, documented they had met with Resident 1 and along with the allergy to onions, noted an allergy/food intolerance to dairy.Review of a Progress Note, dated 05/03/2026 at 7:05 PM, documented Resident 1 had an allergic reaction from onions served them from the kitchen. The nurse noted Resident 1 complained of swelling of their tongue and throat and had a hard time speaking. Nursing documented that on 05/30/2026 at 6:08 PM, Resident 1 was given an injection of epinephrine [the first-line treatment for life-threatening allergic reactions (anaphylaxis], which was effective, and that the resident's vital signs were stable. The nurse noted the resident was crying in bed, scared.On 05/03/2026, Nursing reported to a telehealth provider via SBAR Summary for Providers (communication tool between nursing and providers), dated 5/3/2026 at 7:11 PM, that Resident 1 had a severe allergic reaction to onions, epipen (injectable epinephrine) given and effective, and the resident was evaluated by a telehealth provider. At 6:30 PM, when paramedics arrived onsite to assess the resident, Nursing documented the resident had started to feel better and speak normally. The resident's provider was notified and ordered continued monitoring of the resident.During an interview on 05/06/2026 at 1:06 PM, Collateral Contact 1 relayed a concern that the facility did not listen to the resident's concerns about their diet, as they were allergic to certain foods and the facility continued to serve them the same food.During an interview on 05/11/2026 at 1:19 PM, Resident 1 said they were allergic to onions and facility staff frequently brought them food with onions in it. Resident 1 said when they could see the onions or smell them, they would notify staff and return the food. Resident 1 said they had had a severe allergic reaction to onions in potato salad about a week before and had to have a shot because of it. Resident 1 said the paramedics came to the facility afterward, and by then the resident was doing better. Resident 1 said they were very scared when that happened and was worried it would happen again.During an interview on 05/14/26 at 4:15 PM, Staff C, the Dietary Manager said they had recently made changes as to how allergies and preferences were coded and flagged on the tray tickets and that they were to be verified by multiple staff before the food reached the resident.During an interview on 05/14/2026 at 4:56 PM, Staff B, a Registered Nurse and the facility Director of Nurses, recalled that Resident 1 was served onions in their food, had an allergic reaction and was treated with epinephrine. When asked how the incident occurred, Staff B said they had new staff and that it was missed by the other staff. Reference WAC 388-97-1100

<Elopement> Review of a facility's policy titled, Elopements (when a resident identified as wandering leaves the facility without staff knowledge or authorization) - Resident Behavior and Facility Practices, dated 02/21/2025 showed when a resident who exhibited wandering behavior and/or were at risk for elopement received adequate supervision to prevent accidents, and received care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement. Review showed monitoring and managing residents at risk for elopement and unsafe wandering showed the effectiveness of interventions would be evaluated and changes made as needed. The procedure for locating missing residents would be followed to include alert personnel using facility approved protocol. Review of the facility's policy titled, Elopement of Resident dated 07/12/2023, showed a process for managing at risk (residents) for elopement, to include residents would be evaluated for elopement risk not only upon admission and quarterly but with any change in condition as part of the clinical assessment process. Those (residents) determined to be at risk would receive appropriate interventions to reduce risk and minimize injury, to include a person-centered care plan developed when applicable. Review of the facility's Inservice record / topic: Elopement, dated 01/02/2025 showed several procedures for staff to initiate to include checking with the front desk (staff) to see if the resident was checked out, announcing three times on the facility's intercom system a code pink (an alert/code use by the facility to indicate possible elopement of a facility's resident). If unable to locate the resident quickly notification of law enforcement as soon as possible (ASAP). Resident 56 Review of the quarterly minimum data set (MDS, a required assessment tool), dated 05/22/2025, showed Resident 56 re-admitted on [DATE] with multiple diagnoses to include Parkinson's disease (a progressive neurodegenerative disorder that primarily affects movement), dyskinesia (impairment of voluntary movement), muscle weakness, and depression. The MDS showed the resident had a brief interview for mental status (BIMS) score of seven which indicated severe cognitive impairment and was dependent on staff for assistance with activities of daily living (ADLs) and was a high risk for falls. The MDS showed staff had documented a change in behavior in Section E1100 for the question How does the resident's current behavior status, care rejection, or wandering compared to prior assessment, a social service staff documented Resident 56 was worse for the behaviors section. Review of Resident 56's current care plan, initiated on 03/08/2025 had impaired / decline in cognitive function impaired thought processes related to dementia, Parkinson's disease, short/long term memory loss. Interventions included for staff to observe and evaluate types of changes in cognitive status i.e. confusion, orientation, forgetfulness, decision making ability and impulsiveness. Review of Resident 56's social services progress note, dated 05/30/2025, showed facility staff documented resident continued to have poor safety awareness, needed reminders about safety, had history of falls and needed to be offered more assistance. The note showed the resident would like to be transferred to an adult living facility and angry and wanted to move to a new setting and can become irritable and angry mostly due to wanting to move to a new setting. Review of Resident 56's EHR, dated 06/02/2025, showed the resident ambulates (walk; move about) using a walker and required supervision one person) for ambulation. During an observation and interview on 06/08/2025 at 9:07 AM, showed Resident 56 sat on their bed, a staff member sat on a nearby chair and observed the resident. When asked what the staff was doing in the resident's room, Staff H, Certified Nurse Aide, (CNA) stated they were told from an earlier report Resident 56's had eloped yesterday 06/07/2025 and they were there to observe the resident to ensure they did not elope out of the facility again. Review of Resident 56's EHR progress note dated 06/07/2025 showed the resident was reported to be missing by the front desk. Front desk staff reported the resident walked out to the parking lot to get some sunshine at 3:15 PM; however, the resident did not return. The front desk staff informed the nurse at 3:45 PM, the resident's emergency contact was notified at 4:00 PM, who was also unaware of the resident's location. At 4:20 PM a facility staff contacted / called 911 related to the missing resident. At 4:40 PM a local nursing home several blocks away contacted the facility after Resident 56 was brought there by a woman who witnessed the resident stumbling/falling. A facility staff (manager on duty) retrieved the resident. Resident 56 stated they were looking for the highway to go home. During an interview 06/10/2025 at 1:10 PM, Staff B, DNS, stated their expectation was for a code pink to be called immediately by the manager on duty and if unable to initially find a resident then 911 should be called simultaneously and not delay the call during the search for the missing resident. During an interview on 06/10/2025 at 1:49 PM, Staff J, Recreation Director (RD), stated they were the manager on duty the day Resident 56 went missing and all the managers received a similar text regarding Resident 56 was missing. Staff J stated they walked around the facility outside for approximately 15 -20 minutes but were unable to locate the resident during that time frame. Staff J stated that another text came in to call 911. Staff J stated there was some confusion as to who was tasked with calling 911, either the manager on duty or the nurse in charge, so there was a delay in calling 911 related to the missing resident. During an interview on 06/10/2025 at 1:51 PM, Staff G, Social Work (SW) stated they had documented a change in Resident 56's MDS (current behavior status) on the previous MDS dated [DATE] and informed Resident 56's care manager. During an interview on 06/10/2025 at 12:45 AM, Staff A, Administrator (ADM) stated their expectation would be anytime a resident had a change in behavior (potential elopement risk) an assessment would need to be done to see if they were appropriate for increase monitoring and whether a placement of a wander guard was necessary. When asked about the front desk staff who observed Resident 56 leave the facility unaccompanied and whether they had elopement training / education, Staff A stated the receptionist was a recent hire (new staff) and they had recognized the receptionist had dropped the ball. The receptionist was now suspended, and education was done related to elopement risks. Staff A stated they were unable to find the front desk receptionist initial elopement training in their training documentation. Resident 14 Review of the EHR showed Resident 14 was at risk for elopement and required a Wander Guard device (an alarm device that triggers when a resident attempts to leave the facility) on their wheelchair. Review of treatment administration record (TAR) for June 2025, showed Resident 14's Wander Guard was not in place for eight of 17 opportunities from 06/01/2025 - 06/09/2025. Review of Resident 14's TAR record for May 2025 showed missed documentation for the Wander Guard for 20 out of 62 opportunities. During an interview on 06/12/2025 at 10:32 AM, Staff Q, Resident Care Manager, stated they just replaced the Wander Guard as the Resident cuts it off. Staff Q stated the expectation was for the licensed nurses to check and ensure Resident 14 had a Wander Guard in place and documented. Refer to F-610 for additional information. Reference WAC 388-97-1060 (3)(g). . . Based on observation, interview and record review, the facility failed to consistently provided the assessed level of supervision to prevent avoidable injuries and falls, assess if care plan interventions were effective and provide timely revisions for 5 of 6 sampled residents (Residents 14, 15, 29, 21 and 110) reviewed for accidents and falls. Resident 29 experienced harm when a staff member provided bed mobility assistance without a second staff member as required per the plan of care resulting in a fall with a periorbital (area around the eye) laceration (cut) to the left eye that required hospital evaluation and sutures. Resident 21 experienced harm when staff failed to implement hip precautions during a transfer resulting in a hip dislocation and severe pain that required surgery and hospitalization. Resident 110 experienced harm from repeated falls, three between 05/14/2025 and 05/27/2025, with injuries to include a head laceration, skin tear to the elbow, and including an occipital hematoma (blood collection at the back of the head). The facility failed to protect residents from eloping (exiting the facility without the required supervision) or attempting to exit the facility for 2 of 2 sampled residents (Residents 56 & 14) reviewed for accidents. These failures placed residents at risk of significant injury and a decreased quality of life. Findings included . <Avoidable Injuries> Resident 29 Review of the electronic health record (EHR) showed Resident 29 was admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (COPD, a condition which blocks airflow that makes it difficult to breath), diabetes (high blood sugar), depression and anxiety. Resident 29 was able to communicate needs. Observation on 06/08/2025 at 10:13 AM showed Resident 29 lying in bed with bruising and sutures (a stitch or row of stitches holding together the edges of a wound or surgical incision) on the left side of their forehead near the left eye. Resident 29 stated they fell from the bed and had to go to the emergency room for sutures. Resident 29 stated the fall happened during repositioning / turning in the bed by one staff member. Resident 29 stated since the incident they were afraid to be turned in bed by staff. Review of Resident 29's progress notes in the EHR showed a fall with injury on 05/30/2025. During routine care by one staff member Resident 29 fell from the unsupervised side of the bed air mattress. Resident 29 struck their head against the floor resulting in deep periorbital (area around the eye) laceration (cut) to the left eye. Review of the care plan self care focus area, dated 05/17/2025, showed intervention Resident is totally dependent on staff for repositioning and turning in bed, and The resident requires 2 staff participation to reposition and turn in bed. Review of facility incident report investigation, dated 06/06/2025 for the fall on 05/30/2025, showed one of the immediate actions was Due to the extent of the eye injury and head trauma, the provider ordered to be transferred to the hospital. Review showed, The care was performed by one staff member, despite the resident requiring two staff, the aide did not follow the care plan, and There was a lack of adherence to care plan protocols and enforcement to ensure compliance with required assistive staffing for high-risk residents. Observation on 06/10/2025 at 11:06 AM showed Staff R, Registered Nurse (RN) performed a skin check and turned Resident 29 in bed by themselves and stated, I am not going to drop you. Resident 21 Review of the EHR showed Resident 21 admitted to the facility on [DATE] with diagnoses that included aftercare for joint replacement surgery, presence of left artificial hip joint and muscle weakness. Resident 21 was weight bearing as tolerated. During an interview on 06/12/2025 at 10:47 AM, Resident 21 stated on 05/29/2025 while staff were attempting to transfer them to their wheelchair Staff X, Certified Nursing Assistant (CNA), moved their left leg in jerking motion while on the bed which resulted in a loud pop. Resident 21 stated they asked the staff, did you hear that? The staff looked at each other and Staff X stated, yes. Resident 21 stated they immediately felt excruciating pain at a level of 110. Staff X lowered Resident 21's left leg back down on the bed and left the room. Resident 21 stated they yelled in pain for the nurse to give them something for pain. Resident 21 stated the nurse ordered an x-ray; however, stated it could take hours. Resident 21 stated their family member requested transport to the emergency department (ED) due to the possible wait time. Resident 21 stated they were crying and screaming in pain while at the ED until they were given pain medication and underwent surgery. Review of the EHR showed an ED Discharge summary, dated [DATE], with a final diagnosis of left hip dislocation which was surgically repaired. Resident 21 was discharged from the ED on 05/30/2025. Review of progress note from Staff W, Licensed Practical Nurse (LPN), dated 05/29/2025, showed Resident 21 complained of popping sound while being moved to the wheelchair from the bed to get weighed. Resident 21 stated, 2 gentleman tried to move me from the other side of the bed to the wheelchair when I heard a popping sound from my left hip and now, I can't move. and Resident was able to transfer from wheelchair to the bed with stand-and-pivot when they first came to the facility without complaint of pain. During an interview on 06/12/2025 at 11:54 AM, Staff W, LPN, stated while coming back from break Staff X reported that Resident 21 was in extreme pain. Staff W stated when asked about the pain, Resident 21 stated they couldn't move their leg and was in excruciating pain because the CNA was careless and hurt my hip. Staff W stated the admissions department was putting Resident 21's orders in the EHR at that time of the incident; however, the resident was weight bearing as tolerated. Review of Resident 21's EHR showed signed discharge orders from the previous facility, dated 05/29/2025, which included an order, Weight bearing as tolerated with walker, posterior hip precaution (eliminating hip flexion/bending and internal rotation / turning leg inward, and adduction / flexing inward) X 6 weeks full weightbearing. Review of the current providers order on 06/12/2025, showed no order for: Weight bearing as tolerated with walker, posterior hip precaution for six weeks full weight bearing. During an interview on 06/12/2025 at 1:35 PM, Staff B, Director of Nursing Services, stated Resident 21 reported to the nurse that a staff member moved their leg and it popped. <Falls> Resident 110 Review of the EHR showed Resident 110 admitted to the facility on [DATE] with diagnoses that included dementia (a group of thinking and social symptoms that interferes with daily functioning), difficulty walking and muscle weakness. Resident 110 was able to make needs known. Resident 110 required extensive assistance for transfers and used a wheelchair for mobility. Resident 110 was assessed as a fall risk. Review of Resident 110's incident report, dated 05/14/2025, showed Resident 110 had a witnessed fall resulting in a two-inch head laceration. At approximately 1:10 PM, housekeeping staff reported witnessing Resident 110 attempting to stand from their wheelchair with foley catheter (tube to drain urine) still attached resulting in a fall. Resident 110 was found lying on the floor on their right side, near the foot of the bed by the window.Review showed a nurse aaplied pressure to an actively bleeding head wound. Resident 110 was unable to verbalize pain but was grimacing and holding their right leg. Resident 110's wheelchair was located outside the bathroom door with a tray table and meal tray. Review of Resident 110's care plan, dated 05/14/2025, showed supervised feeding at nurses' station or dining room for meals were the fall prevention interventions put in place. Review of Resident 110's the incident report, dated 05/20/2025, showed Resident 110 had an unwitnessed fall that resulted in an elbow skin tear. At approximately 7:15 PM a nurse noticed Resident 110 was on the floor on the left side of the bed on top of the floor mat, lying on their left side. Resident 110 denied pain and did not remember why they fell. Resident 110 had a skin tear on left elbow. The fall occurred despite appropriate fall precautions (e.g., floor mat, routine checks). The incident report showed the facility implemented immediate and long-term preventive interventions. The incident report was completed on 05/27/2025, seven days after the incident. Review of Resident 110's care plan showed no new interventions were added following the fall on 05/20/2025. Review of the incident report, dated 05/29/2025, showed Resident 110 had a third fall which was unwitnessed on 05/27/2025 that resulted in an occipital hematoma (blood collection at the back of the head). At approximately 3:50 PM a facility staff heard a loud yell from the hallway. Staff responded immediately and found the Resident 110 on the floor in front of their wheelchair, lying on their left side, with the left occipital area of the head touching the wall. A hematoma was noted on the left occipital scalp (no bleeding). Resident 110 was grimacing, saying ouch. The FACES pain scale indicated pain. Resident 110 was unable to verbalize pain details or fall mechanics due to dementia. The resident was not sent to the hospital. The incident report concluded, The resident's fall occurred due to an unassisted movement from or within an unlocked wheelchair, in the context of cognitive impairment, physical frailty, and brief lack of direct supervision. The resident's dementia likely led to poor safety awareness, and their medical conditions compounded the risk. Review of Resident 110's care plan showed it was updated with new interventions on 05/28/2025 which included continue interventions on the at-risk plan, anticipate and meet the resident's needs, supervision and not to be left unattended at all times (Do not leave up in room when in wheelchair. Keep in high visualized area when up in wheelchair), toileting schedules pre-post meals, before bedtimes, low bed while in bed to help reduce risk of injury from falls. During an interview on 06/10/2025 at 2:13 PM, Staff P, RCM/LPN, stated the care plan was not revised and no interventions were put in place after the 05/20/2025 fall but should have been. During an interview on 06/12/2025 at 2:02 PM, Staff B, DNS stated new interventions should have been implemented and care planned timely after Resident 110's, 05/20/2025 fall. Staff B stated the lack of care implementation, timeliness and care plan revision did not meet expectations. Resident 15 Review of the quarterly minimum data set assessment (MDS), dated [DATE], showed Resident 15 admitted on [DATE] with multiple diagnoses to include quadriplegia (a severe medical condition characterized by the partial or total loss of function in all four limbs and the torso [trunk of the body]), malnutrition, muscle weakness, and depression. The MDS showed the resident was able to make needs known and required substantial assistance with activities of daily living (ADLs) and was documented a high falls risk. Observation and interview on 06/08/2025 at 11:31 AM, showed Resident 15 laying in bed with fall floor mats positioned on both the left and right side of their the bed. Resident 15 stated they had fallen a few times previously when they were either reaching for something that dropped on the floor or attempted to get out of bed without assistance. The resident further stated they had been provided a reacher tool (a device known as a grabber extender, a handheld mechanical device designed to extend a person's reach and grip, allowing them to grasp objects that was otherwise out of arm's length); however, it always seemed to be stored on their wheelchair at the foot of their bed and their call light was also out of their reach. Review of Resident 15's care plan, dated 02/06/2025, showed Resident 15 was at risk for falls due to multiple diagnoses and had recurrent falls. Interventions included for the resident to have positioned floor mats, a reacher tool, call light within reach and to provide verbal cues for safety. Review of Resident 15's incident report, dated 05/07/2025, showed the resident fell next to their bed. The report showed the residents' roommate had used their own call light to alert the facility staff for assistance regarding Resident 15's fall. Prior to the fall the resident had a discussion with a facility staff member, (an unidentified registered nurse, RN) of the need to get out of bed to purchase a soda, the report showed the resident stated they were, going to anyway. The report showed the RN told the resident to wait until additional help arrived; however, the report did not indicate whether the RN waited with the resident until additional help arrived and they were reportedly found on the floor next to their bed a short while later. The report concluded Resident 15 had moderate cognitive impairment and their behavior led to poor judgment and was noted to be impulsive. During an interview on 6/10/2025 at 12:10 PM, Staff B, DNS, stated the licensed nurse should have waited with Resident 15 on 05/07/2025 until additional help arrived, especially after the resident had made the statement they were, going to do it anyway (get out of bed). Staff B stated Resident 15 was a two person assist with transfer and had impulsivity and poor judgement. Resident 14 Review of the EHR showed, Resident 14 was admitted to the facility on [DATE] with diagnoses to include dementia, COPD, hypotension (low blood pressure), and anemia (low blood cell count). Resident 14 was unable to make needs known. Review of the EHR showed Resident 14 had falls on the following dates 02/05/2025, 02/13/2025, 03/18/2025, 03/31/2025, 04/02/2025, 04/29/2025, 05/24/2025, and 05/26/2025. Review of the facility's incident investigation showed an investigation of fall on 05/24/2025. Review showed no new interventions were put in place. Review of the EHR showed Resident 14 had a repeat fall on 05/26/2025.

Based on observation, interview and record review, the facility failed to ensure residents consistently received restorative care (movement of joints to maintain range of motion) to maintain or prevent declines in mobility and services to improve mobility for 3 of 5 sampled residents (Residents 7, 10 & 85) reviewed for range of motion (ROM)/mobility. Resident 7 experienced harm when they had an avoidable decline in range of motion where their splints could not be applied without risking skin breakdown due to ankle contractures. Resident 10 experienced harm when they had an avoidable decline in bilateral ROM when passive ROM was not implemented. This failure placed the residents at increased risk of decreased motion, contractures, decreased mobility and a diminished quality of life. Findings included . Review of a document titled, Resident Mobility and Range of Motion, undated, showed Residents would not experience an avoidable reduction in range of motion (ROM). Residents with limited range of motion will receive treatment and services to increase and/or prevent further decrease in ROM. Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. Resident 7 Resident 7 admitted to the facility on [DATE] with diagnoses of right foot drop, left foot drop unspecified, abnormalities of gait and mobility. The admission minimum data set assessment (MDS), an assessment tool, dated 09/21/2022, showed Resident 7 required extensive assistance with activities of daily living. Review of Resident 7's form titled Physical Therapy PT Evaluation, dated 11/15/2022, showed current reason for referral as Patient recently referred to physical therapy after receiving B dynamic Ankle Foot Orthotics (AFOs) for ankle contractures and needing to establish a wearing schedule. The evaluation showed Resident 7 had right ankle active range of motion (AROM) Dorsiflexion (flexing up) = -50 (-70) and left ankle AROM Dorsiflexion = -50 (-64). Short Term Goals were documented as follows: 1. Patient will establish wearing schedule of B dynamic AFOs for up to 2-3 hours a day in order to prevent worsening of B ankle contractures with a target date 11/29/2022. 2. Patient will be able to improve right ankle ROM to -50 degrees in order to allow for improved mobility and ankle ROM target date 11/29/2022. 3. Patient will be able to improve left ankle ROM to -44 degrees in order to allow for improved mobility and ankle ROM target date 11/29/2022. Review of the form Physical Therapy PT Discharge Summary, signed 12/22/2022, showed Patient has demonstrated good progress in therapy. Patient has made small but steady improvements in ROM. Patient is now tolerating up to 2 hours a day of wearing dynamic AFOs. Documentation showed Resident 7's right ankle AROM improved to -60 and left ankle AROM improved to -54. The Discharge Recommendations and Status section showed, Discharge Recommendation= RNP (Restorative Nursing Program) and Prognosis to Maintain CLOF (current level of functioning) = Excellent with consistent staff support. Review of Resident 7's form titled Physical Therapy PT Evaluation, dated and signed 03/27/2024, showed current reason for referral as, Patient referred by nursing. The ROM section listed RLE (right lower extremity) ROM = Impaired (with chronic ankle contracture); LLE (left lower extremity) ROM = Impaired (with chronic ankle contracture). No new measurements were documented. The Assessment Summary showed, Patient is functioning at prior level which is SBA (standby assist) for transfers with the slide board. Patient does not need PT services at this time. Patient is however, concerned that nursing has not been donning (putting on) the Podus (brace for lower extremity disorders associated with trauma or immobility) on bilateral LE [lower extremities]. Patient's concern communicated to DOR (Director of Rehabilitation) and placed on communication board for nursing to address. Review of Resident 7's Care plan and Kardex on 08/22/2024, showed an intervention of Restorative Program Splint/brace assistance #1: See care plan/Kardex for program description. Review of the Resident 7's Restorative Program Splint/brace assistance flow sheets for July 2024 and August 2024, showed 27 days documented as Not Applicable. On 07/24/2024 and 07/26/2024 the EHR noted Resident 7 tolerated splint/brace assistance good for 15 minutes. Additionally, it was documented on 08/07/2024 that Resident 7 tolerated splint/brace assistance good for 10 minutes. Observation on 08/22/2024 at 9:44 AM, showed a pair of Ankle Foot Orthotics, Podus boots, under a table in Resident 7's room. During an interview on 08/22/2024 at 11:14 AM, Resident 7 stated they couldn't remember the last time they wore the Podus boots because nursing staff weren't putting them on. Resident 7 stated they believed they were losing feeling in their left foot and had told therapy staff in the past about the concern with nursing staff not applying them. Resident 7 stated they were not receiving any restorative services and had not done physical therapy since the beginning of the year. During an interview on 08/26/2024 at 9:02 AM, Staff Y, Certified Nursing Assistant (CNA), stated the Restorative Aides were the ones who did restorative with residents not CNA's. Staff Y stated if needed they could assist a resident with putting on brace or splint with the nurse's permission. During an interview on 08/26/2024 at 9:04 AM, Staff P, Licensed Practical Nurse (LPN), stated nurses are responsible for putting braces/splints on residents. Staff P stated they were unaware Resident 7 had AFO's. Staff P stated it was not on the resident's Treatment Administration Record. Review of Resident 7's form titled, Physical Therapy PT Evaluation, dated and signed 08/27/2024, showed, Assessment Summary as follows; Accurate measurements for planar ROM on bilateral ankles is not possible as reference points for measurements has shifted due to deformity. Patient donned the PRAFO [pressure relief ankle foot orthotics] on left foot to assess however due to club foot deformity said boots will only increase pressure on calf and toes which may cause skin integrity issues. During an interview on 08/26/2024 at 10:28 AM, Staff M, Physical Therapist, stated, the facility no longer did discharge recommendations to the RNP as they had been without a Restorative Aide since April 2024. Staff M stated Resident 7 had voiced concern about nursing staff not putting on the AFO's however Staff M was unaware if there was any follow-up. Staff M stated they were unable to obtain measurements of the resident's contractures and stated they could not determine if there was a decrease in ROM as it would require an x-ray. Review of a radiology report dated 08/28/2024 showed FINDINGS: The ossification was normal for the right and left foot, including the tarsal bones. There was mild degenerative joint disease seen. There was no fracture, dislocation, or soft tissue swelling. No osteomyelitis (bone inflammation) was seen. CONCLUSION: Mild degenerative joint disease. During an interview on 08/28/2024 at 9:20 AM, Staff B, Director of Nursing Services (DNS), stated although the restorative splint/brace assistance should have been discontinued when we no longer had restorative aides, there should have been an order for nursing staff to don the AFO's as directed. Staff B stated the expectation was that if a resident had a concern with lack of care, staff should have filed a grievance to ensue follow-up. Resident 10 Resident 10 readmitted to the facility on [DATE] with a diagnosis of paraplegia (the inability to voluntarily move the lower parts of the body/hips, legs, and feet) and was able to make needs known. Review of Resident 10's MDS, dated [DATE], showed that the resident had traumatic spinal cord dysfunction (damage to the spinal cord that blocks communication between the brain and the body), Hammer Toe(s) (a foot condition in which the toe has an abnormal bend in the middle joint) on both feet, contracture (shortening of muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become very stiff, preventing normal movement) on both feet, muscle weakness and depression. It showed that the resident had one day of occupational therapy on 09/15/2020 and physical therapy services that started on 09/15/2020 and ended 10/15/2020. Resident 10 was not on a restorative nursing program and was at risk for pressure ulcer injuries. Review of Resident 10's Occupational Therapy (OT) initial evaluation dated 09/15/2020 showed that the resident was referred to therapy to assess and update restorative nursing program (RNP) for maintenance of resident's strength and ROM. It showed that Resident 10 was dependent for functional mobility and lower body activities of daily living (ADLs) and required moderate assistance for upper body ADLs. It showed ROM for right upper extremity (limb of the body such as an arm) was impaired; left upper extremity was within functional limits; and right and left lower extremity were impaired (both knee contractures). It showed grip/strength [rating 0 to 5, with 0 = none and 5 = full strength] for right upper extremity was impaired (shoulder 3/5, wrist in moderate flexion [bent] contracture, poor grip strength); left upper extremity was impaired (shoulder, wrist, and elbow 4/5, poor grip strength); right/left lower extremity strength was impaired (paraplegia). Review of Resident 10's current care plan on 08/27/2024 showed no care plan for a restorative nursing program to maintain strength for the upper body parts and/or interventions to provide ROM to maintain available ROM to joints. During an interview on 08/22/2024 at 2:28 PM Resident 10 stated that they were paralyzed (incapable of movement) from the waist down and did not go to therapy or participate in a restorative nursing program. Resident 10 stated that staff would move their body parts upon request and had not been offered to be on a restorative program; however, they would like to be on a restorative program. Observation and interview on 08/28/2024 at 11:29 AM, showed Resident 10 lying in bed and had a right wrist contracture. Resident 10 stated they did not wear any braces or splints on their feet or right wrist/hand but, would be interested in participating in a restorative program to have their legs exercised. Resident 10 did not know if their mobility had maintained or declined. During an interview on 08/28/2024 at 8:08 AM Staff M, Physical Therapist, stated Resident 10 was last on physical therapy (PT) case load from 09/15/2020 - 10/15/2020. Staff M stated Resident 10's PT Discharge Summary dated 10/15/2020 showed measurements of ROM for Resident 10's lower body parts and Resident 10 was referred to a Restorative Nursing Program for a functional maintenance program (FMP). However, they were unable to locate any other subsequent measurements documented by therapy. Staff M stated that they were not sure if Resident 10 was on a restorative nursing program or not; however, the resident should have been receiving some type of passive range of motion (PROM, moving a joint for a person who is unable to move their own body part) to their right wrist and lower body parts, at least three times a week and/or as tolerated by the resident. Staff M stated that if Resident 10 had not been on a restorative program or receiving PROM, then the resident should be referred back to PT to see if there were any changes in their ROM/mobility. On 08/28/2024 at 9:20 AM, Staff B, Director of Nursing Services (DNS), stated when they had Restorative Aides, it was easier. Staff B said now Certified Nursing Assistant's (CNA) did range of motion, active and passive, and could apply braces/splints. Staff B stated they did not have orders for restorative services due to no Restorative Aides. Staff B stated they would discontinue orders for past restorative services due to staffing issues. Staff B the sprint/ brace assistance should have been discontinued. Staff B said the Podus boots should have been getting put on regardless of restorative staff availability and there should have been an order. During an interview on 08/28/2024 at 1:10 PM, Staff D, Resident Care Manager/Licensed Practical Nurse (RCM/LPN), stated that physical therapy would be responsible to assess, measure contractures and joints with limited ROM, and maintain the documentation. Staff D stated they believed the measurements should be conducted every 90 days. Staff D stated they could not explain why Resident 10 was not on a restorative nursing program but probably should have been receiving restorative services. Staff D stated that without subsequent ROM measurements there was no way to ensure that care plan interventions were effective to maintain ROM and prevent further decline in ROM/mobility and this did not meet expectations. During an interview on 08/24/2024 at 2:16 PM, Staff B, Director of Nursing Services (DNS) stated they were unable to locate documentation of additional ROM/contracture measurements for Resident 10 and there should have been subsequent measurements taken after therapy's 2020 measurements. Staff B stated Resident 10 was not receiving restorative services and that the facility had not had a functioning restorative nursing program since 05/01/2024. Staff B stated Resident 10's care plan needed more interventions to prevent ROM decline and they should have been on a restorative program, and this did not meet expectations. A request was made to obtain and provide Resident 10's current ROM/contracture measurements. Review of the measurements received on 08/30/2024 at 2:48 PM showed a decrease in the ROM from the measurements completed on 09/15/2020 compared to therapy evaluations completed on 08/28/2024 as follows: -Right knee flexion (bending) went from 120 degrees to -88 degrees. -Right ankle dorsiflexion went from -5 degrees to -7 degrees /plantar flexion (downward movement of the foot) went from 50 degrees to 39 degrees. -Left hip ROM abduction (leg move outward from center) and internal rotation (leg rotate inward) went from 110/70 to -30/5. -Left knee flexion went from 135 degrees to 84 degrees / extension went from -70 degrees to -60 degrees. -Left ankle dorsiflexion went from 120 degrees to 20 degrees / plantar flexion went from 30 degrees to 35 degrees. -Initial OT evaluation dated 09/15/2020 did not include hand/wrist measurements and the completed evaluations on 08/28/2024 did not include upper extremity strength to be able to compare and determine if there was a decline in ROM and strength for upper extremities. During an interview on 09/09/2024 at 9:15 AM Staff A, Administrator, was asked about two referrals to the Restorative Program, an OT eval on 09/15/2020 and a PT discharge summary on 10/15/2020. Staff A stated if Resident 10 was referred and staff were unable to locate documentation of follow through, then that did not meet his expectations. Staff A was asked about a lack of documentation for Resident 10's Restorative Nursing Program services and stated there should have been consistent follow up and documentation showing ROM measurements for contractures and mobility and that we were tracking the progression of Resident 10's contractures; this did not meet his expectations. Staff A said not following facility's policies and procedures for Resident Mobility and Range of Motion, did not meet expectations. When Staff A was asked if he thought the facility had followed the policy for Resident 10, Staff A said if there was no documentation that proved it was unavoidable then we didn't follow it. Staff A stated, I agree that we did not follow our policy. Staff A stated they were aware of not having a functioning Restorative Nursing Program since May 1st of 2024. Resident 85 Review showed Resident 85 admitted to the facility on [DATE] with diagnoses to include acquired absence of right leg above knee and muscle weakness. Resident 85 was able to make needs known. During an interview and observation on 08/22/2024 at 12:43 PM, Resident 85 stated they had a referral for a prosthetic leg and hand surgery from the hospital when they admitted to the facility. Observation showed that Resident 85 used a wheelchair, and one hand was contracted. Resident 85 stated he was unaware if the appointments had been made. Review of the EHR showed a document titled Hospital Document w/ H&P (pg 28).pdf, dated 05/13/2024, showed Resident 85 received a referral for a right prosthetic from their medical provider on 05/09/2024 Review of the EHR showed a document titled Ambulatory Referral to Hand Surgery, dated 05/16/2024, showed Resident 85 was referred to hand surgery for a Dupuytren contracture (a condition that causes the fingers to bend toward the palm of the hand). During an interview on 08/28/2024 at 1:38 PM, Staff N, Admission Nurse/Registered Nurse, stated hospital documentation was provided to the medical transporter to determine what referrals were needed after admitting to the facility. During an interview on 08/28/2024 at 1:57 PM, Staff D, RCM/LPN stated the admission nurse would review hospital documentation to determine what referrals were needed. Staff D stated Resident 85 had not had any follow-up on the referrals for hand surgery or a prosthesis. Staff D stated this did not meet the expectation. During an interview on 08/28/2024 at 2:31 PM, Staff B, DNS, stated the admission nurse should review the hospital documentation and inform the medical transporter what referrals were needed. Staff B stated Resident 85's lack of referral for hand surgery and prothesis did not meet expectation. 388-97-1060 (3)(d) 38344 40817

Based on observation, interview and record review, the facility failed to ensure the safety of four of four sample residents who smoked (Residents 8, 9, 10 and 11) by failing to assess residents' ability to safely smoke without supervision; and by allowing, and assisting, residents to convene in a known resident smoking area on the facility property, unsupervised by staff, while oxygen was in use by one resident (Resident 8). In addition, the facility's designated smoking area did not have safety items readily available, as outlined in the facility policy. These failures placed residents at risk of exposure to fire, burns, other serious injury, harm, impairment, or death. On 01/26/2023 at 4:56 PM, the facility was notified of an Immediate Jeopardy at Code of Federal Regulations (CFR) 483.25 (d)(1)(2), F689, for Free of Accident Hazards/Supervision/Devices related to the facility's failure to ensure the safety of residents who smoked and used oxygen (Resident 8) as well as the safety of other residents who smoked and were in close proximity to oxygen while smoking (Residents 9 and 10). The facility removed the immediacy on 01/31/2023 by implementing a removal plan that included removal of Resident 8's personal portable oxygen concentrator; reeducating the residents who smoked, and all staff, on the facility smoking policy and agreement of compliance with non-smoking facility rules, safe smoking practices (to include never smoking with oxygen present), and the dangers of smoking; and completing smoking evaluations on all residents who smoked. Findings included . In interview on 01/26/2023, at 11:45 AM, Staff A, Administrator, stated that they were a non-smoking facility, but that there were three or four residents that they had seen go out to smoke every day. Upon request, Staff A, Administrator, provided surveyor with a document titled, Residents Currently Smoking, which listed Residents 8, 9, 10 and 11. Review of the facility smoking policy, dated 08/09/2022, showed that smoking was allowed by residents in designated, marked smoking areas, with the following safety measures readily available: ash tray, portable fire extinguisher and fire-retardant blanket. The policy further stated that oxygen use was prohibited in smoking areas. Additionally, the policy stated that residents who smoked would be evaluated by a nurse quarterly, with any significant change in condition and as needed, and that the evaluation would be reviewed by the facility interdisciplinary team (IDT, a team of health care professionals who coordinate and manage each residents' comprehensive health care) for safety. Furthermore, the policy stated that if the facility were to become smoke-free, any residents living in the facility, prior to the effective date, would be allowed to continue to smoke in designated areas. RESIDENT 8 Review of the quarterly Minimum Data Set (MDS, a required assessment tool), dated 01/23/2023, showed that Resident 8 admitted on [DATE] with diagnoses to include physical weakness and chronic obstructive pulmonary disease (COPD, a condition involving constriction of the airways and difficulty breathing). Further review of the MDS showed that Resident 8 was alert and oriented to self, time and situation, was able to make needs known, and required the assistance of one staff for activities of daily living to include mobility throughout the facility. Review of physicians' order, dated 01/16/2023, showed that Resident 8 was to have oxygen administered continuously through a nasal cannula (tube, which is placed in the nostrils, from which oxygen flows). Review of the facility medical record showed no smoking evaluation had been completed for Resident 8. RESIDENT 9 Review of the quarterly MDS, dated [DATE], showed that Resident 9 admitted on [DATE] with diagnoses to include physical weakness, COPD, and Alzheimer's disease (the most common type of dementia, which causes progressive meal deterioration). Further review of the MDS showed that Resident 9 was alert and oriented to self, time and situation, was able to make needs known, and was independent with many activities of daily living to include mobility throughout the facility. Review of physicians' order, dated 09/02/2022, showed that Resident 9 was to have oxygen administered continuously through a nasal cannula. Review of the facility medical record showed no smoking evaluation had been completed for Resident 9. RESIDENT 10 Review of the quarterly MDS, dated [DATE], showed that Resident 10 admitted on [DATE] with a primary diagnosis of other neurological conditions. Further review of the MDS showed that Resident 10 was alert and oriented to self, time and situation, was able to make needs known, and was independent with many activities of daily living to include mobility throughout the facility. Review of the facility medical record showed no smoking evaluation had been completed for Resident 10. In addition, there was no care plan to address smoking/safety with smoking for Resident 10. RESIDENT 11 Review of the quarterly MDS, dated [DATE], showed that Resident 11 admitted on [DATE] with a primary diagnosis of medically complex conditions, and other diagnoses to include history of a stroke which resulted in limited ability to use on side of the body. Further review of the MDS showed that Resident 8 was alert and oriented to self, time and situation, was able to make needs known, and required the assistance of one staff for activities of daily living to include mobility throughout the facility. Review of the medical record showed the most recent smoking evaluation for Resident 11 was dated 01/21/2022. In addition, there was no care plan to address smoking/safety with smoking for Resident 11. Observation on 01/26/2023 at 2:23 PM showed Staff C, Nursing Assistant Certified (NAC), pushing Resident 8 in her wheelchair, down the hall. Resident 8 requested that Staff C, NAC take them out, to where they smoke, and Staff C, NAC, assisted Resident 8 outside to the paved walkway on the side of the facility. Staff C, NAC, left Resident 8 there, unsupervised with an oxygen concentrator hanging on the back of their wheelchair, until the surveyor intervened. Continued observation showed that Residents 9 and 10 were self-propelling in their wheelchairs toward the area where Resident 8 was left. In interview on 01/26/2023 at 2:30 PM, Staff C, NAC, stated that Resident 8 had stated that they wanted to go outside to get some fresh air. Staff C, NAC, stated that they were not aware if Resident 8 smoked, but that Resident 8 had asked to be brought to the known resident smoking area, and the other residents who were out there (Residents 9 and 10) were known smoking residents. In continued observation on 01/26/2023 at 2:32 PM, Residents 8, 9, and 10 were sitting near one another, in their wheelchairs, all smoking cigarettes. Resident 8 had a portable oxygen concentrator hanging from the back of their wheelchair. In interview on 01/26/2023 at 5:00 PM, Staff B, Director of Nursing Services (DNS), stated that they are a non-smoking facility, but that Residents 8, 9, 10 and 11 were observed going in and out of the facility, all day, to smoke. Staff B, DNS, further stated that the staff are not aware of how the smoking residents got their smoking materials or where they kept them, and that the facility did not complete smoking evaluations for residents who smoke because they are a non-smoking facility. In interview on 01/30/2023 at 12:25 PM, Resident 10 stated that they had been concerned, before, with another resident being in the designated smoking area with their oxygen present. Resident 10 stated, I don't want to blow up! Observation of the designated smoking area on 01/31/2023 at 1:45 PM showed a cigarette disposal receptacle, three signs posted around the area which stated, NO SMOKING, no fire extinguisher present, no fire-retardant blanket present, and no call light system or way to contact facility staff. In observation and interview on 01/31/2023 at 1:45 PM, Residents 9 and 10 were heading back to the facility entrance, from the smoking area, and when asked about their ability to call staff in an emergency, while in the smoking area, they both indicated they had personal cell phones, but if someone did not have a personal cell phone, then there would be no way to call staff. Reference WAC 388-97-1060 (g) .

Based on observation, interview, and record review, the facility failed to provide care and services to prevent the development of avoidable pressure injuries for Resident (1 &2). This failure resulted in harm when Resident 1 developed Stage III pressure injury and Resident 2 developed Stage IV pressure injury. The facility failed to provide preventative interventions consistent with the professional standards of care and did not act timely and self-correct skin system failure. Findings include . Review of the National Pressure Ulcer Advisory Panel, pressure ulcers that reach full thickness, that is stage III or IV, deep tissue injury or those that are unstageable are considered never events; that is they should never happen. On 06/22/2021 between 10:33 AM and 6:10 PM; 06/23/2021 between 8:20 AM and 12:30 PM, and on 06/30/2021 between 12:00 PM and 3:30 PM, interviews were conducted with licensed nurses and nursing assistants (NA). Eleven direct care staff on various units (P, I, W, T, R, U, S, T, E, Y, V) anonymously reported diminished capacity to meet residents' needs including repositioning and skin assessments due to heavy assignments, unsafe staffing levels, high acuity residents, chronic staffing problems, and burnout. Resident 1 Resident 1 was admitted to the facility on [DATE] with a broken pelvis (large bony structure near the base of the spine to which the legs are attached) and sacrum (lower backbone located between two hip bones). Other diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Admission MDS (Medical Data Set, a comprehensive assessment tool) dated 06/02/2021 showed Resident 1 had moderately impaired cognition, required extensive assistance with bed mobility, occasionally was incontinent of urine, and always incontinent of stool. The same assessment showed Resident 1 was at risk for developing pressure injuries. A 'SKIN CONDITION SHEET dated 05/26/2021 showed Resident 1 did not have any open areas to the coccyx at the time of admission. Incident report dated 06/08/2021 and a Nurse Practitioner note on 06/09/2021 showed Resident 1 developed stage III pressure injury to the sacrum (damage to deep layers under the skin containing fat cells, nerves, and vessels) two weeks after admission to the facility. During the interview on 06/18/2021 at 4:14 PM Staff C, RN, CN (Corporate Nurse) said she did not know how and why Resident 1 developed Stage III pressure injury. During an interview on 06/21/202 at 12:29 PM, Staff B, DNS (Director of Nursing) stated she did not know why Resident 1 developed Stage III pressure injury. Both Staff B, DNS and Staff C, RN, CP could not explain whether the developed Stage III Pressure Injury was clinically avoidable or unavoidable. A closed record review showed the Care Plan dated 05/26/2021 documented Resident 1 was at risk for skin breakdown related to fragile skin. The interventions on the care plan included providing preventative skincare i.e. lotions, barrier creams as ordered, and remind the resident to reposition every 2-3 hours. The care plan did not outline how the resident was to reposition herself in bed with a broken pelvic and sacrum. There was no assistive device initiated to help the resident effectively shift weight in the bed. The care plan did not include how staff should verify that the resident was physically and cognitively capable of repositioning herself. The care plan did not include individualized intervention to manage pain as a risk factor for ineffective pressure relief. A review of treatment administration records for May 2021 and June 2021 did not find orders or documentation to support that cream or lotion were applied as a preventative intervention. A nursing progress note dated 05/26/2021 at 5:04 PM described Resident 1 was observed in bed without bed rails. The resident was unable to move upper or lower extremities. The documentation read No Rails will be implemented. A review of nursing progress notes between 05/26/2021 and 06/08/2021 described Resident 1 experienced moderate to severe pain. Refer to F697 Resident 1 for additional information related to pain management. Further record review showed an electronic Skin Check assessment document dated 06/02/2021 and locked six days later on 06/08/2021 described open area to the sacrum measured 0.7cm x 0.6cm. The documentation showed there was moderate drainage to an old dressing. During an interview on 06/18/2021 at 4:14 PM Staff C, RN, CN said the weekly skin check on 06/02/2021 was missed and that is why the skin check was locked six days later. Staff C, RN, CN was asked about old dressing identified on the skin check locked on 06/08/2021. Staff C, RN, CN said she did not know how long the old dressing was there and who placed it on the resident. On 06/09/2021 a provider referred Resident 1 for an evaluation by a wound care provider. Record review showed Resident 1 did not receive wound evaluation. On 06/09/2021, or 14 days after admission the facility obtained an order for [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 06/18/2021 at 4:14 PM Staff C, RN, CN said she was not sure why the wheelchair cushion was not obtained at the time of admission. A review of the incident report and progress notes showed that on 06/08/2021 and 6/11/2021 Resident 1's family reported concerns about care including wound development and requested the facility to have orders to remind staff to help the resident with repositioning. On 06/24/2021 at 11:18 AM during a telephone interview Resident 1 recalled she was in a lot of pain while at the facility and that her mattress was hard. Resident 1's representative reported the family decided to remove the resident from the facility due to inadequate care related to skin management and pain. On 06/13/2021 while visiting the resident at the facility the family member felt the resident's mattress and found it to be hard and she asked a nurse on duty to replace the mattress. The mattress was replaced on 06/13/2021, a day before discharge. The family member stated she regretted not identifying the hard mattress sooner because maybe it would have prevented the pressure sore. Resident 1 was discharged from the facility on 06/14/2021 with home health. On 06/18/2021 at 3:48 PM review of facility evidence of investigation dated 06/08/2021 did not find facts exploring whether the developed pressure injury was clinically avoidable or unavoidable. On 06/22/2021 between 10:33 AM and 6:10 PM and on 06/23/2021 between 8:20 AM interviews were conducted with the Staff F, H, N & I (licensed nurses and nursing assistants) who were familiar with Resident 1. The staff anonymously reported that Resident 1 was confused, incontinent, spent a lot of time in bed, and needed to be repositioned. Staff members said they could not get to Resident 1 timely due to chronic staff shortages. Employees also described that frequently staff was put in a position where prioritizing involved cutting corners including not repositioning residents and not completing skin assessments thoroughly and/or timely. Refer to F610 for failure to investigate neglect indicators for Resident 1. Resident 2 Admission MDS assessment dated [DATE] showed Resident 2 had moderately impaired cognition and required one person assistance with bed mobility, dressing, and personal hygiene. According to hospital records, Resident 2 was admitted to the facility on [DATE] after hospitalization for a urinary tract infection. The resident was admitted with an indwelling urinary catheter (a medical device that drains urine from the bladder). Record review of the initial skin assessment on 04/07/2021 did not show any pressure injuries to the penis or the urethra (the tube that carries urine from the bladder). Observations on 06/23/2021 at 9:44 AM with Staff G, NA (Nursing Assistant) of Resident 2's penis and a urinary catheter revealed meatus erosion (severe damage to the urinary opening.) The full-thickness pressure-related erosion was through the head of the penis and down the shaft. Resident 2 was grimacing from pain and said it was sore. The damage to the urethra from a urinary catheter is considered a Never Event or a serious event because they are preventable and should never happen with proper anchoring of the urinary catheter. On 06/23/2021 at 10:05 AM, Staff B, Director of Nursing (DNS) was asked about penis erosion. Staff B, DNS stated she did not know about developed pressure injury and there was no investigation. Record review showed that on 04/23/2021 facility nurse removed the urinary catheter and reinserted another one on 04/25/2021 because Resident 2 was retaining urine. There was no documentation indicating the presence of tissue damage at the time. Record review showed on 04/26/2021, 19 days after the admission an order to complete foley catheter care was obtained. Record review showed on 06/07/2021, or two months after the admission facility obtained an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review showed on 06/06/2021 a treatment order was initiated for a sore to the left side of the penis and directed staff to clean it with soap and water. Record review did not find measurements or monitoring of the wound of the identified sore on the left side of the penis between 06/06/2021 and 06/23/2021. The facility did not identify and investigate the occurrence using comprehensive root cause analysis of what potentially went wrong, how and why, and implement changes to prevent reoccurrence. Refer to F610 for failure to investigate neglect indicators for Resident 2. Refer to F677 for failure to assist with re-positioning Resident 2. Reference WAC 399-97-1060(3)(b)

Based on observation, interview and record review the facility failed to ensure the resident environment was free of accident hazards, provide adequate supervision and evaluate assistive devices for safe use for four of five Residents (3, 9, 11, &12) reviewed for accident prevention. This failure resulted in harm to Resident 12 who sustained a fall requiring transportation to the Emergency Department and placed other residents at risk for harm. Findings include . Resident 12 Resident 12 was admitted to the facility on [DATE] after hospitalization for a stroke. The resident is no longer at the facility. The Activity of the Daily Living Care Plan initiated on 06/17/2021showed Resident 12 had right-sided weakness, paralysis affecting the right arm and leg. The care plan did not specify the number of people required to move the resident in bed. The facility's evidence of investigation provided on 07/02/2021 described Staff AA, NAC was changing Resident 12's brief when the resident fell from the bed on 06/23/2021 at 3:30 AM. The progress note described Resident 12 fell out of bed hit her head and her face and bled from the lips. Resident 12 was transferred to the hospital and was found to have a broken left elbow that required surgery. A review of Kardex (care directive) on 06/30/2021 at 11:35 AM with Staff B, Director of Nursing (DNS) showed the document was incomplete and did not specify how many persons were required to assist the resident during bed mobility. Staff B, DNS said the care directive should have said two-person assist. Resident 11 The Admission MDS assessment dated [DATE] showed Resident 11 admitted to the facility on [DATE]. Resident's diagnoses included [CONDITION(S)] and dementia. The resident had cognitive impairment and depended on staff for assistance with activities of daily living. Resident 11 discharged from the facility on 06/12/2021. During an interview on 06/29/2021 at 4:22 PM, a family member reported Resident 11 had repeat falls while at the facility and did not receive adequate supervision. A review of progress notes and incident reports showed Resident 11 fell on [DATE], 05/31/2021, and on 06/07/2021. On 05/28/3031 at 9:21 PM progress notes documented Resident 11 fell on the floor in the bathroom. Record review showed the Care Plan was not updated after the fall and a fall risk re-assessment was not found in the record. Progress notes dated 05/31/2021 at 11:23 PM and on 06/01/2021 at 2:54 AM documented Resident 11 fell in the room next to the bed on 05/31/2021 at the end of the evening shift. The resident had redness to the scalp and reported blurry vision. The resident was sent to the emergency room for evaluation and returned to the facility on [DATE]. Record review showed the Care Plan was not updated after the fall on 05/31/2021 and a fall risk re-assessment was not found in the record. Progress notes on 06/07/2021 at 7:45 PM documented Resident 11 stood up to use a urinal and fell . The resident was found laying on the floor next to the bed with his head on the feet of the table. Record review showed the Care Plan was not updated after the fall on 06/07/2021 and a fall risk re-assessment was not found in the record. On 06/30/2021 at 1:23 PM Staff B, DNS was asked about Resident 11's falls and lack of fall risk reevaluations after each fall and lack of care plan revision. Staff B, DNS recalled that Resident 11 had changes in blood pressure which could have contributed to the falls. Staff B, DNS said she will review records and provide supporting documentation if available. No additional information was provided as of 07/02/2021. Failure to reassess fall risk after each fall and update the care plan resulted in avoidable accidents for Resident 11. Resident 3 According to the Admission MDS (Minimum Data Set, an assessment tool) dated 04/12/2021, Resident 3 was admitted to the facility on [DATE] with diagnoses to include lung cancer. The resident required one-person assistance with bed mobility. During an interview on 06/23/2021 at 11:17, AM Resident 3 said she had been waiting for a softer mattress because she had pain in the lower back. On 06/23/2021 during observations sometime after 12:30 PM Resident 3 received a Low Airloss Mattress (a specialized or therapeutic air-filled mattress.) A progress note dated 06/24/2021 at 3:30 AM documented Resident 3 was found on the floor next to the bed. The resident was noted to have a skin tear to the right arm. During observation and interview on 06/30/3031 at 2:10 PM Resident 3 was on her back on a Low Airloss Mattress. Resident 3 said she fell out of bed because she was trying to reach the call light. During an interview on 6/30/2021 at 11:35 AM Staff B, DNS said the low air loss mattress assessment was not done but she would ensure that it was completed today. Record review showed the Low Airloss Mattress device assessment was completed on 06/30/2021, six days after the fall. Resident 9 Resident 9 was admitted to the facility on [DATE] following hospitalization for shortness of breath. The hospital discharge records dated 06/17/2021 showed Resident 9 was coughing when eating and needed 1:1 assistance with feeding. During observations on 06/22/2021 at 5:50 PM, Resident 9 sat on the edge of the bed with a metal tray on the bedside table. The meal tray included pureed foods. On the same table, there was a pitcher of water or thin liquid and 1/4 clear glass filled with water. The meal ticket on the tray showed Resident 9 was on a pureed diet and nectar thick liquids. On 06/22/2021 at 5:54 PM, Staff J, NA (Nursing Assistant) was asked if it was safe for Resident 9 to have thin liquids when the diet slip specified nectar thick. Staff J, NA stated that the resident only received thickened liquids during meals and he needed water between meals. Staff J, NAC was asked to verify if Resident 9 could have regular water or thin liquids and staff member stated yes. On 06/22/2021 at 6:18 PM Staff O, Licensed Practical Nurse (LPN) reviewed electronic records and stated Resident 9 was ordered to have nectar thick liquids due to aspiration risk and should not have thin liquids. Record review on 06/22/2021 showed the Kardex (care guide) inaccurately directed staff to Encourage resident to consume all fluids of choice during meals The Kardex did not specify Resident's diet, liquid consistency, and a safety alert for choking risk and required supervision. The lack of clarity on the Kardex or care directive was a potential accident hazard. On 06/30/2021 at 11:35 AM Staff B, DNS said the care directives should be accurate and completed at the time of admission. WAC 388-97- 1060(3)(g)

Based on observation, interview and record review, the facility failed to ensure all measures to reduce the risk of falls were implemented, to include adequate supervision and re-evaluate for effectiveness for two of 14 residents (Resident #38, #56) reviewed for accidents and incidents. Failure to identify all risk factors, develop an action plan to mitigate the risk of known avoidable hazards, revise the plan of care, adequately assess/monitor resident responses to planned interventions to mitigate all risks, resulted in a fall with significant injury for Resident #56, and at risk for subsequent falls with injury. Findings included . RESIDENT #56 Refer to F610 for additional information. Record review of the Quarterly Minimum Data Set (MDS), a required assessment tool, dated 08/21/17, showed Resident #56 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident exhibited short-term memory loss, periods of confusion, vision impairment, and no mood or behavioral issues. She required two person assist for transfers, bed mobility, dressing, and assistance of one staff for ambulation. Record review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. In an observation on 12/04/17 at 10:10 AM, Resident #56's room was located halfway down D Hall. The privacy curtain was drawn, blocking her bed located by the window, and unable to determine if the resident was inside. When knocking on the door and using the resident's name, a voice granted permission to enter the room. Upon arrival, Resident #56 was in bed, and wore a hat that covered her eyes. She lifted the hat, showing a bruise on the right side of her forehead. Resident #56 declined an interview because she was not feeling well and was in a funk. In an observation on 12/04/17 at 1:08 PM, Resident #56 sat at a table in the dining room and visited with a family member. The resident presented with a worried affect, asked the family member why she was in the facility, that nothing was wrong with her, wanted to leave, and was wondering why it was taking so long. The resident exhibited word finding difficulty, spoke in sentences that did not always make sense, and occasionally used hand gestures to compensate for word finding difficulty. The resident stated she was worried about losing something and if she lost something, she would lose everything and did not know what would happen. The resident had confusion, short-term memory loss and difficulty making needs and wants known. The family member explained Resident #56 had a stroke a few months ago, did not recover as expected, and was reviewing discharge options. Observation on 12/06/17 at 10:42 AM, Resident #56 propelled her wheelchair using her feet and hands, and headed to her room. Observation at 12/06/17 at 10:54 AM, the curtain was drawn, and Resident #56's bed was not visible from the hallway. In an observation at 12/08/17 at 11:32 AM, moaning and other verbalizations indicating pain was heard from the hallway, near Resident #56's room. Upon arrival, Resident #56 was in bed holding Staff F, Licensed Practical Nurse (LPN)'s hand while in bed, and was surrounded by an ambulance crew who instructed the resident not to move. Moments later, Resident #56 was carried out on a stretcher. In interview on 12/08/17 at 12:15 PM, Staff H, LPN, stated Resident #56 was sent to the Emergency Department due to a possible arm fracture after she fell in her room. Record review of Resident #56's care plan dated 10/11/17, showed the resident was anticipated as a short-term stay for rehab, was at risk for falls related to cognitive loss, lack of safety awareness impaired mobility and [MEDICAL CONDITION]. The goal was for the resident to have no falls with injury. Fall interventions included reminding the resident to use the call light for assistance, monitor and assist toileting needs, required assistance for transfers and toileting, encourage the resident to participate in all activities, medication evaluation as needed, Physical Therapy (PT) treatment as ordered, provide verbal cues for safety and sequencing, proper pacing, and energy conservation techniques when needed, self-releasing seat-belt to transport w/c for positioning safety, maintain clutter free environment and bilateral transfers bars to bed to promote bed mobility. Review of the (MONTH) (YEAR) through (MONTH) (YEAR) Incident and Accident Log showed Resident #56 sustained five falls, all resulted in injuries or patient reported pain, that occurred on 06/07/17, 09/01/17, 10/06/17, 11/27/17 and 12/02/17. 06/07/17 Fall Record review of the incident report dated 06/07/17 showed Resident #56 sustained a fall in her room at 4:50 PM. The fall resulted in a [MEDICAL CONDITION]. The incident report identified a nurse practitioner (ARNP) as a witness, where she observed Resident #56 from the hall, ambulate to the bathroom without her walker, and without staff assistance. Prior to the fall, interventions included bilateral transfer bars to promote bed mobility. Resident #56 required supervision to assistance of one person with toileting. Staff was not present at the time of the fall. Record review of the document titled, Fall Risk Evaluation, dated 06/7/17, Resident #56 scored a 19, which indicated a high risk for a falls. Interventions put in place after the fall included visual cue to use the call light and wait for help prior to getting up. Staff were to offer and assist with hourly toileting to decrease the risk of falls, and maintain supervision with a walker for ambulation. It was unclear if the care plan was followed, or previous interventions were effective to ensure safety with all identified risk factors. The investigation showed the call light was not on, and why staff did not assist Resident #56 to the restroom at the time of the fall. It was identified the resident had short-term memory loss, impaired mobility, poor safety awareness and a history of falls. Resident #56 resided in a room halfway down the rehab hall, in the bed by the window, in a low-supervised area. The resident was hospitalized and obtained surgical repair of the fracture, and readmitted to a room on the long-term care hall, halfway down the hall, in a bed by the window. 08/27/17 Fall Record review of the incident report showed Resident #56 reported the incident when staff discovered the injury on 09/01/17. According to the resident, the fall occurred on an outing with a family member on 08/27/17. The family member was pushed the resident in the wheelchair, the chair hit a bump in the walkway and the resident fell out of the chair. The family did not report the fall when returning Resident #56 to the facility after the outing. The skin tear and bruise were not observed until 09/01/17, four days later. It was unclear if staff observed or reported the bruise or skin tear after returning from the outing with the family. It was unclear if training or education was provided to the family, or if the family was familiar with maneuvering a wheelchair and what precautions were communicated, prior to taking Resident #56 out in the community, to ensure the resident's safety. 10/06/17 Fall Record review of the incident report of the unwitnessed fall that was sustained on 10/06/17, showed a housekeeper found Resident #56 on the floor in front of the bedside commode in her room, at 8:15 AM. The call light was not on. Resident #56 was last observed at 7:30 AM, 45 minutes earlier, in bed with her eyes closed. The resident exhibited right sided weakness, slurred and incoherent speech. Resident #56 was sent to the emergency department for evaluation and treatment, and diagnosed with [REDACTED]. The root cause of the investigation concluded the fall was precipitated by the stroke. Record review of the document titled Fall Risk Evaluation, dated 10/09/17, showed Resident #56 scored an 18, indicating high risk for falls. The resident has had a history of [REDACTED]. When Resident #56 returned from the hospital, she was readmitted to the same room, halfway down D hall, in the bed by the window. Record review of the Admission MDS dated [DATE], showed Resident #56 was readmitted on [DATE], with a new [DIAGNOSES REDACTED].#56's short-term memory and mood worsened since last assessment, experienced periods of decreased attention and level of consciousness, range of motion decreased on both upper and lower extremity on the right side of the body, and did not ambulate during the assessment period, as previously demonstrated. No new interventions were added to the care plan to address Resident #56's ongoing high fall risk and ensure the resident's safety. The care plan was not updated with the new [DIAGNOSES REDACTED]. 11/27/17 Fall Record review of the incident report of the 11/27/17 fall, showed the roommate alerted staff at 7:00 PM that Resident #56 had fallen. Upon arrival, the licensed nurse saw the resident sitting on the floor next to her bed and commode. The commode had fecal matter inside the bucket. Resident #56 complained of pain to the right ribs. The area was pink and tender to the touch. It was unclear if staff followed the resident's care plan, as she got herself up out of bed without getting assistance, used the commode, attempted to transfer back to bed, and fell without staff supervision during that uncertain period of time. Staff did not hear the resident fall or if she called for help. Record review of the fall risk evaluation, showed Resident #56 scored a 23, which indicated a significantly high fall risk. The corrective action was to offer and assist with toileting every hour while awake and staff will provide visual checks every 1 hour while resident is in bed to ensure resident is properly positioned in the center of the bed and to decrease the risk of injury R/T fall or potential fall. Staffing and level of supervision was not considered or reviewed, to ensure Resident #56's safety with known fall risks. The care plan did not provide alternate interventions for staff for when Resident #56 refused to toilet at the time offered. The resident had a history of [REDACTED]. An assessment was not conducted to determine if it was related to cognition, attention or bowel and bladder routine or changes. 12/02/17 Fall Record review of the incident report of the fall that occurred on 12/02/17, showed Resident #56 was heard calling for help at 3:00 PM. Upon arrival, the nursing assistant and licensed nurse found the resident on the floor by her bed, laying on her right side. Resident #56 stated she attempted to ambulate to the bathroom and fell . The call light was in reach, and not on. A bruise later developed on the right side of the forehead. According to the incident report, Resident #56 was last seen at 2:30 PM. The resident was offered to use the bathroom, declined, and was put to bed. It was unclear the last time the resident voided. Interventions initiated after the fall, included to offer the resident afternoon activity of interest to decrease risk of falls. Interventions did not include what staff were directed to do, if the resident declined to participate in an activity, to continue to ensure resident safety when in her room. No new interventions were initiated for when the resident refused toileting. 12/08/17 Fall Record review of the incident report showed Resident #56 sustained an unwitnessed fall on 12/08/17 at 10:15 AM, in room at the bedside. A nursing assistant (NA) heard the resident calling out for help and found her laying on her stomach, with her right arm twisted to her back. Resident #56 stated she was trying to ambulate to the bathroom by herself. The incident report showed the assigned NA offered the resident assistance to the bathroom after she ate, she declined, and laid her down at 10:00 AM. It was unclear the last time the resident used the restroom. Resident #56 complained of severe pain in her right shoulder, demonstrated decreased mobility, and pain when touched. The resident was sent to the hospital for evaluation and treatment. Resident #56 was diagnosed with [REDACTED]. Recent changes were identified in the resident's condition, to include mobility, change in her cognitive and behavioral status since her stroke on 10/06/17. Two blood pressure medications were administered less than eight hours prior to the fall. The nurse practitioner recommended a psychiatric evaluation on 12/07/17 due to the behavioral and mental status changes the resident had incurred since the stroke The facility determined the root cause of the fall was related to Resident #56's desire to be independent with care, attempted to get up to the bathroom and fell due to poor balance and weakness. New interventions included a referral to occupational therapy (OT), physical therapy (PT), and speech therapy (ST). In addition, the resident was required to wear an immobilizer sling, room move performed to be closer to the nurses' station, bed against wall, and mat on the right side of the bed on the floor. In an observation on 12/13/17 at 8:46 AM, Resident #56 was sitting in her wheelchair at a table the in the dining room. The resident was not wearing her sling, and was holding her left arm and shoulder with her other arm. She moved her left arm up, and cried out in pain. The breakfast in front of her was untouched. The unidentified staff picked up a bite of her breakfast on the fork, and presented it to Resident #56 to eat. In an observation on 12/14/17 at 12:00 PM, Resident #56 was lying in a bed in a different room, located across from the nurses' station. The resident's eyes were closed and appeared to be sleeping. The medication cart was parked to the right of the door. Resident #56 was visible from the hallway and as staff walked by. Interview on 12/13/17 at 12:10 PM, Staff H, LPN stated Resident #56 had a recent fall. She was moved closer to the nursing station because of it. Staff H, LPN stated the resident had been seen in the past attempting to transfer herself without assistance, on several occasions, but not since she fractured her arm. Resident #56 was not tolerating the pain very well, and various medications had been tried. In interview on 12/14/17 at 1:04 PM, Staff J, Social Services (SS), stated the department discussed falls in the morning and a weekly meeting. Resident #56 was known as not being able to sit still. Staff J, SS stated she was not aware of any mood or behavioral issues, but was aware Resident #56 would get into a funk, which meant she didn't want to be bothered. The resident was forgetful, made basic needs known, and staff anticipated the rest of her needs. She was max assistance now, since the fall with the arm fracture. In an interview on 12/14/17 at 3:08 PM Staff N, RN/Investigations Nurse (IN), stated investigations are initiated by the floor nurse. The floor nurse gathers all the pertinent information and puts interventions in place immediately to keep the resident safe. When determining if interventions were effective, the resident was put on alert charting, and care plans were updated. The period of time the resident was on alert charting and utilizing the intervention, usually was sufficient time to determine whether the intervention was effective. In further interview, Staff N, RN/IN, stated she would have expected the 06/07/17 fall investigation to include if there was a history of Resident #56 ambulating without her walker, the last time she used the restroom, if there was a change in frequency or voiding pattern, and the last time the resident was observed by staff. Staff N, RN/IN stated she was not aware and did not include in the 09/01/17 fall investigation what education or training Resident #56's family actually had prior to taking the resident out with them. When asked about Resident #56's room and her bed being by the window, curtain drawn and visibility of the resident was considered, Staff RN/IN stated she believed the resident was sensitive to light, which was a change since she had a stroke The expectations of staff were to conduct frequent checks, but was not certain how they could actually do that since they could not see her behind the curtain from the hallway. When asked if the level of supervision was reviewed for sufficiency for the resident, Staff N, RN/IN stated that was why they initiated encouraging Resident #56 to participate in activities as often as possible. The resident refused to participate in activities at times, which made the intervention ineffective and inappropriate to prevent falls, when the resident remained in her room. In interview on 12/15/17 at 4:45 PM, Staff B, DNS, stated there were no rooms available at the nursing station at the times of previous falls, as the rooms were already filled with high fall risk residents. No additional interventions were considered at those times. Staff B, DNS, was unable to locate documentation that a room move or other means of increased supervision was considered. The facility did not address all risk factors and initiate appropriate interventions, to include level of supervision, for Resident #56's short term memory loss, poor safety awareness, ability to change her mind, balance issues, weakness, and to ensure Resident #56's safety, minimize her fall risks and maintain her goal of having no falls with injury. RESIDENT #38 Refer to F610 for additional information Review of the Annual MDS dated [DATE], showed Resident #38 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident had short-term memory loss, and impaired mobility that required extensive assistance for balance, bed mobility, toileting and transfers. Review of the (MONTH) (YEAR) MAR indicated [REDACTED] Review of the care plan dated 09/09/17, Resident #38 had impaired decision making skills, impaired hearing and vision, and was at risk for falls due to stroke and muscle weakness. The goal was for Resident #38 not to have falls with injuries for 90 days. Fall interventions included to encourage and provide a visual cue to use the call light and ask for help, grip strips to grab bars in bathroom, assist the resident to get in and out of bed, verbal cues and sequencing when needed, resident/caregiver education for safe techniques, monitor and assist for toileting needs, maintain a clutter free environment and encourage activity participation. In an observation on 12/05/17 at 10:18 AM, Resident #38's room was located near the nursing station. The resident was in her room in her wheelchair by the window. Resident was hard of hearing, as evidenced by the resident stating she had difficulty hearing and required repeating the question with a louder voice and speak in her left ear. Resident #38 declined an interview because she said she was feeling ill. A bluish-green bruise was seen under and above the left eye. In an observation on 12/06/17 at 8:06 AM, Resident #38 sat next to her heater, leaned over to pick up an unidentified item off the floor with her hand. A reacher was laying on the top left side of the heater, out of arm's length. In an observation on 12/08/17 at 8:11 AM, Resident #38's bathroom door was open, blocking the view of a portion of the room. A breakfast tray was on the bedside table by the window, the television was on, and the bed was unmade. A shadow moved in the space between the bathroom door and doorframe. The light in the bathroom was off. A toilet flushed, and movement was seen between the crack in the doorframe and the door. At 8:14 AM, the toilet flushed again, and Resident #38 backed her wheelchair out of the bathroom using her feet and right arm to propel the wheelchair, and headed to the sink. Resident #38 washed her hands. The call light was not activated, and staff were not around. Various times throughout the observation, staff walked by the room and headed down the hall, but did not look in the room. Other staff were standing at the medication cart, or sitting at the nurses' station reading or typing on the computer. The nurses' station was around the corner and not in a direct line of sight. In an interview on 12/08/17 at 8:15 AM, Resident #56 stated she did use the bathroom because she had to go. She stated she told staff but they did not come. Review of the (MONTH) (YEAR) through (MONTH) (YEAR) Incident and Accident Log showed Resident #38 sustained three unwitnessed falls on 08/27/17, 10/24/17, and 11/23/17. 08/27/17 Fall Review of the incident report for the 08/27/17 fall, showed Resident #38 sustained an unwitnessed fall at 8:30 AM, which resulted right hip pain and a possible sacral fracture. According to the investigation, the resident used the bathroom independently, and the call light was not on and did not ask for assistance. Resident #38 had a history of [REDACTED]. It was unclear if the resident's hands were wet, causing them to slip. Resident #38's toileting care plan directed staff to toilet her before and after meals, at bedtime, per resident request and every two hours. The resident was last toileted at 7:00 AM, before breakfast. It was unclear if the resident had received breakfast and if she had if she was offered toileting after she completed breakfast. The incident report further stated, when asked Resident #38 why she did not put on the call light for assistance, the resident stated, I probably should have. Grip strips were added to the grab bar in the bathroom. The level of supervision was not considered as this was not Resident #38's first fall, and the resident was toileting herself without staff assistance. The incident report determined no failed practice as Resident #38 denied caregiver harm, did not want any further interventions, and remain independent to move about at will, and participate in activities as desired. It was unclear if staff anticipated the resident's needs or level of supervision was appropriate. 10/24/17 Fall Review of the incident report for the fall on 10/24/17, showed Resident #38 sustained and unwitnessed fall at 11:30 AM when she attempted to reach something from her table, that resulted in falling forward. No injuries were sustained. The interventions immediately added after the fall included giving the resident a reacher to use when picking up items. The reacher was instructed to be kept in close proximity, so the resident could use it at will. It was unclear if the care plan to keep other necessary personal items within reach was followed, as the specific personal items were not care planned, listed or described. It was unclear if staff anticipated the resident's needs or level of supervision was appropriate. 11/23/17 Fall Review of the incident report for the 11/23/17 fall, showed the unwitnessed fall occurred in Resident #38's room at 7:45 PM. The resident stated she was trying to reach something from the top of the bed before she fell . Resident #38 sustained an 8cm by 4cm bump with bruising to her left forehead, and pain to the affected area. Staff last visualized the resident in her room in the wheelchair at 7:30 PM. Resident #38 was interviewed and stated she fell out of her chair when trying to reach something from the top of the bed. The call light was in reach and was not activated. It was not clear what item the resident was trying to reach, or what commonly and frequently used items were in reach, to include the reacher, as it was not identified in the previous fall. The facility did not identify any failed practice, as Resident #38 desired to complete tasks independently, despite needing supervision and assistance. The intervention immediately put in place after the fall was for staff to provide visual checks every hour while the resident was in her wheelchair unattended in room, and educate/encourage the resident to use her grabber bar to pick up items. A therapy referral was made for a new wheelchair. Level of supervision was not considered to ensure Resident #38's safety, as she continued to complete tasks independently. Review of documents titled, Fall Risk Assessment, dated 08/28/17 and 11/24/17, showed Resident #38 scored a 13 and 14, which indicated a high fall risk, as evidenced by high risk medications prescribed, change in medication regime, impaired mobility, strength, and impaired judgement/insight. In an interview on 12/12/17 at 8:31 AM, Resident #38 stated she did not sleep well the night before because her head and legs hurt. The resident said she fell and hit her head, and her head and hip (pointed at left hip) had not been the same since. Resident #38 stated, I fell in the bathroom. I do not know what happened to make me fall. I was in there alone, tried to transfer myself, and I fell . I called out and screamed for help. I must have been a sight as I had blood all over my face. They thought I poked my eyes out because they shined a light in my eyes. I am supposed to have someone with me when I transfer to the toilet. I can go in there myself. I think I can do it, but they want to be with me just in case. The resident stated she enjoyed sitting next to the heater because she was always cold. She did everything to keep warm but crawl up inside the heater. Resident #38 pointed at her feet and non-skid socks, which showed the right sock was not on foot all the way. The resident stated she had wraps around her ankles and because they are swollen, which was why the sock only covered her toes. The wheelchair had no footrests. When asked where they were, the resident said she used to have them, but they took them off when I fell in my wheelchair. When I need to put my feet up, I go into bed, but then I have to wait until I get someone to do it. In an interview on 12/13/17 at 12:10 PM, Staff H, LPN, stated she checked on Resident #38 more than every four hours for pain. The resident kept to herself in the room by the heater. She required assistance in the bathroom for transfers, on and off the toilet. Staff H was not aware of any attempts to transfer herself since her last fall. In an interview on 12/14/17 at 10:30 AM, Staff K, RN, stated Resident #38 fell because of the foot rests on her wheelchair. It was determined the resident fell forward and over the foot rests when she fell . The resident was to refrain from using the footrests until her new wheelchair arrived, which has been approximately five weeks. Staff K, RN, further stated Resident #38 preferred to perform tasks independently, asked for assistance when she needed it, and was not aware of attempts to self-transfer to the bathroom since her fall on 11/23/17. In an interview on 12/14/17 at 1:30 PM, Staff J, SS, stated Resident #38 had some memory loss, was very hard of hearing, did not like to wear her hearing aids, was a private and independent person. She likes to do things on her own. She has not too many falls. Staff J, SS, stated the last fall was caused by reaching something. In an interview on 12/14/17 at 3:08 PM, Staff N, RN/NI, stated when reviewing the incident reports, she expected to see all potential causative factors identified. When reviewing the fall on 08/27/17, Staff N, RN/NI stated one factor she wanted to know was what might have been on the resident's hands that caused them to be slippery and if staff had offered assistance. In continued interview, when asked about the risk factors in the fall that occurred on10/24/17, Staff N, RN/NI stated if the resident was reaching for something, it was the expectation to identify the item what the resident was reaching for, like a call light. The resident should have been asked. When asked to define close proximity as stated the reacher was supposed to be as stated in the care plan, Staff N stated within an arm's length reach. Resident #38 had reacher and was supposed to keep it in close proximity at all times. Staff N stated she did not know why she didn't use it. WAC reference: 388-97-1060 (3)(g)