Every finding on record at Parkside Care

Based on interview and record review, the facility failed to provide copies of medical records within two working days as required for 1 of 1 resident (Resident 1), reviewed for access to medical records. Additionally, the facility failed to ensure its medical records policy was consistent with regulations pertaining to skilled nursing facilities. This failure placed the residents and/or representative at risk of not being fully informed of services and treatments provided and violated their rights. Findings included.Review of the facility [DATE] policy titled, Medical Records Request/Release of Information, showed when the facility received a request for medical records, they were to have an authorization form completed and provide records for an active within two working days and records requested for those who were deceased /discharged residents within 15 days. Review of the medical record showed Resident 1 was admitted with diagnoses including Multiple Sclerosis (MS) a chronic disease where the immune system attacks the nerve coverings in the brain and spine), diabetes (condition where the body's blood sugar levels are too high and does not use insulin appropriately), malnutrition (deficiency in nutrition intake), tube feedings, trouble swallowing, respiratory (lung ) issues and multiple other chronic physical conditions. The [DATE] comprehensive assessment showed Resident 1 required dependent assistance of one to two staff members for activities of daily living. Resident 1 was alert and oriented. During an interview on [DATE] at 5:46 PM, Resident 1's representative (RR), stated they had requested Resident 5's records and the facility would not provide them. Review of an email dated [DATE], showed the RR requested Resident 5's records and they were not provided. Review of a facility document titled Authorization for Release of Information, showed the RR completed the document and provided to the facility on [DATE]. Further review of the documents showed the facility provided Resident 5's records on [DATE], nine days later, despite being verbally requested prior to [DATE]. During an interview on [DATE] at 12:10 PM, Staff D, Medical Records Director, stated the process for a records request was when a resident was a current resident the facility had two days to provide them. Staff D stated that when the resident was no longer a current resident the facility had 15 days to provide the records. Staff D stated when they received the verbal request, they would provide the release of records form to be filled out and when the form was returned, they would process the records. Staff D had e-mailed the RR, and the RR returned the information and payment to have a copy of Resident 1's medical record. During an interview on [DATE] at 1:00 PM, Staff A, Administrator, stated they had to follow their company's policy of having 15 days to provide a copy of Resident 1's medical record to the RR. Reference WAC: 388-97-0300(2)(a)(b)

Based on observation, interview, and record review, the facility failed to identify hazards and risks to ensure the Resident's environment remained free of accident hazards and the Resident received adequate supervision 1 of 3 residents (37) reviewed for falls. Resident 37, who had severely impaired cognition, required maximum assistance for Activities of Daily Living (ADLs) and identified as a high fall risk, experienced harm when four of 14 falls occurred in the facility within a timeframe of less than a month; two of the falls resulted in injury that required hospital intervention. Findings included. Based on observation, interview, and record review, the facility failed to identify hazards and risks to ensure the resident's environment remained free of accident hazards and the resident received adequate supervision 1 of 3 residents (37) reviewed for falls. Resident 37, who had severely impaired cognition, required maximum assistance for Activities of Daily Living (ADLs) and identified as a high fall risk, experienced harm when four of 14 falls occurred in the facility within a timeframe of less than a month; two of the falls resulted in injury that required hospital intervention.Findings included.Review of a 01/30/2023 policy titled Fall/Injury Management-Post Fall or Injury, showed the facility would revise the resident's care plans or the facility practices to reduce the likelihood of another fall, and that it was necessary to provide consistent interventions to prevent further falls. The policy showed the Interdisciplinary Team would .identify trends or potential for new risk factors.communicate interventions to the nursing staff.Review of Resident 37's medical records showed they admitted to the facility on [DATE] with diagnoses of a broken bone to their right lower arm, dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), and had a history of falling. The 01/29/2026 comprehensive assessment showed Resident 37's cognition was severely impaired, they used a wheelchair (w/c) and required substantial to maximum assistance from staff for all activities of daily living. The assessment showed Resident 37 had experienced a fall prior to admission and had experienced one non-injury fall since admission.Review of Resident 37's Fall risk assessments showed on 02/06/2026 their fall risk score was 55 (anything greater than a score of 45 was considered a High Fall Risk). On 02/09/2026 Resident 37's fall risk score was 105.During a telephone interview on 03/17/2026 at 3:59 PM, the Resident Representative (RR) for Resident 37 stated they had been contacted by facility staff (later identified as Staff Z, Unit Manager and Staff D, Social Service Director) and was told the resident required one-on-one assistance in order to keep them safe from falling, and the facility did not provide that type of care, and the RR needed to send family to sit with the resident. The RR stated they had a full-time job and lived out of town, two and a half hours away, and did not have anyone that they could send to sit with the resident. The RR stated when they came to town, they would pick the resident up and take them overnight to visit with them. The RR stated they would walk with the resident and take them to the restroom, and they did not have issues with them falling.During an observation on 03/17/2026 at 4:48 PM, Resident 37 sat in a w/c in the dining room at a table at the back of the room, in front of the fireplace, with three other residents. Resident 37 had a wander guard (an alarm that is used for protecting residents at risk of wandering) attached to the back of their w/c, they were sitting sideways in the w/c, leaning towards their right side, with the footrests in place, and a black brace to their lower right arm.During an interview on 03/18/2026 at 2:38 PM, Staff D stated Staff Z and themselves placed a call to the RR to inform them Resident 37 needed one-on-one care because they kept falling. Staff D stated they informed the RR the facility did not provide that type of care at the facility and gave them contact information for other facilities.An observation and concurrent interview on 03/19/2026 at 11:31 AM, Staff EE, Contracted NA, stated this was their first day working in this facility and had not been given information regarding Resident 37's falls or care. Staff EE stated they would watch Resident 37 and when they appeared restless or anxious, or propel in and out of their room, or point, it would indicate to them they needed something. Staff EE then asked Resident 37 if they needed to use the restroom and they stated yes. Staff EE then assisted Resident 37 to the restroom.During an observation on 03/20/2026 at 10:11 AM, Resident 37 was sitting in their w/c, with the footrests on, and they were attempting to independently ambulate. Resident 37 was holding on to the brake handle of the w/c, that was located below the left side of the seat of the w/c, with their left hand, grasping onto the right-side arm rest with the right hand, to push themselves up. Resident 37 was attempting to step over the front of the footrests on the w/c to reach the floor. Just as Resident 37 was about to stand, Staff AA, Nursing Assistant (NA), exited another resident's room, seen Resident 37, and asked them if they had to use the bathroom, Resident 37 responded with yes and was assisted to their room to use the bathroom.During an observation on 03/23/2026 at 9:45 AM, Resident 37 was in their w/c, outside of their room, and the footrests were on. Resident 37 attempted to self-propel themselves with their feet by placing one foot on the floor behind the footrest and the other on the floor in front of the other footrest.Review of the 01/01/2026 through 03/17/2026 incident log showed Resident 37 had experienced 14 falls starting 01/29/2026 with the most recent fall on 02/22/2026.Review of Resident 37's 01/29/2026 through 02/22/2026 fall investigation reports showed. 12 of the 14 falls Resident 37 experienced were unwitnessed falls even after an intervention on 02/06/2026 and 02/09/2026 to keep the resident in the hall next to the nurse to prevent self-transfers during the day, on 02/11/2026 the resident was to be kept within visual sight of staff, and 02/16/2026 a one-on-one staff was called in for the remainder of the night shift after the fall (three interventions in 14 falls). Six of the falls (02/06/2025 at 7:15 PM, a bump to the left side of their head and pain to the left hip area, 02/14/2026 at 12:00 PM, golf sized bump to the back of the head, 02/15/2026 at 4:45 PM, Hematoma to the back of the head and a torn off finger nail, 02/16/2025 at 12:01 AM, pain and redness to the back of the head, 02/18/2026 at 3:15 PM, pain to their right arm fracture repair, and 02/22/2026 at 7:08 AM, a laceration to the left side of their head) Resident 37 received an injury. Three of the falls (01/29/2026 at 12:45 AM, 02/06/2026 at 4:50 AM, and 02/14/2026 at 12:00 PM) showed the resident needed to use the bathroom or had a fall while in the bathroom. There were no interventions to attempt a toileting program for the resident, nor did they have scheduled assistance with toileting. Two of the falls (02/18/2026 at 3:15 PM and 02/22/2026 at 7:08 AM) required hospital intervention for Resident 37's injuries.Lastly, the reports showed Resident 37 had signs and symptoms of a urine infection and a urine test was pending provider assessment starting 02/06/2026, to the results were pending as of 02/11/2026, to 02/18/2026 when the lab was called for results and they were lost. The urine test was completed at the hospital on [DATE] after the third fall of the day that resulted in an injury. Review of the hospital records showed on 02/18/2026 at 5:30 PM, Resident 37 arrived at the hospital after falling and landing face-down on the ground. The record showed the resident had four falls that occurred today and complained of pain to their right eyebrow, the right side of their head, and both sides of their neck. The records showed a Computed Tomography (CT, a diagnostic imaging exam that uses X-ray technology to produce images of the inside of the body) scan was completed and was negative for injuries. The records showed the resident would benefit from a higher level of care with more frequent monitoring.Review of the hospital records showed on 02/22/2026 at 7:58 AM, Resident 37 arrived at the hospital after a fall, when they had a brief loss of consciousness, and sustained a head injury. The record showed Resident 37 complained of new back pain and left hip pain from the fall. The records showed there was a large scalp laceration [traumatic injuries that involve rips or tears in your body's tissues] to the left side of the back of the head that was four centimeters (cm, a unit of measure) in length and required five staples to close the wound. The records showed Resident 37 could not lift their left leg up off the bed during examination due to increased pain and had a contusion (an injury resulting from blunt force trauma that damages underlying tissue without breaking the skin's surface) to their left hip and thigh.Review of Resident 37's 01/30/2026 Care Plan (CP), showed a focus for trauma related to [Resident 37] falling, with an intervention that showed it worried me because I had to drag myself on the floor.I couldn't get up and it was dark and I couldn't see. The CP showed on 01/24/2026 (the day of admission) a behavior monitor was initiated for the resident crawling out of bed and an ADL intervention for having the bed up against the wall for a sense of safety and security and extensive assistance by staff for toileting. The 01/24/2026 fall CP showed the resident would regularly crawl out of their bed or their w/c and sit on the floor and an intervention for a fall mat at the bedside while the resident was in bed to mitigate serious injury. Review of an updated fall risk CP on 02/23/2026 showed episodes of crawling out of bed and sitting on the floor and frequent falls are inevitable. The CP showed no additional interventions for toileting, to keep the resident within visual sight to keep them safe, to remove the footrests when the resident experienced increased independent ambulation activity, or the injuries they sustained during the falls.Review of Resident 37's February 2026 Medication Administration Records, showed an order on 02/11/2026 for Resident 37 w/c footrests to be removed while they were in the w/c related to fall risk. The order was then discontinued on 02/12/2026.An observation and concurrent interview on 03/23/2026 at 9:48 AM, Staff AA stated they had not been given any additional directions or interventions regarding Resident 37 with their fall precautions. Staff AA stated they were not given any direction to keep the resident in their line of sight or to watch them closely. Staff AA stated they did not know if the footrests being on would cause the resident to fall more frequently or easier. Resident 37 was self-propelling by us during the interview with one foot in front of the footrest on the floor and the other foot behind the footrest on the floor. Staff AA stated Resident 37 had just had another fall this morning (fall number 15). Staff AA stated they did not have a schedule for toileting Resident 37 and that they waited for the resident to let them know, maybe every three hours. Staff AA continued to enter another resident's room. During an observation on 03/23/2026 at 9:53 AM, Resident 37 was sitting in their w/c at the back door of the facility, with their footrests on. Resident 37 had their right foot on the right footrest and the left foot behind the left footrest on the floor and used the arm rests to push themselves up. Staff C, Director of Clinical Operations, was walking down the hallway and intercepted, assisting the resident to sit in the w/c, and took the resident with them to the front of the facility.During an interview on 03/23/2026 at 9:55 AM, Staff E, Licensed Practical Nurse (LPN), stated Resident 37 was very impulsive and not sleeping well. Staff E stated there was no one that was watching or sitting with the resident to prevent them from falling. Staff E stated the NA staff should have toilet the resident per protocol, at least every two hours. Staff E stated Resident 37 would benefit from one-on-one supervision for their safety and had not seen that happen, I am not sure if we have the staff for that. Staff E stated they believed the footrests on the residents' w/c could be the cause of some of their falls because they try to stand or bend down to get something off the floor. Staff E stated Resident 37 did not required assistance with self-propelling in their w/c, they propel on their own.During an interview on 03/23/2026 at 10:01 AM, Staff F, NA, stated they were to attempt to keep Resident 37 in sight, but when they had to go into another room or got busy, that was not possible.During an interview on 03/23/2026 at 10:48 AM, Staff Z stated Resident 37 had been treated for a urine infection during the time frame of their falls. Staff Z stated they initiated a fall mattress at bedside but that was contraindicated because Resident 37 was too active. Staff Z stated staff were to remove the resident's footrests from their w/c when they experienced increased activity. Staff Z stated staff should have known when Resident 37 was repeatedly attempting to ambulate on their own that it was time to remove the foot pedals. Staff Z stated when Resident 37 would fall, they would have staff sit with them for a little bit one-on-one, but nothing consistently. During an interview on 03/23/2026 at 10:50 AM, Staff R, Infection Preventionist/LPN, stated when they worked and Resident 37 fell, twice, they could not assign staff to sit with the resident one-on-one because the facility did not have the staff capability for a one-on-one. Staff R stated they did not provide a one-on-one on 02/16/2026 as the investigation showed. Staff R stated keeping Resident 37 within visual line of sight did not seem to work very well when the staff would have to go and take care of others.During an interview on 03/23/2026 at 11:12 AM, Staff B, Director of Nursing, along with Staff C, stated they were at a loss as to what to do for Resident 37's falls. Staff B stated Resident 37 would go home to visit and the family would walk with Resident 37, and then the resident would come back and want to walk. Staff B stated the family was able to provide the resident with one-on-one assistance at home, so they were not falling, but the facility did not have the staff to provide one-on-one assistance. Staff B stated they did not know Resident 37 had the footrests on their w/c and they thought those were being removed. Staff B stated staff were to keep Resident 37 in their line of sight, but the resident continued to fall. Staff B stated they had called the family to the facility to provide the resident with one-on-one assistance, but they could only send someone one time for 40 minutes. Staff B stated they were aware the resident had dementia, there was a high risk for falls, and that they had left their home in the middle of the night, to be found outside on the ground hours later, prior to them being admitted , and it was their responsibility to provide them with safety.Reference: WAC 388-97-1060 (3)(e)(g)

Based on observation, interview, and record review, the facility failed to ensure, A) staff prepared, distributed and served resident food in accordance with professional standards of practice along with the maintenance of a sanitary (relating to the conditions that affect hygiene and health) kitchen environment for 1 of 1 kitchen, reviewed for food safety requirements and, B) resident foods brought in from outside sources were stored, labeled and dated with opened by and expiration dates for 1 of 1 resident refrigerator located in the kitchen, review for food safety. This failure placed residents at an increased risk for cross contamination (the harmful spread of diseases) of food borne illnesses.Findings included. Review of the facility's policy titled, Food: Safe Handling for Foods from Visitors/Residents, revised August 2025, showed resident would be assisted in properly storing and safely consuming foods brought into the facility by residents and/or visitors. The policy showed that food item would be stored in a sealed container to prevent cross contamination and labeled with the resident name/date. Additionally, uneaten resident foods brought in would be discarded after 72 hours. Observations of the initial kitchen visit and concurrent interviews with facility staff on 03/17/2026 from 9:15 AM to 10:27 AM showed: The kitchen's entrance way had an ice machine, resident refrigerator, a sink and cabinets. The walls of the entrance way had multiple old, dried splashes of red, brown, and tan colored liquids/food particles scattered across them, where post meal food trays/carts were stacked up against, along with a current white, wet liquid that had made a puddle on the entrance ways floor. The ice machine display panel showed off and noted a melted ice block at the bottom of the machine ice storage container. Staff M, Dietary Manager, stated the ice machine was broken, was not currently being used for ice, needed to be fixed and stopped working about one to two days ago. Staff M stated they were currently utilizing bags of ice that were stored in a deep freezer. The refrigerator had storage of specific resident foods brought in by family, visitors or purchased by the resident. Inside were more than 30 residents' two ounce (oz, a unit of measure) pudding cups and apple sauce cups prepared by the facility. The pudding/apple sauce were labeled for expiration on 03/12/2026, 03/15/2026, and 03/16/2026. Staff M stated the food should have been discarded before the expiration date and not stored in the same refrigerator as resident food from outside sources. The juice machine dispenser nozzle with masking tape (a thin tape that is easy to tear with a paper backing, used during painting) over some of the buttons on the nozzle. The tape was soiled (dirty or unclean) discolored and worn. Staff M stated they did not have a record of when the nozzle was last cleaned, and the tape needed to be changed. On top of the dishwasher was a thick layer of dust and food particles. Below the dishwashing machine was a black substance caked around the pipes and on the floor and walls. The built-up grime and grease was wet and a discolored brown liquid was noted. The walls under the dishwasher table/machine had a hole where piping, from the machine, was coming thorough and caked in the same black greasy grime with unknown debris. The light green painted walls were noted to be peeling off behind the dishwasher. After observing the black, grim/greasy build-up caked on the walls and pipes under the dishwasher, Staff M and Staff T, Regional Registered Dietician, stated that below the dishwasher was a safety concern and not sanitary. Staff M stated, it could be mold. The kitchen stove top burners had a half an inch (a unit of measurement) of grime (a combination of dirt, oils, and dust) and food particles built-up on each burner. The burners had multiple areas where food had been spilled and not cleaned. The backsplash of the stovetop had multiple splashes and food particles scattered on it. Staff M stated the stove top should have a deep or thorough clean weekly and then daily if there were splashes or spills. After observing the stove top, Staff M stated that it had not been cleaned weekly nor daily due to the buildup noted on the burners, very heavy dirt and grime. Staff M observed opening the grease traps on the stove and noted it was not cleaned, with multiple layers of buildup, from multiple cooking sessions noted. Staff M stated the routine and deep cleaning of the stove top was not being done and the stove was not sanitary. Shelves above the food preparation tables were dusty with a buildup of grease noted. Staff M and Staff T stated they could not show records that routine or deep cleaning was being performed during the beginning of February 2026, and Staff M showed records of incomplete routine/deep cleaning from 02/25/2026 through 02/28/2026. Under the two food preparation counters against the back wall of the kitchen and oven was a thick layer of dust, grime, and food particles with a fork/cup along with trash. An upside-down mouse [NAME] p was noted under one of the food preparation counter tops and when moved by staff an imprint of the box was outlined in a thick layer of dust/grime.During an interview on 03/17/2026 at 2:55 PM, Staff M and Staff FF, Cook, stated they did not know the last time the stove top and oven had been deep cleaned. Staff M stated they had taken pictures of the kitchen environment, under the dishwasher, counters/sinks, holes in the wall with the debris/grease, grime and showed them to the Administrator. Staff FF and Staff M stated the stove top, burners and grease trap should have been clean regularly and the correct process was not followed.Observations of the kitchen during cooking and serving out with concurrent interviews of facility staff on 03/17/2026 from 3:43 PM to 4:33 PM showed: Staff FF in the kitchen cooking. Staff FF was noted preparing a spinach, broccoli and cheese salad. Staff FF doffed (to take off) their gloves and opened a refrigerator door then proceeded to the dried food storage area to grab items without performing hand washing. Staff FF then, without donning (to put on) new gloves or hand washing, proceeded to flip a hamburger patty that was cooking on the stove top with a utensil, opened the oven, pulled back the tin foil from the roast beef in the oven and placed the thermometer into the roast beef without performing hand washing or donning new gloves. Staff FF had just pulled a baking sheet of Tator Tots out of the oven and with ungloved bare hands grabbed the thermometer probe device and while holding a Tator Tot, from the baking sheet, with their bare hands, stuck the thermometer device into the Tator Tot. After reading the temperature Staff FF washed their hands and donned a new pair of gloves then proceeded to place the same soiled Tator Tot back onto the baking sheet with the rest of them. The sound of someone whacking at ice was overheard and observed Staff FF hitting the melting ice block within the ice machines storage container, with ungloved hands. Staff FF stated they were going to use the ice to put on top of the resident juices, milk and ice cream. Staff FF stated the ice machine had been turning off/on recently, and that it was still okay to use. After placing ice from the ice machine within a bin around and on top of resident drinks/ice cream, Staff GG, Dietary Aide, stated the ice was used to keep resident drinks cold and the drinks included cups of cranberry juice, orange juice, and milk along with ice cream cups. The ice cream was in Styrofoam (a specific type of material) cups that had a paper pull-off lid that was sunken down into the cup from the top, with melted ice sitting on top of the ice cream. The juice cups had a precut cross notch in the lid, where a straw would be placed and melted ice noted on top of the juices. Additionally, the ice machine display screen still showed the machine was off. On the other side of the kitchen, Staff M stated the ice within the ice machine was not to be used, and the machine needed to be fixed. Staff M stated they did not want a staff member to have to use a device to break up the ice, since it had already been melting into a block, and risk introducing bacteria, so ice bags were to be used. Staff M stated they were verbally informing staff of not using the ice machine but had not placed a sign on the ice machine's storage lid yet. While serving out drinks to residents, it was noted that the same contaminated ice, from Staff FF breaking it up with bare hands, had been melting on top of the plastic drink lids which had a precut opening(a cut made in a plastic lid so a straw can be inserted) on all the resident juices/mil k. The ice was also melting on top of the paper ice cream lids, and both the ice cream and drinks were served out to numerous residents in the dining room.During an interview on 03/17/2026 at 5:25 PM, Staff DD, Maintenance Director, stated the facility had one ice machine in the kitchen that was turned off sometime Sunday (03/15/2026) and they had not turned the machine back on since then. Staff DD stated that it was not being used for ice and since it was off the ice had been melting. Observation of the kitchen on 03/18/2026 at 3:01 PM showed the main ceiling ventilation cover, in the middle of the kitchen, had been covered in a thick layer of dust. The kitchen windows over the food preparation area were opened and the screens were caked in a black and brown dust/soot.During a concurrent observation and interview on 03/18/2026 at 3:13 PM showed Staff M and Staff T going through food items within the resident refrigerator. The items included: Homemade pasta in a Tupperware container with no date on it. Half of a peanut butter and jelly sandwich, not labeled or dated. A 32 oz plastic crate of shriveling (a shrinking or withering away) strawberries, with no labeled resident or received by date. A second 32 oz plastic crate of strawberries that was noted with fuzzy growing mold covering the strawberries and did not have a received by date or expiration date. A 12 oz Pepsi soda can, which had been opened and was half empty, with no date. A bag of Mozzarella cheese with no open or use by date. Staff M and Staff T both stated that food items needed to be in a container, labeled and dated with the resident's name, room number, date that the item was brought into the facility and the date it was to be used by or discarded. Both staff stated the correct process for the storage, labeling/dating of resident food items for consumption, in regard to food safety, was not followed. During a continued interview on 03/18/2026 at 3:54 PM, Staff M and Staff T stated the kitchen staff should not have been using the ice, for resident drinks, from the ice machine storage bin since it had been broken/turned off. Staff M stated the drinks and ice cream should not have been served to the residents with the potential for contamination from the melting ice. Both staff stated the facility did not follow the correct process regarding maintaining a clean, safe/sanitary kitchen environment or storage, labeling of resident foods and the correct process was not followed. During an interview on 03/20/2026 at 5:10 PM, Staff B, Director of Nursing, and Staff C, Director of Clinical Operations, stated the kitchen should have routine and deep cleaning to keep a sanitary environment for the storage, preparation and serve out of resident foods. Both staff stated the right process had not been followed regarding the kitchen environment and potential cross-contamination of resident drinks from the potentially contaminated ice utilized by dietary staff.Reference: WAC 388-97-1100(3)This is a repeat citation from the Statement of Deficiencies dated 02/07/2025.

Based on observation, interview, and record review, the facility failed to provide meal services in a dignified manner for 4 of 4 residents (23, 31,33 and 18) reviewed for dignity related to Residents (23, 31,33 and 18) waited an hour for lunch to be served. This failure placed the residents frustrated and embarrassed. Findings included . During an observation on 03/17/2026 at 11:45 AM, Residents (23, 31, 33 and 18) were seated at their tables and required assistance with meals in the main dining room. There were two tables that residents required extensive assistance and cueing. Other residents that sat in the main dining room were either setup assistance or independent with eating their meals. The lunch meal was served to residents on trays from the steam table located in the main dining room at 12:45 PM, (one hour after lunch trays were served to rooms in the 100 hall). The dining room was served their meals after hall 100 which was delayed. During an interview on 03/17/2026 at 12:18 PM, Staff T, Regional Registered Dietician, who had observed the lunch meal serve out stated the facility dietary department brought the food from the kitchen to the main dining room steam table and served the 100 hall first then the main dining room. Staff T stated it was not dignified to make residents in the main dining room wait to be served their meal. Staff T stated it would make sense to serve the dining room first since some of the residents required assistance. Resident 23 Review of the medical record showed the resident was admitted on [DATE] with diagnoses of progressive Multiple Sclerosis (an autoimmune disease that attacks the insulation covering of nerve cells leading to muscle weakness and coordination issues) and Dementia (a group of symptoms that affect cognitive functioning, thinking and reasoning). During an observation on 03/17/2026 at 11:45 AM, Resident 23 was seated at the Progressive Self Feeding Program (PSFP) where residents are assessed by nursing who are in need of one-on-one directions and cueing for drinking fluids or eating their meals. Nursing initiates a care plan to assist residents on a specified those specific instructions such as swallowing precautions, sufficient chewing of their foods, and cues to each one bite at a time during meals. This is usually done with a Restorative Aide (RA) who is trained to carry out the PSFP care plan. Resident 23's 10/31/2024 care plan identified memory loss and swallowing issues. Resident 23 required assistance with meals with instruction to slow down and to take small bites due to difficulty swallowing. During an observation and concurrent interview on 03/17/2026 at 12:55 PM, Staff Q, RA was standing and instructed Resident 23 to use their spoon and take a bite of food. Staff Q then went to the other residents at the table standing to instruct residents to eat. Staff Q stated they did not have time to sit with residents who need assistance because they had to pass other residents' lunch trays. During an interview on 03/17/2026 at 1:10 PM, Staff Q, RA, stated that Resident 23 had issues with eating which included shaking when using their adaptive spoon and spilling food. Resident 31 Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses of dyskinesia (significant tremors), kidney disease, insulin dependent diabetes (a group of diseases that effects how the body uses blood sugar and insulin (a hormone). Review of the 03/12/2026 nursing comprehensive assessment showed the tremors (involuntary shaking movements) interfered with the resident's ability to eat independently without staff assistance. Additionally, Resident 31 had problems with swallowing their food. An observation and concurrent interview on 03/17/2026 at 1:00 PM showed Resident 31 was using their adaptive spoon made so the resident could scoop food off their divided lipped plate. Resident 31's right hand was shaking holding the spoon and spilling food on their chest and lap. No available staff were present until Resident 31's shaking became worse. At 1:00 PM Resident 31 asked for assistance so they could be wheeled back to their room. Resident 31 stated they were embarrassed and were tearful and wanted to return to their room as they needed to be fed due to the inability to assist themselves without shaking. The tremors interfered with Resident 31's eating and required assistance with meals with instruction to slow down and to take small bites due to difficulty swallowing. During an observation and concurrent interview on 03/19/2026 at 12:01 PM, Resident 31 was seated at the PSFP assist table holding their sippy cup (a cup with a lid and straw with handles on each side of the cup), an adaptive spoon and a divided plate. On 03/19/2026 at 12:05 PM, Resident 31 had picked up their spoon, had tremors and dropped food on themselves, became frustrated (dropped the spoon and asked to leave the dining room) and did not want to eat anymore. Staff P, RA, was sitting at the table and began to assist Resident 31, who started coughing. Staff P then wheeled the resident out of the main dining room to the resident's room. Staff P stated they did not have enough time to assist residents fully with their meals. Additionally, during an observation on 03/19/2026 from 12:00 PM to 12:20 PM of the lunch meal in the main dining room showed Staff P continued to move from one side of the residents at the PSFP table to the resident assisted table (separate table) and did not sit with the residents fully assisting with the residents' meals. Resident 33Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses of dementia and diabetes. Review of the 03/12/2026 nursing comprehensive assessment showed the resident was impaired cognitively and needed assistance from the staff with eating their meal. During an observation on 03/17/2026 at12:07 PM, Resident 33 was first seated at the PSFP table then moved to the assistance table. Coffee was served to the resident with a lid and straw over the coffee up. The resident sat in their wheelchair at the dining table without supervision. Resident 33 took their clothing protector off and wrapped it around their coffee cup. During an observation on 03/17/2026 at12:45 PM, Resident 33 had their tray served uncovered for 15 minutes until 1:00 PM. Resident 33 started touching the rim of their lunch plate then started to touch their food with their fingers. Staff were not available until 1:10 PM to assist the resident with their meal. Resident 18A review of the medical record showed the resident admitted to the facility on [DATE] with diagnoses to include dementia with behavioral disturbances and hard of hearing. The 01/16/2026 quarterly nursing assessment showed Resident 18 was dependent on staff for all Activities of Daily Living (ADL) with exception of meals which required set up and clean up only. During an observation on 03/17/2026 at 1:06 PM, Resident 18 was seated at their table for lunch in the main dining room. The resident 's table was at upper chest level and made it difficult for the resident to independently pick up their fork or spoon when their lunch was served to their table. Resident 18 was at their table alone, observed eating with their fingers, utensils on table, not used, resident observed attempting to eat pudding with fingers and scraping corn bread off table. The corned beef was thinly sliced, and potatoes were in bite sized pieces. No staff came to assist the resident. During an observation on 03/18/2026 at 12:50 PM, Resident 18 sat at their table with two other residents. Resident 18 was served and was unable to pick up their utensils. The dining table was too high for the resident as they reached for their drink that was covered with a lid and straw. While Resident 18 reached small plastic cup they dropped it on the table. Residents at the table assisted Resident 18 to pick up the cup. Additionally, the resident could not cut their breaded chicken to eat it. Staff F, Nursing Assistant, (NA), stated they usually set up Resident 18's meal and must cut up the meat into small pieces. During an interview on 03/19/2026 at 2:00 PM, Staff B, Director of Nursing, (DON), stated there were issues at mealtimes in the dining room and there are more people wanting to eat there. It was a lack of dignity and led to weight loss. Reference: WAC 388-97-0180 (1-4)

Based on observation, interview and record review, the facility failed to provide assistance with activities of daily living (ADL's) related to shower/bathing for 5 of 6 residents (Residents 6, 44, 24, 31, and 18) reviewed for ADL care. This failure placed the residents at an increased risk for poor hygiene, skin breakdown, an undignified existence, infection, and pain. Findings included . Resident 6 Review of the resident's medical records showed they admitted with diagnoses to include Multiple Sclerosis (a disease that disrupts the communication between the brain and the rest of the body that leads to fatigue, vision problems, and muscle weakness) and diabetes (increased sugar in the blood). The 12/08/2025 comprehensive assessment showed Resident 6's cognition was intact and was dependent on staff assistance for their showering and bathing needs. During an interview on 03/18/2026 at 8:42 AM, Resident 6 stated the facility only had one staff person that did showers. Resident 6 stated they were scheduled for two showers a week and would only get one shower a week, if even that. Resident 6 stated when the floor Nursing Assistants (NAs) did not show up for their scheduled shift, the shower NAs would be taken from their shower duties to cover the floor and then nobody would get a shower. Resident 6 stated it had been months since they received their shower on Tuesday. Resident 6 stated they returned from the hospital on [DATE] and really wanted a shower but did not get one until 03/15/2026 because there was no one available. Review of Resident 6's shower tasks for 02/01/2026 through 03/21/2026 showed Resident 6 was scheduled to receive showers on Tuesdays and Saturdays. The tasks showed Resident 6 received a shower on 02/10/2026, 02/14/2026, 02/17/2026, 02/28/2026, 03/14/2026, and 03/21/2026. The tasks showed Resident 6 received six out of the 14 showers that were scheduled. Resident 44 Review of the resident's medical records showed they admitted with diagnoses to include diabetes and anxiety (a feeling of worry, nervousness, or unease about something with an uncertain outcome). The 03/11/2026 comprehensive assessment showed Resident 44's cognition was intact and required substantial to maximum assistance from staff for bathing and showers. During an interview on 03/19/2026 at 1:54 PM, Resident 44 stated they had gone as long as two weeks without a shower and more recently, ten days. Resident 44 stated they had reported this to the Staff D, Social Services Director, and they would get better for a little bit but then go back to missing them again. Review of a 03/13/2026 bathing schedule showed Resident 44 received showers on Tuesdays and Fridays. Review of an 11/04/2025 customer concern showed Resident 44 reported they had not received their showers and wanted the two showers a week they were scheduled to have. The concern showed an attached shower schedule that showed Resident 44 had not received three of their showers. The concern showed two of the showers missed were because floor NAs had called in [did not report for their scheduled shift] and the shower NAs were pulled to work the floor, and the third one because Resident 44 was not in the facility. The plan was to hire additional shower NAs or floor NAs for better coverage. Review of a 11/14/2025 customer concern (ten days from the last shower concern reported) showed Resident 44 reported they had not had a shower in ten days I do pay for two a week. The concern showed on 11/15/2025 the facility had a NA stay over so they could complete Resident 44's shower. The concern showed the plan was to hire two NAs to replace the shower NA that had been terminated. During an interview on 03/21/2026 at 11:21 AM, Staff B, Director of Nursing Services, along with Staff C, Director of Clinical Operations, stated they had recently terminated a shower NA, and another one had been out on family medical leave. Staff B stated they had not been able to have the staff to replace the shower aids because they were needed for care on the floor. Staff B stated they had staff available to complete showers for the past few days who were able to complete showers, but they were not on the resident's scheduled days. Staff B stated they had recently obtained access to Contracted NAs to assist with filling in those gaps. Resident 24 Review of the medical record showed Resident 24 was admitted to the facility on 02/27/2026 with diagnoses including left knee bacterial arthritis (a serious condition that causes inflammation, pain and limited mobility), malnutrition, and spondylolisthesis (a condition of the backbone that causes pain and stiffness). The 03/05/2026 comprehensive assessment showed Resident 24 required one to two staff members for dependent/moderate assistance for ADLs, including showers. The assessment also showed Resident 24 had an intact cognition. Review of Resident 24's bathing record showed they were scheduled for bathing/showers on Mondays and Thursdays. Review of the record showed on a 30-day look back that began on 03/18/2026, Resident 24 was provided with one shower on 03/05/2026. Review of the bathing record showed no documented refusals for bathing. The record showed four missed opportunities for showers. During an interview on 03/18/2026 at 9:21 AM, Resident 24's Representative (RR), stated Resident 24 was scheduled for showers on Mondays and Thursdays and they had only received one shower since they had arrived at the facility. RR stated the facility had not offered bed baths either. The RR stated they called their mom on Monday, and they stated they did not get their shower and their bottom was hurting, and looked red, cracking, and peeling. During an interview on 03/18/2026 at 1:05 PM, Staff B, Director of Nursing, stated the process for showering residents was the nursing assistants (NA) were to document in the NA tasks section of the residents' charts when a shower was completed or refused. Staff B stated Resident 24 was scheduled to have two showers per week and they were not performed. Staff B stated the facility had recently terminated a shower aide. Resident 31 Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses of dyskinesia (significant tremors), kidney disease, insulin dependent diabetes (a group of diseases that effects how the body uses blood sugar and insulin (a hormone). Review of the 03/12/2026 nursing comprehensive assessment showed the tremors (involuntary shaking movements) interfered with Resident 31's independence and depended on staff to provide transfers and showers/bathing. Resident 31 was alert, oriented and able to make their needs known. During an interview and concurrent observation on 03/18/2026 at 10:16 AM, Resident 31 complained about not getting baths/showers. The resident stated they had complained about not receiving a shower on 03/04/2026 and had not received two showers out of seven scheduled due to staff call outs and no replacement staff. Staff 31's hair was greasy and skin to face was flakey. During an interview on 03/18/2026 at 11:00 AM, Staff O, Nurse Assistant, (NA), stated that they had a bath team to do showers twice a week but that was taken away. So, we don't have help doing showers and baths and do not do them or bed baths. Resident 31's 02/12/2026 care plan showed the resident needed assistance with bathing and was scheduled twice a week. Review of the bath task documentation for bathing showed the resident was to receive showers twice a week on Monday and Friday. The task sheet showed four showers from 02/20/2026, 02/23/2026, 02/27/2026 and 03/06/2026. As of 03/20/2026 the resident had not received a shower from the last date of 03/06/2026. Resident 18 A review of the medical record showed the resident admitted to the facility on [DATE] with diagnoses to include dementia (a group of symptoms that affect cognitive functioning, thinking and reasoning) with behavioral disturbances and hard of hearing. The 01/16/2026 quarterly nursing assessment showed Resident 18 was dependent on staff for all ADLs to include showers/baths. Review of Resident 18 's 02/16/2026 care plan showed the resident was dependent on staff for bathing and would have showers two times a week. During an observation and concurrent interview on 03/18/2026 at 1:20 PM, Resident 18 sat in their wheelchair at the dining table with fingernails that had brown substances under fingernails. Asked the resident if they got enough baths/showers. Resident 18 stated they did not get showers at the facility and was unaware when they had a bath but stated they would be available for a bath. Review of the shower/bath task documentation for bathing showed the resident was to receive showers twice a week on Thursday and Sunday. The task sheet showed five showers from 02/22/2026, 03/08/2026, 03/12/2026, 03/18/2026 and 03/19/2026. The total number should have been 10 total baths. During an interview on 03/19/2026 at 1:45 PM, Staff B, Director of Nursing, (DON), stated they have not had consistent bathing/showers of residents because they have had to pull NAs from bathing tasks to work on the floor with assignment of residents due to the fact they had been short of staff. Staff B stated that there were not enough staff who were assigned to residents' cares to do baths/showers. Reference WAC 388-97-1060(2)(c)

Based on observation, interview and record review, the facility failed to monitor and address nutritional needs for 4 of 5 residents (Residents 5, 10, 18 and 33) reviewed for nutrition. This failure placed the residents at risk for medical complications, nutritional weight loss, and a diminished quality of life. Findings included . Resident 5 Review of the medical record showed the resident readmitted to the facility on [DATE] with diagnoses that include end stage kidney disease with dialysis (a treatment that filters fluid and waste from your blood when your kidney are failing), dental caries (cavities), missing teeth, diabetes type 2 (a chronic condition where the body does not use insulin effectively), malnutrition (poor nutrition due poor diet intake) and heart disease. Review of Resident 5's 02/17/2026 comprehensive assessment showed the resident required setup only with their meals. Resident 5 had some cognitive and hearing loss but was able to make their needs known. Resident 5's 03/05/2026 care plan showed the resident attended dialysis three times a week from 5:00 AM to 8:00 AM. During an observation and concurrent interview on 03/17/2026 at 1:12 PM, Resident 5 had a few missing on the top and bottom. Resident 5 stated they had a problem with swallowing foods. Resident 5 stated they could not eat the puree foods (smooth, creamy food) at the facility as it was too sweet. Resident 5 signed a deviation of care from a puree diet to regular diet with soft foods. Resident 5 had asked resident representatives to bring soft foods like beans and rice and vegetables. Additionally, the resident stated that there was too much sugar in some food like mash potatoes and liked fresh vegetables, wraps and soft tortillas, no bread, soups such as potato soup and asparagus or broccoli soups or vegetables. The resident stated they like Paella, which consists of rice, saffron, seafoods or meat, stuffed peppers with meat and rice. Resident 5 also stated the small glass of supplement they gave them was too sugary and did not drink it and had refused to take it. Review of the 02/10/2026 Food Preference Record showed Resident 5 was able to make food selections and did not have special food request for meals and no snacks requested. Dislikes were orange juice, bananas and mashed potatoes. The resident did request a Hispanic Diet (which was not defined). No other preferences/ dislikes were identified by dietary staff. Review of the 02/11/2026 nutrition at risk evaluation showed Resident 5 had weight loss and added four ounces of supplement to lunch and dinner. Resident 5 received insulin (hormone) daily. Resident 5 was at risk for weight loss and malnutrition. Resident 5's weights from 02/07/2026 was 142.4 pounds and on 03/17/2026 was 123.1 pounds. Resident 5 had a 13.55% weight loss. Review of Resident 5's 02/10/2026 laboratory report showed a Comprehensive Metabolic Panel that measured proteins, minerals and electrolytes in the body that measured the balance of these substances in the body, in which results were low. The protein goal was 4.0 mg/dl (milligrams per deciliter which is a unit of measure) but measured 2.2 mg/dl, phosphorous goal was 3.0 to 5.5 mg/dl but measured 2.1mg/dl. During an observation on 03/17/2026 at 1:05 PM, Resident 5 was in bed eating food that the Resident Representative (RR) brought into the facility including rice, salad and a small bowl of refried beans. The resident had eaten a small amount of lunch. During an observation on 03/18/2026 at 12:00 PM the resident was served cornbread, meat and cooked mixed vegetables that had yellow and red bell pepper with onions. The resident stated that this was what they liked to eat. Resident 5 did not eat the cornbread and meat and did not accept the supplement drink. During an observation on 03/19/2026 at 11:45 AM, the resident chose not to eat but a small amount of their lunch meal. During an interview on 03/19/2026 at 2:15 PM, Staff T, Regional Dietician, (RD), stated that the previous facility RD did not confer with the dialysis dietician with the low laboratory results and it could affect Resident 5's nutritional wellbeing. Staff T also stated that with dialysis and fluid weight gain and loss was a factor and the resident could benefit from some renal (kidney) vitamin supplementation for low laboratory results. Resident 5 did not have steady weights and easily lost weight. Additionally, Staff T stated the dietary manager should have had a detailed list of what Resident 5's food preferences. Resident 10 Review of the medical record showed the resident was admitted on [DATE] with aftercare of bowel surgery, dementia (a group of symptoms that affect cognitive functioning, thinking and reasoning) and malnutrition. The 01/29/2026 nursing comprehensive assessment showed the resident was confused but able to make needs known, and an elopement risk which required assistance from staff. Resident 10 required supervision and setting up of meals. A review of the 01/30/2026 care plan showed the resident was to have setup assistance and had a regular texture diet. Other interventions included offering finger foods if resident had difficulty using meal utensils. Additionally, the resident was assessed to have difficulty with solid foods and to offer milk shake supplements. Review of the 01/09/2026 nutrition at risk assessment showed the resident was to maintain their body weight of 148.6 pounds. During an observation on 03/17/2026 at 12:45 PM, Resident 10 was seated at a table in the dining room and served the lunch meal which consisted of corn beef, cabbage and a dessert. The resident picked up their fork and picked at their food and tasted it. Observation of Resident 10's meal plate showed they did not eat the rest of their meal. During an interview on 03/17/2026 at 1:22 PM, Resident 10 sat at their table and served their lunch meal. The resident was unable to use their utensils to pick up their turkey with gravy opened faced sandwich and spilled it on their lap. Resident 10 wheeled themselves out of the dining room and did not finish their meal. During an interview on 03/19/2026 at 1:30 PM, Resident 10 stated they had enough food and were not hungry. Resident 10 went to their room and transferred themselves to their bed. Review of Resident 10's weights from 01/08/2026 where the resident weighed 148.6 pounds and 03/13/2026 the resident weighed 135.2 pounds. This was a 9.02% weight loss. Resident 18 A review of the medical record showed the resident admitted to the facility on [DATE] with diagnoses to include dementia with behavioral disturbances and hard of hearing. The 01/16/2026 quarterly nursing assessment showed Resident 18 had some cognitive impairment but able to make needs known, dependent on staff for meals which required set up and clean up only. The nursing assessment further showed Resident 18's weight to be 112 pounds. During an observation on 03/17/2026 at 1:06 PM, Resident 18 was seated at their table for lunch in the main dining room. The resident 's table was at upper chest level and made it difficult for the resident to pick up their fork or spoon when their lunch was served to their table. Resident 18 was observed eating with their fingers, utensils on table, not used, resident observed attempting to eat pudding with fingers and scraping corn bread off table. No staff came to assist the resident. During an observation on 03/18/2026 at 12:50 PM, Resident 18 sat at their table and was served breaded chicken and was unable to pick up their utensils to cut their chicken. The dining table was too high for the resident as they reached for their drink that was covered with a lid and straw. There was no staff assistance for some time to set up Resident 18's meal and cut the resident's chicken. Review of the 01/30/2026 nutritional risk assessment showed Resident 18's was on a low salt regular textured diet. The assessment showed the resident ate 25-50 % of meals and refused nutritional supplements. Additionally, the resident's weight goal was to be over 105 pounds. Review of Resident 18's weight from 12/26/2025 was 112 pounds and 03/16/2026 showed 101.8 pounds. This loss was 9.1 % of the resident's body weight. During an interview on 03/19/2026 at 2:16 PM, Staff T stated they had not reviewed Resident 18 yet and were not aware of their weight loss. Staff T stated they had just recently arrived at the facility to assist them. Resident 33 Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses of dementia and diabetes. Review of the 03/12/2026 nursing comprehensive assessment showed the resident was impaired cognitively and needed assistance from the staff with eating their meal. During an observation on 03/17/2026 at12:07 PM, was first seated at the Progressive Self Feeding Program (PSFP) where residents are assessed by nursing who are in need of one-on-one directions and cueing for drinking fluids or eating their meals. Nursing initiates a care plan to assist residents on a specified those specific instructions such as swallowing precautions, sufficient chewing of their foods, and cues to each one bite at a time during meals. table then moved to the assistance table. Coffee was served to the resident with a lid and straw over the coffee cup. Resident 33 removed their clothing protector and had wrapped it around the coffee cup. Staff P, Restorative Aide, then observed Resident 33 wheeling themselves towards the hallway and returned the resident to their table. During an observation on 03/17/2026 at 12:45 PM, Resident 33 had their tray served uncovered for 15 minutes until 1:00 PM. Resident 33 started touching the rim of their lunch plate then started to touch their food with their fingers. At 1:00 PM Staff O, Nursing Assistant (NA), readjusted Resident 33's clothing protector and gave the resident a spoon and instructed the resident to eat their food. Resident 33 took a few bites and started to wheel themselves away from their table. Review of the 02/12/2026 care plan showed the resident was on a restorative plan for eating and swallowing issues with verbal cues with instruction from staff to take liquids after two to three bites of food throughout the meal. Staff were to report any weight loss. Resident 33's weight on 01/21/2026 was 162 pounds and their weight measurement on 03/16/2026 was 154.4 pounds. Resident 31 weight loss was 4.69% of their weight. Review of the nutrition at risk book from12/01/2025 though 03/01/2026 contained notes of meetings for residents with risk for weight loss and actual weight loss but no actual recent notes for named Residents 5, 10, 18 and 33. During an interview 03/18/2026 at 11:45 AM, Staff G, Licensed Practical Nurse, (LPN) stated that there were no residents on a restorative nursing eating program and the Restorative Aide (RA) were to assist residents in the dining room that needed assistance. During an interview with Staff B, Director of Nursing, stated they had many changes in staff and were not surprised there were residents with some weight loss. Reference WAC 388-97-1060(3)(h)

Based on observation, interview, and record review, the facility failed to ensure there were enough competent nursing staff to provide care and services for 6 of 9 residents (Residents 37, 6, 24, 31, 18, and 44) as evidenced by failures related to Activities of Daily Living (ADLs) and prevention of accidents. This failure placed residents at risk of not having their needs met and potential/actual negative outcomes to their physical and mental health. Findings included. Review of the 02/25/2026 document titled Facility Assessment showed the facility had an average census of 48 residents. The assessment showed the facilities staffing plan was eight Nursing Assistants (NA) for day shift, seven NAs for evening shift, and four NAs for night shift per their census, and the resident population and their care needs and would be adjusted as needed. Review of the 02/15/2026 through 03/17/2026 (31 days), Staffing Pattern (a document that showed actual nursing staff on duty), completed by the facility, showed 29 of the 31-day shifts had four NAs scheduled. The staffing document showed 21 of the 31 evening shifts had four NAs scheduled, and one evening that had three and a half NAs scheduled. Review of the 02/15/2026 through 03/17/2026 daily census sheets showed 29 of the 31 days reviewed on the Staffing Pattern showed the facility had a census of over 50. F689 Accidents The facility failed to provide adequate supervision to prevent further falls and injuries. Resident 37 experienced harm when they fell and required hospital intervention twice. Review of Resident 37's fall from 01/29/2026 through 02/22/2026 showed they had 14 falls, in which 12 of them were unwitnessed. The review showed Resident 37 sustained some kind of injury during six of the falls, and two of the six falls, required hospital intervention. During an interview on 03/23/2026 at 9:55 AM, Staff E, Licensed Practical Nurse (LPN), stated they felt Resident 37 required one-on-one supervision to keep them safe from falling but they did not have enough staff to provide that care. During an interview on 03/23/2026 at 10:50 AM, Staff R, Infection Preventionist/LPN, stated Resident 37 they could not assign additional staff to keep Resident 37 safe because the facility did not have the staff capability to do that. During an interview on 03/23/2026 at 11:12 AM, Staff B, Director of Nursing Services, stated they did not have enough staff to provide Resident 37 the supervision they required to keep them safe from falling. F677 ADLs The facility failed to provide residents that required assistance with routine and consistent bathing or shower care. Resident 6 During an interview on 03/18/2026 at 8:42 AM, Resident 6 stated the facility did not have enough staff to provide them with their two scheduled showers a week. Resident 6 stated they would receive only one shower a week, if even that. Resident 24 During an interview on 03/18/2026 at 9:21 AM, Resident 24's Representative stated the resident had only received one shower since they admitted to the facility on [DATE] but were scheduled to have them twice a week. Resident 31 During an interview and concurrent observation on 03/18/2026 at 10:16 AM, Resident 31 stated they had not received two of their seven scheduled showers due to staff not showing up for their scheduled shifts and there were no staff to replace them. Resident 18 During an interview and concurrent observation on 03/18/2026 at 1:20 PM, Resident 18 had brown substances underneath their fingernails. Resident 18 stated they did not prefer showers and did not know when they last had a bath. Resident 44 During an interview on 03/19/2026 at 1:54 PM, Resident 44 stated they were scheduled for two showers a week but were but were often missed. The Resident stated they were told there were not enough shower NAs, or the floor NAs would not show up for their scheduled shift, and the shower NAs would need to take their place. Resident 44 stated they went for ten days and up to two weeks without a shower. Review of two customer concerns on 11/04/2025 and again on 11/14/2025 showed Resident 44 complained they were not receiving their two scheduled showers a week. Both concerns showed it was because the facility did not have enough staff to provide showers. Staff Interviews On 03/17/2026 at 9:26 AM, Staff A, Administrator, along with Staff B, Director of Nursing Services, when asked about any staffing needs stated during their entrance conference interview that the facility needed to hire five to six NAs. On 03/18/2026 at 11:00 AM, Staff O, NA, stated they had their bath team taken away and no one else was put in their place to help. Staff O stated they did not have the time to give bed baths or showers during their shifts because they were too busy. On 03/18/2026 at 4:06 PM, Staff JJ, NA, stated they normally had two shower aides but were unaware one had recently left. Staff JJ stated they did not offer bed baths to their residents when they worked their shifts and neither did the other NAs. On 03/20/2026 at 9:56 AM, Staff AA, NA, stated they did not have a shower aide scheduled for that day. Staff AA stated they were trying to call and see if they could find someone to come in during the evening. On 03/21/2026 at 11:21 AM, Staff B, Director of Nursing Services, stated they had recently lost a shower aide, and another one had been on medical leave, and they were unable to pull any of the floor NAs because they needed them to provide care on the floors. Reference: WAC: 388-97-1080 (1), 1090 (1) Cross reference: F677, F689, and F692

Based on interview and record review, the facility failed to complete a thorough grievance process for 1 of 3 residents (Resident 3) reviewed for grievances. This failed practice placed residents at risk for unmet care needs. Findings included. Review of the 01/27/2023 policy titled Grievances, showed to read the grievance immediately when received and determine if the grievance is an allegation of .misappropriation of resident property, and exploitation., and if so, to take immediate action to prevent further potential violations. The policy showed the Grievance Officer/Executive Director/Designee Responsibilities would follow up with the Resident or the RR to ensure satisfaction with the outcome of the investigation. Review of the Resident's medical records showed they admitted with diagnoses to include a right leg, below the knee amputation (the surgical removal of all or part of a limb), diabetes (when the sugar in the blood is too high), and asthma (a lung condition that makes it difficult to breathe). The 12/28/2025 and the 02/06/2026 comprehensive assessments showed Resident 3's cognition was intact. During an interview on 03/17/2026 at 1:21 PM, Resident 3 stated they had reported to the facility (later identified as Staff D, Social Service Director) that they had $40.00 missing from their room. Resident 3 stated they had tucked two $20.00 bills, into their iPad case about a month ago and it came up missing. Resident 3 stated about a week ago they also had $8.00 in silver coins they used for the pop machine came up missing, that they had in their drawer. Resident 3 stated the facility did not replace their missing money nor did they hear anything about their missing money after they reported it. I guess I am just out $40.00, and the resident felt no need to report the missing $8.00. Review of a 02/01/2026 grievance showed Resident 3 claims they had $40 missing from their room. The grievance showed the Resident last saw the money on Friday (01/30/2026) and neither of their Resident Representatives had taken or removed the money from their room. The grievance showed on 02/02/2026, Resident 3's RR was called and the RR stated the Resident did not have any cash on them and the RR had their wallet. The RR stated a family member had left money with the facility to be added to their trust account for things the Resident might need, but the money was not given to the Resident. The grievance showed no follow up had been completed with Resident 3 regarding their missing money and had been reviewed as completed by Staff A, Administrator, on 02/03/2026. During a telephone interview on 03/20/2026 at 9:12 AM, Resident 3's RR stated the facility called them to ask them if they had Resident 3's wallet and money. The RR stated they told them they had the wallet and his money, but the facility did not relay to them why they were asking. The RR stated they just assumed they asked because it was no longer there. The RR stated they found out about the missing money when they visited and Resident 3 told the RR, and at that time had found out the Resident had another family member visit, and they had given the Resident two $20.00 bills. The RR stated they confirmed with the family member and did not think they needed to report that to the facility, since Resident 3 already had. During an interview on 03/20/2026 at 9:49 AM, Staff A, along with Staff B, Director of Nursing, and Staff C, Director of Clinical Operations, stated they did not do a follow-up with the resident because they thought the resident was okay with the outcome and because they were not the one who had completed the investigation. Staff A identified Staff D as the one who completed the interview. Staff B stated the RR was probably called, even though the Resident's cognition was fully intact, because with the resident's hospitalizations and stuff [other medical issues], there were times they were not fully cognitive. During an interview on 03/20/2026 at 11:08 AM, Staff D stated they called the RR because they had previously asked the facility not to leave money with the resident. Staff D stated there were a few times Resident 3 had returned from the hospital where they were not alert and oriented and did not know if this incident was one of those times even though the resident was cognitive at the time of the report and reported the RRs did not take or remove their money. Staff D stated the last time they were at the hospital was well over a month ago. Staff D stated they did not know if Resident 3 was alert or oriented when reporting the concern. Staff D stated they did not follow up with Resident 3 upon completion of the grievance and were not sure if that was their responsibility. Staff D stated they were the Grievance Officer and were not aware of the missing $8.00 in silver. Review of Resident 3's admission dates, showed they last returned from a hospital stay on 12/22/2025. Review of the 12/28/2025 comprehensive assessment showed Resident 3's cognition was intact. During an interview on 03/23/2026 at 3:20 PM, Staff B along with Staff C, stated the process for missing money would be to start an investigation, make a report if needed, and follow up with the Resident. Staff C stated the report of missing money should have been elevated to an investigation into financial exploitation. Reference: WAC 388-97-0460 (1)(2)(3)

Based on interview and record review, the facility failed to protect a resident's right to be free from verbal abuse for 1 of 3 resident's (Resident 64) reviewed for abuse/neglect. This failure placed residents at risk of experiencing fear, intimidation and mental anguish.Findings included.Review of a policy titled, Abuse Prevention and Reporting: Resident Mistreatment, Neglect, Abuse, Including Injuries of Unknown source, and Misappropriation of Resident Property, revised 08/2025, showed verbal abuse/mental abuse included the use of oral, written, or gestured communication or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability that would demean or humiliate. Examples of verbal abuse included threatening residents, depriving a resident of care or withholding a resident from contact with family and friends. Review of the medical record showed Resident 64 was admitted on [DATE] with diagnoses including right foot/ankle osteomyelitis (a serious bone infection), multiple sclerosis (a disease that damages the communication between the brain and body, leading to muscle weakness, vision changes and memory issues), and anxiety. Review of a 03/11/2026 nursing admission progress notes showed Resident 62 was independent for activities of daily living and was able to make their needs known. During an interview on 03/17/2026 at 11:20 AM, Resident 64 stated during their admission to the facility they were approached by Staff K, Business Office Manager, and told after 21 days they would be required to apply for Medicaid and would owe 20% of the bill and if they would be holding any of their money at the facility. Resident 64 stated they needed more understanding and explanation of the financial responsibilities, and the interaction was confusing and off-putting (unpleasant, uncomfortable). Resident 64 stated the interaction with Staff K was overwhelming. Resident 64 stated Staff K had no finesse, empathy, or kindness, and should not have been aggressive, regarding their financials. During an interview on 03/19/2026 at 8:56 AM, Resident 64 stated they had another negative interaction with Staff K the day before on 03/18/2026. Resident 64 stated they when they were leaving the facility, Staff K approached them by their ear and stated they could only be gone four hours from the facility, because if the state looked at the sign out book, they would think they did not need to be at the facility. Resident 64 stated that interaction from Staff K scared them and they did not want to speak with Staff K again. Resident 64 stated they did not appreciate the interactions they had with Staff K. Resident 64 stated first they were going to be required to pay 20% and second, they were going to be kicked out of the facility for visiting with a friend. Resident 64 stated they felt they were targeted, by Staff K. During an interview on 03/19/2026 at 11:41 AM, Staff K stated they provided Resident 64 with an application for Medicaid. Staff K stated Resident 64 said if they did not get approved for Medicaid, they would not be able to pay for the facility. Staff K stated they told residents when Medicaid was approved, the residents would be able to keep a small amount of money after Medicaid paid for the facility. Staff K stated Resident 64 was on Social Security Disability for their income and told Resident 64 they would lose their Social Security Disability payments and only receive the remaining amount from Medicaid, $108.00. Staff K stated they did see Resident 64 leaving the facility a second time on the same day and they did tell them since they were at the facility on Medicare, they were only allowed four hours per day to leave the facility. Staff K stated they stated that to Resident 64 because Medicare would think the resident did not need to be at the facility. During an interview on 03/19/2026 at 4:08 PM, Staff A, Administrator, stated when they were informed of the allegations of verbal abuse, Staff A suspended Staff K to protect the resident pending an investigation. During an interview on 03/20/2026 at 5:00 PM, Staff B, Director of Nursing, stated the process when there was an allegation of abuse was to suspend the identified staff and continue investigating the allegations. Reference WAC: 388-97-0640(1)(3)(a)

Based on interview and record review, the facility failed to implement their abuse/neglect prohibition policy for identification of verbal abuse for 1 of 1 resident (Resident 64) reviewed for abuse. This failure placed residents at risk of unidentified abuse/neglect, potential for continued exposure to abuse and psychological harm. Findings included. Review of the policy titled, Abuse Prevention and Reporting: Resident Mistreatment, Neglect, Abuse, Including Injuries of Unknown source, and Misappropriation of Resident Property, revised 08/2025, showed residents had the right to be free from abuse/neglect and staff were prohibited from using verbal abuse. The facility would provide immediate safety for a resident upon identification of potential abuse/neglect by staff and protect from retaliation. Resident 64 Review of the medical record showed Resident 64 was admitted on [DATE] with diagnoses including right foot/ankle osteomyelitis (a serious bone infection), multiple sclerosis (a disease that damages the communication between the brain and body, leading to muscle weakness, vision changes and memory issues), and anxiety. Review of a 03/11/2026 nursing admission progress note showed Resident 62 was independent for activities of daily living and was able to make their needs known. Review of the facility's investigation received on 03/24/2026, showed the facility identified opportunities for improvement for customer service, timeliness of reporting, and recognizing and responding to alleged abuse allegations. The facility would be educating the interdisciplinary department team [IDT) a group of healthcare professionals from different disciplines to help people receive the care they need] on the grievance process. Additionally, Staff A, Administrator, and Staff K, Business Office Manager, received disciplinary action. During an interview on 03/17/2026 at 11:20 AM, Resident 64 stated during communications with Staff K they felt the interactions were confusing, overwhelming and off-putting. Resident 64 stated Staff K lacked empathy and kindness and had been aggressive regarding their financial situation. During an interview on 03/19/2026 at 8:56 AM, Resident 64 stated they had another encounter with Staff K when they were leaving the facility with a friend when Staff K told them they were not allowed to leave the facility for more than four hours or they would lose their medical coverage. Resident 64 stated they felt scared and targeted and was concerned they would be kicked out of the facility. During an interview on 03/19/2026 at 9:29 AM, Staff Y, Licensed Practical Nurse, stated Resident 64 stated they felt that Staff K did not like them and they were offended and affected when Staff K told them they could not be gone from the facility for more than four hours. Staff Y apologized to Resident 64 on how they were made to feel. Staff Y stated they would be informing Staff A of Resident 64's concerns. During an interview on 03/19/2026 at 1:00 PM, Staff A stated they were informed by Staff Y that Resident 64 was upset about how Staff K spoke with them. Staff A stated they did not proceed to speak with Resident 64; they went and spoke with other management staff about what they heard about the four-hour Medicare requirement of being out of the facility. Staff A stated they spoke to Staff K, and they were told the conversation with Resident 64 was fine. During an interview on 03/18/2026 at 3:08 PM, Resident 64 stated Staff A came to see them around 1:30 PM and wanted to know what happened with Staff K. Resident 64 stated they told Staff A what was said by Staff K and the response they received was huh? and Staff A explained they had worked with Staff K for years and they did not mean what Resident 64 had heard. Resident 64 stated Staff A asked them, what do you want to happen? Resident 64 stated retraining, at the least. Resident 64 stated Staff A told them the rules had always been that residents could not leave the facility for more than four hours. Resident 64 stated they told Staff A they did not understand their concerns and their interactions with Staff K had been too much for them and that should be Staff A's concern. Resident 64 continued to state Staff K was abrupt and unkind and should be held accountable for their actions. Resident 64 stated they had two interactions with Staff K and made them feel they would be homeless and they were bullied and should not have to feel defensive. Resident 64 stated Staff A immediately took Staff K's side, despite Resident 64's allegations of verbal abuse. During an interview on 03/19/2026 at 4:08 PM, Staff A stated they had spoken to Resident 64. Staff A stated Resident 64 stated Staff K was unprofessional and needed education and Resident 64 seemed fine. Staff A stated they provided customer service education to Staff K. Staff A stated they told Staff K that when they needed to have any further conversations with Resident 64, they were to take a second staff member with them. During a follow-up interview the same day at 4:35 PM, Staff A was informed by this surveyor that Resident 64 reported feeling targeted, bullied, and scared by Staff K. Staff A stated they were unaware of the allegations. Staff A stated they had known Staff K for a long time, and they were stunned as that was not how Staff K was. During an interview on 03/20/2026 at 11:25 AM, Staff Y stated Resident 64 stated they felt intimidated, talked down to, scared, and terrified by Staff K. Staff Y stated Resident 64 stated they felt Staff K was out to get them. Staff Y stated they informed Staff A of these allegations from Resident 64 on 03/19/2026. During an interview on 03/20/2026 at 4:52 PM, Staff A stated when they spoke to Resident 64, they stated that Staff K was rude. Staff A stated they told Resident 64 that it was not the intention of Staff K and they had worked with them for a long time. Staff A stated there had been a lot going on for the last few days and did not remember the exact conversation with Staff Y. Staff A stated they provided Resident 64 with a grievance form to report their concerns. Reference WAC: 388-97-0640(1)(3)(a) Refer to F600

Based on interview and record review, the facility failed to develop a patient-centered discharge plan by the interdisciplinary team for 1 of 2 residents (Resident 37) reviewed for discharge planning. This failure placed residents at risk for unmet discharge care needs. Finding included. Resident 37 Review of the resident's medical records showed the resident admitted with diagnoses to include a surgical repair of their right ulna (long bone in the forearm that runs from the elbow to the wrist), had a history of falling, and dementia (a group of symptoms that cause a loss of cognitive functioning). The 01/29/2026 comprehensive admission assessment showed Resident 37's cognition was severely impaired and used a wheelchair (w/c) for mobility. The assessment showed the Resident required substantial to maximum staff assistance for all their activities of daily living. During a telephone interview on 03/17/2026 at 3:59 PM, Resident 37's Representative (RR) stated they were in the process of looking for another facility that would accept Resident 37. The RR stated they were continuously called by facility staff who was thought to be the Social Worker and told they had to find another facility that would accept Resident 37 due to their dementia and requiring one-on-one care, they don't offer that kind of care there. The RR stated they were offered a phone number for another facility and the number of a senior support service navigator but offered no other assistance in finding alternative placement for Resident 37. The RR stated Resident 37 liked to walk and the facility did not want to walk them very often and so Resident 37 had become very weak and started to fall. The RR stated the facility would consistently call them to come and sit with Resident 37 one-on-one, but they lived two and a half hours out of town and had a full-time job themselves and could not do that. The RR stated they had reached out by telephone and visited the recommended facility to see if they could take Resident 37, but they did not have any beds available for the Resident's pay status so they would have to pay privately. During the same interview, the RR stated they called the senior navigator contact number, but they charged and the RR stated they could not afford to do either of those things, so they were going to take Resident 37 home. The RR stated Resident 37 was only allotted 400 hours a month to have an in-house caregiver come in and that would leave night-time hours without a caregiver. The RR stated they relayed that information to the facility when they called them and informed them that they would have to take Resident 37 home against medical advice [AMA, a resident's decision to leave a healthcare facility or refuse treatment despite a physician's recommendation to continue care] because the resident required 24-hour care and the provider would not approve of that plan. The RR stated they had communicated to the facility that they had no placement or any other alternative so I am at a loss of what I am supposed to do and would have no other choice. The RR stated they felt like they would have to take Resident 37 home AMA because they did not feel Resident 37 was wanted at the facility any longer and were worried Resident 37 would not continue to receive the care they needed (the Social Worker was later identified as Staff Z, Unit Manager, and Staff D, Social Services Director). During a telephone interview on 03/18/2026 at 12:11 PM, the RR called the Surveyor to inform that Staff Z had just called the RR and told them they had four days to come and get my [Resident 37] because their time was up and after 03/21/2026 they would start charging them $475 a day because they had not completed the paperwork for Medicaid (a federal and state health care program that provides coverage to low-income individuals). The RR stated they informed Staff Z the Resident did have Medicaid and Staff Z told the RR We do not specialize in dementia patients so [Resident 37] cannot stay here. The RR stated they told Staff Z they did not know what they were going to be able to do with four days' notice and Staff Z told them they were actually giving them an extra two days' notice because they were only required to give them two days' notice. During an interview on 03/18/2026 at 2:38 PM, Staff D stated their process for discharge planning was to begin working on discharge planning within the first week of admission. Staff D stated the RR for Resident 37 has not done anything that was needed and we have called them multiple times. Staff D stated Staff Z and themselves, as a witness to the conversation, had called to inform the RR that Resident 37 required a higher level of care because we were not a one-on-one facility because they were falling. Staff D stated they had called several facilities and the Resident had been denied. When Staff D was asked for information on the facilities they had contacted, Staff D could not provide that information. Staff D stated the RR was given the contact information to a local facility and the RR did nothing with that information. Staff D stated they had also given the RR information for a senior navigator that could assist them. Staff D stated normal process would be to help the family or the resident if finding alternative placement was needed. Staff Z was asked to attend the interview, Staff Z stated they had offered the RR the contact information about another facility and someone who could help them and the RR stated they would call the facility. Staff Z stated the RR wanted to take the resident home, but they would not have a caregiver for at night so they were told they would have to take the Resident home AMA because Resident 37 required 24-hour care. Staff Z stated the resident could not continue to stay in the facility beyond 03/21/2026 unless they paid the daily rate ($475 a day) because the Resident's Medicare (a federal health insurance program that provides coverage for people aged 65 and older) benefits ended on 03/21/2026 and the RR had not done anything to complete the Medicaid application. Staff Z stated they did not know if Resident 37 already had Medicaid prior to admission. During an interview on 03/18/2026 at 3:01 PM, Staff K, Business Office Manager, stated they discussed discharges weekly in their Interdisciplinary Team (IDT) meetings. Staff K stated they checked all residents' Medicaid status upon admission so they would know if they needed to start the Medicaid application process sooner than later. Staff K stated they checked Resident 37 and they already had Medicaid with long term coverage prior to admission so there was nothing else needed. Staff K stated at the 03/17/2026 IDT meeting there was nothing mentioned about Resident 37 discharging or that they needed to complete a Medicaid application, or they would have informed them of their existing coverage. Staff K looked at their notes from the meeting and the notes showed Resident 37's last covered Medicare day was 03/21/026 and would transition right over to Medicaid on 03/22/2026. Staff K stated the Unit Managers would not always make it to the weekly meeting so probably had no idea what Resident 37's coverage was. During an interview on 03/18/2026 at 3:56 PM, Staff B, Director of Nursing Services, stated they were unaware of the discharge plan for Resident 37 until recently. Staff B stated the facility accepted dementia patients and they knew on admission Resident 37 had dementia, a history of falling, and left their home in the middle of the night to later be found outside after a fall but then continued to accept the Resident. Staff B stated Resident 37 was going to reside in the facility until the family found caregivers or until they decided if they wanted to leave the Resident long term in the facility. Staff B stated Staff Z was newer in the position and there was confusion with the Residents medical coverage. Staff B stated there needed to be better communication between the Business Office and the Unit Managers, so everyone knew what coverage the resident had or needed. Staff B stated Resident 37 had an uptake in falls during a urine infection and required one-on-one care and thought a higher level of care was needed. Reference: WAC 388-97-0120 (1)(b-f),(2)(a-e),(3)(a-b)

Based on interview and record review, the facility failed to issue a written notice of bed hold (holding or reserving a resident's bed while the resident was absent from the facility) for 1 of 3 residents (Resident 6), or provide a written notice of a hospital transfer or discharge to the Office of the State Long-Term Care Ombudsman (a representative who helps residents in long-term care facilities, such as nursing homes and assisted living, understand and exercise their rights) for 2 of 3 residents (Residents 6 and 62) reviewed for hospitalization and discharge. This failure placed the residents at risk for lack of knowledge regarding their right to hold their bed and any monetary charges associated with the bed hold and lack of discharge needs. Findings included. Review of a 04/2025 policy titled Bed-Hold showed the facility was required to provide a written notice of their bed-hold rights and the policy would be given to the Resident or the Resident's Representative (RR) upon transferring to the hospital or for a therapeutic leave. Review of a 04/2025 policy titled Notice of Transfer showed the written notice of transfer or discharge would be given to the RR or the Resident before or at the time of discharge. the policy showed the facility would send a copy of the notice of discharge/transfer to the LTC Ombudsman. Hospitalization Resident 6Review of the resident's medical records showed they admitted with diagnoses to include Multiple Sclerosis (MS, a chronic disease where the immune system mistakenly attacks the protective covering of nerve fibers in the brain and spinal cord, leading to communication problems between the brain and the rest of the body) and diabetes (the sugar in the blood is too high). The 12/08/2025 comprehensive assessment showed Resident 6's cognition was intact and was dependent on staff for their activities of daily living. Review of Resident 6's 03/11/2026 discharge hospital records showed Resident 6 was admitted for treatment of a urine infection on 03/07/2026 through 03/11/2026. Additional review of Resident 6's medical records showed the facility did not issue a written bed hold policy or a hospital transfer/discharge notice to Resident 6 nor did they notify the LTC Ombudsman of the discharge. Discharge Resident 62Review of the resident's medical records showed they admitted with diagnoses to include respiratory and heart failure. The 02/27/2026 comprehensive assessment showed Resident 62's cognition was intact. Review of Resident 62's progress notes, showed on 02/27/2026 at 3:34 PM Resident 62 discharged to home Against Medical Advice (AMA, a resident's decision to leave a healthcare facility or refuse treatment despite a physician's recommendation to continue care). The note showed education was provided to the resident regarding the need to stay and receive the care they needed. The note showed the Resident continued to want to discharge and signed the appropriate paperwork. Review of Resident 62's discharge documents showed no notification of discharge had been sent to the LTC Ombudsman. During an interview on 03/23/2027 at 2:27 PM, Staff C, Director of Clinical Operations, stated they had rechecked Resident 6 and 62's records and were unable to find that a bed hold had been completed or an appropriate transfer/discharge notification had been completed for Resident 6 and notification to the LTC Ombudsman had not been done for Resident 6 or Resident 62, and they should have. Reference: WAC 388-97-0120 (4)(5)

Based on interview and record review the facility failed to ensure a Preadmission Screening and Resident Review (PASRR-an assessment used to identify people referred to nursing facilities with Serious Mental Illness [SMI], Intellectual Disabilities [ID]; or Related Conditions [RC] are not inappropriately placed in nursing homes for long-term care) Level I form was completed after a 30-day exempt hospital discharge (EHD-an expected stay to be less than 30 days at a nursing home) for 2 of 5 residents (Residents 1 and 10) reviewed for PASRR. This failure placed residents at risk for inappropriate nursing home placement, and/or not receiving necessary services for mental health needs.Findings included. Review of policy titled, PASRR Requirements, dated 04/2023, showed the facility would review all PASRR's for accuracy and would immediately complete a new PASRR Level I form and notify the PASRR evaluators. Additionally, when a resident was admitted on an EHD, the facility would notify the PASRR evaluators prior to exceeding the 30 days. Resident 1 Review of the medical record showed Resident 1 was admitted on [DATE] with diagnoses including schizophrenia (severe mental disorder that affects how a person thinks, feels and behaves), malnutrition, and heart failure. The 02/25/2026 comprehensive assessment showed Resident 1 required substantial/set-up assistance with activities of daily living (ADLs) and was cognitively intact. Review of Resident 1's PASRR assessment dated [DATE], showed they were admitted with a 30-day EHD. Further review of the assessment showed a Level II PASRR form must be completed when a scheduled discharge does not occur. Resident 10 Review of the medical record showed Resident 10 was admitted on [DATE] with diagnoses including Alzheimer's (a progressive brain disorder that destroys memory and thinking skills), bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity level, and concentration), major depressive disorder (MDD -a mood disorder of persistent feelings of sadness, loss of interest, changes in sleep affecting how a person feels, thinks and behaves) and anxiety. The 01/29/2026 comprehensive assessment showed Resident 10 required substantial/set-up assistance of one to two staff for ADLs and had severe impaired cognition. Review of Resident 10's PASRR assessment dated [DATE], showed they were admitted with a 30-day EHD. Further review of Resident 10 record showed no updated PASRR. During an interview on 03/20/2026, Staff D, Social Services Director, stated they were unsure of the requirements for 30-EHD PASRR's. Staff D stated they recently found Resident 10's PASRR when reviewing Resident 10's chart, as Resident 10 had behaviors and completed a new PASRR. Staff D stated they did not review the PASRR's in a timely manner as they were unsure of what the 30-EHD meant. During a concurrent interview on 03/23/2026 at 3:26 PM, Staff B, Director of Nursing, stated the process for PASRR was when a resident was to be admitted to the facility, corporate central admissions obtained the residents records, including a PASRR and placed them in the resident's charts. Staff B stated when a resident was admitted for a 30-day EHD, the facility was to submit a new PASRR for review prior to the end of the 30 days when they were not expected to be discharged . Staff C, Director of Clinical Operations, stated they needed to identify the reason PASRR's were incorrect and training would be provided for facility staff. Reference WAC: 388-97-1975(1)(2)(5)

Based on interview and record review the facility failed to ensure the nature/terms of entering into a binding arbitration agreement (an alternative means of settling disputes without a jury by trial) were explained to residents in a form and manner in which they could understand for 1 of 4 residents (Resident 64) reviewed for arbitration. This failure placed the residents at risk for a lack of understanding concerning the legal contract that had been signed/entered into and being fully informed regarding the resident's choice in the event of a dispute with the facility.Findings included.Review of the medical record showed they were admitted to the facility on [DATE] with diagnosis including a right foot/ankle bone infection, Multiple Sclerosis (MS, a chronic disease where an individual's own immune system attacks the protective covering of the brain and spinal cord nerve fibers which can lead to communication issues between the brain and the rest of the body). The 03/11/2026 admission assessment showed the resident was cognitively intact and able to make their needs known. Record review of Resident 64's arbitration agreement showed they had electronically signed the legal contract themselves on 03/13/2026 at 11:45 AM. Staff K, Business Office Manager (BOM), signed the arbitration agreement on 03/13/2026 at 11:24 AM, as a witness (prior to Resident 64 signature).During an interview on 03/18/2026 at 1:58 PM, Staff K stated the facility's process was to review/explain the facility arbitration agreement with residents and/or the residents' representatives (RR) on admission to the facility and the document was part of the admission packet paperwork. Staff K stated they usually reviewed a specific situation that would involve a loss of money or something of value to explain what arbitration was to resident and/or the RR. Staff K stated they would explain the arbitration document in their office or electronically over the phone and send the admission packet documents via email. Staff K stated they explained to the residents/RR that the binding arbitration agreement was voluntary, did not have to sign the document to be admitted and had 30-days to revoke the agreement if the resident/RR changed their mind. During an interview on 03/19/2025 at 9:20 AM, Resident 64, stated they did not know what arbitration was nor that they had signed the binding arbitration agreement with the facility, I don't know what that is and I just signed things. The resident stated that Staff K did not go over the arbitration agreement within the admission paperwork, did not explain that the arbitration agreement was voluntary, that they did not have to sign the arbitration agreement nor that the resident had 30-day to revoke their signature on the agreement. The resident stated that Staff K had emailed all the admission paperwork documents and that it was really hard to read on my cellphone screen, and that admitting into the facility was very overwhelming at the beginning. Resident 64 stated they had signed all the documents because they thought that was what was required to show they had received the documents and to be admitted . Additionally, Resident stated that after understanding what arbitration was and that it was signed in agreement, they would want to revoke the binding arbitration agreement.During an interview on 03/19/2026 at 1:33 PM, Staff K stated they had emailed the arbitration form with all the admission paperwork to Resident 64 and offered to go over the paperwork if the resident had questions. Saff K stated that Resident 64 did not have questions. Staff K stated they used to have an electronic iPad/tablet with a bigger screen to show/review admission documents with residents but had not been using them recently. Staff K stated they could understand how it would have been hard for Resident 64 to read all the admission paperwork on a small phone screen. Staff K stated they did not offer another format to explain or review the documents, including arbitration for Resident 64, nor did the staff member personally go over the arbitration document or assess if the resident understood what arbitration was.During an interview on 03/20/2026 at 5:10 PM, Staff B, Director of Nursing, and Staff C, Director of Clinical Operations, stated that staff were to go over/explain arbitration agreement page by page with resident in a form and manner the resident can understand. Staff C stated that emailing the arbitration agreement with the admission paperwork for a resident to review on a small cellphone screen would not be explaining the documents in a manner they could understand. Both staff stated the correct process was not being followed regarding the facility's arbitration agreements.Reference: WAC 388-97-1620(2)(b)(i)

Based on interview and record review, the facility failed to implement, maintain, and enforce an effective compliance/ethics program that utilized monitoring/auditing systems designed to be effective in preventing/detecting criminal, civil, and administrative violations of the Social Security Act S 1819 (Title 42 United States Code 1395i-3, a set of laws that identifies the requirements for and assuring the quality of care in skilled nursing facilities) to promote residents quality of care for 2 of 2 staff (Staff A and Staff W) reviewed for compliance and ethics. This failure placed residents at an increased risk of negative outcomes related to care and services provided by the facility.Findings included .Review of the facility's policy titled, Abuse Prevention and Reporting: Resident Mistreatment, Neglect, Abuse, Including Injuries of Unknown Source, and Misappropriation of Resident Property, revised August 2025, showed residents had the right to be free from abuse/neglect, and facility staff were prohibited from using verbal/mental abuse. Verbal/mental abuse included threatening a resident, depriving a resident of care or humiliation. The policy showed that facility staff would provide immediate safety/protection for a resident upon identification of potential or alleged abuse/neglect. Additionally, the policy showed all potential employees would have a criminal background check completed, during the hiring process, to screen for potential history of abuse, neglect, or mistreatment of residents. Review of the facility's policy titled, General Compliance, revised date 09/2024, showed the policy was to provided clear direction to facility staff for compliance procedures in accordance with relevant laws/regulations and reference the facility's employee handbook. The policy showed a criminal background check for all employees was conducted when an offer of employment had been extended and the employment of the potential staff member was conditional upon a successful completion of a background check/verification of credentials. Review of the facility's policy titled, Compliance Reporting, showed the facility staff were to report activity or conduct suspected of not being consistent with the compliance program and federal, state or local laws/regulations. Additionally, the policy showed the report could be made via telephone or the staff member might seek advice from their supervisor, Chief Nursing Officer, Compliance officer to determine if something should be reported. Review of a Staff M's, Dietary Manager, personnel records showed they were hired on 02/18/2026 and a background inquiry (BGI, a criminal history review which screens individuals for a potential account of abuse, neglect, or mistreatment that would disqualify them from working with vulnerable adults) document was submitted by the facility for review on 02/17/2026, but was not completed. During an interview on 03/20/2026 at 11:15 AM, Staff M stated their BGI was still in process and not resulted yet. Staff M stated the Administrator was aware and approved them to work without a background check completion. Staff M stated they had been working since they were hired.During an interview on 03/20/2026 at 3:33 PM, Staff A, Administrator, stated that Staff M did not have a current background check completed and was currently working in the facility. Staff A stated they hired Staff M on 02/18/2026 and on 03/20/2026 Staff M's BGI was still pending. Staff A stated that a previous background check was completed, during the previous employment of the staff member, but could not remember the date or how long Staff M had worked for the facility before leaving employment back in 2024. During an interview on 03/20/2026 at 3:49 PM, Staff W, Human Resources Director, stated that a background check had been completed on 02/06/2024 when Staff M was first employed, to which the staff member may have worked one to three weeks, but Staff W did not know for sure. Staff W stated the current BGI for Staff M had not come back yet and was still pending. Staff W stated the normal process was to have a background check completed before a new staff member was hired and if the BGI was still pending that staff would not be allowed to work on the floor with unsupervised access to the vulnerable residents. Staff W stated that Staff M had been working on the floor with vulnerable residents, unsupervised, since the staff member started working on 02/18/2026, this is not the normal process. Staff W stated Staff A made the decision to let Staff M work with the vulnerable residents without completing their background check. Staff W stated they had questioned the process and asked Staff A if they wanted Staff M to be supervised while working in the facility with vulnerable residents, but Staff A did not think it was needed. Staff W stated they did have a compliance and ethics hotline number they could call, that was not on my radar. Additionally, Staff W stated another potential hire was also pending a background check and had not been hired or worked in the facility. During an interview on 03/20/2026 at 4:18 PM, Staff A stated they did not feel it was necessary to have another staff member supervise the Dietary Manager when working with vulnerable residents. Staff A stated they personally knew Staff M, I trust (Staff M), and (Staff M) is a good person, so Staff A did not attempt to implement an intervention, such as supervision of the staff member when with residents, even though Staff M had not completed a background check. Staff A stated, the facility's process for abuse screening was not being followed, but I am confident the background will come back with the same thing (regarding Staff M background check). Staff A stated the decision not to have a completed background check for Staff M was not unethical.During an interview on 03/20/2026 at 5:01 PM, Staff B, Director of Nursing, and Staff C, Director of Clinical Operations, stated that new potential staff were not even brought in to go over onboarding information and should not be working with vulnerable resident until a background check was completed, which was in line with the facility's policy. Neither Staff B nor Staff C were aware of Staff M being approved by the administrator to work unsupervised with the staff members BGI in process and not completed yet. Staff C stated Staff A should not have approved Staff M to work without a validated background check completion, that is not ethical and not the correct process. Reference: WAC 388-97-1620(2)(b)(ii), -1800(1)(2)(a)Cross Reference: F607

Based on observation and interview the facility failed to provide a safe, functional and sanitary (relating to the conditions that affect hygiene and health) Laundry room environment for 1 of 2 washing machines (WM1) and 1 of 1 drainage system (DS1), reviewed for environmental conditions. This failure placed residents and staff at an increased risk of cross-contamination (the harmful spread of diseases).Findings included.Observations of the Laundry room on 03/18/2026 at 5:11 PM showed: The facility had two washing machines and WM1 had a one foot (ft, a unit of measure) by one ft puddle of water underneath the back end of WM1, on the concrete floor, which was in the process of drying. The water was coming from a pipe supplying water to WM1 and was slowly dripping down the back left side of WM1's metal plate, which was wet to the touch. The water had been dripping down to the bottom of the washing machine and then to the ground. The ground beneath the washing machine had a white soap-like substance that had formed a white dried up two ft by three ft ring, which extended underneath WM1's left side. Both sides of the bottom of WM1 had three big metal nuts/bolts securing a metal plate that was attached to the machine to the concrete floor on. The nuts/bolts on the right side were clean, noted shiny silver metal, and had no signs of rust on the bolts or the black plate securing WM1 to the floor. The nuts/bolts and black metal plate on the left side of WM1 were caked and covered in a white dried soap-like substance and a dark reddish brown rust color was noted underneath. The white caked soap substance extended out from the left side of the WM1 and connected to the dried-up soap like substance ring from the back of the machine. The laundry room had a concrete one and a half ft wide commercial grade deep channel drainage trough (a heavy duty system used to drain large amounts of soiled waste water from machines like washing machines) with stagnate water (liquid that is not flowing or circulating for extended periods of time and often found in places like ponds, puddles, clogged drains and water tanks). The stagnant water had a thick layer of grayish sludge floating on top, three to five inches (a unit of measure) from being full and a strong foul odor was noted. During an interview on 03/18/2026 at 5:25 PM, Staff BB, Laundry Director, in the laundry room with the surveyor, stated they were not sure how long WM1 had been leaking and noted the white substance that was caked onto the bottom left side of WM1, that is soap and it shouldn't be there. Staff BB observed touching the back of WM1, their hand was visibly wet after touching the back of the machine. Staff BB stated the leak was coming from a hose that was supplying WM1 with water and they were not sure how long the machine had been leaking. Staff BB stated the caked-up soap around the rusted blots and previous puddle that was drying up should have been cleaned and was not. Staff BB stated the leak, it needs to be fixed.During a concurrent interview and observations on 03/19/2026 at 7:33 AM, Staff CC, Laundry Aide, stated that WM1 had a lot of build-up of the white soap-like substance on the bolts/ground around the base of WM1 and that the machine had been leaking for over a week. Surveyor observed the deep channel drainage trough water as the same level with the same thick layer of grayish sludge floating on top. Staff CC stated, I have never seen it empty all the way, and I have been here eight years.During an interview on 03/19/2026 at 7:45 AM, in the laundry room, Staff DD, Maintenance Director, stated they were not aware of WM1 leaking. Staff DD stated the leak needed to be fixed and the residue (a small amount of something that remains after the main part has been taken away or used) of the soap/water leak from WM1 needed to be cleaned. Staff DD observed the deep channel drainage trough system and stated that it was not sanitary with the water not fully draining and that it was not working properly.Reference: WAC 388-97-3220(1)

Based on interview and record review, the facility failed to provide thorough skin assessments to develop pressure offloading interventions and notify the provider timely of change in skin condition for treatment to prevent the worsening of pressure injuries (PI, localized damage to the skin and underlying soft tissue usually over a bony prominence) for 1 of 3 residents (Resident 1) reviewed for pressure injuries. Resident 1 experienced harm when their coccyx (tailbone) had a Stage 1 PI (intact skin with localized area of non-blanchable redness [red color does not change when area pressed]) present on admission that worsened to a Stage 3 PI (full-thickness loss of skin, in which fat is visible in the wound) and progressed to an unstageable PI (wound bed not visible with full-thickness skin and tissue loss) requiring wound debridement (removal of dead skin and tissue) by a wound care specialist and hospital evaluation. This failure placed the resident at risk for additional PIs and wound infection. Findings included.Review of The National Pressure Ulcer Advisory Panel (NPUAP) April 2016, showed PI Stages as follows: Stage 1 PI is intact skin with a localized area of non-blanchable redness (when the redness of the skin temporarily disappears when pressure is applied to the area). Stage 2 PI is partial-thickness skin loss with exposed dermis (middle layer of skin). The wound bed is viable, pink or red, and moist. These injuries commonly result from pressure and an adverse microclimate such as moisture associated skin damage (MASD, a term used to describe skin inflammation or erosion caused by prolonged exposure to moisture such as urine or feces.) Stage 3 PI is full-thickness loss of skin, in which fat is visible in the ulcer wound Stage 4 PI is full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage or bone in the wound Unstageable PI is obscured full-thickness skin and tissue loss in which the extent of tissue damage within the wound cannot be confirmed because it is obscured by slough (dead skin tissue that appears yellow or white and can cover parts or the entire wound bed) or eschar (dead tissue that falls off healthy skin). If slough or eschar is removed, a Stage 3 or Stage 4 PI will be revealed. Resident 1Record review showed Resident 1 admitted to the facility on [DATE] with diagnoses to include rheumatoid arthritis (a chronic autoimmune disorder that primarily affects the joints causing pain), heart failure (a progressive heart disease that affects pumping action of the heart muscles) and a urinary tract infection. Record review of a 09/10/2025 nursing admission assessment showed Resident 1 was at risk for PI and the 09/10/2025 skin check showed Resident 1's coccyx had blanchable redness (the redness temporarily disappears when the area was pressed) and a barrier cream was applied. Review of Resident 1's 09/10/2025 care plan showed the interventions to maintain clean and intact skin as follows:Avoid scratching and keep fingernails short,Encourage good nutrition and hydration,Keep skin clean and dry. Use lotion on dry skin,No further interventions were added to the care plan prior to their discharge on [DATE]. Review of a 09/15/2025, 9:09 PM progress note showed Resident 1 had an open wound on their coccyx. The wound was cleaned, and a dressing was applied. (no measurements, description or staging of the wound were documented) Review of the 09/16/2025 comprehensive assessment showed Resident 1 was cognitively intact and required extensive assistance from staff for their activities of daily living (ADL) such as hygiene, toileting and dressing. Resident 1 required extensive assistance from two staff to change position in bed and transfer between bed and wheelchair. Review of the skin assessment worksheet showed Resident 1 was at risk for developing PIs due to urine/bowel incontinence, dependence on staff to reposition in bed and presence of one Stage 1 PI observed on their 09/10/2025 admission. Review of a 09/17/2025, 1:21 PM progress note showed Resident 1 was seen by the facility physician (MD) to follow up on their admission. The MD's narrative showed that nursing staff and Resident 1 voiced no new concerns. Review of a 09/17/2025, 1:27 PM progress note showed Resident 1 and their representative attended a care conference with members of the interdisciplinary team and nursing reported no new concerns. Review of a 09/18/2025 Nutrition at Risk (NAR) meeting progress note showed Resident 1's diet order was low salt, regular consistence and thin liquids. There were no nutritional supplements to increase protein intake. The meeting was attended by Staff B, Director of Nurses (DON), Staff C, Licensed Practical Nurse/Resident Care Manager (LPN/RCM) and Staff D, Registered Dietitian (RD). Review of the meeting notes also showed there were no current skin issues (three days after an open wound had been observed). Review of Resident 1's September 2025 Treatment Administration Record showed a 09/19/2025 physician order to cleanse the coccyx wound with normal saline, apply an ointment and dressing once daily. Further record review showed no progress note or skin assessment with measurements or wound staging on 09/19/2025 (four days after the coccyx wound was first documented). Record review of a 09/24/2025 wound care specialist report showed Resident 1 was assessed and diagnosed with a Stage 3 PI that measured 2.8 centimeters (cm) by 1.6 cm by 0.2 cm deep with 100% granulation tissue (a type of tissue formed on surfaces of a wound during the healing process) and a moderate amount of serosanguinous (wound drainage that appears light pink, thin and watery) drainage. (nine days after the coccyx wound was first documented). Record review of a 10/01/2025 wound care specialist report showed that the coccyx wound was reclassified from a Stage 3 to unstageable pressure-induced tissue damage and measured 2.6 cm by 1.5 cm with 100% slough, moderate drainage and no odors. The wound care specialist debrided (the removal of dead skin) the necrotic subcutaneous tissue (death of cells in the subcutaneous tissue of the skin by injury infection or lack of blood flow) from the wound bed. Guidance in the report requested staff to change the coccyx dressing as ordered and if wet or soiled; also change resident's positions often with pillows. Review of record showed no documentation of positioning change until 10/06/2025. Record review of a 10/08/2025 wound care specialist report showed the coccyx wound continued to be unstageable, measured 3.0 cm by 2.5 cm and noted the overall wound condition had declined. Review of a 10/13/2025, 11:23 AM nursing progress note showed the physician was at the facility, reviewed Resident 1's continued functional decline and had Resident 1 sent to the hospital for acute loss of ADL function and weakness. Review of a 10/13/2025, 5:56 PM nursing progress note showed a hospital emergency room Registered Nurse (RN) reported that Resident 1 was placed on intravenous (a medical process that administers fluids, medications and nutrients directly into the vein) antibiotics (a medication that kill or stop bacteria from growing) for suspected wound infection and was being assessed to identify the cause of the resident's recent condition decline. During a telephone interview on 12/10/2025 at 9:30 AM, Resident 1's Representative (RR1) stated that they were upset that Resident 1 developed a deep wound at the base of their spine while at the facility. RR1 stated that when Resident 1 went to the hospital on [DATE], the hospital staff told them the wound had a foul odor and was most likely infected. RR1 stated they were concerned about Resident 1's recovery as they now need 24/7 total care and was bedbound. During an interview on 12/10/2025 at 1:50 PM, Staff B, DON, stated they could not produce written policies or guidelines for PI prevention interventions or interventions once a PI developed, there were none. Staff B stated, we have a wound consultant come out once a week and we run everything by [them], even intact red skin. Staff B stated they have a weekly NAR meeting that addresses wounds, nutrition and weight loss. During that meeting they would review residents with PI for their protein needs, improved surfaces such as an alternating air mattress (a medical device that uses air to dynamically redistribute pressure throughout a lying surface) and wheelchair cushion. When asked where these interventions would be documented, Staff B stated there would be physician orders and in the resident's care plan. During an interview on 12/10/2025 at 3:30 PM, Staff C, LPN/RCM, stated that they recalled Resident 1 declined in their ADLs, stayed in bed most of the time and were in their wheelchair for meals. Staff C stated the residents' PI interventions would be documented as physician orders and would be added to their care plan. While reviewing Resident 1's record they could not find documentation for additional interventions such as an air mattress. Staff C reviewed their equipment tracking log and stated Resident 1 did not have an air mattress and they should have had one. Staff C stated they implemented every two hours reposition schedule and showed in the resident's record that the turn schedule began on 10/06/2025 (21 days after coccyx wound opened and not added to their care plan). Staff C stated when a resident had a PI, they would usually have a protein supplement or health shake added to their lunch and dinner meals. While looking through Resident 1's record they stated there were no orders for supplements or shakes, and there should have been. Staff C stated they were not aware of any facility policies related to PI. During an interview on 12/10/2025 at 4:17 PM Staff D, RD, stated they would review a resident's protein needs when they were at risk for PI. While looking at Resident 1's record they stated they reviewed the resident's 09/18/2025 hospital labs on admission that showed their albumin (a protein that plays a crucial role in wound healing) were 3.3 grams per deciliter (g/dl) and stated that would be mildly low (range 3.4 g/dl to 5.0 g/dl) and would not require protein supplements. Staff D reviewed a lab result from 10/13/2025 that showed Resident 1's albumin levels were 2.6 g/dl, (abnormal) and supplements would have been ordered. Further review of Resident 1's record, Staff D stated Resident 1 did not have protein supplements ordered during their stay. During an interview on 12/10/2025 at 4:45 PM, Staff A, Administrator, stated this should not have happened, the DON was on vacation at that time and sometimes things slip through. Reference: WAC 388-97-1060(3)(b)

Based on interview and record review the facility failed to ensure a comprehensive person-centered care plan was followed related to transfer guidelines for 1 of 3 residents (Resident 1) reviewed for implementation of the care plan. This failure placed the resident at risk for injury and unmet care needs. Findings included. Resident 1 Review of the resident's medical record showed they were admitted with diagnoses that included multiple sclerosis (a chronic condition that damages the nervous system causing muscle weakness), epilepsy (a brain disorder which results in seizures) and osteoporosis (a disease that weakens bones). Review of the comprehensive assessment dated [DATE] showed the resident was cognitively intact and required total staff assistance to perform activities of daily living (basic tasks such as eating, grooming, mobility, transfers and personal hygiene) related to their chronic weakness. Review of Resident 1's care plan dated 09/25/2025 showed they were unable to bear weight or stand and had multiple leg contractures (a permanent tightening of muscle and tendons). The care plan directed staff to use a mechanical lift (a device which uses a sling to lift a resident for transfer purposes who no longer stands) with two staff assistance to transfer Resident 1 between surfaces such as their bed and wheelchair. During an interview on 11/14/2025 at 11:00 AM, Resident 1 stated about a week ago reported that two staff members had not used the mechanical lift to transfer them into their wheelchair and lifted me from the bed into my chair. Resident 1 stated they knew staff were supposed to use the mechanical lift to transfer them and was not sure why they didn't. In an interview on 11/14/2025 at 11:50 AM, Staff B, Resident Care Manager (RCM), stated they were aware of the incident that had occurred with Resident 1 in which staff performed an inappropriate manual lift transfer and did not use the mechanical lift. They should not have done that. I changed the transfer on the resident's care plan last July to a two-person mechanical lift because they are so fragile. Staff B further stated an incident investigation had been completed related to staff not following Resident 1's care plan. Review of an incident investigation dated 11/04/2025 at 2:00 PM showed on 11/03/2025 during the day shift Staff C nursing assistant (NA) and Staff D, NA, stated during the morning on day shift they had lifted Resident 1 from their bed to the wheelchair manually and did not use the mechanical lift. During an interview on 11/18/2025 at 10:10 AM, Staff A, Director of Nursing, stated they had completed an investigation into the incident on 11/03/2025 and had established that Staff C and Staff D had not followed Resident 1' care plan directives for transfer guidelines. Staff A stated the resident was very fragile and had a history of pathological fractures (a bone fracture caused by weakness of the bone structure) and required a mechanical lift to protect them from injury. Reference WAC 388-97-(1)(2)(a)(b)

Based on observation, interview and record review, the facility failed to ensure proper sanitization and food handling practices in accordance with standards of practice for 1 of 1 kitchen reviewed for food safety. The failure to maintain a clean/sanitary kitchen and complete Hand Hygiene (HH, washing or sanitizing hands) as required, placed residents at risk for foodborne illnesses. Findings included . Review of the policy titled, Food Safety Requirements, revised 01/2024, showed food safety practices would be followed throughout the entire food handling process. All equipment used for food handling would be cleaned, sanitized and handlined to prevent contamination. Clean dishes would be kept separate from dirty dishes. The policy also showed staff were to follow safe hygienic practices to prevent contamination of foods by washing hands and change gloves appropriately. Review of the policy titled, Handwashing Guidelines for Dietary Employees, revised 03/2023, showed employees were to perform handwashing to prevent the spread of bacteria that may cause foodborne illness. Dietary employees were to clean their hands in a handwashing sink and may not use a sink used for food preparation or washing kitchen ware. Additionally, the hand washing sink must have a supply of hand cleaning solutions and a means to dry the employees' hands. Staff were to perform hand washing often during the preparation of food, using clean equipment/utensils or after touching soiled surfaces or donning (put on) gloves, to prevent cross contamination when they changed tasks. <Kitchen Sanitation> An observation on 02/02/2025 at 9:36 AM, showed the following: Upon entrance to the kitchen department was a ceiling fan that had thick dark brown/gray substance inside and on the outside of the fan. The ceiling fan was above the area of a resident refrigerator, ice machine and an open cabinet that held resident clean drink cups and pitchers. The right side of the wall in front of the entrance doors had a stainless sink with sink handles and faucet covered in a thick yellow/white crusty substance. The sink drain was wet and covered in a reddish/brown substance and had pieces of food in the drain and sink. The cabinet below the sink contained a crockpot heating element, a large roll of paper towels and a 12 inch by eight inch open cut out missing cabinet base and ride side of the cabinet. The area of the missing cabinet base showed exposed concrete debris, two rodent traps and pipes covered in a white/brown substance. The cut out of the ride side of the cabinet showed exposed pipes, spray foam insulation and concrete. The bottom of the cabinet showed a large area of yellow film with a brown outline and multiple dark black/brown splatter spots. Upon entrance to the main kitchen area to the left was the dishwashing station. The dishwasher counter contained dirty trays, dishes, and watery food debris. Next to the dishwasher station to the right was an open wire rack that contained clean uncovered dishes, that included cups, mugs, bowels, plates, and pitchers. In front of the wire rack, next to the cook top, was a large triple basin sink used for washing dirty cooking utensils, pots and pans. The sink had two large food covered silver tubs in the sink. The faucets were corroded with a brown and yellow crust on the handles, faucets, and sink basin. Under the sink was a shelf that contained a basin with brushes with black/brown chunky debris. The back of the large triple basin sink that was next to the cooktop had multiple areas of dried yellow/brown food debris splatters and dried white and blackish/brown crust on the pipes. To the left of this sink was a room length stainless steel countertop. Above the countertop was an open window that had a plastic drink cup with red liquid and a straw on the window ledge. To the right of the countertop was an electrical outlet that was covered in a thick brown substance and yellow particles. There was a shelf below the countertop on the left that showed brown/white dried food debris on two pot lids, a white powder spilled on a plastic measuring container, two boxes of unopened cake mix, and a half-used jug of vegetable oil. The shelf also contained a large pot, a large colander, and a black hand mixer with many areas covered with brown/white hardened food debris and the power cord laying on the kitchen floor. There was a hallway between the main kitchen and the food storage area. This area also contained a door to the outside, a hand-washing sink, a mop sink, a closet next to the mop sink that had a mop bucket and wet mop stored in the bucket and an employee restroom. The hand washing sink showed the faucet had a thick brownish thick crust surrounding the entire faucet base. The sink had a separation from the wall that showed a gap with brown/yellow debris along the sink and wall. The hand soap dispenser above the sink was open and displayed a crushed plastic bag of hand soap. The paper towel dispenser was empty and there was no trash receptacle in this area. The mop sink had stained brown/black basin and around the rim of the sink, the faucet, and the spout were covered with green/white thick substance. <Food Preparation and Staff Hygiene> During an observation and interview on 02/06/2025 at 10:33 AM, Staff P, Dietary Cook, stated the large triple basin sink was where they washed the large cooking dishes, pots and pans prior to placing them into the dishwasher. Staff P proceeded to wash their hands in this sink that contained dirty dishes. Staff P used the jug of dish soap for hand soap and after washing their hands proceeded to the hand washing sink and obtained a paper towel, dried their hands, and put the used paper towel into the kitchen trash. An observation on 02/06/2025 at 10:36 AM, showed Staff Q, Dietary Aide (DA), preparing desserts on the prep counter, when Staff Q removed one glove from their right hand, walked across the kitchen, opened a drawer and removed a food scoop. Staff Q returned to the prep counter, scooped up food and placed it into a resident dessert cup, then put a new glove on their right hand. Staff Q did not perform any hand hygiene. An observation on 02/06/2025 at 11:08 AM, showed Staff O, Registered Dietician, stirring a large basin of food on the cook top next to the large triple bay sink. Staff P was washing dishes and soapy water was splashing around and onto the cook top. Staff P washed their hands in the triple basin sink after washing the dishes, then obtained paper towel from the hand washing sink area and dried hands. Staff P removed a cup from the dishwasher ' s gray wash bin, rinsed it with water from the large triple basin sink, and then placed onto the wire rack wet. An observation on 02/06/2025 at 11:15 AM, showed Staff Q, washed their hands in the hand washing sink. Staff Q used their hands to squeeze the soap from the soap bag, as the dispenser was open and not working. An observation on 02/06/2025 at 11:16 AM, showed an opened white, Red Bull drink can on top of the food delivery cart. A second opened Red Bull drink can was on the ledge above the food prep counter. The food delivery cart had four shelves, each shelf had multiple areas of splattered dried food debris and drips. During an observation on 02/06/2025 at 11:17 AM, Staff P put on clean gloves, without performing HH, and removed a cooking utensil from the clean dishwasher tray and placed it onto the back counter. They returned to the dishwasher area and placed their gloved hands onto the dishwasher sink edge for 10 seconds. Staff P opened the dishwasher from the entry (dirty) side during the dishwashing cycle, removed a gray dish tray bin and another cooking utensil and placed them onto the back counter. Staff P, still wearing the soiled gloves, obtained potholders and removed biscuits from the oven and placed them onto the food prep counter. Staff P proceeded to use the cooking utensil from the back counter and placed cooked vegetables into a blender. Staff P, wearing the same soiled gloves, performed a temperature check for the biscuits with a thermometer. They removed the biscuits from the baking sheet with a scraper and placed the biscuits into a large silver metal container. During the same observation, Staff P then removed their soiled gloves and did not perform HH. Staff P obtained foil, covered the container of biscuits and placed them on top of the food delivery cart with the opened can of Red Bull. Staff P then donned new gloves, without performing HH, and blended the cooked vegetables in the blender. Staff P opened a thickening powder container wearing the same gloves, used their finger to poke a hole into the paper cover and tore the cover off. They proceeded to open a drawer and retrieved a measuring spoon. While wearing the same gloves, they added the thickening powder to the blended vegetables and re-blended. Staff P placed the vegetable mixture into a small silver container, rinsed the blender in the large dish sink, and placed it into the dishwasher. Staff P returned to the food prep counter, obtained additional dirty dishes and put them into the dishwasher, started the cycle and, while wearing the same gloves, covered the blended vegetables with foil. An observation at 11:30 AM, showed Staff P remove their soiled gloves, obtained food scoops and utensils from a drawer, placed them into a silver bin and set the bin onto the food delivery cart uncovered, without performing HH. An observation on 02/06/2025 at 11:55 AM, showed Staff R, DA, removed clean wet cups from the dishwasher tray and stacked them into the cabinet that contained resident drink cups without the cups being dry. During an interview on 02/06/2025 at 12:05 PM, Staff O stated dishes placed into the dishwasher were to run the entire wash cycle and once the cycle was completed, staff were to remove the cleaned dishes from the dishwasher from the opposite side, which was the clean side. Staff O stated dishes removed from the dishwasher were to air dry and needed to be completely dry prior to putting clean dishes away. Staff O stated kitchen staff should always be moving from an area of clean to dirty and remove their gloves and perform HH. Staff O stated kitchen staff were to use the designated hand washing sink and not any of the other sinks in the kitchen as they were for washing dirty dishes only. An observation and interview on 02/06/2025 at 12:08 PM, showed there was no trash bin by the designated hand washing sink. Staff O pointed to a large white plastic bin with a lid on the floor and stated that was the trash bin. Staff O proceeded to remove the lid which showed the bin contained dirty rags and used wet paper towels. Staff O reached into the bin and removed the wet paper towels, walked them into the kitchen and disposed of them in the kitchen trash can. Staff O returned to the hand washing sink area and did not perform any hand hygiene. During an observation and interview on 02/06/2025 at 12:10 PM, showed the shelf below the food prep countertop on the left-hand side, had white powder spilled on a plastic measuring container, a jug of vegetable oil that was 1/4 full, and an uncapped can of non-stick cooking spray. The shelf also contained a black hand mixer with many areas covered with brown/white hardened food debris. Staff O stated they were unsure why these items were on this shelf and were uncleaned. During an interview on 02/07/2025 at 11:34 AM, Staff P stated they used the large dish sink to wash their hand as it was located near their work area. Staff P stated it was not the designated hand washing sink. Staff P stated they did not perform hand hygiene as they should have during the meal preparation. During a concurrent interview on 02/07/2025 at 12:04 PM, Staff A, Administrator, stated their expectations were for kitchen staff not to have any personal drinks in the food/kitchen areas. Staff B, Director of Nursing Services, stated they understood the identified areas of concern in the kitchen were an infection control issue. Staff A stated they expected the kitchen staff to pay attention to detail and follow proper hand hygiene practices. Reference WAC: 388-97-1100(3), 388-97-2980 (3)(5)

Based on interview and record review the facility failed to ensure that direct care staffing information was electronically submitted to the Centers for Medicare and Medicaid Services (CMS) for 1 of 3 quartersof 2024 reviewed for Payroll Based Journal (PBJ a mandatory report for staffing based on payroll data submission). This failure caused CMS to have inaccuraterelated to Nursing home staffing levels and the potential impact on care and services provided by direct care staff. Findings included . Record review of the Certification and Survey Provider Enhanced Report (CASPER) showed the facility had failed to report PBJ data for the 4th Quarter July 1, 2024 to September 30, 2024. During an interview on 02/07/2025 at 3:50 PM, Staff A, Administrator, stated they were unaware that the PBJ data had not been submitted as required and would look into it. Reference WAC 388-97-109(1)(2)(3) 44922 46722

Based on interview and record review, the Governing Body failed to ensure financial systems were in place to pay facility vendors who supplied essential care, services and/or necessary supplies for the residents. The facility staff had to resort to utilizing their own funds for the vendor payments which placed the residents at risk of not having necessary supplies,care and services, and potential psychological harm and distress due to the fear of becoming displaced in the event the facility was unable to meet their basic and immediate care needs.The lack of a reliable financial system was determined to be an immediate jeopardy. On 10/15/2024, the facility was notified of an Immediate Jeopardy (IJ) at F837 S483.70(d)(1), Governing Body, when the Governing Body failed to have processes in place to ensure bills were paid in a timely manner. This resulted in vendors denying necessary goods and services for residents or refusing to provide needed services without up front means of payment, leading to unsustainable methods of making payments, relying on staff personal funds, petty cash (the money that a business or company keeps on hand to make small payments, purchases, and reimbursements), and prepaid debit funds. The immediacy was removed on 10/21/2024, with an onsite validation from investigators. The facility removed the immediacy by providing documentation of payments, and arrangements of payment plans with identified essential vendors to ensure good and services would continue. Findings included . Review of a policy titled Governing Body, revised 12/2022, showed the facility would have a governing body that was legally responsible for establishing and implementing policies regarding the management and operation of the facility. During an interview on 10/09/2024 at 10:16 AM, Staff C, Business Office Manager, (BOM), stated the facility was provided a debit card with a limit of $5000 per week to use and currently Staff I, Dietary Manager, was using the debit card to purchase groceries for the residents. Staff C stated Staff A, Administrator, Staff B, Director of Nursing Services (DNS), Staff J, Housekeeping Supervisor, and other managers would purchase items for residents and the facility would reimburse on their paychecks. Staff C stated the facility had been without any petty cash for over one week and they requested petty cash from the owner and had not received any. Staff C stated the process used for invoices was to send to accounts payable for the facility. Staff C stated they never heard if the bills were paid. Staff C stated they did not have a contact person for the accounts payable department. Staff C stated the facility was told by their oxygen supplier as of 10/09/2024 the facility was placed on a credit hold for non-payment and the power company was also past due. Staff C stated the system was broken, and this is the most scared I have ever been, if it weren't for the management team not afraid to spend their own money, I don't know where we would be. During an interview on 10/09/2024 at 11:29 AM, Staff A, stated the Governing Body was the owner. Staff A stated they had not received or reviewed any financial statements or budget for the facility since April 2023. They stated the facility was utilizing a debit card provided by the owner to pay for goods and services for vendors that would no longer provide a line of credit. Staff A stated they were providing goods and services for the facility residents by utilizing their own personal credit card to ensure the residents did not go without when the debit card was low on funds. Staff A stated one vendor that was being paid on their personal credit card was an autopay for Collateral Contact 1, (CC1), a vendor that completed document destruction for confidential information. Staff A stated they had also purchased a commercial toaster, as they did not want to waste the debit card funds for that, as it would take away from groceries for the residents. Staff A stated the facility did not have a food vendor to provide food for the residents, therefore the Staff I was purchasing food locally with the debit card. Staff A asked for an increase in the debit card and was declined by the owner. Staff A stated the owner said the resident census of the facility needed to be above 60 to provide an increase for the debit card and the current census was 56. Staff A further stated they would continue to use their own personal credit card when funds were unavailable as they would not let the residents go without. During an interview and record review on 10/10/2024 at 2:20 PM, Staff C, provided a vendor list that showed 59 identified vendors that provided care and services to the facility. Review of the vendor list showed 43 vendors had a past due balance. There were nine vendors, including those who supplied behavioral health services, wound supplies, two food vendors, heating and air conditioning and a collection agency with four accounts over two years past due were identified that would no longer provide goods and services to the facility. In addition, one vendor that provided medical supplies was on a credit hold as the facility had reached their credit limit and was required to make a substantial payment before supplies could be ordered and a second vendor that provided oxygen and oxygen supplies was also on a credit hold. The pharmacy (with a six-figure past due amount) and x-ray vendors had not been paid for at least one year. Staff C stated they were called daily from past due vendors. Review of a utility bill from the electrical power company, dated 10/02/2024, showed the facility must act now to avoid shut off and the electric service past due amount must be received by [DATE], to avoid shut off. The utility bill showed a past due and current amount due. During an interview on 10/11/2024 at 1:31 PM, CC2, a representative from a supplier of wound vac's (a device that helps a wound by providing negative pressure to the wound), stated the facility had a past due account. They stated the account was on hold and the facility would not be able to place an order or provide goods and services until the facility made a payment to make the account current. During an interview on 10/14/2024 at 12:42 PM, CC3, a representative from a mobile imaging vendor that performed x-ray imaging services for the facility, stated the facility was outside their contract for payment (90 days) and had not received a payment for over one year. CC3 stated they received a payment for about half of the past due amount on 09/12/2024. CC3 had contacted a facility representative by email on 10/01/2024 requesting payment for the remaining balance. CC3 stated as of 10/14/2024, they had not received a response to that email, nor had they received any additional payments. During an interview on 10/14/2024 at 1:46 PM, CC4, a representative from a primary vendor that provides medications to the residents, stated they had not received a payment since October of 2023. CC4 stated the facility had issued a check for payment in January of 2024, but the check had been pulled back (cancelled payment) by the facility. CC4 stated they had not had any communication from the facility or corporate management. During a second interview on 10/17/2024 at 12:57 PM, CC4 stated the facility was served legal forms in August 2024 related to the past due account. During an interview on 10/15/2024 at 3:19 PM, CC5, a representative from an oxygen supply vendor, stated they supplied the facility with all their oxygen needs, including oxygen concentrators, canisters, positive air pressure machines that keep airways open, and all the associated disposables. CC5 stated the facility had finally paid their past due balance on 10/10/2024. CC5 stated the facility did not voluntarily pay their account on their own, only when they were put on hold and services were suspended. CC5 stated they sent monthly invoices to both the Business Office Manager and the facility's third-party payment center. CC5 stated the facility had been on hold for services in January 2024, on 05/29/2024, and 10/09/2024. During an interview on 10/17/2024 at 12:49 PM, CC6, a representative from a medical supply and equipment vendor, stated the facility had a past due account. They stated the account was under review and the facility would not be able to place an order. During an interview on 10/14/2024 at 1:03 PM, Staff H, Governing Body/Owner, stated they coordinated with the Administrator to ensure the facility always had funds available on the debit card and petty cash. Staff H stated they refilled the debit card at least twice a week and when the balance dropped below $2500.00, the card was automatically reloaded. The facility had been using the debit card for groceries instead of a food vendor. Staff H stated the facility did not have many vendors, all accounts were current, and utilities were on autopay. Staff H stated the Administrator was using their personal credit card for facility debt. Staff H stated the facility had been financially solid since March 2024. During an interview on 10/18/2024 at 4:33 PM, Staff A stated there was a lack of leadership and was not provided information on the financial stability of the facility. Reference WAC: 388-97-1620(2)(b)(i-ii)(c) Cross Reference F835, F838, F867

Based on observation, interview, and record review, the facility failed to prevent an avoidable accident by ensuring the care plan regarding transfers was followed for 1 of 2 residents (Resident 1) reviewed for accidents. The failure to safely transfer Resident 1 using two-person assist resulted in actual harm when Resident 1 sustained a skin tear to their lower left extremity [leg (LLE)] requiring evaluation and intervention by the local emergency room (ER), and later required antibiotic (medications that treat infections caused by bacteria) therapy when the skin tear became infected. Findings included . Review of the facility policy Safe Resident Handling/Transfers, last revised in March 2023, showed staff members were expected to maintain compliance with safe handling/transfer practices and all transfers were to be performed according to the residents' individual care plan. <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses of chronic kidney disease (a long-term condition where the kidneys' ability to filter toxins from the blood is impaired), malnutrition (poor nutrition), and chronic pain. Review of the comprehensive assessment dated [DATE] showed Resident 1 was cognitively intact and required the assistance of two people for transfers. Review of the facility's incident reporting log showed Resident 1 experienced an injury during handling on 08/27/2024 at 4:00 PM. Review of the facility's investigation showed on 08/27/2024 at 4:00 PM, Resident 1 sustained a large skin tear, measuring eight centimeters [(cm) a unit of measure] by seven cm, to their LLE while being transferred from the wheelchair to the bed by Staff E, Nursing Aide (NA). The investigation showed subcutaneous (tissue under the layers of skin) tissue was visible and Resident 1 was transported to a local ER for evaluation and wound care intervention. Review of the care plan, dated 08/03/2024, showed Resident 1 was to be transferred using a front wheeled walker (FWW) assistive device and the assistance of two people. Additionally, the care plan showed two staff members were to provide all cares due to a history of false accusatory behavior. During an interview, on 09/03/2024 at 3:30 PM, Staff B, Resident Care Manager (RCM) stated the care plan for Resident 1 was to utilize the assistance of two people for all cares, including transfers, due to Resident 1's history of making false accusations toward staff at previous facilities. During a concurrent observation and interview, on 09/09/2024 at 10:50 AM, Resident 1 stated the skin tear to their LLE occurred when they bumped their leg on the wheelchair during a transfer. Resident 1 stated they felt the NA who transferred them panicked midway through the transfer, and the quick movement did not allow Resident 1 to move their legs appropriately around the wheelchair footrest. Resident 1 stated they felt safest when two people assisted them to transfer. An observation of Resident 1's LLE showed a 14 cm gauze (loosely woven fabric used to bandage wounds) dressing intact with dark purple bruising to the surrounding skin. Resident 1 stated they were worried about skin tear because it was infected, and they were currently taking antibiotics. During an interview, on 09/09/2024 at 11:00 AM, Staff D, Registered Nurse (RN)-Wound Care Nurse, stated Resident 1 began showing signs of infection on 09/04/2024 with a fever, an increase in drainage from the skin tear, and the skin tear edges peeling back causing the wound to open. Staff D stated the facility's medical provider evaluated the wound and ordered antibiotic treatment for 10 days. During an interview, on 09/09/2024 at 2:30 PM, Staff E stated they used verbal report from other staff members to determine the amount of assistance the residents required. Staff E stated they were aware the care plan was available electronically, but they did not always have time to look at it. Staff E stated they knew Resident 1 required the assistance of two people for transfers but had been unsuccessful in finding staff to assist. Staff E stated Resident 1's skin tear was caused by the incorrect transfer, and they should have waited for a second staff member to assist. During an interview on 09/09/2024 at 2:45 PM, Staff F, Certified Occupational Therapy Assistant (COTA), stated prior to the incident, Resident 1 had been participating well in therapy, and was working with therapy staff on transfers and strengthening. Staff F stated although Resident 1 was doing well, there were no recommendations to nursing for care plan revisions. Resident 1 was still a two person transfer at the time of the incident and has had a huge decline in therapy participation since the incident. During an interview, on 09/09/2024 at 2:50 PM, Staff C, RN-Charge Nurse, stated the NAs were expected to refer to the electronic care plan for directions on how to provide care to the residents. Staff C stated Resident 1's care plan showed they needed two people to assist with all cares, including transfers. Staff C stated Resident 1's injury during handling and subsequent wound infection had caused Resident 1 to experience a decline in condition. During an interview, on 09/09/2024 at 3:15 PM, Staff A, Administrator, stated the NAs were expected to follow each residents' individual care plan which was available for reference with their electronic documentation. Staff A stated Resident 1's care plan was not followed regarding this incident. Reference: WAC 388-97-1060 (3)(g)

Based on interview and record review the facility failed to implement their abuse/neglect policies and procedures to identify, prevent, protect, investigate, and report abuse/neglect allegations for three of five Residents (#s 1, 2, and 3) reviewed for abuse/neglect. This failure resulted in the allegations of abuse from three residents (#s 1, 2, and 3) whose grievances were not recognized by administrative staff as potential abuse. Thus, the staff failed to thoroughly review and investigate grievances and determine if actual abuse was experienced by residents who had repeated complaints of derogatory comments made to them by nursing staff. The facility did not identify allegations of abuse/neglect that were written as grievances and required thorough investigations. This failure to identify abuse/neglect from resident grievances disallowed the prevention of abuse/neglect. The facility also failed to report the allegations to the State Complaint Resolution Unit as required. This failed practice placed other residents at risk for abuse and neglect. The lack of recognizing allegations of abuse and neglect and taking necessary and timely action, increased the likelihood of psychosocial harm, emotional distress, and constituted an immediate jeopardy (IJ). On 02/03/2021 at 2:47 PM the facility was notified of an IJ related to CFR 483.12 F-607, Develop/Implement Abuse/Neglect Policies. The IJ was removed on 02/08/ at 3:00 PM after the facility implemented a removal plan to protect the residents from further abuse/neglect. Findings included . Review of a facility policy titled Abuse -Washington, revised on 02/2019, showed the facility staff were required to: *Identify types of abuse *Prevent abuse *Investigate all allegations of abuse or neglect *Report allegations of abuse to appropriate reporting authority *Protect residents from abuse Resident #2. Review of the medical record showed the resident had chronic pain, diabetes and complications with her back. The most recent comprehensive assessment, dated 01/05/2021, showed the resident was alert and oriented and required extensive assistance with transfers. During an interview on 01/27/2021 at 1:30 PM, Resident #2 stated that the Nursing Assistants, (NA), were rude and got in her face and yelled at her. The resident stated that previously she had been on the phone with her representative and had the call light on to go to the bathroom. The NAs would not take her to the bathroom because she was talking on the phone and stated my roommate even asked them to take me to the bathroom. During an interview on 02/01/2021 at 1:00 PM, the resident's representative stated that she was on the phone with Resident #2 on 12/28/2020, and the resident told her that she had her call light on and had been waiting for the NAs, to come and help her. The NAs were heard by the respresentative to say that the NAs would not take the resident to the bathroom because she was on the phone and they were leaving. According to the representative the resident said I need to go now, and again the NAs said no to the resident and in very rude voices, told the resident to put the call light on when she was off the phone. The representative stated this went on for a two minutes and she heard Resident #2's roommate at the time, beg the NAs to take her to the bathroom. The representative stated this had happened before and she reported it to Staff B, the Director of Nursing Services, (DNS), but there was no real solution to the problem. During an interview on 01/27/2021 at 2:15 PM, Staff B DNS, stated she was notified on 12/28/2020 by the resident's representative that Resident #2 made a complaint against the rudeness of the NAs who were not going to take the resident to the bathroom. Staff B stated she provided follow-up training on customer service with staff on 12/29/2020 and allowed staff to return to work. The in-service was for all staff on body language and conversations with residents. Staff B stated she had ruled out abuse after talking to the resident and resident's representative, and failed to identify the NAs involved in the 12/28/2020 incident as they continued to work with other residents. The DNS failed to report the allegation of abuse and left the allegation as a grievance and failed to thoroughly investigate the allegation. Additional complaints from Resident #2 were reported on 01/25/2021 and 01/27/2021. During an interview on 01/27/2021 at 1:30 PM, the resident clearly stated that the incident happened on her bath day which was 01/21/2021. Staff Q the Social Services Coordinator logged it as occurring on 01/25/2021. Resident #1. Review of the medical record showed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The 12/31/2020 comprehensive assessment showed the resident was alert and oriented and required extensive assistance with all Activities of Daily Living, including transfers with the use of a mechanical lift. During an interview on 01/27/2021 at 10:30 AM, the resident stated that the medication incident at the beginning of 12/2020, (12/09/2020), concerned Staff E, Licensed Practical Nurse, (LPN), when she came in the resident's room and the resident's medication and very rudely demanded that she take the medication. The resident stated she said, No, I do not take this medication until later so I can sleep without pain. Resident #1 stated that Staff E said that she wouldn't be back by then and left the room. Resident #1 reported the incident. During an interview on 01/27/2021 at 1:27 PM, Staff B stated that Resident #1 received her medication. Staff B stated that after an interview with the resident and Staff E, it was determined to be a customer service issue, an education on customer service was completed, and abuse was ruled out. Additionally, Resident #3 made an allegation the he had not received his medication from Staff E on 12/10/2020, (which was actually the evening of 12/09/2020), and the DNS ruled out abuse/neglect. The DNS stated the medications were signed off but did not note the time the medications were given and the time the resident requested the pain medication. Staff B failed to identify the abuse/neglect and did not throughly investigate the reason why Resident #1 and Resident #3 had the same complaint with Staff E on 12/09/2020. During an interview by telephone on 02/05/2021 at 11:18 AM, Staff E, LPN, stated that she had two complaints from both Resident #1 and #3 about not receiving their medications from her. Staff B, DNS stated to Staff E that the medications were given. Staff E stated she was never educated or reprimanded. During an interview on 02/07/2021 at 9:00 AM Resident #1 stated she was going to move to another facility. She stated she was happy to move and could get better care. Resident #3. Review of the medical record showed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The 11/20/2020 comprehensive assessment showed the resident was alert and able to make his needs known, but required extensive assistance. During an interview on 01/27/2021 at 10:25 AM, the resident was not able to respond to questions asked. The 12/01/2020 through 01/25/2021 greviance log showed the resident had previously voiced several allegations of abuse/neglect that were documented as grievances. During record review of a grievance dated 12/10/2020, Resident #3 alleged that Staff E on the evening of 12/09/2020 was rude to him and medications were not given. Staff Q, Social Services Director, (SSD), documented it on the grievance log and Staff B, DNS, was given the complaint. Staff B documented that after interview with the resident and Staff E she ruled out abuse. There was no thorough investigation on why the incident occurred. Review of the 01/22/2021 grievance showed Resident #3 alleged Staff S NA was rude and he didn't want her in his room. During an interview on 02/07/2021 at 8:45 AM, Staff F stated it was Staff S who was rude to the resident and she reported the incident. During an interview 01/27/2021 at 1:49 PM, Staff A, Administrator, stated she felt along with Staff B the resident was perseverating about the previous incidents that occurred and ruled out abuse/neglect, and allowed Staff S to continue to work with other residents, and the allegation was not thoroughly investigated. Review of the 01/18/2021 allegation of abuse/neglect by the resident to the physician during a care conference on 01/12/2021 where Resident #3 stated to the physician, SSD, and Activities Director, that the nursing staff treated him like crap and he was tired of lying in his own feces. During an interview on 01/27/2021 at 2:20 PM, Staff B stated she was unaware of the incident until she received the 01/12/2021 physician's notes with allegations of neglect and not answering call lights on 01/18/2021. Staff B ruled out abuse/neglect after her investigation, and educated staff on abuse mandated reporting. The resident's allegations were not reported on 01/12/2021 by SSD or the Activities Director even though they were present during the resident's care conference and an investigation was not immediate. Refer to F-600 for additional information. Reference WAC 388-97-0640(2)(a)(b) Repeat citation from 09/14/2020

Based on interview and record review, the facility Administration failed to develop and implement a system to identify allegations of abuse and neglect. This failure resulted in an Immediate Jeopardy (IJ) on 02/03/2021 , which had the likelihood to endanger all residents' safety and physical, mental and psychosocial well-being. Additionally, the facility Administration failed to ensure residents were protected from abuse/neglect by not thoroughly investigating and reporting allegations of potential abuse increased the likelihood of harm due to abuse/neglect for all residents. The Administration failed to to ensure sustained compliance from a previous IJ identified on 09/03/2020. Findings included . Failures of the facility Administration were identified as the following: 1) F-600 CFR 483.12 (a)(1), Free From Abuse and Neglect; The Administration failed to review grievances, which resulted in allegations of abuse/neglect for three of five resident reviewed for abuse/neglect. 2) F-607 CFR 483.12 (b)(1)-(4), Develop/Implement Abuse/Neglect Policies; The Administration failed to recognize grievances as allegations of abuse/neglect and protect residents from ongoing abuse and neglect. This resulted in an Immediate Jeopardy related to the failure to identify, prevent, report, and investigate allegations of abuse/neglect, thus failing to protect the residents. The Administration also failed to sustain compliance from a previous Immediate Jeopardy identified on 09/03/2020 and removed on 09/08/2020 in F-607. 3) F-609 CFR 483.12 (c)(12-14) Reporting Abuse/Neglect; The Administration failed to report allegations of abuse/neglect to the State agency as required. 4) F-610 CFR 483.12 (c)(12-14), Investigate/Prevent/Correct Alleged Violations; The Administration failed to thoroughly and timely investigate allegations of abuse filed as grievances. 5) F-725 CFR 483.35 (a)(1)(2) Sufficient Nursing Staff; The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and [DIAGNOSES REDACTED]. 6) F-745 CFR 483.40(d) Provision of Medically-Related Social Services; The Administration failed to provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. During an interview on 01/27/2021 at 2:15 PM, Staff A, Administrator, stated the Social Services Director (SSD) and herself determined if grievances were allegations of abuse or neglect that needed further action. Staff A, further explained that the SSD had been unavailable, and she also was unavailable during the time of the if grievances for Resident #1 dated on 12/09/2020, Resident # 2 dated 12/28/2020, Resident #3 dated 12/10/2020. The allegations of potential abuse were not reviewed by the Administrator for those dates. During an interview on 02/09/2021 at 10;30 AM, Staff C, Regional Nurse, stated she had not been informed nor reviewed the facility grievances as stated above for Residents #1, #2, #3 and recognized that the facility should have identified the grievances as allegations of abuse and neglect. Reference WAC 388-97-1620 (1) This a repeat citation from 09/14/2020.

Based on interview and record review the facility failed to implement their abuse/neglect policies and procedures to identify, prevent, protect, investigate, and report abuse/neglect allegations for eight of eight Residents (#s 1, 2, 3, 4, 5, 6, 7, and 8) reviewed for abuse/neglect. This failure resulted in the allegations of abuse for three of eight residents (#s 1, 2, and 3) not being thoroughly investigated and psychological harm to Resident #1 due to fear and intimidation by a Nursing Assistant (Staff C). The facility did not identify allegations of abuse/neglect, that were written as grievances and required thorough investigations. This failure disallowed the prevention of abuse/neglect. The facility also failed to report the allegations to the State Complaint Resolution Unit as required. This failed practice placed other residents at risk for abuse and neglect. The lack of recognizing allegations of abuse and neglect and taking any needed action constituted an immediate jeopardy (IJ). On 09/03/2020 at 4:45 PM the facility was notified of an IJ related to CFR 483.12 F-607, Develop/Implement Abuse/Neglect Policies. The IJ was removed on 09/08/2020 at 4:35 PM after the facility implemented a removal plan to protect the residents from further abuse/neglect. Findings included . Review of a facility policy titled Abuse -Washington, revised on 02/2019, showed the facility staff were required to: *Identify types of abuse *Prevent abuse *Investigate all allegations of abuse or neglect *Report allegations of abuse to appropriate reporting authority *Protect residents from abuse During an interview on 09/02/2020 at 1:30 PM, Resident #1 reported that she had concerns with Staff C, Nursing Assistant (NA), treating her rough and mean. The resident stated Staff C frequently pushed on her right knee which caused her pain. Resident #1 stated the prior week (could not recall the exact date) Staff C became mad at her after Resident #1 soiled the bed with stool. Later that evening Staff C refused to give the resident a whole sandwich (only half) and stated it was because the resident would mess the bed again. Resident #1 expressed she felt embarrassed and was scared of Staff C and later reported her concerns to facility staff. During an interview on 09/02/2020 at 3:05 PM, Staff B, Director Nursing Services, stated she received a report on 08/24/2020 involving Resident #1's allegations against Staff C, which included the resident's embarrassment and fear of Staff C. Staff B stated she did not report or log the above concerns from Resident #1 as Staff B did not feel it was an allegation of abuse after she talked to the resident and Staff C. Staff B stated she re-assigned Staff C to another area to prevent her from working with Resident #1 and provided education on customer service. Resident #1. Review of the medical record showed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent comprehensive assessment, dated 06/17/2020, showed the resident required extensive assistance for transfers, mobility, and incontinent care. The resident was alert and had no cognitive impairment. Review of the facility incident reporting log on 09/02/2020 at 3:15 PM, (a log that reflects the facility's investigations and outcomes) showed no documentation that Resident #1's allegation had been logged, reported, or investigated as required. Review of the grievances alleging abuse/neglect, showed two of the eight residents (#s 2 and 3) identified Staff C as the alleged perpetrator. The following grievances alleged abuse/neglect: 06/23/2020 Resident # 2 reported Staff C was rough with her. 06/23/2020 Resident # 3 reported Staff C was roughly handling her. 07/08/2020 Resident #s 4 and 5 allegedly did not receive incontinent care and were left saturated in urine. 07/10/2020 Resident # 1 reported she had not been changed for hours. 08/11/2020 Resident #s 6, 7, and 8 had allegedly not received incontinent care and were saturated in urine. During an interview on 09/02/2020 at 2:30 PM, Staff A, Administrator, stated that she was responsible for reviewing the grievances and determined whether a grievance was an allegation of abuse or neglect and required further investigation. Staff A stated that she had not identified the grievances of rough treatment made by Resident's #s 2 and 3 against Staff C as allegations of abuse, but as customer service concerns. On 09/04/2020 at 8:30 AM, a review of the State tracking system for reported incidents showed no evidence that any of the above grievances, or the concerns reported by Resident #1 had been reported by the facility to the Complaint Resolution Unit as allegations of abuse or neglect. Resident #2. Review of the medical record showed the resident was admitted to the facility on [DATE] and discharged on [DATE]. The resident's admitting [DIAGNOSES REDACTED]. The most recent comprehensive assessment, dated 06/22/2020 showed the resident required extensive assistance with transfers, dressing and toileting. The resident was cognitively intact with no memory impairment. During a telephone interview on 09/15/2020 at 9:30 AM, Resident #2 stated she recalled a grievance she filed against Staff C during her stay at the facility. The resident stated Staff C abruptly pulled a pillow from under her head causing her to hit her head on the bed frame. The resident stated Staff C also abruptly pulled the pillows from under her legs which caused her pain. She (Staff C) scared me, she should not be working with patients. Resident #3. Review of the medical record showed the resident was admitted to the facility on [DATE] and discharged on [DATE]. The residents admitting [DIAGNOSES REDACTED]. The most recent comprehensive assessment, dated 06/24/2020, showed the resident required extensive assistance with transfers, dressing and toileting. The resident was cognitively intact with no memory impairment. On 09/11/2020 at 10:00 AM an attempt was made to contact Resident #3 to review the grievance she filed against Staff C during her stay at the facility, however the contact information that was available was no longer current. Record review of Staff A's training records showed Staff A had been trained on 12/17/2019 on definitions of abuse/neglect and the responsibility to immediately report resident allegations of abuse. In a follow-up interview on 09/09/2020 at 10:45 AM, Staff A stated she re-reviewed the grievances and realized she had failed to recognize the grievances as abuse or neglect, which resulted in the failure to protect the residents. Refer to F-600 for additional information. Reference WAC 388-97-640(2)(a)(b)

Based on interview and record review the facility failed to ensure one of eight residents (#1) reviewed for abuse, was free from abuse. This failure resulted in actual harm to Resident #1 who experienced psychological harm due to fear and intimidation. The facility had knowledge of the abuse and neglect allegations based on previous grievances and witness statements that Staff C, Nursing Assistant (NA), had allegedly abused/neglected other residents. Staff C continued to work with unsupervised access to vulnerable residents until 9/02/2020 when she was placed on administrative leave after additional allegations were made during the survey. This failure placed all residents in the facility at risk for abuse/neglect. Findings included . Record review of the facility's policy titled Abuse -Washington, revised on 02/2019, showed the facility staff were required to implement the required components, which included the prevention and protection of residents from abuse. During an interview on 09/02/2020 at 1:30 PM, Resident #1 reported that she had concerns with Staff C, NA, because she was rough and mean and frequently pushed on her right knee during transfers, which caused her pain. Additionally, the resident stated that sometime last week (could not recall exact date), Staff C was mad at her because she soiled the bed with stool and the linens needed to be changed. The resident stated Staff C placed garbage bags under her, which embarrassed her. Staff C had informed the resident, I'm not going to change the bed linens again. The resident stated, I don't know why she is so mean .I cant help it (incontinence). Resident #1 further stated that later on in the evening she asked Staff C for a sandwich and was told she could only have a half of one because, You might mess the bed again. The resident stated she felt embarrassed and afraid of Staff C. The resident stated she waited until Staff C left for the day before reporting her concerns to Staff F and Staff G (both licensed nurses). On 09/02/2020 at 2:35 PM Resident #1's allegations of abuse were reported to Staff A, Administrator, and Staff B, Director of Nursing Services (DNS). On 09/02/2020 at 3:00 PM Staff A, Administrator, informed the surveyor that Staff C had been placed on administrative leave pending investigation into her conduct with Resident #1. During an interview on 09/02/2020 at 3:50 PM, Staff E, Licensed Nurse (LN), stated at the end of the evening shift on 08/24/2020, Resident #1 asked to speak to her. The resident reported she had been treated badly by Staff C. The resident stated Staff C had been angry with her because the resident was incontinent of stool in her bed, and Staff C placed garbage bags under Resident #1 which upset the resident. Staff E stated Resident #1 additionally reported when the resident requested a sandwich, Staff C refused to get her a whole sandwich and told the resident it was because she might mess the bed again. Staff E stated she consoled the upset resident and contacted the DNS to report the incident and stated, I really felt it was abuse. During an interview on 09/02/2020 at 4:00 PM, Staff F, LN, stated that she went to Resident #1's room on 08/24/2020 and stated the resident told her how Staff C treated her. Staff F stated, I have never seen her so upset before. Staff F stated she had reported the incident to the DNS. During an interview on 09/02/2020 at 4:15 PM, Staff B, DNS, stated she was notified on 08/24/2020 by Staff E that Resident #1 made a complaint against Staff C. Staff B stated she reassigned Staff C to another area in the facility and provided follow-up training on customer service with Staff C. Staff B stated she had ruled out abuse after talking to the resident which was why Staff C continued to work with other residents. Record review of the facility's grievances showed Staff C had prior allegations of abuse involving two residents, #s 2 and 3, on 06/22/2020. The grievances showed Staff C was accused of rough treatment by the residents on the same day. The follow-up plan documented on the grievance form was to re-assign Staff C to another area in the facility, have Staff C apologize to the residents, and receive education on customer service. On 09/03/2020 at 2:40 PM, investigations were requested for the above grievances filed by Resident #s 2 and 3 on 06/23/2020. Staff A stated, I don't have any more paperwork on those grievances except for what is already on the form. Resident #1. Review of the medical record showed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent comprehensive assessment, dated 06/17/2020, showed the resident required extensive assistance for transfers, mobility and incontinent care. The resident was alert and had no cognitive impairment. Review of the June through September 2020 NA schedules showed Staff C continued to work with unsupervised access to the residents on a full-time basis until 09/02/2020, when she was placed on administrative leave by Staff A. In a follow-up interview on 09/04/2020 at 11:45 AM, Resident #1 stated after she reported Staff C, she returned a few nights later to the resident's room and stood in the doorway and angrily stated, Why did you turn me in? I got in trouble. Resident #1 stated she turned away from Staff C because she was afraid that Staff C would hurt her. During an interview on 09/08/2020 at 3:30 PM, Staff D, Regional Nurse, stated she reviewed the abuse allegations made by Resident #1 and stated they were abuse. Refer to F-607 for additional information. Reference WAC 388-97-0640(1)(3)(a)

Based on observation, interview and record review the facility failed to ensure one of one resident (#3), reviewed for substantial injury, had their care plan implemented for mechanical device transfers between surfaces when staff used a stand assist lift device (sit-to-stand) instead of a total body lift device (Hoyer) that caused harm to Resident #3 diagnosed with [REDACTED].#6), reviewed for falls with injury, had appropriate supervision by staff, when the resident was left alone on the toilet and fell causing injury to the skin and unnecessary discomfort at end of life. Findings included . Resident #3. Review of the resident's medical record showed they were admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a [DATE] comprehensive assessment showed the resident was cognitively intact, required extensive assistance from two staff for transfers, had lack of muscle coordination and was on Hospice. Review of the resident's [DATE] transfer care plan showed they required a mechanical lift (Hoyer) with two staff assistance for transfers. During concurrent interview and observation on [DATE] at 9:20 AM, Resident #3 was lying in bed watching television. The resident stated they had a broken right ankle when staff transferred using a sit-to-stand lift from the wheelchair to bed. When I stood up, there was a jerk, a slip and a lot of pain in my right ankle. Further the resident stated the pain was bearable, especially with the splint on. Review of the facility's [DATE] investigation showed on [DATE] at approximately 9:30 AM, Resident #3 asked Staff D, Nursing Assistant (NA), to transfer them from the bed to the wheelchair. The resident requested staff use the sit-to-stand to transfer. Staff D and Staff E, NA, transferred the resident using a sit-to-stand mechanical lift from the bed to the wheelchair. The resident was up approximately two hours. Further review of the [DATE] investigation showed, Sometime between 11:30 AM and 12:00 PM, resident requests to get back into bed. (Staff D) proceeds to set up the sit-to-stand, and place resident in the sling for transfer Staff F, NA, reports that when arriving in the room (to assist), resident was in mid transfer out of (their) chair. (Resident #3) was complaining of (their) foot hurting, (Staff F) adjusted the left foot, while Staff D adjusted the right foot, and they continued to the transfer (the resident) to the bed. Per (Staff D), at some point during the transfer .the wheelchair was stuck on the sit-to-stand below the resident's right foot and the right foot bent at the ankle as we were moving the sit-to-stand away from the wheelchair. Review of the initial [DATE] incident report, showed Staff G, Licensed Practical Nurse (LPN), documented: Resident voices his feet were mishandled and bend {sic} the wrong way while being transferred from w/c (wheelchair) to bed, (resident) voices the right ankle hurts the worse and (they) were scared that (their) ankles have been broken. Review of an x-ray obtained and reported on [DATE] showed Resident #3 had a fractured right ankle. Review of a [DATE] progress noted at 10:35 AM showed the x-ray results were reported to the facility physician and an order received to send the resident to the hospital. The same day a 5:14 PM progress noted showed the resident's right ankle fracture was not splinted. During an interview on [DATE] at 3:15 PM, Staff B, Director of Nursing, stated Staff D should have followed Resident #3's transfer care plan and used the Hoyer lift, but did not. Resident #6. Review of the resident's medical record showed they were admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of a [DATE] comprehensive assessment showed the resident had mild cognitive impairment, was in constant pain and on hospice care. Review of the facility incident log showed Resident #6 had four falls between [DATE] and [DATE]: * On [DATE] the resident was walking in hall with walker, fell near room doorway and sustained skin tear to the left eyebrow. The cause of the incident included Resident has [MEDICAL CONDITION] and is weak with altered gait at times. * On [DATE] the resident was found on the floor next to the bed with no injuries identified. A contributing cause was the resident'[MEDICAL CONDITION] seemed to be progressing and the resident was becoming weaker. * On [DATE] the resident was found to have multiple bruises on their arms. The resident stated they fell the prior day and got back up. A contributing cause was (Resident #3) was overestimating their abilities and declining rapidly [MEDICAL CONDITION]. Review of the [DATE] fall investigation showed at around 6:00 PM, Staff H, Registered Nurse (RN), assisted the resident to the bathroom on the commode. The RN left the resident on the commode and returned one minute later and found the resident on the floor. The resident sustained [REDACTED]. The investigation concluded the resident fell trying to get up off of the commode due to declining health and actively dying. Review of a [DATE] Hospice progress note showed the resident had a fall and acquired skin tears on (their) right back and left upper arm above the elbow. The right forearm skin tear had steri strips intact. The progress note further showed the resident's spouse was upset that the facility did not take care of (Resident #6) and he fell . During an interview on [DATE] at 3:00 PM, Staff H stated that day she saw Resident #6 trying to climb out of bed so the RN assisted the resident to the bathroom. I knew (Resident #6) had poor impulse control and I should not have left (their) side. During an interview on [DATE] at 3:00 PM a collateral contact stated (Resident #6) was declining rapidly and should not have been left alone on the toilet. (Resident #6) had bruises and abrasions that should not have happened. (Resident #6) died a week later. Reference: WAC [DATE](3)(g)

Based on observation, interview and record review, the facility failed to identify, assess and intervene for one of three residents (#51) reviewed for nutrition that experienced weight loss. This failure resulted in harm to Resident #51, who experienced unplanned severe weight loss (defined as more than 5% in one month, more than 7.5% in 3 months and more than 10% in 6 months). Findings included: Resident #51. Review of the medical record showed the resident was admitted to the facility on [DATE] with multiple diagnoses. The Minimum Data Set, an assessment tool, dated 08/02/18, documented the resident required set up and supervision for meals. Significant weight loss, (defined as 5% in the last month, 7.5% in the last 3 months or 10% in the last 6 months) was documented. Multiple observations during breakfast and lunch on 10/29/18 at 9:25 AM and 12:30 PM, during breakfast on 10/30/18 at 8:31 AM, and during breakfast on 10/31/18 at 8:32 AM showed Resident #51 struggling to feed himself with no assistance from staff. A Nutritional care plan, initiated on 07/05/18 and revised on 08/10/18, listed an intervention, dated 08/10/18, weigh and record weekly. Review of Resident #51's weight records showed the following: * 05/04/18 admission weight was 156 pounds * 07/10/18 weight was 144 pounds - significant loss of 7.69%. No weights were documented after 07/10/18 for July. * No weights were documented for (MONTH) (YEAR) * 09/10/18 weight was 134 pounds - an additional loss of 10 pounds. No other weights were documented in September. * 10/10/18 weight was 127 pounds - an additional 7 pounds lost. * No weight was documented between 10/10/18 and 10/31/18 * 10/31/18 weight was 123 pounds - severe weight loss of 21% in 6 months A weight loss care plan, initiated 08/10/18, included interventions, dated 08/10/18, to monitor and evaluate any weight loss and to refer to dietician. Review of progress notes from 07/10/18 through 10/15/18 showed no documented evaluation, monitoring or notification of the RD of Resident #51's weight loss. On 11/01/18 at 11:35 AM, Staff L, Registered Dietician (RD), said weights were reviewed weekly for weight loss and if weight loss was identified the resident would be brought to the nutrition at risk (NAR) meeting. The team, consisting of the RD, Resident Care Manager (RCM), and Director of Nursing Services (DNS) discussed the weight loss, made recommendations for interventions and made a progress note. The resident would then be followed weekly by the team. A NAR note, dated 10/16/18, documented the resident's weight loss and made a recommendation to add sugar free health shakes twice a day. Progress notes from 10/17/18 through 10/31/18 did not document a weekly follow up NAR meeting for Resident #51. The (MONTH) (YEAR) Medication Administration Record [REDACTED]. At 3:11 PM, Staff G, Registered Nurse (RN)/RCM, said the weights for Resident #51 for (MONTH) were missed. Staff G reviewed the NAR meeting log and progress notes for Resident #51 and said the first NAR meeting he was reviewed on was 10/16/18. When asked if there was a delay in identifying weight loss and implementing interventions with no weights between 07/10/18 and 09/10/18, and no NAR meeting until a month later on 10/16/18, Staff G replied, Yes. On 11/02/18 at 8:36 AM, Staff B, DNS/RN, said, I 100% agree there was an issue, when asked if the process for identifying and intervening with weight loss had been followed for Resident #51. The facility's failure to ensure timely identification, evaluation and implementation of interventions caused harm to Resident #51 when he experienced unplanned severe weight loss. Cross reference F677 for further details regarding failure to assist the resident with meals. Reference WAC 388-97-1060 (3)(h)

Based on observation, interview and record review, the facility failed to ensure one of three residents (#1) reviewed for elopement, had timely appropriate interventions in place to prevent an elopement, resulting in an accident with injury. This failed practice caused harm to the resident, resulting in a fractured ankle, while missing from the facility. Findings included: Resident #1. Review of the medical record showed the resident admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the admission comprehensive assessment dated [DATE] documented the resident with moderately impaired cognition. During an interview with Resident #1 on 11/06/17 at 3:31 PM, he stated he walked out of the facility in the morning after he ate breakfast. The resident could not recall the exact date, but recalled it was toward the end of September 2017 (09/27/17). He stated he was able to punch in the correct code for the front door, so the alarm did not sound off. The resident explained he did not let any staff know he was leaving. The only one that saw me leave was my roommate .he knew. The resident discussed his history and stated, I'm good at sabotaging myself, in reference to making poor choices and not thinking of the consequences. The resident further explained he eventually caught a ride to a different town (located approximately 17 miles away), became inebriated and woke up outside at the compound. The resident explained the compound was a location where homeless people frequent. The resident further explained when he woke up the next morning, he immediately noticed pain to his left ankle and leg and his sister located him and drove him to the local hospital where he was diagnosed with [REDACTED]. On 11/06/17 at approximately 3:40 PM, Resident #1 was observed in his room self-propelling his wheelchair. The resident demonstrated the hard cast to his left ankle. Review of Resident #1's medical record showed a physician order [REDACTED]. Review of a 07/20/17 admission Elopement Risk Evaluation completed by the Activity Director did not document the resident's cognitive impairment. During an interview on 11/07/17 at 2:25 PM with Staff C, Registered Nurse (RN), she stated she was the nurse assigned (evening shift, 2:30 - 10:30 PM) to Resident #1 on the day he left the facility (09/27/17). She first noticed the resident missing from the facility sometime after dinner, around 5:00 PM that day. She explained she did not see the resident leave the facility and was told he had an appointment that day. I did not do anything because I was not concerned. Later in the evening during her shift, she stated she called the Director of Nursing Services (DNS) to let her know the resident had not returned, attempted to call the family and left a message. She stated she did not check the resident sign in/out log (which the resident did not sign out) and stated she only reviewed it when she had a missing, confused resident. She added that she was later concerned due to the resident's poor judgement. Review of the facility appointment calendar showed Resident #1 did not have an appointment on 09/27/17. Review of the progress notes showed a note , dated 09/28/17 at 3:06 PM, that documented Staff B, Licensed Practical Nurse (LPN), called the resident's family member and asked if she had seen him. The LPN ended up speaking to a different family member that saw the resident the night before at 7:30 PM where the resident asked for a ride (to a town located approximately 17 miles from the facility), but the family member did not give him the ride. The initial family member stated she went out driving and looking for the resident because she received a message from the facility and would call facility back if she found the resident. A progress note dated 09/28/17 at 4:23 PM documented by the DNS showed a family member called the facility at 4:15 PM that day and stated the resident was found (in the town located approximately 17 miles from the facility), was alcohol-impaired and with an injury to his left leg. The sister took the resident to the local hospital emergency department. In an interview on 11/06/17 at 4:30 PM, Staff D, Nursing Assistant (NA), stated she was familiar with the resident and he ate his meals in his room. She further explained she was looking for the resident around 4:00 PM that day (09/27/17) and informed a Licensed Nurse that resident was missing. She stated she did not see the resident leave the facility. During an interview on 11/07/17 at 10:42 AM with Staff E and F, both NAs, they stated they were always assigned (day shift, 6:30 AM - 2:30 PM) to the front area of the facility where Resident #1 resided. The NAs were unable to recall seeing the resident the day he left the facility and explained he did not require assistance with Activities of Daily Living since he was independent. Staff E stated the only thing she recalled was talking to the resident's roommate the day after he left (09/28/17) and the roommate stated Resident #1 left and was not coming back. During an interview on 11/07/17 at approximately 3:45 PM with Staff A, DNS, she stated she was aware of the resident's history of poor judgement/choices, alcohol/drug abuse, his medical conditions related to a traumatic brain injury, and his previous suicide attempt. She further explained Staff C, Registered Nurse (RN), called her the evening the resident was missing from the facility and had not returned. The DNS stated she did not consider Resident #1 an elopement due to the local fair being in town and the resident having a history of going on outings with a family member or other responsible party and not coming back until later in evening. Review of the resident's progress notes did not show any documented evidence that the night shift RN acted in accordance with the facility policy and procedure for a missing resident. The facility policy and procedure for missing residents located in the Emergency and Disaster Manual, last revised 01/16, documented, .In the case of actual missing person or elopement, the following procedures are to be followed: Notify administrator .coordinate emergency team for vehicle and foot search .Have staff member knock on every door (homes or business) within a 2-3 block radius .call all motels, restaurants, casinos and shopping malls .Notify Regional Director of Operations and Nurse Consultant with Prestige Reference WAC 388-97-1060(3)(g)

Based on observation, record review, and interview, the facility failed to ensure 1 of 3 sampled residents (#1) involved in accidents had their environments as free of accident hazards as possible. Resident #1 placed a hot pack, heated by a staff member, and sustained a large burn on his arm. Findings include: Resident #1: Review of the medical record revealed the resident was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident's plan of care noted he was at risk for skin impairment due to having decreased sensation on his paralyzed left side. The resident required staff assistance for all his activities of daily living. An 11/27/14 nursing entry noted the resident was complaining of left shoulder pain. Staff Member A, a Licensed Nurse (LN), documented a warm pack was applied and it offered some relief. When interviewed on 12/11/14 at approximately 4:00 p.m., Staff Member A stated Resident #1 had experienced some left shoulder pain. She had applied a warm, moist towel wrapped in plastic and another towel to his shoulder and it was helpful in reducing the pain. Review of a 12/01/14 nursing entry by Staff Member B, a LN, revealed the resident was noted to have "what appears to be a burn to left upper arm. two (sic) blisters noted, one popped the other is still fluid filled, surrounding skin is red in color. total (sic) measurement is approx (approximately) 11.5 cm (centimeters) by 5 cm (approximately 4 1/2 inches by 2 inches)." A physician's orders [REDACTED]. Staff Member B was interviewed on 12/11/14 at approximately 1:00 p.m. and stated that on 12/01/14 in the morning a Nursing Assistant (NA) was assisting the resident with dressing. The NA noted the skin on the resident's left upper arm was bright pink. There was also a popped blister and an intact blister present. The LN asked the resident about the cause of the burn. Resident #1 stated the burn was caused by a hot pack that Staff Member C, a NA, had brought in on Saturday (11/29/14). According to the 12/01/14 facility investigation, Resident #1 stated he had requested that Staff Member C get a "hot pack" for his arm. He reported that the warmth helped his pain. Resident #1 stated he awoke the evening of 11/29/14 and saw the pack on his bedside stand. He rolled the pack up in the sleeve of his gown and placed it on his arm. He didn't feel it burning. No further heat was applied to the area after that occasion. Staff Member C had brought the "hot pack" from home thinking it would work well for the resident. Staff Member C stated she was not aware that she was not to apply heat to a resident. She heated the pack and took it to his room. He was asleep so she left it at his bedside. The facility investigation concluded that Staff Member C was administering treatment outside the scope of her practice. She took this action without the direction or knowledge of the Registered Nurse who was on shift. Staff Member C had made this hot pack out of rice. She brought the pack from home to give to the resident. Bringing objects for medical care from home to use for a resident was prohibited. On 12/01/14 the resident was noted to have a second degree burn on his left shoulder. Observations on 12/11/14 at approximately 10:50 a.m. revealed a rectangular dark green brocade pack with whitish stitching around the edges. The pack appeared to be approximately 8 inches by 5 1/2 inches (per observation). At approximately 2:40 p.m. on 12/11/14 the resident's left upper arm was observed. There was a large scabbed area at the top of the left arm with bright pink intact skin surrounding the scabbed area and extending below. The affected area appeared to be approximately 4 inches long and 1 1/2 inches wide. Staff Member C was interviewed via telephone on 12/13/14 at approximately 3:20 p.m. The NA stated she was aware that some residents had received warm towel packs in the past. She recalled that during the evening (on 11/29/14) the resident reported his left shoulder was hurting. He wanted a heat pack for his shoulder. Staff Member C stated she could get him one. She made home-made rice packs to use for her family. During her lunch break she went home and picked up the rice pack. She placed the rice pack in the microwave at the facility for approximately 55 seconds. She went to the resident's room. He appeared to be sleeping so she left the heated rice pack at his bedside. She stated she heard later he awoke and placed the hot pack. During interviews with alert Resident #1 on 12/11/14 at approximately 1:20 p.m. and on 12/15/14 at approximately 1:25 p.m., the resident stated his left shoulder kept hurting and the warmth seemed to help the pain. He had mentioned that the warm packs helped his shoulder to Staff Member C. She stated she had something at home that would help. That evening (on 11/29/14) she brought the pack in. He found the warmed pack and placed it on his left shoulder. He did not have a towel to use so he rolled it up in his gown. It felt warm so he layed on his left shoulder with the pack in place. The next morning he put his hand to his left shoulder, felt fluid, and identified a blister. He reported it to staff. The resident stated the (rice) pack was only used once. Resident #1 recalled Staff Member B looking at the burn later. Resident #1 experienced harm, a burn, as a result of the unauthorized heat pack provided to the resident. The resident's diminished sensation on his left side placed him at increased risk for injury.

Based on observation, record review, and interview, the facility failed to provide timely care for 1 of 6 sampled residents (#6). Resident #6 experienced harm when she was left on the bedpan for an extended period of time resulting in discomfort and skin breakdown on her left buttock. Finding include: Review of a 6/23/11 grievance form written by the Social Service Director (SSD) documented Resident #6 had spoken to therapy staff about being on the bedpan for 1 1/2 hours with her call light on. Staff finally responded when she started yelling. She complained of being very sore on her bottom and tailbone. "Very upset with staff and wants to return home where she can have the help she needs." Resident #6: Review of the 6/21/11 nursing admission note revealed the resident was admitted to the facility on [DATE] for aftercare following a right total hip replacement. The resident was 183.5 pounds. Her 6/21/11 care plan documented she was to be transferred to a bedside commode for toileting. A 6/22/11 wound assessment noted a purplish area on the resident's left inner buttocks 3.5 centimeters (cm) by 1.5 cm (Approximately 1 1/2 inches by more than 1/2 inch) and a 6/22/11 treatment order noting "some skin abrasion due to friction with skin off". (On 7/26/11 the Director of Nursing (DNS) stated the dates on the wound assessment were inaccurate and should have been documented as 6/23/11, the morning after the bedpan incident.) Although the DNS did not have a written investigation pertaining to Resident #'s allegation, on 7/22/11 at approximately 1:40 p.m. she recalled she had spoken to staff and identified that during the evening shift of 6/22/11 Resident #6 was placed on the bedpan by NA #1. The resident's call light was on and she waited a long time for assistance getting off the bedpan . Resident #6 was found to have a purple streak on her left buttock but it "developed into something worse". It had broken open according to the 6/29/11 wound assessment and was yellow inside. Staff were unable to determine the stage (depth) due to the yellow slough tissue present. Resident #6 was interviewed via the telephone on 7/25/11 at approximately 9:00 a.m. The resident stated during the afternoon shift (on 6/22/11) she was left on the bedpan at the facility for 1 1/2 hours with her call light on. She had looked at the clock to keep track of the time. She experienced soreness and developed a sore, like a bedsore, "back there". She was discharged home (on 7/18/11, nearly a month after the onset of the wound site ) and was receiving wound care from home health nurses. She reported it continued to be a "sore area". Review of the 6/22/11 evening shift staff assignment sheet revealed NA #1 was originally scheduled to work a short shift between 2:30 p.m. to 7:00 p.m. but was reassigned to have a resident care assignment on the south end of the building. There were a total of 4 NAs working (short staffing, missing a short shift person). Per observations on 7/22/11 and 7/25/11, the facility was shaped like a backward "E". Resident #6 resided on the north end down the hall from the nurses' station and was out of sight from most of the long hall, other resident wings, and the dining room. When interviewed on 7/26/11 and 7/27/11., NA #1 recalled that on 6/22/11 she was originally scheduled to work a short shift, but they were understaffed due to staff call-ins. She was assigned a group of residents to care for in the south end of the building for the entire shift. During the dinner time it was her responsibility to answer call lights throughout the entire building. The other three NAs had other duties such as feeding in-room residents, passing out trays to residents eating in their rooms, and assisting residents in the dining room. The two Licensed Nurses (LNs) often parked their medication carts in the south end near the dining room to pass out their medications. They occasionally went down the hallway(s) during the dinner period. NA #1 further stated that at approximately 5:00 p.m. on 6/22/11 she answered Resident #6's call light and placed her on the bedpan. The resident stated she needed a few minutes and would put on her call light when she was ready for assistance. NA #1 recalled both LNs were down the long hall toward the dining room. NA #1 continued to answer other call lights throughout the building feeling "stressed" (without the assistance of the other NA that evening). After the facility dinner service NA #1 returned to caring for her assigned residents at the south end of the building. On 7/26/11 at approximately 9:05 p.m., NA #2 stated she was working the evening when Resident #6 was left on the bedpan for a long time (6/22/11). NA #2 was the assigned caregiver that evening for Resident #6. During the dinner timeframe it was her responsibility to feed the residents who ate in their rooms and transfer a couple of residents to bed. Those tasks could have taken more than an hour. When NA #2 returned to her assigned residents she answered Resident #6's call light and took her off the bedpan. The resident reported she had been on the bedpan a long time. The NA stated she apologized to the resident and reported the issue to the LN on-duty. Further review of the medical record revealed the resident continued to receive treatment and monitoring of her left buttock wound. The last wound assessment was on 7/11/11 and documented the wound had yellow tissue present at the base and was 3.5 cm by 1 cm. The resident discharged seven days later, on 7/18/11, with wound management orders through home health. When interviewed on 7/25/11 at approximately 9:00 a.m., the Home Health Nurse stated the left lower buttock wound size on admission (7/20/11) was 4 cm by 1 cm and was .5 cm in depth, a "Stage III" (pressure ulcer, full thickness tissue loss often with subcutaneous tissue exposed). During the evening shift of 6/22/11 there was insufficient staff available to meet Resident #6's needs. She was placed on the bedpan with the expectation that she would receive timely care. When she put on her call light staff members were busy with other resident related tasks. No one responded timely to meet her needs. The resident was left on the bedpan for an extended period of time and this resulted in skin breakdown that had extended for more than a month.

Based on record review and interview, the facility failed to ensure 5 of 9 sampled residents (#1, #5, #6, #7, & #9) received care and services to maintain optimal health, prevent deterioration of their health, and/or provide timely emergent services. Resident #7 remained at the facility following a change of condition despite the family member's repeated requests for medical treatment and the resident's unstable condition. Resident #6, an alert and oriented resident, requested to go to the ER but was encouraged to remain in the facility for treatment. The resident later experienced a significant change of condition and was transported to the hospital the next morning in respiratory distress. Resident #5 experienced a fall with injury. The physician was not notified in a timely manner and there was a lack of adequate pain management. Later, Resident #5 experienced a change of condition. There was no resident assessment, notification of the physician, or provision of comfort care prior to her death. Resident #1 experienced harm related to a delay in the provision of her narcotic pain medication resulting in pain and psychosocial distress. Resident #9, a resident with a heart condition, experienced an excessive weight gain. There was a delay in assessment and securing timely treatment. Findings include: Resident #7: Review of the medical record revealed the resident was admitted on [DATE] with multiple medical [DIAGNOSES REDACTED]. The resident was receiving therapy services to enable him to return home. The resident's son was the primary contact for information and decision making. According to a 3/28/11 nursing entry, at 8:00 a.m. the resident was witnessed having "what appeared to be a [MEDICAL CONDITION] of several seconds in duration. He subsequently aroused and indicated he felt fine, resident did not appear to be in any distress. A few minutes later resident became unarouseable." The resident's vital signs revealed a pulse of 128 (significantly elevated above his usual rate) and a blood pressure of 80/40 (much lower than normal). Staff were unable to obtain an oxygen saturation reading. The nursing entry further stated, "Resident's hands, feet and face were blue. Oxygen applied to 4 liters. Continue to observe resident for postictal (after the [MEDICAL CONDITION]) response. Physician notified, family request resident transport to ER for eval (evaluation) and tx (treatment)." The resident was transported to the hospital at 1:50 p.m. On 4/11/11 Bath Aide (BA) #1 was interviewed. BA #1 recalled on 3/28/11 a Licensed Nurse (LN) #1 had asked her to shower Resident #7. The BA recalled at approximately 9:30 a.m. she entered the resident's room. She observed the resident "pause". Staff patted him and he appeared to snap out of it. Therapy staff was present in the resident's room and they assisted her with the transfer to the shower chair. The resident did fine during the shower but while shaving him his head dropped onto his chest. Licensed Nurse (LNs) #1 and #2 came to evaluate him. They had difficulty getting him back into bed due to the change in his condition. LN #1 was interviewed on 4/12/11. The LN recalled entering the facility at approximately 8:00 a.m. or earlier. Staff approached her with the report that Resident #7 had experienced a [MEDICAL CONDITION]. When she entered the room the resident was in the shower chair on his way to the shower. He was awake and looked alert. The resident developed problems during the shower and appeared to be sleeping. They returned him to bed where he demonstrated snoring behavior. His face appeared blue in color and his blood pressure was 80/40. Oxygen was provided. LN #1 went to perform her other duties thereafter. She recalled the resident's wife was in at approximately 1:00 p.m. and the resident was not rousing. The family member said she wanted the resident sent to the hospital. When asked why the resident was not sent sooner, she stated the resident was a DNR (Do Not Resuscitate) and that might have been a factor. Interviewed on 4/12/11, the Physical Therapy Assistant (PTA) recalled being in Resident #7's room at approximately 9:30 a.m. on 3/28/11. At first the resident appeared to be himself but he then demonstrated a "glare" behavior [MEDICATION NAME] approximately 7-8 seconds. After that episode he was able to refocus and she continued to work with him with a transfer exercise but it was "not working". The resident experienced another pause with increased glaring (staring) with a similar facial expression and duration. The PTA discontinued her treatment at that time stating, "This isn't right." A LN was notified. review of the resident's medical record revealed [REDACTED]. Licensed Nurse #2, the Charge LN, was interviewed on 4/12/11. LN #2 recalled she responded to evaluate Resident #7 in the shower area following a reported change of condition. The LN stated the resident had a low blood pressure and was shivering. Staff assisted him to bed. The LN further stated she notified a family member. She thought it was the resident's spouse (not the legal decision maker). LN #2 recalled she reported on the resident's condition and asked the wife if she wanted them to send him to the hospital. The spouse reportedly stated she wanted to see how he did. She would be in later in the day and they could discuss his condition later. The LN also had contacted the Alternative Physician and reviewed the resident's history. The resident had no history of [MEDICAL CONDITION]. LN #2 stated they were going to watch him. According to LN #2, the Physician stated if the resident did not improve to send him to the hospital. No monitoring timeframe was provided. There were no details documented in the nursing entry, such as timeframe or content/directives, related to the notification of the family and physician. On 4/11/11 and 4/15/11 the resident's son/emergency contact was interviewed. The resident's son identified himself as Resident #7's Power of Attorney (POA) with health care and financial provisions (the legal decision maker). The POA stated on 3/28/11 he was contacted by facility staff sometime between 10:00 a.m. and 12:00 noon. The staff member reported the resident had a high fever that morning, had demonstrated [MEDICAL CONDITION] activity, and wasn't responding well. The son further stated the resident had no history of [MEDICAL CONDITION]. He asked if the physician on-staff could evaluate the resident. The staff member explained there was no physician present. The son stated he requested the resident be sent to the hospital at that time but was told the Alternate Physician wanted to monitor him at the facility. The son reported he was called again about 20 to 30 minutes later and staff reported Resident #7 was no better. The son stated he had wanted the resident evaluated by a physician (as he had before). He asked the staff member to call the resident's community based physician to notify him that the resident was being sent to the hospital. The son reportedly called another family member and asked them to transport the resident's spouse to the facility. When the resident's spouse arrived she also requested hospital transport. The son stated, "It was delayed, that's what was upsetting. Someone wanted to just monitor". There was a [DIAGNOSES REDACTED]. It took "three requests" by family to send the resident to the hospital before it happened. The son recalled there was a delay of about 2 hours between his first request for transport to the hospital and the time it occurred. On 4/12/11 the Director of Nursing stated she had assessed the resident neurologically following his return from the shower possibly around 11:00 a.m. Although the assessment was not documented, she stated the resident was definitely different neurologically at that time. He was unable to grip her hands and was not able to answer questions appropriately. Despite the resident's deteriorated condition he remained in the facility. On 4/15/11 the resident's spouse was interviewed. The wife recalled being contacted by a facility nurse (LN), thought to be the Charge LN. The CN reported her husband had a [MEDICAL CONDITION] that morning. The LN was asking her what she wanted them to do. Although she was unable to recall exactly what she said, she recalled thinking, "Why are you asking me, you're the medical people". The LN had told her she needed to come into the facility. The wife stated she did not drive so she needed a ride to the facility. Another family member drove her to the facility. When she arrived her husband was "what I would call almost comatose". She couldn't raise more attention from him than "an eye batting". After observing him she requested he be sent to the hospital. The wife stated her husband did not want heroic measures but she was "counting on their decision-making to act" (to provide necessary treatment at the right time). The facility failed to thoroughly assess the resident's condition directly following the initial suspected [MEDICAL CONDITION] activity in a resident without a known [MEDICAL CONDITION] history. Shortly thereafter, he was sent to the shower where he experienced additional neurological symptoms, further physical decline, and staff had difficulty arousing him. His vital signs revealed a significant change and his skin tone was bluish. Oxygen was administered. The decision to retain the resident in the facility was based on a presumption of [MEDICAL CONDITION] activity. Additional vital signs during the interval of concern were requested but not received. Facility staff failed to recognize the resident's decline as emergent, sought care directives from a family member other than the legal decision maker, and failed to secure timely emergent services despite repeated requests from the appropriate legal decision maker. Review of the records from the emergency transport company revealed at 2:00 p.m. on 3/28/11 the resident's blood pressure remained low at 82/54 and his oxygen saturation was low at 84% on 4 liters of oxygen. At the hospital the physician's 3/28/11 history and physical document revealed the resident had [MEDICAL CONDITION] (an infection involving the whole body) and a [MEDICAL CONDITION] as well as other diagnoses. Resident #6: Review of the medical record revealed the alert and oriented resident was admitted to the facility on [DATE] following cardiac by-pass surgery on 3/11/11. The resident had additional [DIAGNOSES REDACTED]. On admission the resident had 3-4 plus [MEDICAL CONDITION] in her legs (a designation usually used with the amount of persistent pitting/indention up to one inch ). The physician had prescribed a daily diuretic (water pill), [MEDICATION NAME] SR 15 milligrams (mg) twice a day for pain control, Klonopin 0.5 mg twice daily and [MEDICATION NAME] 10 mg daily for anxiety management. Two additional narcotic pain medications were ordered to be given every 4 hours as needed, Endocodone ([MEDICATION NAME]) 5 mg and [MEDICATION NAME] 5/325. The resident was to receive breathing treatments every six hours. Additionally, oxygen was to be administered between 2-6 liters per minute as needed to keep her oxygen saturation level at 90% or above. The resident was planning to return to independent living after leaving the facility. On the day of admission, the resident's weight was 338 pounds. Her lungs were clear and her saturation level was 96% on room air. On 3/22/11 the residents oxygen level was 88% on room air and oxygen was administered. On 3/23/11, two days after admission, her weight was 342.6 pounds, a weight gain of 4.6 pounds in two days. There was no documentation related to staff recognition of the weight gain (possibly related to fluid accumulation) or about notification of the physician. Over the next few days the resident had intermittent oxygen usage. Nursing documentation revealed she didn't always complete her breathing treatments and she wouldn't always keep her oxygen in place. Review of the plan of care noted the resident had a history of [REDACTED]. Although the plan stated, "management of lower extremity [MEDICAL CONDITION] and monitoring oxygen status, there were no specific approaches related to how the [MEDICAL CONDITION] would be monitored, such as measuring or weights. There were no specific directives on how her cardiac and respiratory status would be monitored. Nursing entries on 3/26/11 at 2:32 p.m. and 2:47 p.m. documented the resident was noted to have a problem with pain control, stating "her pain is a 10 and mostly in her legs from the [MEDICAL CONDITION]". She was instructed in her low salt diet. No significant issues were identified with her incisions at that time. The resident was walking with her walker. "Very anxious and asking for pain meds (medications) before times able to give her (before the next allowable administration time). [MEDICATION NAME] was given for anxiety and appeared to help her relax". According to a 3/27/11 3:55 p.m. entry, the resident's lungs were clear but her oxygen saturation was 77% (a significant drop in her saturation level) on room air. She had a dry cough. Her saturation level rose to 93% when oxygen was administered. The resident complained of being weak with severe pain in her lower legs. There was 4+ [MEDICAL CONDITION] in her legs extending up to her knees. The March 2011 Treatment Record (TAR) was set up for monitoring the resident's oxygen saturation level three times a day but no entries were present on the TAR. Intermittent checks were recorded in the nursing notes at a less than daily frequency. No follow-up assessment of the resident's condition was noted on the night shift. A 3/28/11 11:50 a.m. nursing entry documented the resident complained of increased pain 9/10 in her legs stating her pain medication is not effective. She was medicated with her routine and additional, as needed, narcotic pain medications. She slept for a short while then awoke 30 minutes after being medicated requesting more pain medication. The Alternate Physician was contacted and there was an order for [REDACTED]. Review of a 3/28/11 1:42 p.m. social service entry noted the contact occurred as a result of a report that the resident was depressed. The resident acknowledged the depressed mood because she was not feeling better. She didn't need medication to get over it. She should be feeling better. The 3/28/11 2:00 p.m. nursing entry written by LN #2 documented the resident was complaining of "severe LE (lower extremity) pain from her knees up. She states nothing alleviates it and nothing makes it worse. She states it is a burning pain and that the pain is not alleviated with current pain medications. Upon assessment resident was sleeping in bed. She does grimace with movement and stated the pain is making her afraid. Reassured we are monitoring her and her pain." A nursing entry later that afternoon at 5:55 p.m. documented the resident had requested to go to the ER for evaluation of her uncontrolled leg pain. "I informed her (LN #2) that we just began her new order for MS ER 15 mg TID ([MEDICATION NAME] increase to three times a day)." (The resident received the new dose at 4:00 p.m. per the MAR and still made the request). The March 2011 MAR revealed on 3/28/11 the resident received both as needed narcotic pain medications, [MEDICATION NAME] and [MEDICATION NAME] at 3:30 p.m., [MEDICATION NAME] 15 mg at 4:00 p.m., the routine Klonopin dose sometime in the "pm" and [MEDICATION NAME] at 7:30 p.m. The resident was noted to be sleeping at 8:30 p.m. Although there were vital signs at around midnight, there was no further written assessment of the resident's condition on the night shift, the MAR documented the resident received a [MEDICATION NAME] dose at midnight and breathing treatments at midnight and 6:00 a.m. A 3/29/11 8:03 a.m. nursing entry documented that at 7:05 a.m. the resident was non-responsive to verbal stimuli with white foam-like drainage found in both nostrils. Her blood pressure was "78/?" (very low) and her oxygen saturation was 67% (excessively low). Lung sounds were course. The physician was notified and the resident was sent to the ER for evaluation at about 7:30 a.m. When interviewed on 4/08/11 LN #4 stated she had cared for Resident #6 on the evening shift of 3/28/11. The resident had complained of pain in her legs. The physician had been contacted earlier in the day and they had received an order to increase the resident's pain medication. LN #4 recalled the resident stated to her, "I want to go to the hospital." LN #4 recalled telling the resident, the physician is aware and we need to give it time to work (the medication increase). LN #4 had heard LN #2 use that approach with the resident earlier. The resident was provided care and slept for an interval. LN #4 recalled a nursing assistant had reported to her that the resident was ready for pain medication at 10:30 p.m. Although no assessment was documented in the medical record by LN #4 on 3/28/11, she provided a written statement later. LN #4's statement recorded the resident "was non-cooperative with physical therapy that morning and agitated. (The resident) stated she wanted to go to the hospital because her legs hurt. I asked her pain scale, she replied 10/10." Upon assessment the resident's affect (outward expression of mood) appeared slightly down and somewhat anxious..."lung sounds wheezy...lower extremities 3+ [MEDICAL CONDITION]" (no timeframe was noted). LN #4 explained to the resident that the new medication needed time to work and that LN #4 was concerned about the resident 's anxiety level and suggested an as needed [MEDICATION NAME] dose, which was provided. On 4/09/11 LN #5 was interviewed. LN #5 recalled working the night shift of 3/28/11 going into 3/29/11. Although only the medications and vital signs were documented, the LN recalled Resident #6 had awakened for a pain medication and a breathing treatment that night. LN #5 recalled the resident had a dry cough and was using oxygen but he did not listen to her lungs or check her oxygen saturation level that night. He stated he last checked her between 4:00 a.m. and 4:30 a.m. and she did not appear to be in any apparent distress. (Per the MAR, the 6:00 a.m. breathing treatment appeared to be signed by LN #5). LN #5 further stated he suspected the resident had gained a lot of weight. Staff could not easily see an increase due to her size (accumulation of fluids). The LN stated the resident should have been weighed daily. LN #5 further stated he suspected the dry cough was a precursor to [MEDICAL CONDITIONS] that came on quickly based on his observations of the resident early on the day shift on 3/29/11. Review of the 3/29/11 ER records revealed three plus [MEDICAL CONDITION] was noted in the resident's feet, face, and hands. The ER discharge [DIAGNOSES REDACTED]. The resident was sent to the ICU as her condition continued to decline while in the ER. The nursing facility failed to develop a comprehensive plan for monitoring the resident's physical symptoms including [MEDICAL CONDITION] monitoring , lung, and heart assessments. Additionally, when the resident's pain level in her legs increased, staff provided more pain medication and anti-anxiety medication to address the symptoms rather than evaluating/assessing the potential underlying cause of the increasing pain and distress. Despite the resident's repeated requests for a physician evaluation in the ER during the afternoon/evening of 3/28/11, facility LNs encouraged her to wait for pain relief from the increase in the [MEDICATION NAME] dose. Administration of multiple doses of narcotics and anti-anxiety medications provided some measure of comfort that evening but the resident's condition continued to decline and it was not discovered until early morning on 3/29/11 when she was in distress. Resident #5: Review of the medical record revealed the resident had multiple medical [DIAGNOSES REDACTED]. The resident's POLST form documented she did not wish to be resuscitated but she did wish limited interventions including the use of antibiotics. The resident received twice daily [MEDICATION NAME] 5 mg/500 mg, a narcotic pain medication, at 8:00 a.m. and at 8:30 p.m. She also had an order for [REDACTED]. The care plan noted the resident was to have assistance with transfers and ambulation. However, nursing entries documented the resident wanted to be independent and often got up without assistance. Therapy services were provided to enhance the resident's abilities. On 2/09/11 the resident was diagnosed with [REDACTED]. According to a 2/25/11 nursing entry, the resident was found on the floor in her room by a nursing assistant. The resident had skin tears on her left arm and complained of pain to her left shoulder "guarding when attempting to assist Res (resident) from floor and refusing for LN to touch her arm." The resident was taken to the bathroom and upon transferring her to the toilet she soiled her disposable briefs and blood was noted in the stool. Instead of calling the physician to report the fall and the resident's condition, a fax was sent. The LN recommended to the night shift LN that an x-ray be obtained in the morning. The resident was documented as lying in bed on her back with no complaints of pain at the end of evening shift. Nursing entries, dated 2/25/11 (likely 2/26/11) 7:14 a.m., documented the resident slept throughout the night "but ROM (range of motion) is decreased dislocated bone appears more pronounced". A portable x-ray was ordered. Later that morning the results revealed a new fracture of the humural shaft (upper arm bone). The information was forwarded to an Orthopedic Physician. Review of the February 2011 MAR revealed no additional pain medication was provided to the resident after the fall on 2/25/11 or during the night shift following. A 2/26/11 nursing assessment stated the resident's shoulder was painful only when moved, "will not ask for anything for pain". Review of the February 2011 MAR noted the resident received additional [MEDICATION NAME] on 2/26/11 at 1:00 p.m. for left shoulder pain because she was agitated and moaning. Only two additional as needed doses were provided through the end of the month. A 2/28/11 nursing entry documented the resident continued to have discomfort to her left shoulder related to the fracture. She has routine and as needed [MEDICATION NAME] which she states "helps some". According to the 3/01/11 nursing entry, the resident saw the Orthopedic Physician and he ordered a splint. On 3/02/11 the Registered Dietician (RD) documented the resident had lost 5.9 pounds in the past month. The RD documented, "Decrease in appetite resulting in wt. (weight) loss may be related to increased pain (due to) fx (fracture) and upper respiratory infection." On 3/05/11 and 3/06/11 nursing documentation continued to report pain issues. "Using [MEDICATION NAME] for pain which helps but she does not want any movement or anyone to touch" and "Using [MEDICATION NAME] routine and prn (as needed) for pain. Does help some but does not want anyone near her arm". There was a similar nursing 3/09/11 nursing entry documented the resident had pain with movement and she did not want to be touched." Review of the March 2011 MAR revealed the resident received her twice daily routine [MEDICATION NAME] ([MEDICATION NAME]) but only received two as needed doses of the [MEDICATION NAME] during the month, on 3/01/11 and on 3/03/11, both for 8/10 left shoulder pain. On 3/02/11 she also received a dose of Tylenol for pain (and an elevated temperature). Following an unremarkable 3/11/11 nursing entry during the afternoon was a 3/12/11 12:44 a.m. entry documenting that the resident was found without a pulse or respirations. Review of the facility investigative documents revealed on the evening shift of 3/11/11 the resident did not 'look good, her speech unclear and she seemed more lethargic and more confused' per two identified Nursing Assistants. The change in the resident's condition was reported to the LN. When interviewed by the Director of Nursing, LN #6 was aware the resident had a change of condition. The resident was noted to be uncooperative, non-verbal, and using accessory muscles for breathing but LN #6 failed to notify the physician or place oxygen. LN #6's employment was terminated. Resident #1: Review of the medical record revealed the resident had a RIGHT total knee replacement on 1/14/11 and admitted to the facility on [DATE] after a LEFT total knee replacement. The resident was admitted for rehabilitation therapy prior to returning home. The history and physical documented the resident was allergic to Tylenol and it caused her to "itch and feel dizzy". The resident also had a [DIAGNOSES REDACTED]. According to the April 2011 Medication Administration Record (MAR), the resident received two Endocodone 5 mg tablets on 4/03/11 at 1:00 p.m. No other doses were documented until 4/05/11 at 12:30 a.m., approximately 35 1/2 hours after the last dose (despite complaints of pain). During an interview with LN #3 on 4/08/11, LN #3 recalled that on 4/03/11 the physician was called because the facility ran out of the resident's narcotic pain medication. The physician directed them to offer [MEDICATION NAME] and notify him if it was not effective. LN #4 was interviewed on 4/08/11. The LN stated she had worked hard building a relationship with the resident and had encouraged her to take the [MEDICATION NAME]. It appeared to make her more comfortable and even relieved some of her agitation; "she needs to feel in control". On 4/03/11 the pharmacy stated the medication would not be available until Monday. "She (the resident) was upset totally." It was a trust issue for the resident. Without the medication she felt helpless. The 4/2011 MAR documented on 4/03/11 at 5:00 p.m., the resident was given [MEDICATION NAME] (a medication generally less effective than Endocodone) for a complaint of 6/10 (10 being the most intense pain) left knee pain. A 4/04/11 8:57 a.m. nursing entry documented the resident had approached the Administrator to report she had not received pain medications for 48 hours. The resident refused the [MEDICATION NAME] that morning. There was no further documentation of a follow-up call to the physician until 4/04/11 during the day shift to report the "resident's accusations against staff member". A 4/04/11 2:32 p.m. social service entry recorded, the resident continued to be "accusatory of certain staff members c/o (complaining of) pain doesn't understand why her medication was not here in a timely manor (sic) very upset with the nursing staff d/t (due to) verbalizes she can not eat or drink r/t (related to) increased anxiety..." A 4/04/11 3:00 p.m. nursing entry revealed the resident had refused nursing care that shift and reported to the Nursing Assistant that she did not trust the nurses. They were giving her the wrong medications. According to the 4/2011 MAR the resident reported 10/10 left knee pain and took the [MEDICATION NAME] at 3:45 p.m. on 4/04/11. The documentation stated she did not receive relief and the pain remained at 10/10 despite the medication. At 5:00 p.m. on 4/04/11, the resident was given an anti-anxiety medication due to complaints of increased anxiety. Review of the meal monitor noted the resident refused breakfast and lunch on 4/04/11 and refused her physical therapy appointment on 4/04/11 (due to her unmanaged pain and distress). When interviewed on 4/08/11, the Physical Therapy Assistant (PTA) recalled that on 4/04/11 the resident said something about not having pain medication, having pain, and not wanting to do any therapy without pain medication. Interviewed on 4/08/11, LN #3 recalled that on 4/05/11 Resident #1 had told her she hadn't eaten for two days because of not having her pain medication. According to the 2011 MAR the resident received two [MEDICATION NAME] tablets for complaints of 10/10 pain on 4/05/11 at 12:30 a.m., nearly 36 hours after running out of the medication. Interviewed on 4/07/11, Resident #1 stated she had returned home that day with her medications and she felt safer. She recalled not receiving her pain medications when she needed them and experiencing "pounding pain". She had stopped doing therapy when she did not have her pain pills. Resident #9: Review of the medical record revealed the resident was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. On the day of admission, the resident weighed 156.4 pounds. The resident was admitted with an order for [REDACTED]. A 1/05/11 nursing entry documented a physician's orders [REDACTED]. A nursing entry, dated 1/19/11, reported there was a new order to discontinue the diuretic medication. Staff were to watch/monitor the resident's weight. A 3/09/11 nursing entry recorded the resident had an increase in weight. The resident continued to have "lower extremity and left hand [MEDICAL CONDITION]. Lab work was planned on 3/15/11. A chest CT exam was performed on 3/09/11 and had findings compatible with [MEDICAL CONDITION]. A 3/18/11 quarterly nutritional review documented the resident had gained 14.6 pounds in the past 30 days. There was a recommendation to change her milk from 4% to 2% to slow her weight gain. On 3/21/11 the resident's lab reports were faxed to the physician . It was noted in the same nursing entry that the resident was having weakness in her legs. According to a 3/25/11 nursing entry, the resident was presenting with respiratory symptoms. A chest x-ray that day revealed the resident had an enlarged heart (often present with [MEDICAL CONDITION]) and pneumonia. There was a new order for an antibiotic. On 3/31/11 the resident's weight was 191 pounds, up from 165 pounds (on 3/01/11), a 26 pound increase in one month. Additionally, the resident had some [MEDICAL CONDITION] in both lower extremities. Despite the excessive weight gain, the physician was faxed rather than called. There was no documentation of further follow-up for five days. On 4/05/11, the Director of Nursing (DNS) identified an "extreme wt (weight) gain" and notified the physician. The resident had 2+ [MEDICAL CONDITION] in her lower extremities and 3-4+ [MEDICAL CONDITION] in her left arm. The physician ordered a diuretic and follow-up lab work. Although some facility LNs assessed the resident's [MEDICAL CONDITION] and weight issues periodically, the facility failed to have a plan to regularly and systematically evaluate the resident's weight gain and [MEDICAL CONDITION] status despite the discontinuance of the resident's diuretic and the directive to monitor her weight. Facility staff failed to correlate the excessive weight gain and the resident's [DIAGNOSES REDACTED]. The facility failed to facilitate timely treatment for [REDACTED]. Interviewed on 4/18/11, the DNS stated she had called the physician when she discovered the resident's excessive weight gain. She further stated the facility was changing their policy for monitoring residents' weights and for [MEDICAL CONDITION] monitoring.