Every finding on record at Park Rose Care Center

Based on interview and record review, the facility failed to accurately complete the comprehensive assessment for 2 of 21 sampled residents (Residents 4 and 5) reviewed for accuracy of the comprehensive assessment. Failure to accurate code Resident 4's mental health status and Resident 5's pressure ulcer status placed residents at risk of unidentified care needs, inadequate plan of care, and a diminished quality of life. Findings included.Resident 4 Review of the electronic health record (EHR) showed Resident 4 admitted to the facility on [DATE] with diagnoses to include chronic kidney disease, anxiety disorder, depressive disorder, and schizoaffective disorder (a chronic mental health condition characterized by a combination of psychotic symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania). Resident 4 was able to make needs known. Review of documents showed Resident 4 received a Pre-admission and Resident Review level 2 (PASSAR, a mental health evaluation) on 08/24/2024. Review of the annual minimum data set assessment (MDS), dated [DATE], showed Resident 4 was not currently considered by the state level 2 PASSAR process to have a serious mental illness. During an interview on 07/30/2026 at 11:22 AM, Staff D, Licensed Practical Nurse/Minimum Data Set Coordinator (LPN/MDSC), stated Resident 4 had a serious mental illness, received a level 2 PASSAR evaluation, and the 04/20/2026 annual MDS was inaccurate. During an interview on 07/30/2026 at 11:28 AM, Staff B, Director of Nursing Services (DNS), stated Resident 4 had received a level 2 PASSAR evaluation and the 04/20/2026 annual MDS was inaccurate. Resident 5 Review of the EHR showed that Resident 5 readmitted to the facility on [DATE] with diagnoses to include respiratory failure, persistent vegetative status (a severe neurological condition where a person with extensive brain damage appears awake but has no awareness of themselves or their environment), and high blood pressure. Resident 5 was not able to communicate needs. Review of Resident 5's wound evaluation dated 05/29/2026 showed the resident had a Stage 4 pressure ulcer (PU)/injury (a wound caused by pressure featuring deep tissue loss, exposed muscle or bone, and high risk of infection). Review of Resident 5's quarterly MDS, dated [DATE], showed Resident 5 was coded 0 (did not have a PU) for a stage 4 PU. During an interview on 08/03/2026 at 12:18 PM, Staff D, LPN/MDSC, stated Resident 5's 06/04/2026 quarterly MDS was not coded correctly based on their wound evaluation dated 05/29/2026 which showed Resident 5 had a stage 4 PU. Staff D stated Resident 5 needed their 06/04/2026 MDS modified. During an interview on 08/03/2026 at 12:27 PM, Staff B, DNS, stated they were not aware Resident 5's quarterly MDS dated [DATE] was not coded for a stage 4 PU and the MDS needed to be modified to show stage 4 PU status. Reference WAC 388-97-1000(1)(a)(b)(4)(a)

Based on observation, interview, and record review, the facility failed to ensure residents care plans were revised and accurately reflected the resident's status and care needs for 2 out of 21 sampled residents (Residents 4 and 5) reviewed for care planning and revision of care plans. Failure to accurately address Resident 4's impaired visual needs related to glasses, and Resident 5's actual skin alterations, placed the residents at risk for unmet care needs, medical complications, inaccurate care plan documentation, and a diminished quality of life. Findings included.Resident 4Review of the electronic health record (EHR) showed that Resident 4 readmitted to the facility on [DATE] with diagnoses to include diabetes (high blood sugar), chronic obstructive pulmonary disease (a progressive lung condition that makes breathing difficult), and depression (mood disorder). Resident 4 was usually able to make needs known. During an interview and observation on 07/29/2026 at 10:43 AM, Resident 4 stated they had glasses, but they broke a while ago and now they did not have glasses. Resident 4 stated they had told staff about it, but they still did not have any glasses. Glasses were not visible in Resident 4's room. Review of the quarterly minimum data set assessment (MDS) dated [DATE] showed Resident 4 had adequate vision with corrective lenses. Review of the focused care plan for impaired visual function, initiated on 10/20/2023, showed Resident 4 was fitted for new glasses on 12/08/2025 and would be arriving in two weeks. It showed Ensure glasses are available to support resident's participation in ADL's [activities of daily living] and other activities. New glasses received 10/19/23. It showed an intervention initiated on 10/20/2023 to Remind resident to wear glasses when up. This care plan did not show an alternative device to assist with vision. During an interview and joint observation on 07/31/2026 at 12:28 PM, Staff G, Certified Nursing Assistant (CNA), stated they were not sure if Resident 4 wore glasses. Staff G looked for glasses in Resident 4's room after obtaining permission; however, they were unable to locate glasses. During an interview on 07/31/2026 at 12:38 PM, Staff H, Registered Nurse (RN), stated Resident 4 used to wear glasses about a year ago. Staff H stated Resident 4's glasses broke and they were fitted for new glasses; however, they had not seen Resident 4 with glasses on. Staff H stated Resident 4's care plan showed to remind the resident to wear glasses when up, but they wondered if the glasses that were supposed to come in two weeks ever came. During an interview on 07/31/2026 at 1:04 PM, Staff J, Licensed Practical Nurse/Resident Care Manager (LPN/RCM), stated Resident 4's EHR documentation did not clearly indicate if glasses were delivered and because of that they were not following Resident 4's care plan. Staff J stated if Resident 4 did not have glasses the care plan needed to be revised. During an interview on 07/31/2026 at 1:48 PM, Staff B, Director of Nursing Services (DNS) stated Resident 4's care still showed Resident 4 had glasses and the care plan should have been updated/revised when Resident 4 did not have access to their glasses. Resident 5Review of the EHR showed that Resident 5 readmitted to the facility on [DATE] with diagnoses to include respiratory failure, persistent vegetative status (a severe neurological condition where a person with extensive brain damage appears awake but has no awareness of themselves or their environment), and high blood pressure. Resident 5 was not able to communicate needs. Review of Resident 5's EHR showed they were being treated for various skin alterations; however, the focused care plan for potential alteration in skin integrity that included Actual Skin Alterations, initiated on 03/27/2026, did not include all pressure wounds and showed skin issues that had resolved. Resident 5's skin integrity care plan did not reflect Resident 5's current skin integrity status. During an interview on 08/03/2026 at 12:38 PM, after reviewing Resident 5's skin integrity care plan initiated on 03/27/2026, Staff E, RN/RCM, stated it did not meet expectations for accuracy and for actual status of wounds. Staff E stated the care plan showed Resident 5 had scattered rash to face and a left heel pressure injury, but they had resolved and it did not include pressure wound to the left buttock. Staff E stated Resident 5's care plan needed to be revised to reflect any change in condition such as new issues, change in current issues, or resolved issues. During an interview on 08/03/2026 at 12:48 PM, Staff B, DNS, stated Resident 5's care plan should reflect the resident's current status. Staff B stated Resident 5's skin integrity care plan initiated on 03/27/2026 did not include all current pressure wounds and still showed skin issues that were resolved. Staff B stated Resident 5's care plan needed to be revised. Reference WAC 388-97-1020(2)(c)(d), -1020(5)(b)

Based on observation, interview, and record review, the facility failed to implement bowel management programs for 2 of 5 sampled residents (Residents 69 and 74) reviewed for bowel management and failed to follow provider orders for skin treatment for 1 of 4 sampled residents (Resident 56) reviewed for quality of care. These failures placed the residents at risk of complications and poor clinical outcomes. Findings included .<Bowel Management> Resident 69 Review of the electronic health record (EHR) showed Resident 69 admitted to the facility on [DATE] with diagnoses of quadriplegia (unable to move from chest down) and respiratory failure. The resident was able to make needs known. During an interview on 07/29/2026 at 11:20 AM, Resident 69 stated they were concerned about the nurses helping them with their bowel care as they required frequent assistance. Review of the EHR showed Resident 69 had no documented bowel movement (BM) on the dates of 07/09/2026 through 07/12/2026 (four days) and on 07/14/2026 through 07/19/2026 (six days). Review of the EHR on 07/30/2026 at 4:15 PM showed no documentation that Resident 69 was offered as needed bowel medications during those dates. Resident 74 Review of the EHR showed Resident 74 admitted to the facility on [DATE] with diagnoses of diabetes (when there is too much sugar in the blood) and infection of a chronic foot wound. The resident was able to make needs known. Review of the EHR on 07/30/2026 at 4:25 PM showed Resident 74 had no documented BM on 07/16/2026 through 07/20/2026 (five days). Review of the provider orders for the month of July 2026 showed no as needed bowel medications were offered to Resident 74 during those dates. During an interview on 07/31/2026 at 9:18 AM, Staff B, Director of Nursing Services (DNS), stated the facility has standing orders for bowel management medications that should have been started for Residents 69 and 74 after three days with no documented BM. <Non-pressure Skin> Resident 56 Review of the EHR showed Resident 56 readmitted to the facility on [DATE] with diagnoses to include diabetes, depression, and bullous pemphigoid (a rare, long-term skin condition that causes large, fluid-filled blisters). Resident 56 was able to make needs known. Observation and interview on 07/29/2026 at 1:51 PM showed Resident 56 with scattered scabbed areas on both hands and lower forearms. Resident 56 stated they were taking medication for their skin condition. Review of the July 2026 medication administration records (MAR) showed a start date of 04/13/2026 for Clobetasol Propionate Cream 0.05 % (an effective, first-line treatment for the diagnosis of bullous pemphigoid flare) to be applied topically to blisters on Resident 56's leg, arms, thigh, and shoulder, two times a day. This order did not show exact location of affected areas. This order was discontinued on 07/21/2026; however, documentation showed it was coded 9, (Other/ See Nurse Notes) and was not provided on 07/14/2026 AM shift, 07/15/2026 AM shift, 07/17/2026 AM shift, and on 07/24/2026 PM shift. Review of Resident 56's progress notes on 07/14/2026, 07/15/2026, and 07/17/2026, showed the reason for Clobetasol Propionate Cream not being provided was due to the medication was reorder, or ordered, or on order. There was no documentation to show the provider had been notified of the medication not being provided. Review of the progress note dated 07/20/2026 showed, Resident requesting to go to ED [emergency department] due to intractable [difficult to control] discomfort caused by [Resident 56's] generalized rash. Not alleviated with current medications or treatment. Provider notified and gave OK to send. It showed Resident 56 was sent to the hospital emergency department via a non-emergency transportation service. Review of the EHR showed Resident 56 was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of the July 2026 MAR showed an order with a start date of 07/23/2026 for Clobetasol Propionate Cream 0.05 % to be applied externally/topically twice a day for rash; however, this order did not show location of affected rash areas. Documentation showed it was coded 9, and was not provided on 07/24/2026 PM shift. Review of Resident 56's progress note dated 07/24/2026 showed the reason for Clobetasol Propionate Cream not being provided was due to medication was on order. There was no documentation to show the provider had been notified of the medication not being provided. Review of the progress note dated 07/23/2026 showed Resident 56 was readmitted to the facility with diffuse worsening desquamating (skin peeling) skin lesions. During an interview on 08/03/2026 at 1:12 PM, Staff E, Registered Nurse/Resident Care Manager (RN/RCM), stated Resident 56's order for Clobetasol Propionate Cream should have included the location of where the medication was to be applied and this did not meet their expectations. Staff E stated if the medication was not available it should have been documented that the pharmacy was called to determine how to resolve any issues with filling the prescription, determine when the medication would be delivered, the provider notified, and this did not happen for Resident 56 and should have. During an interview on 08/03/2026 at 1:31 PM, Staff B, Director of Nursing Services (DNS), stated Resident 56's orders for Clobetasol Propionate Cream should have included the location of the rash/lesion areas to apply the medication. Staff B stated licensed nurses should have called the pharmacy and notified the provider to resolve medication issues in a timely manner. Staff B stated the documentation relating to Resident 56's prescribed Clobetasol Propionate Cream did not meet expectations. Reference WAC 388-97-1060(1)-(3)

Based on observation, interview, and record review, the facility failed to provide prompt services to maintain vision for 1 of 3 sampled residents (Resident 4) when reviewed for communication/sensory. This failure placed the resident at risk of unmet vision needs, continued visual impairment, decreased mood, and diminished quality of life. Findings included.Review of the electronic health record (EHR) showed that Resident 4 readmitted to the facility on [DATE] with diagnoses to include diabetes (high blood sugar), chronic obstructive pulmonary disease (a progressive lung condition that makes breathing difficult), and depression (mood disorder). Resident 4 was usually able to make needs known. During an interview and observation on 07/29/2026 at 10:43 AM, Resident 4 stated they had glasses, but they broke a while ago and now they did not have glasses. Resident 4 stated they had told staff about it, but they still did not have any glasses. Glasses were not visible in Resident 4's room. Review of the minimum data set assessment (MDS) dated [DATE] showed Resident 4 had adequate vision with corrective lenses. Review of the focused care plan for impaired visual function, initiated on 10/20/2023, showed Resident 4 was fitted for new glasses on 12/08/2025 and would be arriving in two weeks. It showed, Ensure glasses are available to support resident's participation in ADL's [activities of daily living] and other activities. New glasses received 10/19/23. It showed an intervention initiated on 10/20/2023 to Remind resident to wear glasses when up. Review of the optometry consult visit progress note dated 12/08/2025 showed Resident 4 was prescribed glasses and would be shipped to the facility two weeks from receipt of payment. Review of the social services progress note dated 02/27/2026 showed Resident 4's family member was not interested in purchasing glasses at that time. During an interview and joint observation on 07/31/2026 at 12:28 PM, Staff G, Certified Nursing Assistant (CNA), stated they were not sure if Resident 4 wore glasses. Staff G looked for glasses in Resident 4's room after obtaining permission; however, they were unable to locate glasses. During an interview on 07/31/2026 at 12:38 PM, Staff H, Registered Nurse (RN), stated Resident 4 used to wear glasses about a year ago. Staff H stated Resident 4's glasses broke and they were fitted for new glasses; however, they had not seen Resident 4 with glasses on. During an interview on 07/31/2026 at 1:04 PM, Staff J, Licensed Practical Nurse/Resident Care Manager (LPN/RCM), stated Resident 4's EHR documentation did not clearly indicate if glasses were delivered. Staff J stated at a care conference, Resident 4's family-member did not want to purchase new glasses for Resident 4. Staff J stated if Resident 4 did not have the funds for glasses, then the facility should pay to get new glasses and that did not happen for Resident 4. During an interview on 07/31/2026 at 1:48 PM, Staff B, Director of Nursing Services (DNS), stated they were not aware Resident 4 did not have glasses. Staff B stated the facility should have advocated for Resident 4 to obtain prescription glasses and that did not happen for this resident. Staff B stated this did not meet their expectations for addressing Resident 4's vision issues. Reference WAC 388-97-1060(3)(a)

Based on observation, interview, and record review, the facility failed to provide care and services to prevent or maintain range of motion for 1 of 3 sampled residents (Resident 69) reviewed for position and mobility. This failure placed the resident at risk for decreased range of motion and other complications in their lower extremities. Findings included .Resident 69Review of the electronic health record (EHR) showed Resident 69 admitted to the facility on [DATE] with diagnoses of quadriplegia (unable to move from chest down) and respiratory failure. The resident was able to make needs known. Observation and interview on 07/29/2026 at 12:17 PM showed Resident 69 laid in bed. Both feet were laying on the mattress without any positioning devices such as pillows or splints. Resident 69 stated they used to wear splints, but they were not being put on for a while now. Observation and interview on 07/30/2026 at 11:22 AM showed Resident 69 laid in bed. Splints were on the counter by the sink and Resident 69 stated Staff F, Certified Nursing Assistant/Restorative Aide (CNA/RA), came in and put the splints on for the first time in a long time. Review of Resident 69's plan of care for restorative nursing program (RNP) showed an entry dated 05/07/2026 to Apply AFO [ankle-foot orthosis] splint to bilateral LE [lower extremity] prior to transfer for positioning in W/C [wheelchair]. Leave on while up in W/C. Remove once in bed again. And an entry for Passive ROM [range of motion] to Lower extremities- all joints, planes x 10 reps. Stretch as tolerated on calf muscles. Upon completion, place bilateral splints. Offer 3-7 x week for 15 minutes. Review of Resident 69's physical therapy discharge recommendations dated 05/29/2026 showed the resident was to be referred to the RNP to resume RNP. During an interview on 07/30/2026 at 1:24 PM, Resident 69 stated Staff C, CNA/RA, came in five days a week and helped with their shoulders but did not put splints on their feet. Resident 69 stated they thought they should wear the splints more often. During an interview on 07/31/2026 at 9:45 AM, Staff C, CNA/RA, stated they had been injured and working light duty for two months and had not put splints on since their injury. Staff C stated they thought the splints were assigned to another CNA/RA. During an interview on 07/30/2026 at 2:07 PM, Staff F, CNA/RA stated they were just assigned to work with Resident 69 on 07/28/2026 and had not been putting on the splint prior to that. During an interview on 07/31/2026 at 9:34 AM, Staff D, Licensed Practical Nurse/Minimum Data Set Coordinator (LPN/MDSC), stated they had received a restorative referral to resume the prior RNP on 05/29/2026 and Resident 69 should have been assigned to another restorative aide and had the splints placed per their program. During an interview on 07/30/2026 at 2:31 PM, Staff B, Director of Nursing Services, stated it was their expectation that Resident 69 received their restorative services per their restorative nursing program. During an interview on 07/31/2026 at 10:09 AM, Staff A, Administrator, stated Resident 69's splints should have been assigned to another restorative aide when Staff C went on light duty. Reference WAC 388-97-1060(3)(d)

Based on interview and record review, the facility failed to ensure the Quality Assessment and Performance Improvement (QAPI) program self-identified deficiencies and failed to develop/implement effective plans of action to sustain plan of corrections for previous deficiencies. Failure to have an effectively functioning QAPI program that consistently self-identified deficient practices led to repeated deficiencies, and a pattern of deficiencies that placed residents at repeated risk for unmet needs that could negatively impact their safety, quality of life and quality of care. Findings included . Review of the facility's policy and procedure titled, Quality Assurance and Performance Improvement, revision dated 03/2025, showed QAPI would oversee the identification and correction of quality issues. Effective QAPI would help lead to resident-centered care, satisfied customers, outstanding survey outcomes, and positive financial performance. Review showed, Improvements realized as the result of quality improvement plans will be monitored and sustained. During the entrance conference interview on 06/24/2025 at 9:36 AM, Staff A, Administrator, stated they were familiar with the [NAME] report (a report with previously cited deficiencies) to identify any repeat deficiencies that needed to be addressed. A copy of the [NAME] report dated 06/18/2025 was provided to Staff A during the interview for review. During an interview on 07/02/2025 at 4:57 PM, Staff A, Administrator, stated they were not aware of issues found during survey related to the restorative nursing program, nutrition issues related to fluid restrictions and inaccurate consumption documentation, or pain management issues related to non-pharmacological interventions (NPI, health interventions/approaches used instead of medication). Staff A did not provide an explanation as to why these issues were not identified by the facility prior to survey. Staff A stated they were aware of staffing issues related to long call light waiting times and had implemented a Performance Improvement Plan (PIP, a structured process used to address performance issues in an individual or an organization) that was initiated on 06/10/2025. When asked why the PIP was not established sooner since there were grievances related to call lights since January 2025, Staff A stated they had provided staff education related to call lights previously and thought that would help; however, it did not, so then the PIP was put in place. The facility had the following repeated citations: F688 - Increase/Prevent Decrease in ROM/Mobility (05/2022 and 10/2024). F692 - Nutrition/Hydration Status Maintenance (07/2019 and 08/2023). F725 - Sufficient Nursing Staff (07/2019). Review of the current QAPI program documentation, year 2025, showed the facility conducted QAPI meetings, but the facility failed to self-identify deficiencies, identify they did not sustain corrections of previously identified deficiencies, and/or make timely revisions to previous action plans to ensure corrections were sustained. Refer to the following citations from the current survey cycle which were not identified, were identified and not addressed, or had ineffective plans of correction to sustain correction by the QAPI program which led to repeated pattern of deficiencies. (D = Isolated and E = Pattern). REFER TO F688 (E) Increase/Prevent Decrease in ROM/Mobility: Previous deficiency dated 05/2022 (D) and 10/24/2024 (D) REFER TO F692 (E) Nutrition/Hydration Status Maintenance: Previous deficiency dated 07/2019 (D) and 08/2023 (E) REFER TO F697 (E) Pain Management REFER TO F725 (E) Sufficient Nursing Staff: Previous deficiency dated 07/2019 (D) Reference WAC 388-97-1760(1)(2) .

Resident 95 Review of the EHR showed Resident 95 admitted to the facility on [DATE] with diagnoses to include respiratory failure, hemiplegia (paralysis/loss of muscle function) and (partial paralysis or muscle weakness) of one side of the body following a stroke (blood flow to the brain suddenly interrupted). Resident 95 was able to make needs known. During an interview on 06/25/2025 at 10:39 AM, Resident 95 stated they had a stroke and the left side of their body was weak. Review of the minimum data set (MDS, a required assessment tool) dated 05/14/2025 showed Resident 95 received occupational therapy (OT) and physical therapy (PT) services and did not receive restorative nursing services. Review showed Resident 95 was dependent on staff for dressing the upper and lower body to include putting on and taking off footwear. It showed Resident 95 utilized a manual wheelchair for mobility and was dependent on staff for transfers from bed to wheelchair and back. Review of Resident 95's care plan initiated on 05/09/2025 showed a focused care plan for Dressing, performance deficit due to left sided weakness which included an intervention to, Make sure shoes are comfortable and not slippery. Resident prefers to wear brace and offloading boots. Review showed interventions dated 05/12/2025 for brace to left foot, and offloading boot when in bed. Resident 95 had a Bed Mobility focused care plan with an intervention dated 05/09/2025 that showed the resident was dependent on one person assistance with bed mobility. During an interview on 06/30/2025 at 9:56 AM, Staff E, Resident Care Manager (RCM), stated Resident 95 was not currently on the therapy caseload (receiving therapy services) or on a restorative nursing program. During an interview on 06/30/2025 at 10:27 AM, Staff C, Director of Rehabilitation, stated Resident 95 came off OT and PT services on 06/04/2025, and PT had recommended home range of motion (ROM, the full movement potential of a joint) exercises, and OT did not indicate a home exercise or a referral for a restorative nursing program. Staff C stated Resident 95 should have been referred to a restorative nursing program when they came off therapy services and remained in the facility. Staff C stated a referral for a nursing restorative program got missed by therapy and Resident 95 needed to be followed up on for either a referral back to therapy or a restorative nursing program. During an interview on 06/30/2025 at 11:17 AM, Staff F, MDS/LPN, stated therapy did not make a referral for Resident 95 to have a restorative nursing program and should have. During an interview on 06/30/2025 at 12:10 PM, Staff B, DNS, stated when Resident 95 came off therapy services there should have been a referral for a restorative nursing program. Based on observation, interview and record review, the facility failed to ensure residents consistently received restorative services (movement of joints to maintain range of motion) and/or splint brace assistance to maintain or prevent declines in mobility for 3 of 4 sampled residents (Residents 14, 35 and 95) reviewed for range of motion (ROM)/mobility. This failure placed residents at risk of decreased motion, mobility and a diminished quality of life. Findings included . Resident 14 Review of the electronic health record (EHR) showed Resident 14 admitted to the facility on [DATE] with diagnoses that included paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease), chronic obstructive pulmonary disease (an ongoing lung condition caused by damage to the lungs) and chronic pain. Resident 14 was able to make needs known. Observation and interview on 06/25/2025 at 11:42 AM showed Resident 14 in a wheelchair with a bent inward left hand. Resident 14 stated they were no longer receiving restorative services and staff was no longer assisting with putting on their hand splint. Review of the care plan initiated 03/03/2023 showed Resident 14 was not receiving restorative services. Review of the care plan history showed restorative services were resolved on 01/05/2024. Review of form Physical Therapy Discharge Summary, dated and signed 04/19/2024, showed, Discharge instructions=Resident will transition to Restorative Nursing Program (RNP) for sit to stand in parallel bars and bilateral lower extremity (BLU) hip and knee stretches. Discharge Recommendation= Other Restorative Program. Review of form Occupational Therapy Summary, dated and signed 08/14/2023, showed, Discharge Recommendation=Restorative Range of Motion Program, Restorative Splint and Brace program. Left resting hand splint as tolerated, likely at night. Review of a provider's comprehensive exam note dated 12/13/2024 showed Resident 14 reported their left hand and left leg needed to be loosened up and were willing to do restorative therapy to maintain current mobility. During an interview on 06/27/2025 at 12:50 PM, Staff D, Resident Care Manager/ Licensed Practical Nurse (RCM/LPN), stated it was the RCM's responsibility to follow up on any recommendations from providers. Staff D stated a referral should have been made to the RNP but was not. During an interview on 06/27/2025 at 12:55 PM, Staff F, Minimum Data Set/Licensed Practical Nurse (MDS/LPN), stated they assessed Resident 14 on 05/26/2025 and determined Resident 14 was not appropriate for the RNP. Staff F stated they did not note any issues with Resident 14's left hand at the time of the visual assessment. During an interview on 07/02/2025 at 11:36 AM, Staff C, Director of Rehabilitation, stated Resident 14 fell through the cracks and was not receiving restorative services as they should have been. Staff C stated they were unable to locate discharge notes on why the program was discontinued on 01/2024. Staff C stated based on the most recent physical therapy evaluation completed 07/01/2025 Resident 14 had a decline in functional mobility related to transfers as their prior level of functioning related to sit to stand was partial/moderate assistance and was currently substantial/maximal assistance. Chair/bed-chair transfer prior level of functioning was substantial/maximal assistance and was currently dependent. Staff C stated they were unable to locate Resident 14's splint, so a new one was ordered. During an interview on 07/02/2025 at 12:53 PM, Staff B, Director of Nursing Services (DNS), stated the expectation was Resident 14 should have been referred to therapy timely. Resident 35 Review of the EHR showed Resident 35 was originally admitted to the facility on [DATE] with diagnoses to include muscle wasting, anxiety, acute/chronic respiratory failure, and tracheostomy (opening in windpipe through the neck). Resident 35 was able to communicate their needs. Observation on 06/25/2025 at 10:01 AM showed Resident 35 in bed with their upper arms folded in front of them. During an interview on 06/26/2025 at 9:29 AM, Resident 35 stated the restorative program was not done, and they wanted to work with them. Resident 35 stated, My arm is getting worse and they had a brace. Review of Resident 35's EHR showed a contracture screening assessment dated [DATE] with functional limitation to upper and lower extremity and restorative program. Review of Resident 35's OT Discharge summary dated [DATE] with discharge instructions for restorative range of motion program with splint/brace. Review of Resident 35's PT Discharge summary dated [DATE] with discharge instruction for restorative program. Review of Resident 35's EHR showed no order or care plan for restorative program. During an interview on 06/30/2025 at 11:08 AM, Staff F, MDS/LPN, stated the general process was for therapy to put a referral to nursing about a restorative program, and Staff F would add the restorative program in the individual resident's care plan. Staff F reviewed Resident 35's EHR and stated the restorative referral was missing. During an interview on 07/02/2025 at 10:32 AM, Staff B, DNS, stated Resident 35's missed restorative program did not meet expectations. Reference WAC 399-97-1060(3)(d),(j)(ix) .

Based on observation, interview, and record review, the facility failed to ensure new interventions were developed to reduce fall incidents for 1 of 3 sampled residents (Resident 12), failed to ensure elopement precautions were in place for 1 of 3 halls (100 Hall), and failed to ensure medication carts were secured for 1 of 6 medication carts (300 Hall) when reviewed for accident hazards. These failures placed residents at risk of continual falls, avoidable injury, elopement, unintended access to medications, and a diminished quality of life. Findings included . Resident 12 Review of the electronic health record (EHR) showed Resident 12 admitted to the facility on [DATE] with diagnoses that included chronic pain, diabetes (too much sugar in the blood) and dementia (a decline in mental ability that interferes with daily life). Resident 12 was able to make needs known. Review of Resident 12's incident report, dated 03/20/2025, showed Resident 12 had an unwitnessed fall. Resident 12 was found lying on the floor near the bed. Resident 12 stated they fell on to their left leg and were unable to move it. Emergency medical services (EMS) was called and Resident 12 was transported to the hospital. Review of the March 2025 incident log showed no documentation of Resident 12's 03/20/2025 fall. Review of a document titled Post Acute and Transition of Care Orders dated 03/27/2025 showed Resident 12 had surgery related to a left femur fracture. Review of Resident 12's care plan dated 08/21/2024 showed no interventions were added following the fall on 03/20/2025. Review of the April 2025 incident log showed Resident 12 had an additional fall on 04/29/2025. Review of Resident 12's incident report, dated 04/29/2025, showed Resident 34 had a unwitnessed fall. Resident 12 was heard yelling and when staff entered the room. Resident 12 was on the floor near the bed and no injuries were reported. An intervention to encourage Resident 12 to use the call light for assistance to transfer was added to the care plan on 04/30/2025. During an interview on 06/30/2025 at 1:45 PM, Staff D, Resident Care Manager/Licensed Practical Nurse (RCM/LPN), stated the care plan was not revised and no interventions were put in place after the 03/20/2025 fall but should have been. During an interview on 07/02/2025 at 12:38 PM, Staff B, Director of Nursing Services (DNS), stated the intervention after the 03/20/2025 fall was missed but one should have been implemented. <100 HALL ELOPEMENT RISK> Review of a progress note, dated 05/25/2025, showed Resident 49 exited the facility via the back door of the gym and was found outside the building. Review showed Resident 49 was encouraged to not go outside the facility without informing staff and the resident was placed on alert for elopement. Observation on 06/26/2025 at 9:13 AM showed a therapy gym near the 100 Hall with an exit to an outdoor patio area with a canopy and outdoor chairs. Exiting to the patio did not cause an alarm. The left-side of the patio had an unlocked gate leading to the facility parking lot and the right-side led around the building to an unlocked gate to a city street. During an interview and observation on 06/26/2025 at 10:40 AM, Staff N, Maintenance Director, stated the door to the patio was alarmed. Observation showed Staff N opened the patio door and an alarm did not sound. Staff N stated the gates to the parking lot and city street were not locked and residents could use them to exit the property from the patio area. During an interview on 06/30/2025 at 10:08 AM, Staff A, Administrator, stated the alarm on the door to the patio was not alarming. Staff A stated the door to the therapy gym, not back patio, should be alarmed and the current alarm situation did not meet her expectations. <MEDICATION CART> Observation on 07/02/2025 at 12:52 PM showed an unsecured medication cart on the 300 Hall with residents sitting nearby in wheelchairs. During an interview on 07/02/2025 at 12:55 PM, Staff O, RCM/LPN, stated the medication cart was left unsecured and the medications were accessible to residents and visitors. Staff O stated the medication cart should not be left unsecured. During an interview on 07/02/2025 at 2:22 PM, Staff B, DNS, stated medication carts were secured with a key to ensure residents and visitors did not have access to the medications. Staff B stated the unsecured medication cart on the 300 Hall did not meet their expectations. Reference WAC 388-97-1060 (3)(g) .

Based on observation, interview, and record review, the facility failed to ensure residents' nutritional status was accurately monitored for 3 of 5 sampled residents (Residents 16, 51, and 44) when reviewed for nutrition. This failure placed residents at risk of unintended wight loss, fluid overload, and a diminished quality of life. Findings included . Resident 16 Review of the electronic health record (EHR) showed Resident 16 admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (COPD, a disease that causes obstructed airflow from the lungs), diabetes (too much sugar in the blood), and dementia (a decline in mental ability severe enough to interfere with daily life). Resident 16 was not able to make needs known. Observation on 06/24/2025 at 12:13 AM showed Resident 13 in bed with their lunch tray on the overbed table. Resident 13 was attempting to put a straw into a plastic cup with dried cereal with no liquid available. Observation on 06/25/2025 at 12:19 PM showed Resident 13 in bed with their lunch tray on the overbed table. Resident 13 was leaning to the right side using their fingers to pick up and place individual pieces of food into a small pile on their food tray. Resident 13 had food items on the front of their clothing. Resident 13 then attempted to use the spoon to self-feed, but was unable to balance the food on the spoon and it fell to the bed. Resident 13 smiled and appeared pleasantly confused. In continued observation on 06/25/2025 at 2:15 PM, Resident 13 laid in bed and leaned to the right side away from their meal tray. Resident 13's eyes were closed, and they had consumed approximately 5% of their lunch meal. Review of the 30-day lookback of meal intake showed Resident 13 ate 50-75% of their lunch meal on 06/25/2025. Observation on 06/26/2025 at 12:47 PM showed Resident 13 in the main dining room with a lunch food tray on the table in front of them. Resident 13 had consumed the piece of cake provided with the meal (approximately 5% of the meal) and left the rest. Review of the 30-day lookback of meal intake showed Resident 13 ate 50-75% of their lunch meal on 06/26/2025. Observation on 06/30/2025 at 12:35 PM showed Resident 13 in bed with the lunch meal tray on the overbed table. Resident 13 was taking food and placing it into different piles. Resident 13 was leaning to the right, away from their lunch tray and had consumed approximately 10% of the meal. Observation on 06/30/2025 at 1:11 PM showed Resident 13's meal tray on a cart of used trays waiting to be washed. The meal tray had approximately 95% of food unconsumed. Review of the 30-day lookback of meal intake showed Resident 13 ate 50-75% of their lunch meal on 06/30/2025. Review of Resident 13's 08/27/2018 initiated care plan showed Resident 13 was at nutritional risk and had a history of significant weight loss. Review of the Registered Dietician annual review, dated 06/13/2025, showed Resident 13 had good intake and ate 50-75% of their meals regularly. Observation on 07/02/2025 at 12:10 PM showed Resident 13 in bed leaning to the right and the bed at a 20-degree angle. Resident 13 had not touched the food but had drunk a glass of milk. During an interview on 07/02/2025 at 1:28 PM, Staff S, Certified Nursing Assistant, stated they would observe how much a resident ate at meals then input it into the 30-day lookback of meal intake. Staff S stated Resident 13 had drank milk and juice and eaten a few bites of corn, so they had coded Resident 13 as having consumed 50-75% of their lunch for 07/02/2025. During an interview on 07/02/2025 at 1:37 PM, Staff D, Resident Care Manager (RCM), stated the facility ensured residents maintained weight by monitoring meal intake and having the registered dietician perform regular reviews. Staff D stated only food should be considered when tracking meal intake and Resident 13's lack of accurate monitoring of meal intake did not meet expectations. During an interview on 07/02/2025 at 2:40 PM, Staff B, Director of Nursing Services (DNS), stated resident weights and food intake were monitored and the registered dietician performed periodic reviews to ensure residents maintained their nutritional status. Staff B stated Resident 13's meal tracking did not meet expectations. Resident 51 Review of the EHR showed Resident 51 admitted to the facility on [DATE] with diagnoses to include COPD, diabetes, and atrial fibrillation (a heart condition characterized by an irregular and often rapid heartbeat). Resident 51 was able to make needs known. Review of a provider's order, dated 06/02/2025, showed Resident 51 was on a fluid restriction of 2000 milliliter (ml) with dietary to provide 1520 ml. Observation on 06/25/2025 at 12:43 PM showed Resident 51 in bed with their meal tray. Resident 51 had been provided coffee, two clear cups which were empty, and a plastic cup of water with a straw. Review of the meal ticket showed Resident 51 was on a 2000 ml fluid restriction, but did not specify how much dietary was to provide. Review of the medication administration record (MAR) for June 2025 showed the nurses documented the amount of fluid they provided and the total amount for the day, but it did not include the amount provided by dietary. During an interview on 06/30/2025 at 2:08 PM, Staff L, Dietary Manager, stated they were aware of resident fluid restrictions by receiving meal slips from nursing which would then be uploaded into the kitchen software and printed on the resident's meal ticket. Staff L stated Resident 51 was on a 2000 ml fluid restriction. Staff L stated they did not know how much of the 2000 ml should be provided by dietary, so they only provided one 4 fluid ounce (approximately 180 ml) cup of juice to Resident 51 with meals. During an interview on 07/02/2025 at 12:40 PM, Staff D, RCM/Licensed Practical Nurse (LPN), stated Resident 51's fluid restriction had been changed recently and the orders had not been updated in the EHR. Staff D stated Resident 51's fluid restriction did not meet expectations. During an interview on 07/02/2025 at 2:45 PM, Staff B, DNS, stated Resident 51's fluid restriction was not adequately communicated to the kitchen, and this did not meet expectations. Resident 44 Review of the EHR showed Resident 44 admitted to the facility on [DATE] with diagnoses to include end stage renal disease (the final, irreversible stage of chronic kidney disease), diabetes, and atrial fibrillation. Resident 44 was able to make needs known. During an interview and observation on 07/02/2025 at 11:23 AM, Resident 44 stated the facility had attempted to limit their fluid intake, but now they managed their own fluid intake. Observation showed Resident 44 had a 20 fluid ounce plastic bottle of water half full and a plastic measured cup with 650 ml of clear liquid on the bedside table. Review of a provider's order, dated 12/02/2024, showed Resident 44 was on a 1500 ml fluid restriction and to notify the provider, RCM, and DNS if the resident was noncompliant. Review of the MAR for June 2025 showed the nurses documented the amount of fluid they provided and the total amount for the day, but it did not include the amount provided by dietary. Review of the care plan, initiated 09/30/2025, showed Resident 44 was on a fluid restriction of 1500 ml with nursing to provide 200 ml and dietary to provide 1200 ml, but refused to follow it. During an interview on 07/02/2025 at 11:46 AM, Staff L, Dietary Manager, stated Resident 44 was not on a fluid restriction. During an interview on 07/02/2025 at 1:02 PM, Staff E, RCM, stated Resident 44 was on a 1500 ml fluid restriction which they did not follow. Staff E stated Resident 44's fluid restriction was not monitored if the resident had unrestricted fluids at bedside. During an interview on 07/02/2025 at 2:33 PM, Staff B, DNS, stated fluid restrictions were ordered and specified how much nursing and dietary should be providing, which was documented in the MAR. Staff B stated Resident 44 was on a fluid restriction, but noncompliant. Reference WAC 388-97-1060 (3)(h) .

Based on interview and record review, the facility failed to manage pain by inconsistently monitoring and/or providing non-pharmacological interventions (NPI, health interventions/approaches used instead of medication) for 4 of 6 sampled residents (Residents 95, 99, 98, and 74) reviewed for unnecessary medications and/or pain management. This failure placed the residents at risk of having unmet pain needs, receiving unnecessary medications, avoidable medication side effects, and a diminished quality of life. Findings included . Resident 95 Review of the electronic health record (EHR) showed Resident 95 admitted to the facility on [DATE] with diagnoses to include respiratory failure, stroke (blood flow to the brain suddenly interrupted), and anxiety disorder. Resident 95 was able to make needs known. Review of Resident 95's June 2025 medication administration record (MAR) from 06/01/2025 - 06/30/2025 showed an order with a start date of 05/09/2025 to monitor for pain prior to giving pain medication and to document pain using a numerical scale (0 = no pain and 10 = worst pain imaginable) or a pain assessment in advanced dementia (PAINAD scale, pain evaluation based on observations) scale for the cognitively impaired (decline in a person's mental abilities) every shift. Review showed no documentation on 06/07/2025 and 06/09/2025 on the day shift, and multiple dashes (-), NAs, and Xs documented for pain code and site/location when there were pain numerical numbers documented ranging from 1 to 5, three times on day shift and seven times on the night shift. In continued review of June 2025 MAR, Resident 95 had an order with a start date of 05/09/2025 for acetaminophen (used to treat minor aches and pain) two tablets every six hours as needed for pain in conjunction with administering pain medication, utilize NPI for pain management and there were listed interventions to document when used. It showed to see progress note, and to document pain site location. Documentation showed Resident 95 received acetaminophen on 06/12/2025 and 06/22/2025 and showed no NPI were documented as provided. During an interview on 06/30/2025 at 9:50 PM, Staff E, Resident Care Manager (RCM), stated the expectation was NPI were offered/provided prior to giving an as needed pain medication and documented. Staff E stated Resident 95's June 2025 MAR did not meet expectation because the documented coding was not correct for attempts for NPI and for the site/pain location. Staff E stated NPIs were not documented for Resident 95's acetaminophen provided on 06/12/2025 and 06/22/2025 and should have been. During an interview on 06/30/2025 at 12:25 PM, Staff B, Director of Nursing Services (DNS), stated Resident 95's June 2025 MAR should have had the pain location and interventions tried documented and this did not meet their expectations. Staff B stated NPIs were to be offered/provided prior to giving a resident an as needed pain medication. Resident 99 Review of EHR showed Resident 99 admitted to the facility on [DATE] with diagnoses to include respiratory failure, stroke, and anxiety disorder. Resident 99 was able to make needs known. Review of a provider's order, dated 05/29/2025, showed oxycodone (a narcotic pain medication) was prescribed. Review of the June 2025 MAR showed Resident 99 was administered oxycodone 13 times between 06/01/2025 and 06/30/2025 without offering/documenting NPI prior to use of the medication. During an interview on 07/02/2025 at 3:30 PM, Staff E, RCM, stated the expectation was that NPIs were offered and accurately documented prior to administering as needed pain medications. Resident 74 Review of the EHR showed Resident 74 was admitted to the facility on [DATE] with diagnoses to include quadriplegia (paralysis that affects the ability to move upper and lower body), dependance on vent (person relies on mechanical ventilator to breath), depression and anxiety. Resident 74 was able to communicate needs. Review of the MAR for June 2025 showed Resident 74 had an order dated 06/11/2025 for oxycodone as needed. Review of the June 2025 MAR showed Resident 74 was administered oxycodone 47 times from 06/11/2025-06/26/2025 without documenting NPI prior to use of the medication. During an interview on 06/30/2025 at 9:40 AM, Staff O, RCM/Licensed Practical Nurse (LPN), reviewed the EHR for Resident 74 and stated the nurse that initiated the order was missing the codes for the NPIs. During an interview on 07/02/2025 at 10:26 AM, Staff B, DNS, stated Resident 74's oxycodone medication administration did not meet expectations. Resident 98 Review of the EHR showed Resident 98 was admitted to the facility on [DATE] with diagnoses to include metabolic encephalopathy (brain disorder caused by chemical imbalances), anxiety and depression. Resident 98 was able to communicate their needs. Review of the MAR for June 2025 showed Resident 98 had order dated 05/22/2025 for oxycodone as needed without documented NPI prior to use on 7 occasions. Review showed Resident 98 had order dated 05/22/2025 for tramadol (pain medication) as needed without NPI documented prior to administration on 21 occasions. During an interview on 06/26/2025 at 12:44 PM, Staff D, RCM/LPN, stated the nurses missed the NPIs for Resident 98. During an interview on 07/02/2025 at 10:29 AM, Staff B, DNS, stated Resident 98's orders did not meet expectations. Reference WAC 399-97-1060(1) .

Based on observation, interview, and record review, the facility failed to have sufficient staff to ensure residents received timely call light responses for 3 or 3 sampled hallways (100, 300 and 400) when reviewed for staffing. This failure placed residents at risk for accidents, injuries and diminished quality of life. Findings included . Observation on 07/02/2025 at 2:22 PM showed a panel at the 400 hall nurses' station with a call light displaying for room [ROOM NUMBER]. No audible sound was heard. Observation on 07/02/2025 at 2:33 PM showed call lights on for rooms 416, 408 and 419 but no tone was heard. <RESIDENT INTERVIEWS> Resident 72 During an interview on 06/24/2025 at 1:43 PM, Resident 72 stated there were long call wait times during evening and dayshift, and sometimes the wait was 45 minutes. Resident 27 During an interview on 06/24/2025 at 11:00 AM, Resident 27 stated, Sometimes the wait time is over an hour for help; I'm scared I'll get trapped. Resident 75 During an interview on 06/25/2025 at 10:36 AM, Resident 75 stated, Staff on night shift are lazy and don't answer call lights for a long time. Resident 4 During an interview on 06/25/2025 at 10:21 AM, Resident 4 stated, Staff take a long time to answer my light, wait time has been up to an hour. Resident 64 During an interview on 06/24/2025 at 1:02 PM, Resident 64 stated nighttime was the worst, and sometimes the call light was not answered for hours. Resident 64 stated after 2:00 AM nobody answered call lights. <RESIDENT COUNCIL> Review of the 01/30/2025 Resident Council meeting minutes showed a resident stated they had to wait a long time for their call light to be answered. Another resident stated they pressed their call light but had to wait a long time and they needed a quick response due to oxygen. Review of the 02/13/2025 Resident Council meeting minutes showed a resident stated they were having an issue with staff answering their call light. Staff would come in and turn off the light and not return. Review of the 03/13/2025 Resident Council meeting minutes showed a resident stated there were still ongoing issues with call light response and when residents were in the bathroom it seemed to take longer for staff to respond. Review of the 04/24/2025 Resident Council meeting minutes showed a resident stated call lights were an issue and it took so long for someone to show up every day and every night. Review of the 06/06/2025 Resident Council meeting minutes showed one resident stated they had to wait four hours for a call light response. Two other residents stated they had to wait over an hour for staff to respond to their call lights. Review of the 06/26/2025 Resident Council meeting minutes showed a resident stated they were having issues with staff answering their call light on night shift. <GRIEVANCE LOG> Review of the grievance log dated January 2025 showed there were two grievances related to call light wait times. Review of the grievance log dated February 2025 showed there were six grievances related to call light wait times. Review of the grievance log dated March 2025 showed there were four grievances related to call light wait times. Review of the grievance log dated April 2025 showed there were five grievances related to call light wait times. Review of the grievance log dated May 2025 showed there were seven grievances related to call light wait times. During an interview on 07/02/2025 at 2:33 PM, Staff K, Maintenance Assistant, stated the 400 hall call lights were not audible. During an interview on 07/02/2025 at 4:57 PM, Staff A, Administrator, stated it was their expectation 300 and 400 hall call lights should light and sound at the panel. Staff A stated they were aware of staffing issues related to long call light waiting times and had implemented a Performance Improvement Plan (PIP, a structured process used to address performance issues in an individual or an organization) on 06/10/2025. Staff A stated prior to the PIP they had provided staff education related to call lights concerns. Reference WAC 388-97-1080(1), 1090(1) .

Based on observation, interview, and record review, the facility failed to ensure sanitary food storage in the facility kitchen and 1 of 2 resident refrigerators (400 Hall) when reviewed for safe/sanitary food storage. This failure placed residents at risk of consuming expired food goods, foodborne illness, and a diminished quality of life. Findings included . <KITCHEN> Observation and interview on 06/30/2025 at 10:33 AM showed a freestanding fridge with uncovered trays of egg, sliced ham, and cooked bacon. A kitchen staff member stated the eggs, bacon, and ham were cooling, but was unsure when they were placed in the refrigerator and did not know of a cooling log. Observation and interview on 06/30/2025 at 10:48 AM showed Staff M, Housekeeping Supervisor, removing two large metal containers covered with metal foil labeled potluck. Staff M stated the metal containers contained beef and chicken cooked at home the night before to be used at a potluck for facility staff members. Staff M stated the meat prepared at home should not have been stored in the kitchen facility refrigerator. Observation on 06/30/2025 at 11:02 AM showed two dented cans of pineapple and one dented can of cream of mushroom soup stored on shelving in the dry storage area. During an interview on 06/30/2025 at 2:00 PM, Staff L, Dietary Manager, stated the facility cooled food over six hours and should be labeled with the time placed in the refrigerator to monitor this timeline. Staff L stated they did not maintain a cooling log for the freestanding refrigerator used for cooling foods. Staff L stated foods that were not prepared in the kitchen should not be stored in the kitchen refrigerator and the meat for the potluck should not have been stored in the kitchen refrigerator. Staff L stated dented cans were removed from shelving, so they were not used, and three dented cans being stored on the dry storage shelving did not meet expectations. During an interview on 06/30/2025 at 2:12 PM, Staff A, Administrator, stated the kitchen was expected to follow the food code. Staff A stated the observations of lack of monitoring of cooling foods, outside food stored in the kitchen refrigerator, and dented cans stored on dry storage shelving did not meet expectations. <400 HALL REFRIGERATOR> Observation and record review on 06/25/2025 at 10:14 AM showed the 400 Hall resident refrigerator was 44 Fahrenheit (F). Review of the refrigerator temperature log showed five of 24 days logged with a temperature greater than 40F, no corrective action taken, and directed staff to report to maintenance any temperatures greater than 39F. Observation showed a strawberry fruit drink with a use by date of 04/09/2025 and a buttermilk ranch dressing with a use by date of 04/06/2025. Observation showed sticky brown/yellow food residue had dried to the shelving. During an interview on 06/25/2025 at 10:39 AM, Staff L, Dietary Manager, stated the kitchen staff monitored the resident refrigerators for temperatures and expired foods. Staff L stated if a refrigerator was out of range the maintenance department would be contacted for repair, but this was not needed recently as the refrigerators were holding temperatures. Staff L stated the 400 Hall refrigerator had dates out of temperature range and they were not informed, and maintenance had not been contacted. Staff L stated the refrigerator had items past their use by date and the shelving was not clean. Staff L stated the 400 Hall resident refrigerator did not meet expectations for sanitary food storage. During an interview on 06/25/2025 at 12:53 AM, Staff A, Administrator, stated the 400 Hall resident refrigerator was monitored by kitchen staff for cleanliness, temperature, and expired foods. Staff A stated the temperatures above 40F, expired food, and dirty shelving did not meet expectations. Reference WAC 388-97-1100 (3), -2980 .

Based on interview and record review, the facility failed to have signed consent prior to administering mood altering medication for 1 of 5 sampled residents (Resident 98) when reviewed for unnecessary medication use. This failure placed the resident or their legal representative at risk of receiving medications without knowledge to make informed decisions regarding the use of the medication, adverse side effects, and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 98 was admitted to the facility on [DATE] with diagnoses to include metabolic encephalopathy (brain disorder caused by chemical imbalances), anxiety and depression. Resident 98 was able to communicate their needs. Review of the medication administration record (MAR) for June 2025 showed Resident 98 had an order dated 05/12/2025 for Buspirone (anti-anxiety mood altering medication) twice a day. Review of the MAR for June 2025 showed an order dated 04/26/2025 for Duloxetine (antidepressant mood altering medication) once a day. Review of the EHR showed Resident 98 had no consents for the use of Buspirone and Duloxetine. During an interview on 06/26/2025 at 12:41 PM, Staff D, Resident Care Manager/Licensed Practical Nurse (RCM/LPN), reviewed the EHR for Resident 98 and was not able to locate consents for the two medications. Staff D stated Resident 98 should have had informed consents prior to the administration of the medications. During an interview on 07/02/2025 at 10:29 AM, Staff B, Director of Nursing Services (DNS), stated Resident 98's lack of consents for mood stabilizing medications did not meet expectations. Reference WAC 399-97-0300(3)(a) .

Based on interview and record review, the facility failed to timely complete an investigation for 1 of 3 sampled residents (Resident 95) when reviewed for accidents related to falls. Failure to ensure Resident 95's fall incident report interventions, investigation summary, and conclusion were completed timely placed the resident at risk for delay in providing interventions, unmet needs, subsequent falls, and a decrease in quality of life. Findings included . According to the Nursing Home Guidelines, also known as the Purple Book, sixth edition, dated October 2015, showed, The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. Review of the electronic health record (EHR) showed Resident 95 admitted to the facility on [DATE] with diagnoses to include respiratory failure, hemiplegia (paralysis/loss of muscle function) and hemiparesis (partial paralysis or muscle weakness) of one side of the body following a stroke (blood flow to the brain suddenly interrupted). Resident 95 was able to make needs known. During an interview on 06/25/2025 at 10:33 AM, Resident 95 stated they had fallen out of their wheelchair when trying to get back into bed. Review of the facility's incident report log dated June 2025 showed Resident 95 had a fall in their room on 06/19/2025. Review of the incident report initiated on 06/19/2025 showed Resident 95's documented interventions, investigation summary, and the conclusion of the fall were dated 06/26/2025 (seven days after the fall). During an interview on 06/27/2025 at 11:49 AM, Staff E, Resident Care Manager (RCM), stated they tried to complete incident investigations within three days; however, sometimes the weekend could push out the timeline to five days. Staff E stated Resident 95's fall incident report investigation dated 06/19/2025 should have been completed prior to 06/26/2025 and this did not meet their expectations. During an interview on 06/27/2025 at 12:07 PM, Staff B, Director of Nursing Services, stated incident report investigations were to be completed within five days. Staff B stated Resident 95's fall incident report investigation initiated on 06/19/2025 did not meet expectations because it should have been completed within five days and that did not happen. Please refer to F657 for additional information. Reference WAC 388-97-0640 (6)(a)(b)(c) .

Based on record review and interview, the facility failed to provide written bed hold notice at the time of transfer to the hospital for 1 of 2 sampled residents (Resident 12) reviewed for hospitalization. This failure placed the residents at risk for lacking knowledge regarding their right to hold their bed while in the hospital and diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 12 admitted to the facility on [DATE] with diagnoses that included chronic pain, diabetes (too much sugar in the blood) and dementia (a decline in mental ability that interferes with daily life). Resident 12 was able to make needs known. Review of Resident 12's EHR showed hospitalization on 03/09/2025 and readmission to the facility on [DATE]. There was no documentation showing a bed hold was offered. Review showed a hospitalization on 03/20/2025 and readmission to the facility on [DATE]. There was no documentation showing a bed hold was offered. During an interview on 06/30/2025 at 12:49 PM, Staff H, Business Office Manager, stated they did not offer Resident 12 a bed holds on either date but should have. During an interview on 06/30/2025 at 12:56 PM, Staff A, Administrator, stated the expectation was for bed holds to be offered and documented when a resident was transferred to the hospital. Reference WAC 388-91-0120(4) .

Based on interview and record review, the facility failed to ensure the minimum data set assessment (MDS) accurately reflected the status for 1 of 20 sampled residents (Resident 14) reviewed for accuracy of assessments. This failure placed the resident at risk for unmet care needs and a diminished quality of life. Findings included . Review of the electronic health record showed Resident 14 admitted to the facility on [DATE] with diagnoses that included paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease), chronic obstructive pulmonary disease (an ongoing lung condition caused by damage to the lungs), and chronic pain. Resident 14 was able to make needs known. Resident 14 had a decrease in upper and lower extremity mobility. Observation and interview on 06/25/2025 at 11:42 AM showed Resident 14 in a wheelchair with a bent inward left hand. Resident 14 stated they were no longer receiving restorative services and staff was no longer assisting with putting on their hand splint. Review of Resident 14's quarterly MDS dated [DATE] showed the Upper Extremity section A. marked No Impairment. During an interview on 06/27/2025 at 12:53 PM, Staff F, Minimum Data Set/Licensed Practical Nurse, stated the Upper Extremity was coded incorrectly. During an interview on 07/02/2025 at 12:53 PM, Staff B, Director of Nursing Services (DNS), stated the expectation was the MDS assessments were coded accurately. Reference WAC 388-97-1000 (1)(b) .

Based on interview and record review, the facility failed ensure a care plan was reviewed and revised timely for 1 of 3 sampled residents (Resident 95) reviewed for accidents related to falls. Failure to timely revise/update Resident 95's care plan after a fall placed the resident at risk of subsequent falls, injuries, unmet needs, and a diminished quality of life Findings included . Review of the facility's policy and procedure titled, Incident Documentation and Investigation, revision dated 10/2022, showed an incident report was to be completed for falls, and Interventions implemented to prevent future events and address resident care needs. Review of the electronic health record (EHR) showed Resident 95 admitted to the facility on [DATE] with diagnoses to include respiratory failure, hemiplegia (paralysis/loss of muscle function) and hemiparesis (partial paralysis or muscle weakness) of one side of the body following a stroke (blood flow to the brain suddenly interrupted). Resident 95 was able to make needs known. During an interview on 06/25/2025 at 10:33 AM, Resident 95 stated they had fallen out of their wheelchair when trying to get back into bed. Review of the facility's incident report log dated June 2025 showed Resident 95 had a fall in their room on 06/19/2025. Review of Resident 95's care plan, dated 05/09/2025, showed no interventions had been created/initiated after the resident's fall on 06/19/2025. During an interview on 06/27/2025 at 11:49 AM, Staff E, Resident Care Manager (RCM), stated Resident 95's care plan did not meet their expectations because it did not show interventions were put into place after the resident's fall on 06/19/2025. Staff E stated interventions should have been put into place on Resident 95's care plan shortly after the fall on 06/19/2025 or within the three-to-five-day window period to prevent subsequent falls. Staff E stated the delay in initiating interventions after Resident 95's fall did not meet expectations. During an interview on 06/27/2025 at 12:07 PM, Staff B, Director of Nursing Services, stated Resident 95's care plan was not updated timely after the resident's fall on 06/19/2025, and should have been. Please refer to F610 for additional information. Reference WAC 388-97-1020 2(c)(d), 5(b) .

Resident 34 Resident 34 admitted to the facility on [DATE] with diagnoses that included aphasia (a language disorder that affects communication due to brain injury or stroke) chronic obstructive pulmonary disease (an ongoing lung condition caused by damage to the lungs) depression and dementia (a decline in mental ability that interferes with daily life). Resident 34's daily decision making was severely impaired. Review of Resident 34's EHR showed a provider's order dated 03/24/2022, for citalopram (an antidepressant medication) for major depressive disorder. The EHR also showed a provider's order, dated 02/20/2025, for Seroquel (an antipsychotic mediation) for dementia with behavioral disturbance. Observations on 06/25/2025 at 9:20 AM, 12:43 PM and 2:45 PM showed Resident 34 slept in bed. Observations on 06/27/2025 at 8:45 AM and 12:07 PM showed Resident 34 slept in bed. Observations on 06/30/2025 at 8:20 AM and 9:48 AM showed Resident 34 slept in bed. Review of Resident 34's EHR showed a provider's order dated 05/06/2022 to monitor sleep patterns and document number of hours of sleep every shift. Review of Resident 34's June 2025 MAR on 06/30/2025 at 10:45 AM showed the dayshift hours for sleep had been completed with number two prior to the completion of the staff's shift. Review showed documentation of zero hours of sleep on dayshift for 06/03/2025, 06/11/2025, 6/17/2025, and 06/25/2025. During an interview on 06/30/2025 at 10:59 AM, Staff G, Licensed Practical Nurse (LPN), stated day shift hours were from 6:00 AM to 6:00 PM. Staff G stated they documented sleep hours during their first break which was usually at 11:00 AM. During an interview on 06/30/2025 at 11:35 AM, Staff D, RCM/LPN, stated nursing staff should only be documenting sleep monitoring at the end of their shift for accuracy. During an interview on 07/02/2025 at 3:57 PM, Staff B, DNS, stated the expectation was that all monitoring was to be documented at the end of shift and reflect the accurate amount of hours Resident 34 slept. Reference WAC 388-97-1060 (3)(k)(i) Based on observation, interview, and record review, the facility failed to ensure nursing staff were following provider's orders for medication administration or sleep monitoring for 3 of 5 sampled residents (Residents 34, 74 and 98) when reviewed for unnecessary medication use. This failure placed the residents at risk of having adverse side effects, medication errors and unmet care services. Findings included . Resident 74 Review of the electronic health record (EHR) showed Resident 74 was admitted to the facility on [DATE] with diagnoses to include quadriplegia (paralysis that affects the ability to move upper and lower body), dependance on vent (person relies on mechanical ventilator to breath), depression and anxiety. Resident 74 was able to communicate needs. Review of the medication administration record (MAR) for June 2025 showed Resident 74 had an order dated 04/01/2025 for midodrine (medication given for low blood pressure) to be given three times a day and to hold when systolic (upper number) blood pressure (SBP) was above 120. Review of the June MAR showed Resident 74 was administered midodrine four times when their SBP was above 120. Review of May 2025 MAR showed Resident 74 was administered midodrine on two occasions (27 and 28th) despite the SBP been above 120. During an interview on 06/30/2025 at 9:40 AM, Staff O, Resident Care Manager/Licensed Practical Nurse (RCM/LPN), reviewed the EHR for Resident 74 and stated the nurses were to follow the providers orders, and hold the medication. During an interview on 07/02/2025 at 10:26 AM, Staff B, Director of Nursing Services (DNS), stated Resident 74's blood pressure medication administration did not meet expectations. Resident 98 Review of the EHR showed Resident 98 was admitted to the facility on [DATE] with diagnoses to include metabolic encephalopathy (brain disorder caused by chemical imbalances), anxiety and depression. Resident 98 was able to communicate their needs. Review of the MAR for June 2025 showed Resident 98 had an order dated 06/05/2025 for lidocaine cream five percent to lower back four times a day, and a second order dated 06/16/2025 for lidocaine four percent to lower back four times a day. During an interview on 06/26/2025 at 12:44 PM, Staff D, RCM/LPN, stated the nurses that took the order for lidocaine four percent should have followed the provider's instruction and discontinued the lidocaine five percent order. Staff D stated Resident 98 was on lidocaine four percent. During an interview on 07/02/2025 at 10:29 AM, Staff B, DNS, stated Resident 98's orders did not meet expectations.

Based on observation, interview, and record review, the facility failed to apply a brace/splint (a device used to immobilize and support a body part) and an offloading boot (a specialized orthopedic device designed to reduce wight bearing pressure on a specific area of the foot or ankle) per provider orders and comprehensive care plan for 1 of 4 sampled residents (Resident 95) reviewed for position/mobility. These failures placed Resident 95 at risk for medical complications, unmet needs, and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 95 admitted to the facility on [DATE] with diagnoses to include respiratory failure, hemiplegia (paralysis/loss of muscle function) and hemiparesis (partial paralysis or muscle weakness) of one side of the body following a stroke (blood flow to the brain suddenly interrupted). Resident 95 was able to make needs known. Multiple observations on 06/25/2025 at 10:39 AM, 06/25/2025 at 2:42 PM, 06/26/2025 at 12:59 PM, 06/27/2025 at 8:10 AM, 06/27/2025 at 12:33 PM, and 06/30/2025 at 9:01 AM showed Resident 95 with no brace/splint and/or an offloading boot in place. During an interview and observation on 06/27/2025 at 12:33 PM, Resident 95 stated they had no brace/splint, or anything applied to their feet. Resident 95 stated they could not remember the last time they wore a brace or an offloading boot. Resident 95 stated they usually wore non-skid socks or tennis shoes when up in their wheelchair. There were no foot brace/splint or offloading boots visible in Resident 95's room. Review of Resident 95's June 2025 treatment administration record (TAR) showed an order with a start date of 05/09/2025 to apply a left foot brace splint every shift for protection. Review showed an order with a start date of 05/09/2025 for an offloading boot to be applied to the left foot every shift for skin protection. Documentation showed both orders were documented as completed per provider orders. Review of the care plan initiated on 05/09/2025 of Resident 95's focused care plan for Dressing, performance deficit due to left sided weakness, included an intervention which showed, Make sure shoes are comfortable and not slippery. Resident prefers to wear brace and offloading boots. Review showed interventions dated 05/12/2025 for brace to left foot, and offloading boot when in bed. Resident 95 had a Bed Mobility focused care plan with an intervention dated 05/09/2025 that showed the resident was dependent on one person assistance with bed mobility. During an interview and observation on 06/30/2025 at 9:04 AM, Staff P, Certified Nursing Assistant, stated Resident 95 did not wear a brace/splint or a boot on their feet; but, if they did it would be on their care plan and Kardex (directions and information to provide care). Staff P stated Resident 95's Kardex showed that the resident was to have a brace to the left foot, preferred to wear a brace and offloading boots, and they had not been aware of this previously. Staff P stated Resident 95 did not have anything on their feet; however, they were able to locate a brace on the bottom of Resident 95's closet. Resident 95 told Staff P they could not recall the last time they had the brace on and that the brace was to be applied to the left foot. During an interview and observation on 06/30/2025 at 9:56 AM, Staff E, Resident Care Manager, stated Resident 95 had an ankle-foot orthotic (AFO, brace) on their left foot; however, they were unable to locate an offloading boot. Staff E asked Resident 95 if they ever wore a pillowy boot/offloading boot. Resident 95 responded by saying yes, but did not know what happened to it. Staff E removed Resident 95's brace and stated the resident should have an offloading boot on the left foot when in bed and the brace/AFO when up in their wheelchair. In continued interview on 06/30/2025 at 9:56 AM, after reviewing Resident 95's June 2025 TAR, Staff E stated the resident's orders for brace and offloading boots were documented that they were in place; however, the orders needed to be clarified with the provider because Resident 95 cannot wear the brace and offloading boot on the left foot at the same time. Staff E stated nursing should have written refusal on the TAR if Resident 95 refused to have the brace and offloading boot in place. Staff E stated the care plan showed Resident 95 was to have the brace/splint to the left foot and the offloading boot when in bed and that did not happen for Resident 95. During an interview on 06/30/2025 at 12:10 PM, Staff B, Director of Nursing Services, stated their expectation was provider's orders to be followed, and care plans implemented. Staff B stated they had not been aware Resident 95's offloading boot was missing, and their brace had not been in place on their left foot per provider's order. Staff B stated nurses should have verified placement and documented in the EHR if Resident 95 had refused to wear their brace and/or offloading boot and not document the devices were in place if they were not. Reference WAC 388-97-1060 (1) .

Based on observation, interview, and record review, the facility failed to provide an environment conducive to healing of a pressure ulcer for 1 of 3 sampled residents (Resident 37) when reviewed for pressure ulcer. This failure placed residents at risk of difficulty healing, worsening pressure ulcers, and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 37 readmitted to the facility on [DATE] with diagnoses to include chronic kidney disease, diabetes (too much sugar in the blood), and depression. The resident was able to make needs known. During an interview and observation on 06/24/2025 at 12:52 PM, Resident 37 stated they had a pressure ulcer (PU) on their heel which had started as a bruise. Observation showed Resident 37's feet touched the footboard of the bed, there was a gap between the mattress and the footboard, and there was a rolled-up blanket in the gap. Resident 37 stated their feet always touched the footboard, but the facility did not have a longer bed. Observation on 06/25/2025 at 11:39 AM showed Resident 37 sat in bed with their legs bent to the right sides and balls of their feet pressed against the footboard. Observation and interview on 06/30/2025 at 12:20 PM showed Resident 37 laid in bed with their feet touching the footboard. Resident 37 stated they were 75 and a half inches tall (6'3.5). Observation on 07/02/2025 at 9:03 AM showed Resident 37 in bed with an inflatable boot applied to the foot with the PU which kept it from pressing against the footboard. Review of Resident 37's provider's orders, dated 06/18/2025, showed for staff to ensure Resident 37's mattress function and their body position while in bed. During an interview on 07/02/2025 at 9:06 AM, Staff D, Resident Care Manager, stated PU development was investigated by creating a risk management. Staff D stated feet pressing against a footboard could be a factor in PU development. Staff D stated Resident 37 was 75 inches tall (6'3) and they were unaware the resident's feet touched the footboard. Staff D stated Resident 37's footboard should have been included in a risk management to rule it out as a factor in the resident's PU development. During an interview on 07/02/2025 at 2:24 PM, Staff B, Director of Nursing Services, stated PU development was investigated with an incident report to determine the root cause. Staff B stated feet pressing against a footboard could be a factor in developing a PU and should be considered in the incident report. Staff B stated the facility should have implemented interventions to ensure Resident 37's foot did not press against the footboard prior to 07/02/2025. Reference WAC 388-97-1060 (3)(b) .

Based on observation, interview, and record review, the facility failed to ensure enteral nutrition (the delivery of nutrients through a feeding tube directly into the stomach or small intestine) was managed in accordance with provider's orders and professional standards of practice to ensure correct placement prior to administering medications, manage the amount of fluids received and implement as needed (PRN) provider's orders for 4 of 4 sampled residents (Residents 33, 73, 77, and 7) reviewed for enteral nutrition. Resident 33 experienced harm when there was no evaluation of whether staff was administering the as needed medication to prevent clogging of a feeding tube or whether additional interventions were needed to prevent the resident from being transferred to the local emergency department four times between 08/04/2024 to 09/10/2024. These failures placed residents at risk for receiving inadequate nutrition and hydration, weight loss, hospitalization , and a decreased quality of life. Findings included . Review of an industry accepted resource for professional standards, Lippincott Manual of Nursing Practice, 11th edition showed the following three recommendations for enteral feeding tube obstruction: flush tube every four hours with 30 milliliters (ml,cc) of water and after administration of medications, administer medications in liquid form if possible; crush medications finely, and attempt to declog by administering water first. If unsuccessful, then administer pancreatic enzyme. Resident 33 Review of the electronic health record (EHR) showed Resident 33 admitted to the facility on [DATE] with a diagnosis of acute and chronic respiratory failure with a tracheostomy (an opening into the neck for breathing) and was receiving nutrition through a jejunostomy tube (J-tube, a tube inserted through the abdomen and stomach into the small intestine). During an interview on 09/12/2024 at 4:45 PM, Collateral Contact 1 (CC1) stated Resident 33 had been to the hospital three times in August because the J-Jube was clogged and needed to be replaced. CC1 stated the facility staff were not providing care to prevent it from clogging. Review of the feeding tube care plan dated 04/25/2023 showed an intervention to administer Viokace (a pancreatic enzyme that helps dissolve clogs) as needed for de-clogging. Review of a provider's order dated 05/26/2024 showed staff were to check placement of the J-tube prior to administering medications, fluids and food by listening during a 20 milliliter (mL, cc) instilled puff of air using a 60 cc syringe or check residual (a practice of checking for extra formula in the stomach, not traditionally used in j-tubes) every shift. Review of the provider's orders showed an order dated 05/26/2023 for Viokace tablet every 24 hours as needed for clogged feeding tube. Review of the medication administration record for August and September 2024 showed no documented PRN administrations. Review of the EHR showed Resident 33 had been transported to the hospital for J-tube replacement related to a clogged J-tube on 08/04/2024, 08/15/2024, 08/27/2024 and 09/10/2024. The EHR did not show documentation of implemented interventions to unclog the tube prior to transport. Observation on 09/17/2024 at 10:46 AM showed Staff S, Registered Nurse, entered Resident 33's room with a clear cup with multiple crushed medications in liquid. There was visible particles in the bottom of the cup. Staff S flushed the J-tube with 30 cc of clear water using a 60 cc syringe. They did not check for residual or instill 20 cc of air to check placement prior to administering the crushed medications. Staff S stated when the tube got clogged, they used a manual de-clogging device. During an interview on 09/18/2024 at 11:09 AM, Staff B, Director of Nursing Services (DNS), stated it was their expectation that staff checked placement of enteral feeding tubes prior to administering medications and implement PRN interventions per provider's orders. During an interview on 09/23/2024 at 1:21 PM, Staff C, Assistant Director of Nursing (ADON), stated it was their expectation that staff administered PRN medications to prevent complications per provider's orders. Staff C stated staff not attempting to use Viokace prior to sending the resident out to the emergency room did not meet expectations. Staff C stated that the order for Viokace should have been clarified with the pharmacy, and staff made aware of the intervention, and it was possible that Resident 33 may not have needed to be sent to the emergency roiagnom on [DATE], 08/15/2024, 08/27/2024 and 09/10/2024 if they had followed the provider's order. 50945 Resident 7 Review of the EHR showed that Resident 7 was admitted on [DATE] with diagnoses of brain damage and vegetative state. The Medicare 5-day minimum data set assessment, dated 09/05/2024, showed Resident 7 was dependent on staff for care and required a gastric tube for nutrition. Review of Resident 7's provider's orders showed an order, dated 08/29/2024, for staff to administer 30 cc of water before and after medication administration. Review showed Resident 7 had an order for a goal intake of 1500 cc formula and 600 cc water. Observation on 09/16/2024 at 9:28 AM showed a licensed nurse paused and disconnected the tube feed for Resident 7, provided a 30 cc flush, administered medications, then reconnected and resumed the tube feed. No flush was observed after the medications were given. Review of Resident 7's administration record for formula and water showed, from 09/03/2024 - 09/13/2024, Resident 7 did not reach their goal for formula and only once met their goal for water. On 09/09/2024, Resident 7 was recorded to receive 631 ml of formula and 335 ml of water. During an interview on 09/18/2024 at 8:37 AM, Staff C, ADON, stated staff should have charted why Resident 7 did not receive the full amount of their ordered formula and water, notified the provider, and notified the family member. During an interview on 09/18/2024 at 10:06 AM, Staff B, DNS, stated it did not meet expectations that Resident 7 was observed to be given medications without a flush given afterwards, nor did the recorded intake of formula/fluids for September 2024 meet expectations. 49926 Resident 73 Review of the EHR showed Resident 73 admitted to the facility on [DATE] with a diagnosis of acute and chronic respiratory failure with a tracheostomy and was receiving nutrition through a gastric tube (a tube inserted through the abdomen and stomach). Observation on 09/16/2024 at 8:46 AM showed Staff AA, Licensed Practical Nurse, prepared multiple crushed medications in liquid. There were visible particles in the bottom of the cup. Staff AA flushed the gastric tube with 10 cc of water using a 60 cc syringe. They did not check for residual or instill 20 cc of air to check placement. Staff AA then administered the crushed medications using the 60 cc syringe, flushed with 30 cc of water and reconnected the tube to the pump. Resident 77 Review of the EHR showed Resident 77 admitted to the facility on [DATE] with diagnoses of persistent vegetative state and respiratory failure and received nutrition through a gastric tube. Observation on 09/16/2024 at 9:12 AM showed Staff V, Registered Nurse, prepared two crushed medications for Resident 77. During the attempt to flush the gastric tube, fluids sprayed in the air onto the nurse and resident. Staff V obtained assistance from a different nurse and a physical declogger (device used to declog gastric tubes) was used to open the gastric tube. Staff V then flushed the gastric tube with 60 cc of water, administer the crushed medications, and flushed with 30 cc of water using the 60 cc syringe. Staff V did not check for residual or instill 20 cc of air to check placement. During an interview on 09/17/2024 at 10:23 AM, Staff B, Director of Nursing Services, stated it was their expectation that staff checked placement of enteral feeding tubes prior to administering medications and implemented PRN interventions per provider's orders. During a follow-up interview on 09/18/2024 at 10:51 AM, Staff B stated nurses checked placement by checking residuals of the gastric tubes. Reference WAC 388-97-1060 (3)(f)

Based on interview and record review, the facility failed to address a new skin pressure injury, failed to notify the provider timely and failed to implement wound treatment orders timely for 1 of 5 sampled residents (Resident 1) reviewed for pressure ulcers (injuries to skin and underlying tissue resulting from prolonged pressure on the skin). Resident 1 experienced harm when they developed a facility acquired pressure ulcer which deteriorated and became infected. This failure placed other residents at risk for development and/or worsening of wounds, infection, and medical complications. Findings included . Review of the facility's policy titled, Skin at Risk Overview, revised on 04/2018, showed 4. An appropriate treatment order will be obtained from the resident's physician and implemented when a wound is identified. Resident 1 was admitted to the facility on [DATE] with diagnoses of heart and respiratory failure. The admission Minimum Data Set (MDS), an assessment tool, dated 01/04/2024, showed the resident had no pressure ulcers and required partial to substantial assistance by one staff for activities of daily life. Record review of Resident's 1 Point of Care (POC) charting, dated 01/09/2024, showed the nursing aide staff documented an open wound to the buttocks. Review of the electronic health record (EHR) showed no further documentation of the skin injury (noted on 01/09/2024) until 01/12/2024, when a provider note documented a pressure injury of sacral region (bottom of the spine), stage 1 (intact skin with non-blanchable redness) secondary to shearing (tissue layers move over the top of each other causing blood vessels to stretch and break). Offload and reposition every 2 hours and as needed. Apply zinc as needed. No corresponding orders were available for review or documented as implemented. Review of a nurse progress note, dated 01/14/2024, showed Wound care provided by the assigned wound care nurse, tolerated well. Review of the EHR did not show supporting documentation of the nurse visit or any wound treatment orders. Review of a contracted wound care company note, dated 01/17/2024, showed surgical wound debridement (the removal of damaged tissue) was performed on the sacrum (triangular bone located at the bottom portion of spine) and was now a stage 3 after debridement. The wound measured 6.3 x 4.2 x 0.3 centimeters. The assessment/plan showed initial assessment of a new wound that is deteriorating. Debrided thick slough away. Concern for infection. Wound will be a stage 4 once full amount of slough removed. Treatment recommendations were written and included orders for additional problems, osteomyelitis workup, 2 view X-ray of sacrum, blood work. Review of Resident 1's care plan did not show a focus area for alteration in skin integrity until 01/23/2024, when a sacral pressure injury, dated 01/18/2023 (error in year, 2024) was added to the document. Treatment instructions for sacrum pressure injury were dated 01/19/2024. Review of the Treatment Administration Record (TAR), dated 01/12/2024 and 01/19/2024, showed a nurse documented Resident 1's weekly skin checks as negative for any new skin impairment. The instructions for a new condition were to document a progress note and initiate skin documentation form. Review of TAR, dated January 2024, showed the first day of treatment for the sacral injury was 01/20/2024, 11 days after staff identification of the wound by a care aide on 01/09/2024 and 3 days after the contracted wound care company's recommendations. On 01/24/2024, the TAR showed Resident 1 was sent to the local emergency department for sacral wound evaluation and osteomyelitis (bone infection). On 02/05/2024 at 12:30 PM, Staff D, Nurse Aide, said residents should be repositioned every 2 to 3 hours. Staff D said if during care, a new skin issue was observed, then it should be reported to the nurse and charted in the POC tasks that there was a new skin issue. On 02/05/2024 at 2:46 PM, Staff C, Resident Care Manager/Licensed Practical Nurse (LPN), said the care aide would report any new skin issues to the nurse. The nurse would then assess the skin issue. Staff C said a notification form would then be filled out to notify the provider and treatment nurse for any new orders related to the new skin issues. Staff C said if it fell under the right criteria, they would also notify the contracted wound care company. Staff C said an aide would document any new skin issues in POC and verbally tell the nurse at the time of the observation. Staff C said Resident 1 was on an alternating pressure mattress to assist in prevention of skin issues since admission. On 02/08/2024 at 12:07 PM, Staff B, Facility Wound Nurse/LPN, said on 01/12/2024 she was first alerted to a skin issue to Resident 1's sacrum. Staff B said she observed a red area with possible moisture associated skin damage (MASD) that appeared very superficial. Staff B said on 01/16/2024 she was alerted that the skin issue to Resident's 1 sacrum area had worsened. Staff B said this worsened area looked very different from 01/12/2024 and appeared to be complete eschar. Staff B said that she then notified the in-house provider and contracted wound care company practitioner and received orders for treatment. These orders were placed in the TAR on 01/19/2024. Staff B said treatment orders should have been placed on the TAR when the skin issue was first identified (10 days prior). At 1:15 PM, Staff A, DNS/Registered Nurse, said upon the observation of a new skin issue the provider and resident/resident representative should have been notified, orders obtained and entered into the EHR. Staff A said sometimes there was an initial skin report completed by staff and if the wound was significant, the contracted wound care company was asked to see the resident to provide recommendations. Staff A said this issue was brought to her attention once Resident 1 was admitted to the hospital and declined to return to the facility. Staff A said they changed the admission process because they discovered that staff stated they were having trouble with repositioning some residents related to refusals. Staff A said they made other changes too, that should help identify and prevent further skin issues. Reference WAC 388-97-1060 (3)(b)

Based on interview and record review, the facility failed to ensure residents received medications as ordered and notify the provider and resident/resident representative timely of missed medication for 1 of 7 sampled residents (Resident 1) reviewed for significant medication errors. This failure resulted in harm to Resident 1 who experienced a sudden decline in condition that included the inability to swallow and being in an unresponsive state. This failure prevented Resident 1's decision maker from being fully informed of Resident 1's change in condition prior to a transition onto Hospice Service. Findings included . According to the pharmaceutical manufacturer's website titled, Rytary (carbidopa and levodopa) extended release [an extended-release medication used for Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow imprecise movements)] dated 12/2019 stated, Avoid sudden discontinuation or rapid dose reduction of Rytary. The daily dose of Rytary should be tapered at the time of the treatment discontinuation. The subcategory titled, Important Safety Information stated, A symptom complex that resembles neuroleptic malignant syndrome (characterized by elevated temperature, muscular rigidity, altered consciousness, and autonomic instability), with no other obvious etiology, has been reported in association with rapid dose reduction, withdrawal of, or changes in dopaminergic therapy [the regulation of levels of the neurotransmitter dopamine (chemical in the brain)]. Review of Resident 1's significant change Minimum Data Set (MDS), a required assessment tool, dated 12/14/2023, showed that Resident 1 admitted on [DATE] with diagnosis of Parkinson's disease. The MDS showed Resident 1 was severely cognitively impaired and relied on staff to meet their needs. Review of Resident 1's electronic medication administration record (eMAR), dated December 2023, showed an order for Rytary Extended Release. The eMAR documented the resident did not receive the 26 doses of Rytary between the dates of 12/08/2023-12/12/2023. The missed doses occurred on: - 12/08/2023 at 00:00 AM, 3:00 AM, and 3:00 PM. - 12/09/2023 at 9:00 AM, 12: 00 PM and 3:00 PM. - 12/10/2023 at 3:00 AM, 6:00 AM, 9:00 AM, 12:00 PM, 3:00 PM, 6:00 PM, and 9:00 PM. - 12/11/2023 at 00:00 AM, 3:00 AM, 6:00 AM, 9:00 AM, 3:00 PM, 6:00 PM, and 9:00 PM. - 12/12/2023 at 00:00 AM, 3:00 AM, 6:00 AM, 3:00 PM, 6:00 PM, and 9:00 PM. The electronic health record (EHR) for Resident 1 documented: - Awaiting medications to arrive from pharmacy on 12/09/2023 at 11:11 PM and 11:12 PM. - Awaiting pharmacy on 12/10/2023 at 4:15 AM and 6:48 AM. - Medication not in facility on 12/10/2023 at 2:07 PM and 2:08 PM. - Pharmacy states will send on night delivery on 12/10/2023 at 3:00 PM. - Drug not available on 12/11/2023 at 00:04 AM. - Not available from pharmacy on 12/11/2023 at 00:10 AM. - On-call doctor notified on 12/11/2023 at 00:52 AM. - On-call provider notified on 12/11/2023 at 1:17 AM and 3:54 AM. - Pharmacy called and on-call notified on 12/11/2023 at 5:12 AM. - Pharmacy called about delivery on 12/11/2023 at 10:45 AM. - Pharmacy contacted and provider notified on 12/11/2023 at 12:01 PM. - On order on 12/11/2023 at 2:54 PM and 6:22 PM. Review of progress note, dated 12/12/2023, showed a provider's acute assessment for Resident 1. The note documented, Nursing reported patient unable to swollow meds. Referral placed to hospice .Will call and discuss condition with patient's husband. The EHR for Resident 1 documented on 12/12/2023 provider orders for: - STAT chest x-ray, Complete Blood Count (CBC), Basic Metabolic Panel (BMP), COVID-19 test (infectious disease caused by the SARS-CoV-2 virus) - Oxygen at 2 liters per minute (LPM) via nasal cannula and titrate as needed for comfort - Speech therapy to eval and treat as needed - Diet downgraded to puree texture - 2 liters of 0.9% normal saline via hypodermoclysis administration (a method of infusing fluids into subcutaneous tissue that is suitable for mildly to moderately dehydrated adult patients, especially the elderly) with repeat BMP at end of administration. Review of progress note, dated 12/13/2023 showed Resident 1 was in bed, difficult to arouse. Resident 1 was trying to open her right eye. The note documented, continue shaking throughout the night nonstop. The EHR for Resident 1 documented on 12/13/2023 provider orders for: - Initiation of comfort medications-Morphine (narcotic used for pain control and/or air hunger) and Lorazepam (antianxiety medication used for terminal restlessness) - Discontinuation of all other medications by mouth. - Hospice (care for the terminally ill) referral Review of progress note, dated 12/14/2023, showed Resident 1 had an elevated temperature two days earlier on 12/12/2023 at 7:12 PM. Review of progress notes, dated 12/12/2023 to 12/14/2023, of an Interdisciplinary Team (clinical leadership meeting) and two provider assessments, showed Resident 1 had a change in condition but did not document Resident 1 had missed several doses of Rytary medication. The EHR for Resident 1 documented, on 12/14/2023, Hospice Service provided Resident 1 a plan of care. On 01/04/2024 at 11:09 AM, Staff B, Licensed Practical Nurse (LPN), said if a resident did not have a card of medication needed for the medication pass and it was not a narcotic, she would go to the Omnicell (an automated medication dispensing system) and see if the medication was stocked. If the Omnicell had the medication, then it would be pulled and administered. Staff B said she would notify the pharmacy that a refill was needed. Staff B said if she was unable to pull the needed medication from the Omnicell she would reorder the medication from the pharmacy. Staff B said she would notify the provider that the medication was unavailable for administration and see if any new orders were given. Staff B said she would notify family that the medication was unable to be given and of any new orders the provider might have given. Staff B said she would then put a note in the resident's chart and pass the information on in report for charting purposes. At 11:20 AM, Staff C, Resident Care Manger (RCM)/LPN, said she would expect the floor nurse to be checking on Point Click Care (the electronic health record system) to see if a missing medication had been ordered. If not ordered, then the floor nurse should click re-order. If the medication had been reordered and not in the cart, Staff C said the floor nurse should call the pharmacy to find out if there was a problem and the estimated time of arrival. If the dose was missed altogether, the provider and resident or resident representative would be notified. If the provider gave any new orders related to the missed medication, then those orders would be processed and reviewed with the family. The floor nurse would write the missed medication on the 24-hour report log for review during the morning clinical meeting. The resident would then be put on alert status and the resident charted on each shift. Staff C said that on the weekdays she tried to look for any missed medications using point click care and will follow up on them on her own because the nurses did not always update the 24-hour report. At 12:14 PM, Staff A, Director of Nursing Services (DNS)/Registered Nurse (RN), said if there was a missing medication, she expected the nurse to check to see if the medication had been ordered and if not, then order it. Staff A said she expected the pharmacy to be called to find out if there was an issue (such as insurance denying coverage) and try to resolve that issue so pharmacy could deliver the medication. Staff A said that she would expect the provider to be notified the same day as the missed dose is marked as unadministered by either a phone call or through a situation/background/assessment/recommendation form (SBAR). Staff A was asked how do you determine if there is a significant medication error, Staff A said I do not feel we caused the error or were responsible for the error because we ordered the medication and pharmacy did not send it. Staff A was asked how do you decide when a medication error should be investigated, Staff A said, if its an in house issue we would look at the medication error for investigation but if its an error because of something outside of the facility that is not in our control. Staff A was asked if she would use the purple book decision tree as a resource to determine if there was a significant medication error, Staff A reiterated I do not feel we caused the error or were responsible for the error because we ordered the medication and pharmacy did not send it. At 12:43 PM, Staff A said the facility/corporation did not have policies for addressing when a medication was not available to be administered. Staff A said she confirmed this with her Regional Nurse. At 1:14 PM, Staff D, Nurse Practitioner (NP), said she was notified by nursing that the medication (Rytary) was not available due to pharmacy not delivering the medication on 12/11/2023 by floor staff. Staff D instructed nursing to call the pharmacy and have pharmacy bill the facility for the medication or request it to be satellited by another pharmacy for administration as soon as possible. Staff D said nursing reported that after speaking to pharmacy they would be sending the Rytary as soon as possible. Staff D said per progress notes, on-call provider was notified on 12/11/2023 at 00:52 AM and pharmacy promised delivery on 12/11/2023 at 1:20 AM. On 1/05/2024 at 4:03 PM, Collateral Contact A (CCA), said the facility never notified him that Resident 1 had missed any doses of Rytary or that the facility was having trouble obtaining Rytary from the pharmacy. CCA said he never had any trouble filling the medication when Resident 1 was at home; the insurance always covered it. CCA said he visited daily, and Resident 1 had more of a sudden decline, both physically and mentally. CCA said right up until three or four days before Resident 1 was placed on hospice, she was still active, getting up to her wheelchair, and was alert per her baseline. CCA said the last week, after her decline, Resident 1 was very sleepy, and he couldn't wake her up. CCA said Resident 1 just suddenly declined. CCA said Hospice contacted him about starting Hospice services for Resident 1. CCA said he thinks the facility contacted hospice who reached out to him. CCA said the Doctor never talked to him; he only talked to nursing staff. At that point Resident 1 was not very responsive at all and Hospice helped manage Resident 1's pain. CCA stated that when Resident 1 was at home, the neurologist told him it was not good for Resident 1 to miss any doses of Rytary because it could cause pain and stiffness. The facility staff told me Resident 1 could no longer take medication or swallow pills right around when she entered hospice care. CCA said it was because she was no longer swallowing. CCA said the facility never discussed missed doses of Rytary with him. Reference: WAC 388-97-1060(3)(k)(iii).

Based on observation, interview, and record review, the facility failed to ensure necessary care and services were provided to prevent the development of avoidable pressure injuries (PIs) for 1 of 3 residents (Resident 1) reviewed, when the facility failed to implement interventions and to re-evaluate the interventions or the resident's plan of care as multiple PIs developed. These failures caused harm to Resident 1 who developed multiple avoidable full thickness pressure injuries. Findings included . Review of the facility's Skin at Risk Program Overview policy, revised 04/2018, showed the facility would ensure that residents who entered the facility without a significant wound, would not develop wounds unless their clinical condition demonstrated the wound was unavoidable. A thorough assessment would be completed if a significant wound was identified, and appropriate treatment/care would be provided to promote wound healing. A care plan would be developed to address areas of risk identified on the Braden scale (standardized toll used to predict PI risk.) An avoidable PI meant the resident developed a PI and the facility likely failed to do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions consistent with the resident's needs, goals, and recognized standards of practice; monitor and evaluate the impact of interventions; and revise the interventions/approaches as appropriate. According to the National Pressure Injury Advisory Panel (NPIAP), undated, pressure injury stages are as follows: Stage 1 PI: Non-blanchable erythema (discoloration of the skin that does not turn white when pressed) of intact skin; Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 PI: Partial-thickness skin loss with exposed dermis (thick layer of living tissue below the surface layer of skin): The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. Stage 3 PI: Full-thickness skin loss in which adipose (fat) is visible in the ulcer and granulation (connective) tissue and epibole (rolled wound edges) are often present. Slough (dead tissue) and/or eschar (dry black, necrotic tissue) may be visible. The depth of tissue damage varies by location. Stage 4 PI: Full-thickness skin and tissue loss; Full-thickness skin and tissue loss with exposed or directly palpable fascia (connective tissue), muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible. Epibole, undermining and/or tunneling often occur. Unstageable: There is full thickness tissue loss in which the base of the ulcer is covered by at least 50% slough and/or eschar. Most of the wound bed cannot be seen and therefore cannot yet be staged. Moisture-associated skin damage (MASD) is caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate (drainage), mucus, saliva, and their contents. MASD is characterized by inflammation of the skin, occurring with or without erosion (breakdown) or secondary infection. The injury starts at the top layer of the skin and works inward leading to partial thickness skin loss. The tissue is pink or red in color. Resident 1 Resident 1 admitted to the facility on [DATE]. According to the 01/12/2023 admission Minimum Data Set (MDS, an assessment tool), the resident was cognitively intact, had a diagnosis of quadriplegia (the inability to voluntarily move the upper and lower parts of the body,) required extensive two-person assistance with bed mobility, was at risk for pressure injury (PI) formation, but did not have any PIs. Review of Resident 1's 01/06/2023 admission assessment showed the resident had a chronic indwelling urinary catheter (a flexible tube inserted through the urethra into the bladder, used to empty urine from the bladder into a collection bag), was at risk for development of PI related to decreased sensation and dependence on staff for turning and repositioning due to quadriplegia. Resident 1 was assessed to be alert and oriented to person, place, time, and situation. Review of Resident 1's admission skin assessment showed the resident had no MASD or PIs and normal skin turgor (the ability of skin to change shape and return to normal, skin elasticity.) Resident 1's skin had no obvious problems with exception of a 0.2cm (centimeters) x 0.5cm x0.1 cm skin tear to a left toe. Review of the Resident 1's baseline care plan (process for development of an initial person-centered care plan within the first 48 hours of admission, that will provide instruction for care of the resident) showed Resident 1 required two-person assistance with bed mobility and was dependent on staff for transfers. A potential for alteration in skin integrity care plan, initiated 01/06/2023, directed staff to float/offload Resident 1's heels, avoid keeping the resident's head of bed higher than 30 degrees, keep hands and body parts from excessive moisture, and to notify the nurse of any skin changes. Additionally, the care plan directed staff to place disposable absorbent pads under Resident 1 in bed or in the wheelchair to decrease moisture, as Resident 1 did not wear briefs. Review of Resident 1's comprehensive care plan showed an activities of daily living care plan, initiated 01/06/2023, showed Resident 1 required two-person assistance with bed mobility. Review of a 01/25/2023 provider note showed Resident 1 was seen for a new skin issue. Resident 1was assessed with a 2 cm by 1.5 cm Stage 2 PI to the posterior scrotum. The documentation showed Resident 1 was frustrated about the skin breakdown and was referred to wound care for management of their Stage 2 PI. Review of the facility's 01/25/2023 investigation showed the facility completed an initial Non-Pressure Skin Condition (NPSC) assessment, on 01/25/2023. The assessment identified Resident 1 was high risk for PI development. It identified Resident 1 had a 2 cm x 1.5 cm open area to the posterior scrotum and with the surrounding skin appearing normal for skin with no maceration (the softening and breaking down of skin resulting from prolonged exposure to moisture) identified. Review of a 01/30/2023 Braden assessment (a standardized tool used to predict pressure ulcer risk) showed Resident 1 was High Risk for development of PIs secondary to highly impaired sensation and requiring two person extensive assistance with turning and repositioning. Review of Resident 1's 02/01/2023, 02/10/2023 and 02/15/2023 NPSC assessments showed the facility classified the open area on the scrotum as MASD and assessed the surrounding skin as Normal for skin without any moisture or maceration noted. Review of the 02/22/2023 NPSC assessment showed that the open area to the scrotum had resolved. Review of a 03/01/2023 provider wound note showed Resident 1 had a new 0.5 cm x 2 cm partial thickness open area to their right buttock/scrotum. The wound had no drainage and was classified as MASD New acute complicated problem and recommended Pressure Relief: Repositioning, offloading, per facility protocol. Review of a 03/13/2023 provider note showed Resident 1 had a Stage 2 PI to their scrotum which was to be cleansed with gentle cleanser and saline and dried completely twice daily. Zinc cream (treatment for skin irritation) was to be applied after each brief change. Review of three other provider notes from March 2023 showed wound became larger with exposed tissue. All three provider notes recommended Pressure relief, reposition, and off loading per facility protocol yet that was never added to the care plan. Review of the 04/05/2023 provider wound note showed, Resident 1's full thickness wound to the right buttock/scrotum continued to decline and now the wound base was assessed to be 100% slough. A surgical wound debridement (skin around the sore or wound is cleaned and disinfected, and tissue removed) of the right buttock/scrotum wound was done and recommended Pressure Relief: Repositioning, offloading, per facility protocol. Review of a 5/31/2023 provider wound note showed that Resident 1's right buttock PU [pressure ulcer] was larger at 4cm x 2.2cm x 0.7 cm. Resident 1 was educated about sitting up in wheelchair for long hours and recommended: Pressure Relief: Repositioning, offloading, per facility protocol. Review of the 06/07/2023 provider wound note showed Resident 1's right buttock/scrotum had full thickness (Stage 3) PI to the right ischium (part of the pelvis that forms the lower and back part of the hip bone). The wound was surgically debrided and Pressure Relief: Repositioning, offloading, per facility protocol was recommended. Review of a 06/21/2023 provider note showed Resident 1 had breakdown on the sacrum which was classified as Pressure ulcer Sacrum and described an open area that measured 0.4 x 0.4 x 0.1 to the left ischium and a 3 cm x 1 cm x 0.1 cm open area to sacrum. The Stage 3 PI to the right ischium measured 3 cm x 2 cm x 1.6 cm and was surgically debrided. Review of a 07/26/2023 provider wound note showed Resident 1's wounds were assessed as follows: Stage 4 PI to right ischium measured 2cm x 2cm x 01cm, wound bed with exposed muscle/fascia; Stage 3 PI to the sacrum measured 4cm x 3.5cm x 0.2cm, wound bed was 51-75% slough. Surgical debridement on the sacrum and right ischium was performed. Review of a 08/02/2023 provider wound note showed Resident 1's wounds were assessed as follows: Stage 4 PI to right ischium measured 1.8cm x 2cm x 1cm, wound bed with exposed muscle/fascia; Stage 3 PI to the sacrum measured 5cm x 3cm x 0.2cm, with a wound bed that was 26-50% slough; Additionally, a new full thickness open area was identified to Resident 1's left trochanter (left hip) caused by an abscess which measured 1.5cm x 1.5 cm x 0.2 cm. The wound bed was 51-75% slough with exposed subcutaneous tissue. Surgical debridement on the right ischium, sacrum, and left trochanter was performed. During an observation and interview on 08/03/2023 at 08:37 AM, Resident 1 was observed laying on their back in bed with both heels floated utilizing heel lift boots. Resident1 stated that they had not been turned or repositioned since 4:00 AM. When asked how they were certain the last time was at 4:00 AM, the resident stated, I looked at the clock while motioning toward the wall at the foot of the bed. Observation showed there was a large, faced clock in clear view located on the wall. During observations on 08/03/2023 from 8:37AM- 11:32 AM, with intermittent interviews with Resident 1 at 8:49 AM, 9:29 AM, 9:36 AM, 9:50 AM, 9:58 AM, 10:28 AM, 10:47 AM, 11:15 AM, and 11:32 AM. Resident 1 remained supine in bed with their heels floated in heel lift boots during the three-hour time period, without staff offering/assisting Resident 1 to turn and reposition in bed. (Per Resident 1 it was 8 hours, as they reported the last time staff turned or repositioned them was 4:00 AM.) During an interview on 08/03/2023 at 10:47 AM, Resident 1 stated that they had been a quadriplegic for [AGE] years and had the same caregiver for [AGE] years, and never had any skin breakdown. According to Resident 1, they had developed three PIs since they admitted to the facility due to not being consistently turned and repositioned. Resident 1 said that they were supposed to be turned every two hours (left side, right side, back), but the facility did not have enough staff to consistently carry out their plan of care. During an interview on 08/07/2023 at 9:07 AM, Staff G, CNA, and Staff F, CNA, both acknowledged that Resident 1 had reported to them on several occasions that they had not been turned and repositioned per their plan of care, including recently. Neither Staff F nor Staff G was able to recall the time/date(s) of the allegations. During an interview on 08/07/2023 at 10:07 AM, Staff E, Patient Care Coordinator (PCC), confirmed Resident 1 had reported a few times that they had not been turned and repositioned. During an interview on 08/07/2023 at 10:07 AM, when asked how agency staff or facility CNAs knew what care a resident required, Staff E, PCC, stated that they would follow the instruction the resident's Kardex (a quick reference sheet of resident care needs) which is populated from a resident's care plan. When asked if Resident 1's comprehensive care plan instructed staff to turn and reposition Resident 1 Staff E stated, No. During an interview on 08/07/2023 at 11:29 AM, Staff B, Director of Nursing Services (DNS), stated that turning and repositioning residents who required assistance was a standard of practice and should have been incorporated into Resident 1's care plan., but acknowledged that did not occur. Refer to F-609 and F-610 Reference WAC 388-97-1060(3)(b)

Based on observation, interview and record review the facility failed to ensure liquid oxygen was stored according to fire safety code in two of three oxygen storage rooms (the 100 hall), and failed to secure hazardous chemicals and cover exposed live wires in one of three hallways (the 400 hall). In addition the facility failed ensure new interventions were implemented after a fall for one of four Sampled Residents (#86) reviewed for accidents. The failure to secure liquid oxygen placed the facility at risk for fire. This failure resulted in an immediate jeopardy for the safety of all residents, family, visitors and staff. The failure to secure chemicals and cover exposed wires, had the potential to put residents at risk for accidents and injuries. In addition the failure to implemented new interventions after a fall placed Resident #86 at risk for continued falls and potential injury. Finding included . OXYGEN ROOM Record review of the Airgas USA, LLC titled Safety Data Sheet section 2 Hazards Identification showed that oxygen should be stored in a well-ventilated place. Observation on 07/11/17 at 8:51 AM, the oxygen room on the 100 hall was found unlocked of which the door knob did not have the capability to be locked. This oxygen room was 10 feet long, 2 ½ feet wide x 8 feet high, with a linoleum floor. The ventilation in the oxygen room brought air inward verses outward. The oxygen room did not have the required signage posted: -No smoking -Transmission (showing that empty oxygen tanks were in the process of being filled with oxygen) Observation on 7/11/17 at 9:33 AM, showed one of two oxygen rooms located in the basement was unlocked and did not have a transmission sign posted. During an interview on 07/11/17 at 9:38 AM, Staff P, Licensed Practical Nurse (LPN)/ Resident Care Manager (RCM), stated that the oxygen rooms were not locked and no other supplies and or equipment was needed to fill the liquid oxygen tanks. Staff P, LPN/RCM, stated that she knew when the tank was full because it released a white mist. During an interview on 07/11/17 at 9:47 AM, Staff MM, Respiratory therapist (RT), when asked if the oxygen rooms are kept locked Staff MM, RT, stated No, it is always unlocked. During an interview on 07/11/17 at 9:58 AM, Staff NN, NAC, when asked if the oxygen rooms are kept locked Staff NN, NAC, stated No, it is always open. Observation on 07/11/17 at 12:10 PM, the oxygen room on the 100 hall remained unlocked and unsecured with inadequate ventilation. Observation on 07/11/17 at 2:44 PM, the oxygen room on the 100 hall remained unlocked and unsecured with inadequate ventilation. During an interview on 07/11/17 at 3:55 PM, Staff JJ, Respiratory Therapist (RT) Manager, stated that prior to the Pink Room (oxygen room on the 100 hall) being used to store and fill the liquid oxygen tanks the room was used to store oxygen concentrators and other nursing supplies. When asked if she thought the liquid oxygen stored on the 100 hall met all the requirements, Staff JJ, RT Manager, stated Yes. The facility was unaware of the dangers associated with the inadequate storage of liquid oxygen in the 100 hall. The room did not have the required concrete floor, a locking door, reverse ventilation and required signage posted. UNSECURED CHEMICALS Observation on 07/10/17 at 9:31 AM, during initial tour showed a spray bottle of a diluted bleach solution and a spray bottle of Murphey oil was found in an unlocked cabinet adjacent to the sink in the main dining room. The main dining room door was left open and was accessible to residents. Observation on 07/10/17 at 9:57 AM, on initial tour room 409 had a sign on the door that stated room under construction. Upon entering the room, there were multiple safety concerns observed: - 2 five gallon buckets of paint with unsecured lids. - Wall texturing (one spray can that stated on the label highly flammable and keep out of reach of children) - One of the electrical outlets was not covered which exposed live wires. - Room 409 had an adjoined bathroom to room 411 that housed two residents. The bathroom door to room 409 was not secured and gave easy access to enter room 409 through the bathroom. Observation on 07/10/17 at 9:57 AM, on initial tour, room 407 showed all electical outlet covers were removed exposing live wires. During an interview on 07/10/17 at 10:59 AM, Staff A, Administrator, stated that when a room is under construction/repairs the chemicals should be taken out of the room when maintenance is not in the room. Staff A, Administrator, stated that chemicals were kept locked in the maintenance area (a secured area). During an interview on 07/10/17 at 11:05 AM, Staff KK, Licensed Practical Nurse (LPN), stated that resident rooms under construction had a sign posted on the closed door and did not think the door locked. Materials were not supposed to be kept in the room unattended while under construction. Staff KK, LPN, stated that housekeeping kept the chemicals locked in their carts. During an interview on 07/10/17 at 11:13 AM, staff LL, Housekeeping Assistant, stated that chemicals were to be locked in the housekeeping closet or cart and that chemicals should not be left in a room unsecured. During an interview on 7/10/17 at 11:15 PM, Staff FF, Nursing Assistant Certified, (NAC) stated that she was unaware that there was chemicals located in room 409. During an interview on 07/10/17 at 11:17 PM, Staff HH, Maintenance Assistant, stated that the five gallon paint buckets and wall texturing spray was secured in the patients room behind a closed door. We post a sign on the door (the sign stated Attention resident, visitors and staff, this room is currently undergoing some repairs and routine maintenance. We apologies for any extra noise. It will be back in service quickly as possible, Thank you for your patience.). Staff HH, Maintenance Assistant, also stated that the aides were to ensure that no one goes into the room. During an interview on 7/10/17 at 11:35 AM, Student's CC, DD, and EE, Nursing Assistants, stated that that they were not provided any education on what to do with rooms that are under construction. They were unaware that there was unsecured chemicals located in room 409. During an interview on 7/10/17 at 11:24 AM, Staff A, Administrator, stated that the goal is to replace the electrical cover over the outlets in room 407 and one outlet uncovered in 409. Staff A, Administrator stated that she would secure the two rooms (407 and 409) until Staff HH, Maintenance Assistant, was able to replace the outlet covers. Staff A, Administrator, stated that chemicals will no longer be left unattended or unsecured in rooms. FALLS Quarterly MDS dated [DATE], showed Resident #86 readmitted to the facility from an acute hospital on [DATE] with multiple [DIAGNOSES REDACTED]. MDS showed that Resident #86 had clear speech, had clear comprehension (understands), and had demonstrated verbal behavioral symptoms (screaming at others). MDS showed that Resident #86 required extensive assistance with bed mobility, locomotion in room and dressing. MDS also showed that Resident #86 was totally dependent on staff for transfers, locomotion out of room, eating, toilet use and personal hygiene. Record Review of facility's incident report log from April 2017 through May 2017, showed Resident #86 with the following incidents of non-injury falls from his bed in his room: February: 02/09/17 at 9:50PM April: 04/15/17 at 1:05AM April: 04/19/17 at 4:40PM May: 05/01/17 at 10:15AM May: 05/07/17 at 11:58AM May: 05/13/17 at 1:40PM May: 05/17/17 at 4:10AM Each incident listed above had a new intervention provided to prevent an injury from a fall except for the fall that occurred on 05/13/17. Incident report dated 04/15/17 showed new interventions were implemented that included an order on 04/19/17 for Halo bars (mobility bars) on both sides of the bed used to assist with repositioning. Review of Resident #86's medical record showed no assessment had been conducted for the Halo bars which placed the resident at risk for accidents. Record review of Resident #86's care plan included multiple interventions to prevent serious injury related to falls including an intervention revised on 04/20/17 showed do not leave resident unaccompanied in room when up in wheel chair. Observation on 07/14/17 at 9:51 AM, Resident #86 sat in wheelchair and watched TV next to his bed and was left unattended for about ten minutes with no staff around. During an interview on 07/19/17 at 11:06 AM, Staff GG, Housekeeping assistant, stated that she had seen Resident #86 up in his wheelchair quite a few times in the last two weeks by himself with just his roommate in the room. During an interview on 07/19/17 at 11:12 AM, Staff M, NAC, stated that Resident #86 is able to sit in his room in his wheelchair by himself. During an interview on 07/19/17 at 11:22 AM, Staff AA, Licensed Practical Nurse (LPN), stated that Resident #86 can be up in his wheelchair and watch TV by himself. During an interview on 07/19/17 at 11:30 AM, Staff B, Director of Nursing Services (DNS), was asked to provide proof of an assessment for Resident #86's order (on 04/19/17) for Halo bars. Staff B, DNS, did not provide an assessment for Resident #86's Halo bars. Staff B, DNS, was asked if any new interventions had been put in place after Resident #86's fall on 05/13/17 and she responded No, we did not. Staff B, DNS, was informed of Resident #86's care plan intervention for do not leave resident unaccompanied in room when up in wheelchair, had not been followed. Failure to implement new interventions after a fall, not conducting an assessment for an order for [REDACTED].#86 at risk for accidents and injury. Reference WAC: 388-97-1060

Based on observations, record review and interview, the facility failed to provide adequate supervision to ensure the correct diet was provided to 1 of 6 residents (#1) reviewed for altered texture diets. Resident #1 was at risk for choking related to a [DIAGNOSES REDACTED]. Resident #1 received an incorrect diet and was harmed when she experienced respiratory distress related to choking while eating. Resident #1 was transferred to the hospital in acute respiratory distress after attempts in the facility to clear the resident's airway were not successful. Findings include: All interviews and observations were completed on 11/20/14. At 9:15 a.m., Resident #1 was observed asleep in bed in her room. A tube feeding pump and pole were observed at the bedside. Staff C (licensed nurse) stated the resident received continuous tube feeding during the night with bolus feedings during the day. Review of Resident #1's hospital record dated 11/3/14 revealed the resident arrived in the emergency room in respiratory distress and was intubated (breathing tube inserted to assist with breathing). At the time of intubation, the physician "suctioned some solid matter out of her tube including what looked like a piece of steak". Review of Resident #1's facility record revealed she admitted to the facility during 9/2014. The resident had multiple [DIAGNOSES REDACTED]. Review of physician orders [REDACTED]. Review of a facility investigation dated 9/12/14 revealed Resident #1 had a choking episode while eating soft fruit (allowed on the prescribed diet). The resident was found cyanotic, holding her neck; staff completed the Heimlich maneuver which was successful. The resident's dysphagia mechanical diet was modified to include blended fruit. Review of a facility investigation dated 11/3/14 revealed Staff H (certified nursing assistant) served Resident #1 her lunch tray. Staff H passed by the resident's room, heard a noise and went into the room. According to Staff H's written statement dated 11/3/14 the resident was choking. Staff H called for help; Staff C (licensed nurse) responded and initiated emergency interventions including the Heimlich maneuver, suctioning and oxygen prior to emergency response personnel arrival. Resident #1 was transferred to the emergency room for further treatment. During interview on at 9:20 a.m., Staff C confirmed the above response and interventions attempted to clear Resident #1's airway. Staff C stated she could see noodles in the resident's mouth and could see that the resident was choking when she entered the room. At 9:50 a.m., interview with Staff D (dietary manager) revealed confirmation Resident #1 received the incorrect diet. Staff D stated "the meat for a dysphagia mechanical diet should be ground up, noodles are okay if soft; the cook (Staff G) served the incorrect meal and the staff that line-checked (Staff F), were both veteran employees. It was unfortunate and it should not have happened". Review of a written statement by Staff G included in the facility's investigation dated 11/3/14 revealed she stated she served regular texture to Resident #1 instead of mechanical dysphagia. Review of the menu for the lunch meal served on 11/3/14 revealed dysphagia mechanical diet included ground beef tips in gravy and egg noodles in gravy and a regular diet included beef tips in gravy and seasoned egg noodles. During interview at 10:15 a.m., Staff A (director of nursing) stated prior to Resident #1's incident on 11/3/14, it was the facility's expectation that staff checked meal trays for accuracy prior to serving to residents. She stated the facility had just completed all staff in-service on checking accuracy of diets several weeks prior to the incident. Following the incident on 11/3/14, Staff A stated in-service was provided to all staff about a policy change that required a licensed nurse and a second staff member to check every tray in the facility prior to serving the resident. Observations between 11:45 and 12:30 p.m. on 3 of 4 nursing care units and in the main and assisted dining rooms revealed staff were knowledgeable about the above policy change and implemented it accordingly. Observations of the tray line in the kitchen between 11:15 and 11:45 a.m. revealed three staff were involved in checking each tray for accuracy.

Based on observation interview and record review it was determined that the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial wellbeing when staff failed to provide thorough assessment and timely care to 1 of 3 residents (#1) reviewed. This failure caused harm when the resident was sent to the hospital with bleeding from the penis. Findings include: Resident #1 was admitted to the facility with multiple [DIAGNOSES REDACTED]. According to the facility's "event and occurrence report," dated 8/8/14, the resident's son stated the nurse who changed the residents Foley Catheter (a tube inserted into the bladder to drain urine) on 8/4/14 at 3:00 a.m., caused the problem that sent the resident to the hospital." Review of the record revealed a nursing note dated 8/4/14 which documented, "Foley catheter not draining and family requested to have it changed, Licensed Nurse changed catheter at 2:00 a.m. Resident with no urine in drainage bag at 8:00 a.m., with noted abdominal distension, urine noted in the brief and discomfort from resident. Foley balloon deflated and Foley Catheter removed, upon removal of catheter, bleeding noted from the penis, unable to stop bleeding, pressure applied, and 911 called. Resident transferred to the hospital." On 10/3/14 at 1:56 p.m., during an interview, the licensed nurse (Staff A) stated she went and checked on the resident. Staff A stated this happened before, and the resident will act a certain way when his catheter is not draining. According to Staff A the resident's abdomen was distended and she could tell the resident was hurting. On 10/3/14 at 2:38 pm., during an interview, the licensed nurse (Staff B) stated at 12:00 a.m. (two hours into the shift) he was called in the room by the family because the resident was restless and had not voided. Staff B went to check the drainage bag and noted no urine draining. He told the son they should wait for 2-4 hours and if there was no urine, then he would change the Foley Catheter. At 2 a.m., Staff B was called again by the son and was informed the resident was restless, and the drainage bag was without urine. The son opened the brief which was wet, and he noted urine draining around the catheter. Staff B removed the catheter to place a new one, and the son requested for the catheter to remain out. After checking the chart, Staff B inserted a new catheter at 4 a.m., due to the urologist order to keep the catheter in at all times. Staff B stated there was no urine return upon insertion of the urinary catheter. According to Staff B, if the resident had just voided, it could take up to an hour before there was urine output. Staff B went in the room again at 5:45 a.m. (1 ? hours later), and there was no urine draining into the drainage bag. Staff B stated he passed this information on to the charge nurse. When asked, Staff B stated normal urine output is 30cc's an hour. According to "Lippincott Manual of Nursing Practice" ninth edition, pp 780; 782-783, catherizations may be done to relieve acute or chronic [MEDICAL CONDITION] to determine the amount of urine after voiding... Insertion of a urinary catheter includes: When urine begins to flow, advance the catheter another 2.5 cm (1 inch). (Rational), advancing the catheter ensures its position in the bladder... Be sure catheter is draining properly before inflating balloon, then withdraw catheter slightly. (Rational), inadvertent inflation of the balloon within the urethra (a passage way for urine to flow) is painful and causes urethral trauma. Review of the hospital records dated 8/4/14, documented, "it would probably be a mistake, given the recent urethral trauma and bleeding to attempt a voiding trial now, but should be entertained after discharge." The nurse observed the drainage bag empty of urine two hours into his shift, and waited an additional 2 hours (a total of four hours) before thoroughly assessing the resident and removing the catheter. The nurse inserted a new catheter, and without any urine return to ensure proper placement, the nurse inflated the balloon of the catheter. This failure caused harm when the resident was later found to have urine leaking around the catheter, abdominal distention, pain and bleeding form the penis.