Every finding on record at Puyallup Post Acute

Based on interview and record review, the facility failed to submit direct care staffing information to the Centers for Medicare and Medicaid Services (CMS, a federal agency managing healthcare programs and health insurance standards) for Quarter 1 (Q1, January February, and March 2026) 2026 reviewed for Payroll Based Journal (PBJ, mandatory reporting of staffing information based on payroll data) submission. This failure affected the accuracy of Nursing Home (NH) staffing level data collected by CMS and had the potential to impact provisions of resident care and services. Findings included. <CMS-Electronic Staffing Data Submission PBJ> Review of the CMS Long-Term Care Facility PBJ Policy Manual, dated June 2022, showed long-term care facilities were required to electronically submit direct care staffing information based on payroll and auditable data. The data, when combined with the census information can be used to not only report on the level of staff in each nursing home, but reports staff turnover and tenure, that can impact on the quality of care delivered at the facility. The policy manual showed the facility must electronically submit complete and accurate information by the required deadline to include; direct care staff, the category of work for each direct care staff member, resident census data, and direct care staff turnover and tenure. Review of the PBJ showed no data submitted for Quarter 1. During an interview on 08/26/2026 at 1:22 PM, Staff A, Administrator, confirmed the facility failed to ensure accurate data for PBJ was submitted for Quarter 1, 2026 before the deadline date of 05/15/2026. Reference WAC 388-97-1090(1)(2)(3)

Based on interview and record review, the facility failed to ensure 4 of 4 residents (Residents 1, 2, 3 & 4) reviewed for insurance disenrollment were informed of the risks/benefits, options, and alternative changes in their insurance, in ways that were easy for the residents and/or the residents' representative to understand. The facility failed to develop written policies and procedures regarding the process of assisting beneficiaries with changing their health care coverage, including the need to obtain a document signed by the beneficiary or representative that acknowledges that the specific information regarding the impact of a change in coverage was provided to them orally and in writing, and that they understood the information. Failure of the facility placed residents at risk of non-coverage, increased cost out of pocket, and caused undue stress to residents and/or resident representatives and placed 13 Managed Medicare residents at risk of the facility disenrolling them without their request, consent knowledge or complete understanding.Findings included.Review of the undated, Skilled Nursing Facility admission Agreement showed that the facility was an in-network provider for some Medicare Advantage Plans. If a Resident's care was covered by a Medicare Advantage Plan (Managed Medicare), Resident's skilled nursing care was managed through the insurance company. The needs and services were authorized and managed by the insurance provider's case managers and physicians. The facility participated in the Medicare program. If eligible, Medicare would pay 100% of Resident's costs in a semi-private room for the first twenty (20) days. The next eighty (80) days were known as coinsurance days, which meant the Resident was responsible for paying coinsurance on day 21 forward. According to the admission Agreement, the facility assured Residents all the rights in the Resident's [NAME] of Rights.Review of undated, Resident's [NAME] of Rights, showed the residents had the right to be informed, in advance, of risks and benefits of proposed, care, treatment, treatment alternatives, options and to choose the option they prefer. Additionally, Residents had the right to self-determination, and to manage their financial affairs.<RESIDENT 1>Review of Resident 1's record showed they admitted [DATE] on a Managed Medicare plan and transferred to Traditional Medicare effective 05/01/2026. Further reviews showed no documentation to support the resident was explained orally and in writing the impact to the beneficiary if they changed coverage.During an interview on 05/19/2026 at 1:09 PM, Resident 1's representative stated they disenrolled from their Managed Medicare plan to Traditional Medicare at the suggestion of facility Social Services Staff. Resident 1's representative stated they were not told if they changed insurance that after 20 days they would have to pay co-insurance. Resident 1's Representative stated their payment was only one (1) dollar different with the two plans, so if they had known, they would not have gone through with it. They said they were also not informed that that when they re-enrolled it would only be effective on the first day of the month, which increased their stress trying to coordinate Resident 1's discharge to ensure they had insurance coverage. Resident 1's representative stated they were not provided with and did not sign any related documents from the facility.During an interview on 05/19/2026 at 1:40 PM ,Staff C, Medical Doctor (MD), stated Resident 1's representative came to them in tears, as they had only 30 days to revert to Managed Medicare, and it had been 20 or 21 days. They had not been informed of the consequences, for example, the Managed Medicare plan was paying for Resident 1's cancer treatments, and with Traditional Medicare they had to pay co-insurance.During an interview on 05/19/2026 at 1:58 PM, Staff D, Business Office Manager, stated Resident 1's Managed Medicare plan paid the same rate as Traditional Medicare, but they often issued Notice of Non-Coverage sooner.<RESIDENT 2>Review of Resident 2's record showed they admitted [DATE] on a Managed Medicare plan and transferred to Traditional Medicare effective 05/01/2026. Further reviews showed no documentation to support the resident was explained orally and in writing the impact to the beneficiary if they changed coverage.During an interview on 05/20/2026 at 11:57 AM, Resident 2's representative confirmed they recently disenrolled from their Managed Medicare plan at the suggestion of the facility social services staff. Resident 2's representative was unsure if they had a co-pay with Traditional Medicare as that was not disclosed to them. They said they did not have co-pays with their Managed Medicare unless they went out of market. They voiced concerns as they wanted to reenroll in their Managed Medicare plan at discharge but did not know if they had to start all over, pay for prescriptions, I don't know how it works. Resident 2's representative denied receiving information in writing or signing any documentation prior to disenrolling.<RESIDENT 3>Review of Resident 3's record showed they admitted [DATE] on a Managed Medicare plan and transferred to Traditional Medicare effective 05/01/2026. Review of the Managed Medicare plan insurance verification showed the facility was Out-of-Network. Further reviews showed no documentation to support the resident was explained orally and in writing the impact to the beneficiary if they changed coverage.During an interview on 05/20/2026 at 11:06 AM, Resident 3 confirmed they recently disenrolled from their Managed Medicare plan. When asked if someone had talked to them about it beforehand, Resident 1 stated, No, not that I know.During an interview on 05/20/2026 at 1:11 PM, Resident 3's representative stated if the facility left Resident 3 on Traditional Medicare, then they wound have a secondary (supplemental coverage), I hope they switch them back.<RESIDENT 4>Review of Resident 4's record showed Resident 4 was admitted on Managed Medicare then transitioned to Medicaid. There was no documentation of conversations with the resident regarding their insurance.During an interview on 05/20/2026 at 11:09 AM Resident 4 stated the facility staff talked to them about secondary insurance that would cover their stay, but not about who or what. They told me they wanted to make sure what my social security number was because it didn't match, so I had to verify that with them. Resident 4 stated, I didn't understand that either.During an interview on 05/20/2026 at 1:20 PM, Staff A, Administrator, stated the facility social services/case management staff would provide the residents and/or representatives information. Staff A stated it was a conversation and they did not know of any specific paperwork they would review.During an interview on 05/20/2026 at 2:29 PM, Staff A stated they did not have a Policy and Procedure regarding assisting beneficiaries with changing their health care coverage, but they did find a letter they should be providing to them. Staff A stated they did not believe the facility staff were providing the form as it was not readily available.Review of the undated information sheet entitled, Disenrollment from Medicare Advantage and Enrollment in Traditional Medicare showed that switching from Medicare Advantage to Traditional Medicare would likely impact deductibles, co-pays/coinsurance and may result in loss of supplemental coverage. Enrollment in Traditional Medicare will not include prescription drug coverage. Enrollment in the new Medicare health or drug plan will be effective the first day of the month following the plan's receipt of the enrollment request.REFER TO: WAC 388-97-0260, -0300(3)(a)

Based on interview and record reviews, the facility failed to protect 4 of 4 residents' rights to Medicare benefits. The facility disenrolled three (Residents 1, 2 & 3), and attempted to disenroll one (Resident 4) beneficiaries from Medicare Managed Health Plans without their request, consent, knowledge and/or complete understanding. The facility failed to develop written policies and procedures regarding the process of assisting beneficiaries with changing their health care coverage, including the circumstances under which the facility could assist a beneficiary with a plan change, and the need to obtain an attestation signed by the facility staff member that assisted with the change in enrollment, attesting that the beneficiary or representative requested the change. Failure of the facility placed residents at risk of non-coverage, increased cost out of pocket, and caused undue stress to residents and/or resident representatives and placed 13 Managed Medicare residents at risk of the facility disenrolling them without their request, consent knowledge or complete understanding.Findings included.Review of the undated, Skilled Nursing Facility (SNF) admission Agreement, showed that the facility assured Resident all the rights in the Resident's [NAME] of Rights. Review of the attached, undated, Resident's [NAME] of Rights, showed the residents have the right to be free of interference, coercion, discrimination, and reprisal from the facility.<RESIDENT 1>During an interview on 05/19/2026 at 1:09 PM, Resident 1's representative stated the facility social services staff told them it was better to be on traditional Medicare (Med A) while in a SNF, so the facility would transfer Resident 1 to Traditional Medicare and when they were discharged the facility would automatically transfer the resident back to their Managed Medicare program. Resident 1's representative stated they since had questions and tried to talk to the facility social services staff, but they were off duty, so they came in early to meet with Staff A, Administrator, but were told they were on vacation. Resident 1's representative stated they received a letter from their Managed Medicare plan indicating they had disenrolled, and if this was in error to call immediately. Resident 1's representative called, met with an insurance representative, and planned to have their insurance reinstated effective June 1st.During an interview on 05/19/2026 at 1:40 PM Staff C, Medical Doctor (MD), stated Resident 1's representative came to them in tears, having been told by facility staff to disenroll from Managed Medicare, transfer to Traditional Medicare and when out of the facility to re-enroll in Managed Medicare. Staff C stated Resident 1's representative called their prior insurance and was re-enrolling in their Managed Medicare.<RESIDENT 2>During an interview on 05/20/2026 at 11:57 AM, Resident 2's representative confirmed they recently disenrolled from their Managed Medicare plan. Resident 2's representative stated facility staff approached them, but they could not recall the name of the staff. Resident 2's representative stated the facility told them that by going with Traditional Medicare it would cover more of Resident 2's therapy sessions, and when they got better and left, then they could re-enroll in their Managed Medicare plan. Resident 2's representative stated Resident 2 was in pretty rough shape at the time and all they thought about was them and their needs. Resident 2's representative stated they were planning to talk to someone as Resident 2 was planning to discharge soon and they wanted to find out if the facility was going to switch them back as they said they would.<RESIDENT 3>During an interview on 05/20/2026 at 11:06 AM, Resident 3 confirmed they recently disenrolled from their Managed Medicare plan. When asked if they consented to the change, Resident 3 stated, I don't know and added, I get calls all the time about Medicare. During an interview on 05/20/2026 at 1:11 PM, Resident 3's representative stated they were not aware Resident 3 had been disenrolled until after the fact, noting that the facility chose it upon themselves to do it. Resident 3's representative confirmed they did not request the change. They were informed during a meeting that when residents were in a SNF, the facility change (their insurance) and will change it back when they were discharged . Resident 3's representative did not recall who at the facility told them.During an interview on 05/20/2026 at 1:00 PM, Staff E, Director of Rehabilitation, stated they provide the same number of days and minutes of therapy with both Managed and Traditional Medicare plans. Staff E stated at the beginning of the month they were told three residents (1, 2 & 3) changed insurances and to schedule new evaluations.<RESIDENT 4>During an interview on 05/20/2026 at 11:09 AM Resident 4 stated their Managed Medicare plan notified the facility they were discontinuing their healthcare coverage and they weren't going to get therapy anymore. The facility staff talked to them about a secondary insurance that would cover their stay, but not about who or what. Resident 4 stated they told them they wanted to make sure what their social security number was because it didn't match, so they had to verify that with them.During an interview on 05/19/2026 at 1:58 PM, Staff D, Business Office Manager, stated the facility tried to assist Resident 4 to switch over to Traditional Medicare, but there were issues with their social security number.During an interview on 05/20/2026 at 1:20 PM, Staff A, Administrator, stated when a resident is served a Notice of Non-Coverage from their insurance, exhaust appeals and still want to receive therapy, they may change insurance coverage to see if they can get more therapy.During an interview on 05/20/2026 at 1:20 PM, Staff A stated the decision for disenrollment had to be resident led, they could choose to or not to. Staff A stated, We can't tell them to go on one insurance or another. When asked how the above residents would be reenrolled in their Managed Medicare plan, Staff A stated, if at any time they want to go back, they have to tell them and they would help. When asked if it would occur automatically at discharge, Staff A stated, no, they had to request the change and ask for help.Review of an undated, Disenrollment Consent Form, provided by Staff A on 05/20/2025 at 2:29 PM showed, if signed by the Resident Beneficiary, and/or Representative, it would attest the beneficiary or representative requested the change and consented to the disenrollment with the assistance of the facility.Review of Resident 1, Resident 2, and Resident 3's record showed no consent forms, or other documentation to support the beneficiary or representative requested the change.During an interview on 05/20/2026 at 2:29 PM, Staff A stated they did not have a Policy and Procedure regarding assisting beneficiaries with changing their health care coverage, but they did find the above document they should be providing them. Staff A stated they did not believe the facility staff were providing the form as it was not readily available.REFER TO: WAC 388-97-0040(2), -1780(1)(2), -0180(4)(c)

Based on observation, interview and record review, the facility failed to promptly resolve grievances for 2 of 3 residents (Resident 1 & 2) reviewed for grievances and missing property. Failure to initiate, investigate, and resolve grievances timely placed residents at risk for frustration and a diminished quality of life.Findings included .Review of the facility undated admission Agreement showed the facility must listen to and act promptly to resolve grievances and recommendations received from a resident and/or their family. Additionally, the facility had established a program designed to prevent theft and loss, which included providing residents with a written inventory of their personal property upon admission to the facility.<RESIDENT 1>During an interview on 01/22/2026 at 2:34 PM, Resident 1's representative stated Resident 1 was missing two phones and an Echo. Resident 1 was hard of hearing, so they bought an Echo, which was never set up, and had now gone missing and nobody knew where it was. Resident 1's representative stated they sent an email on 12/11/2025 to Staff D, Social Services Aide, regarding the missing Echo, and did not receive a response.Review of an invoice receipt showed an Echo and stand were ordered 03/21/2025 to be shipped to Resident 1 at the facility.Review of an invoice receipt showed a white landline phone, Big Button Phone for seniors, corded phone, ordered 07/03/2024, to be shipped to Resident 1 at the facility.During an interview on 01/22/2026 at 2:34 PM, Resident 1's representative stated they recently purchased Resident 1 and Resident 2 each a portable phone, for people who were hard of hearing. The identical phones were on charging stands. No one set them up and no one knew where they were.Review of an invoice receipt dated 12/27/2025 for a Clarity Amplified Cordless Landline Phone for Hard or Hearing, which was delivered directly to a receptionist or someone at the front desk of the facility on 12/30/2025.In an interview on 01/30/2026 at 2:00 PM, Resident 1's representative stated the facility was still not able to locate the missing items.During an interview on 02/04/2026 at 1:03 PM, Resident 1 stated they had not found the gray phone yet. Observations at that time, in the resident room, showed no cordless or landline phones (white or gray in color), and no Echo.Review of the Grievance Logs on 02/04/2026 from November 2025, December 2025, and January 2026 did not list a grievance for Resident 1's missing items.During an interview on 02/04/2026 at 1:16 PM, Staff C, Social Services Director, stated the grievance regarding the missing items did not reach the social services department.Review of Inventory Sheets for Resident 1, dated 04/29/2025, 11/18/2025 and 01/14/2026 showed the two phones and Echo were not added when received by the facility.During an interview on 02/19/2026 at 11:54 AM, Staff C stated the grievances for Resident 1 and Resident 2 were resolved. When the grievance forms were requested Staff C was unable to locate or provide them. Staff C said they knew that they spoke to the residents and their representatives, they looked through their belongings, unpacked boxes. Staff C stated they believed they found the phone, but they needed to follow up about the Echo, with the floor staff who they had go through and organize their belongings.On 02/19/2026 at 3:30 PM the facility provided the Grievance Logs for January 2026 and February 2026, and Grievances for Resident 1 and Resident 2.Review of the February 2025 Grievance Log showed a 02/04/2026 entry for Resident 1. The nature of the grievance was listed as Missing [NAME] Echo, which was documented as sent to Administration on 02/05/2026. According to the log the grievance was due date was listed as 02/10/2026 but was not documented as resolved until 02/19/2026. The resolution was for the facility to reimburse resident sister/guardian of $200 Echo [NAME] with stand and missing cordless phone.Review of the Grievance/Concern Form, dated 02/05/2026, showed Resident 1 was missing an [NAME] Echo with stand, phone with charger, and another phone that assisted Resident 1 on hearing. Social Services (SS) went into room and had the floor staff reorganize the room on 02/05/2026. SS spoke with Resident's representative regarding missing [NAME] Echo and they would like to be reimbursed the money for missing items. The Action Plan documented was for Administration to reimburse the representative $200 for the Echo, $90 Cordless phone, $30 phone ($320.00) for the missing items. The resolution was documented as communicated by phone to Resident representative on 02/19/2029.During an interview on 02/19/2026 at 2:22 PM, Resident 1's Representative stated the facility called them on 02/19/2026 at 1:30 PM and requested information regarding the missing items. Review of an email showed that Resident 1's representative emailed thefacility receipts of the missing items on 02/19/2026 at 2:24 PM requesting a refund for a total of $370.04.<RESIDENT 2>Review of the Grievance Logs on 02/04/2026 for November 2025, December 2025, and January 2026 did not list a grievance for Resident 2's missing phone.Review of an invoice dated 12/27/2025 for a Clarity Amplified Cordless Landline Phone for Hard or Hearing, which was delivered to Resident 2, directly to a receptionist or someone at the front desk of the facility on 12/29/2025.On 02/19/2026 at 12:38 PM, Resident 2's undated Inventory List was observed with Staff B, Director of Nursing, to be blank and did not include the cordless landline phone. Staff B stated they would have it updated right away.On 02/19/2026 at 12:43 PM, the Clarity Amplified Cordless Landline Phone was observed at Resident 2's bedside, charged and turned on.Review of the February 2025 Grievance Log showed a 02/04/2026 entry for Resident 1. The nature of the grievance was listed as Missing Cordless white phone with charging stand, which was documented as sent to Administration on 02/05/2026. According to the log the grievance was due date was listed as 02/08/2026 but was not documented as resolved until 02/19/2026. The resolution was documented as phone in room and on charger, phone also reflected in inventory list.Review of the Grievance/Concern Form dated 02/05/2026 showed Resident 2 was missing a white wireless phone with charger. SS went into the room and had floor staff reorganize the room on 02/05/2026. Social Services Director spoke with Resident 2's representative regarding the missing phone and charger on 02/19/2026, who agreed that they would like the portable phone replaced if not found. Phone found in room and was reflected in inventory list. Resolution communicated to resident representative on 02/19/2026.REFERENCE: WAC 388-97-0460

Based on observation, interview and record review, the facility failed to ensure there was no discrimination against Medicaid funded residents and failed to ensure Medicaid residents were not being discharged because of payment source. These failures caused residents to not have the right to stay in the facility or to be discharged to a facility that they did not want to live in.Findings included . Review of the Nursing Home Facility License Application, dated 07/23/2025, showed a requested Change of Ownership (CHOW), to go into effect on 10/01/2025. The application indicated the purchasing entity was applying for Medicaid Certification (Medicaid Contract). A Notice of Change in Operations letter was addressed to All Puyallup Nursing and Rehabilitation Center Residents, Families and [NAME] of Attorney dated July 24, 2025. The letter was notification that the facility would be sold effective October 1, 2025. Review of the letter showed the purchasing company brought a reputation of Focusing on being the best long-term care and senior living provider . Additionally the statement, Please be assured that there will be no disruption in your care . Review of the new owner's undated admission Agreement showed a change in facility name to Puyallup Post Acute (PPA). The options for the terms of the agreement were only for Month-to-Month or Respite/Short Term Stay. Review of the facility website on 01/15/2026, showed the facility services included Skilled Nursing, Rehabilitation Services, Resident-Centered Activities, and Social Services. The website did not include Long-Term Care (LTC) Services. During an interview on 01/21/2026 at 2:02 PM, Staff A, Administrator stated they had not changed the facility practices. Staff A stated they discharge more than LTC Medicaid Residents, We discharge all kinds of residents. When asked if the facility accepted and retained LTC Medicaid residents, Staff A stated it depended as each resident was different and added they start discharge planning process on admission. During an interview on 01/21/2026 at 11:20 AM, Staff B, Director of Nursing Services, stated social services went and sought out residents who were willing to transfer to other SNFs (Skilled Nursing Facilities), to increase the availability to provide services to the community. Staff B stated they were putting residents on skilled care on the East wings, which previously was LTC. Review of the 01/21/2026 census showed East Short had 18 residents, 14 of which were Medicaid, East Long had 26 residents, 15 of which were Medicaid. Review of Nursing Home discharges from 01/01/2026 to 01/21/2026 showed 9 Residents were discharged to nursing homes, all 9 of them were Medicaid.During an interview on 01/13/2026 at 4:39 PM, an Administrator and DNS from another Nursing Home where residents were being transferred, stated the discharging facility was referring (transferring) Medicaid residents because they now only accepted Medicare residents, not Medicaid, and were making room for more skilled residents. They understood that the discharging facility wanted to increase skilled care and were sending LTC residents to other facilities; they were trying to transition to skilled care only. Review of Resident 1's electronic health record (EHR) showed their primary payor source was Medicaid. During an interview on 01/14/2026 at 4:24 PM, Resident 1's representative stated Staff C told them the facility was no longer going to do LTC, only rehabilitation, since the change of ownership. During an interview on 01/15/2026 at 1:12 PM, Resident 1's Emergency Contact #2 stated they were told the side of the building Resident 1 was on was Long-Term Care and they had to be discharged . Review of Resident 2's EHR showed their primary payor source was Medicaid. During an interview on 01/15/2026 at 1:38 PM, Resident 2's family member stated they understood the facility was a rehabilitation facility and when the residents reached full potential they would be discharged . The stated it was a short term care facility and no longer a long term care facility. During an interview on 01/16/2026 at 10:06 AM, the Nursing Facility Case Manager (NFCM) stated the new ownership wanted to run the facility like a rehabilitation place, admit as many resident's as they could to fill the beds, then they want to discharge them as soon as possible. During an interview on 01/21/2026 at 10:41 AM, Staff C, Social Services Director, stated they were working on discharge planning options for everyone. During an interview on 01/21/2026 at 11:59 AM, Staff D, Licensed Practical Nurse (LPN), East Resident Care Manager (RCM), stated they were trying to find placement closer to the LTC residents' families, for those residents who were stable and did not need to be in the nursing facility. During an interview on 01/21/2026 at 12:08 PM, when asked why the facility was discharging the LTC Medicaid Residents, Staff E, LPN, RCM, stated that if the resident was stable, and did not need skilled care, they were being transitioned. Staff E stated the facility was moving to a skilled nursing facility, increase the skilled beds. During an interview on 01/21/2026 at 12:39 PM, Resident 4 was aware of where they were discharging to. When asked why they were discharging, Resident 4 stated, They don't want me here. I'm a long-term and they said long-term don't belong. Review of Resident 4's EHR showed their primary payor source was Medicaid.During an interview on 01/21/2026 at 12:46 PM, Resident 10 stated they asked to speak to a social worker because they were moving so many people out they just assumed they would be moving them out too. Resident 10 stated they had been in the facility a couple of years and had no intention of leaving. Review of Resident 10's EHR showed their primary payor source was Medicaid.During an interview on 01/21/2026 at 1:04 PM, Resident 12 stated the facility was getting rid of all the long-term care residents. Resident 12 stated the facility had approached about half of the residents, but had not provided written notices. Resident 12 stated they were a long-term care resident and they were concerned that they would get a phone call eventually asking them to leave, I haven't been called yet, I'm very upset about those that have.In an interview on 01/21/2026 at 1:21 PM, Resident 13's POA stated on Monday (01/19/2026) they received a call from Staff C that they were turning the facility into post acute care and Resident 13 could not stay there as she was not receiving any services. Resident 13's POA stated when the facility was purchased in October 2025 they didn't say they were rehabilitation only. Review of Resident 13's EHR showed their primary payor source was Medicaid.During an interview on 01/21/2026 at 3:55 PM, Resident 11's POA stated the social worker called them and told them the new company wanted to transition to rehabilitation, where residents came in, received rehabilitation and then discharged . Review of Resident 11's EHR showed their primary payor source was Medicaid.During an interview on 01/22/2026 at 3:25 AM, Resident 10's representative stated Resident 10 called in a panic that LTC residents were being moved out of the facility and they were afraid. During an interview on 01/23/2025 at 9:35 AM, an Admissions coordinator from a Nursing Home that had accepted residents from the facility stated they understood the facility was closing down their Long-Term Care and were no longer taking LTC residents. During an interview on 01/23/2026 at 9:43 AM, Resident 8 stated the facility was only going to have short term, they were not going to have long-term residents anymore. Review of Resident 8's EHR showed their primary payor source was Medicaid.During an interview on 01/23/2026 at 10:02 PM, Resident 7's POA stated the facility had been sold and they were now only a short term facility. Review of Resident 7's EHR showed their primary payor source was Medicaid.Refer to F627 Inappropriate Discharge and F628 Discharge ProcessREFERENCE: WAC 388-97-0040 (5)(c)

Based on observation, interview and record review the facility failed to permit each resident to remain in the facility and involuntarily discharged 8 of 9 residents (Resident 1, 2, 3, 4, 5, 6, 7 & 8 ) reviewed for Nursing Home transfers without documentation of the basis for the transfer, and provision of sufficient time and orientation prior to discharge. In addition, the facility failed to develop and implement an effective discharge planning process that focused on the resident's discharge goals and was reflected in the plan of care. This failure placed residents at risk of displacement, discrimination based on ability to pay for services, and a decreased quality of life. Findings included .Review of the facility admission Skilled Nursing Facility (SNF) admission Agreement, undated, showed the facility could involuntarily discharge residents by providing written notice to Resident or the Resident Representative for one or more of the following reasons: 1. Resident's documented medical needs cannot be met in the facility; 2. Resident's health improves sufficiently so Resident no longer needs the services provided by the facility; 3. If appropriate to safeguard or other residents from physical or emotional injury; 4. The health of individuals in the Facility would otherwise be endangered; 5. Resident fails, after reasonable and appropriate notice, to pay for charges for Resident's care and stay at the facility; 6. The facility ceases to operate; or 7. Federal or state law otherwise allows. Except for an emergency involving resident health or well-being, no resident shall be transferred or discharged without prior consultation with the resident, their family or representative, and the resident's attending physician. RESIDENT 1Resident 1 interviewed 01/13/2026 at 4:06 PM, stated they were told the facility wanted to change their room to an office or something else. Resident 1 stated they were only given an option to go to a nursing home or another care unit.On 01/12/2026 at 12:44 PM, Resident 1's representative stated they received a phone call 01/08/2026 stating that the facility was no longer taking Long-Term Care (LTC) residents and stated the resident would be transferred to a SNF in Enumclaw or Federal Way.During an interview on 01/13/2026 at 4:06 PM, Resident 1 stated they liked it at their discharging facility, was very comfortable, liked their roommate and they were friends. Resident 1 stated they would have liked to stay, they liked the people and knew the staff, I was happy there and felt at home. Resident 1 stated their friends and church were in Puyallup close by so could visit. In an interview on 01/14/2026 at 4:24 PM, Resident 1's Representative stated they did not want to move Resident 1. As a result of the move, Resident 1 was upset, disoriented a bit and was afraid people wouldn't visit.During an interview on 01/15/2026 at 1:12 PM, Resident 1's Emergency Contact #2 stated, They didn't ask us, they just said she was moving.During an interview on 01/21/2025 at 12:33 PM, Resident 9 (Resident 1's former roommate), stated they came in one night around 4:00 PM and told Resident 1 they were being moved to Enumclaw the next day. Resident 9 stated that Resident 1 was surprised. Review of Resident 1's Care Plan (CP), 12/15/2025, showed Resident 1 wanted to stay at the facility for long-term care.Review of the Department Service Episode Record showed a 12/18/2025 entry that confirmed Resident 1 had no current discharge plan would continue to stay a a long term care resident at Puyallup NH.Review of the Nursing Home Transfer or Discharge Notice (NHTDN) dated 01/09/2026 showed Resident 1 was being transferred on 01/09/2026, and the transfer was appropriate because the resident's health had improved sufficiently so the resident no longer needed the services provided by the facility.Review of a Discharge Plan of Care, dated 01/09/2026, showed Resident 1 was discharged on 01/09/2026 to another skilled nursing facility by facility bus.During an interview on 01/21/2026 at 10:25 AM, Staff C, Social Services Director, stated they worked with the Resident's Representative, and the resident. When asked why Resident 1 was discharged , Staff C stated, That's the discharge plan we landed on. Staff C stated the resident's representative was aware of the discharge. RESIDENT 2During an interview on 01/13/2026 at 4:20 PM, Resident 2 stated moving was not their idea. Resident 2 said they were told they were going back to [NAME], but they did not have a room available so they [NAME] me here (admitting nursing facility). Resident 2 stated, I wanted to go home, but they brought me here instead. Resident 2 stated they did not get to pack up their own belongings and were missing some items Resident 2 appeared distressed, fixated on their belongings, looking back and forth at boxes and bags in their room. In an interview 01/15/2026 at 10:54 AM, Resident 2's representative stated Resident 2 would probably not have wanted to move. Resident 2 loved the programs at the discharged facility. Resident 2's representative stated Resident 2 needed to have someone help to make decisions as Resident 2 would not know how to advocate for themselves. Resident 2's representative stated the move was a shock to Resident 2 as they thought they were heading to [NAME] Iowa. Resident 2's representative stated they, their mother, and church members were all in Puyallup and Resident 2 was moved far away, making it difficult to visit, We're all she's got.During an interview on 01/15/2026 at 1:38 PM, Resident 2's sister stated the facility did not say why they were moving Resident 2, just that they were moving. Resident 2 would not have been able to make the decision to move as their cognition comes and goes. Resident 2 thought they were going to [NAME]. Resident 2's sister stated Resident 2 had lived at the facility since 2018 or 2019. Resident 2's sister said they asked if the admitting facility was closer or further away from Resident 2's Power of Attorney (POA), and was told they would be 20 miles closer. (The admitting facility is 20 plus miles further away). All of Resident 2's church people and friends live in Puyallup, and they lived there for over 30 years, it is their home ground. Resident 2's sister stated for the elderly moving was very traumatic, and they get disoriented quickly when they don't know where they are.Review of a Discharge Plan of Care, dated 01/03/2026, showed Resident 2 discharged to another skilled nursing facility, by a transport service. Recapitulation of stay showed Resident 2 was a long-term care resident.Review of the face sheet showed Resident 2 admitted in 2022 and resided in the facility for 2,503 days before being discharged on 01/03/2026.During an interview on 01/21/2026 at 10:25 AM, Staff C stated Resident 2 stated they wanted to go to [another city]. During an interview on 01/13/2026 at 4:39 PM, the admitting facility's Administrator and Director of Nursing Services stated the discharging facility was referring (transferring) Medicaid residents because they (new company for discharging facility) now only accepted Medicare residents, not Medicaid, and were making room for more skilled residents. They understood that [new company for discharging facility] wanted to increase skilled care and were sending LTC residents to other facilities. They said they heard [new company for discharging facility] were trying to transition the building to skilled care only. RESIDENT 3Review of Resident 3's CP, dated 08/12/2019, showed Resident 3 wished to reside LTC in the current facility. Review of the census showed Resident 3 resided in the facility since 2017. Review of the Admission/Discharge list, dated for January 2026, showed Resident 3 was transferred to a nursing home on [DATE]. Review of a Discharge Note, dated 01/16/2026 at 11:51 PM, showed, Resident 3 discharged to another facility. Reviewed discharge instruction and medications with husband. Husband verbalized understanding. Resident propelled in wheelchair pushed by husband to facility transport. Facility to send belongings to new facility.During an interview on 01/21/2026 at 10:41 AM, Staff C stated Resident 3 and their representative wanted to stay locally, in Puyallup so they transferred them to another nursing home in Puyallup. When asked why Resident 3 did not remain at the facility, Staff C stated, We're working on discharge planning options for everyone. When asked if resident's could remain in the facility, Staff C stated if it was appropriate, that they required nursing home level of care, then yes they could. Again, when asked why LTC resident's were being discharged , Staff C stated, I'm working with residents and family. RESIDENT 4Review of the Department of Home and Community Service Case Management Service Notes, dated 12/18/2024. showed the resident was staying LTC at the facility with no current discharge plan since 02/29/2024. The resident's case was inactive for no current discharge plan. Review of Resident 4's CP, dated 12/24/2025, did not show a documented discharge care plan. During an interview on 01/21/2026 at 11:01 AM, Staff C stated Resident 4 was discharging to another NH in Puyallup today. Staff C stated they had been working with Resident 4 and their family. During an interview on 01/21/2026 at 12:39 PM, Resident 4 stated they were told they would be shipped out at 10:00 AM and it was 12:30 PM but they were still there. Resident 4 was aware of where they were discharging to. When asked why they were discharging, Resident 4 stated, They don't want me here. I'm a long-term and they said long-term don't belong. Resident 4 stated they had moved into the facility approximately three years prior and were planning on staying at the facility. When asked why they chose the facility they chose to be discharged to, Resident 4 stated they didn't, the facility staff chose it because there was an opening there. Resident 4 stated they were told it was the only place with an opening unless they wanted to go to Tacoma and they did not want to go to Tacoma. RESIDENT 5Review of Resident 5's CP, dated 10/28/2025, did not show a discharge plan of care. Review of the progress notes, dated 01/13/2026, showed Resident 5 was discharged to a SNF in Tacoma. Review of Resident 5's electronic health record (EHR), showed Resident 5 was admitted to the facility on [DATE] for nursing and rehab services. Resident 5 had come off skilled services and was transported in the facility bus, to a SNF which was closer to family friend that visited often. During an interview on 01/21/2026 at 10:53 AM, Staff C stated they were working with Resident 5 and their friend to move Resident 5 to a nursing home closer to his friend for a shorter commute. During an interview on 01/23/2026 at 10:11 AM, Resident 5 stated they did not request to move, they were told they were moving. Resident 5 stated they were not given a choice of facility to discharge to. Resident 5 stated their discharge goal was return to their house with their girlfriend. During an interview on 01/23/2026 at 11:38 AM, Resident 5's friend stated the facility said they had to move, they were not given a choice. The move was quick and they did not even have a chance to go pack up Resident 5's belongings, they just put them in the van and took them. RESIDENT 6Review of Resident 6's EHR showed Resident 6 resided in the facility since February 2019.Review of the CP, dated 09/11/2025, showed Resident 6 wanted to stay at the facility for long-term care. Review of a Discharge summary, dated [DATE], showed the facility transported Resident 6 to another SNF. During an interview on 01/21/2026 at 10:53 AM, when asked why Resident 6 had to move, Staff C stated they let them know what their discharge options were. When asked again, Staff C stated, I'm just offering .if they wanted to. During an interview on 01/23/2026 at 10:19 AM, Resident 6 stated they did not even know they were moving until the morning they moved. Resident 6 stated they received no written notice, and was not given a choice of discharge location. When asked if they wanted to return, Resident 6 stated, No, they're mean people. RESIDENT 7Review of Resident 7's CP, dated 11/05/2025, did not show a discharge plan of care. Review of the Discharge summary, dated [DATE], showed the facility transported Resident 7 to another SNF. The recapitulation of stay showed Resident 7 was at the facility for rehab, had completed their skilled stay and was unable to return to their prior level of living. The resident was discharged to a SNF for long term care. During an interview on 01/21/2026 at 10:53 AM, Staff C stated Resident 7's daughter was at the facility, they previously lived together in an apartment and they wanted to be together so Resident 7 was discharged there. During an interview on 01/23/2026 at 9:53 AM, Resident 7 stated they were told they were only short term care and they were sending them to another nursing home for long term care. Resident 7 stated their POA was in a SNF and acknowledged they wanted to be with them. The facility said that since the facility was short term, they had to go there to be with their daughter. During an interview on 01/23/2026 at 10:02 AM, Resident 7's POA said Resident 7 called them around 7:30 AM and told them the facility wanted to move Resident 7 to a NH in Puyallup or in Tacoma. Resident 7's POA stated they called the facility who told them the facility tried to tell Resident 7 the building had been sold, they were a short term facility now and they were moving Resident 7 that morning. Resident 7's POA stated the facility told them Resident 7 had to leave, that they couldn't stay as it was short term. RESIDENT 8Review of Resident 8's CP, dated 12/16/2025, showed the resident's discharge plan was to discharge to an Assisted Living Facility or an Adult Family Home. Their listed discharge goal was to return home with their roommate. Review of the Discharge summary, dated [DATE], showed Resident 8 was transported in the facility bus to another SNF. Review of the recapitulation of stay showed the resident was admitted for skilled nursing and therapy services, was currently Long-Term Care Medicaid at facility and was transferring to another SNF. During an interview on 01/21/2026 at 10:53 AM, Staff C stated Resident 8 was at the facility for therapy. Staff C stated they worked with Resident 8, offered options of where to go, offered a community assessment, all of which the resident declined and chose the SNF in Tacoma. During an interview on 01/23/2026 at 9:43 AM, Resident 8 stated the facility moved everybody as they're not going to have long-term care residents anymore. Resident 8 stated they were not given a choice of discharge options, they picked one and moved me. Resident 8 stated one day they came in and told them they were making the facility short term and the next day at 9:00 AM someone came in, boxed me up and took me out. Resident 8 denied asking to move. They said they wanted to return home with their roommate, but they moved in with their girlfriend, so now their goal was to move into Assisted Living or an Adult Family Home. During an interview on 01/21/2026 at 12:08 PM, Staff E, Licensed Practical Nurse (LPN), Resident Care Manager (RCM), stated they were not discharging the residents who did not want to leave, as evidenced by they accepted to go somewhere else. During an interview on 01/21/2026 at 2:02 PM, Staff A, Administrator stated that no one had been discharged without agreeing and that they would not discharge people that were not agreeable. Refer to F621 Equal Practices Regardless of Payment Source and F628 Discharge Process.REFERENCE: WAC 388-97-0120 (1)(2).

Based on interview and record review, the facility failed to provide a written transfer notification to the resident/resident representative and notify the Office of the State Long Term Care Ombudsman (LTCO - resident advocates) for 9 of 16 sample residents (Residents 1, 2, 4, 5, 6, 7, 8, 11 & 13) reviewed for Nursing Home Transfers. Failure to notify the LTCO and ensure written notification was provided to the resident/resident representative, in a language and manner they understood, placed residents at risk of a lack of advocacy for not having an opportunity to make informed decisions about their transfer/discharge rights.Findings included .Review of the facility admission Skilled Nursing Facility (SNF) admission Agreement, undated, showed the facility could involuntarily discharge residents by providing written notice to Resident or the Resident Representative for specific stated reasons. According to the agreement, except for an emergency involving resident health or well-being, no resident shall be transferred or discharged without prior consultation with the resident, their family or representative, and the resident's attending physician. If a resident was to be involuntarily discharged from or transferred from the facility, the Facility would provide thirty (30) days' advance written notice to Resident and Resident's Representative .The written notice of transfer shall state the reason for the discharge or transfer and Resident's right, if any, to appeal the transfer or discharge. The facility may not transfer or discharge Resident while an appeal is pending unless failure to discharge or transfer would endanger the safety of Resident or other individuals at the Facility. RESIDENT 1In an interview on 01/14/2026 at 4:24 PM, Resident 1's representative and Emergency Contact #1 stated the facility called them 01/08/2025 to tell them they were moving Resident 1 as they no longer were going to provide long-term care (LTC), only rehabilitation services. The facility called them later that afternoon and told them they were moving Resident 1 the next day. Resident 1's representative stated they did not receive 30 days notice as required and a 24 hour notice was not adequate.During an interview on 01/15/2026 at 1:12 PM, Resident 1's Emergency Contact #2 stated around 4:30 pm on 01/08/2026 the facility told Resident 1 that they were moving the next day. Resident 1's Emergency Contact #2 stated Resident 1 had no time to adjust. Review of the Nursing Home Transfer or Discharge Notice (NHTDN), dated 01/09/2026, showed Resident 1 was being transferred on 01/09/2026, the date documented the notice was given was 01/08/2026. During an interview on 01/21/2026 at 10:25 AM, Staff C, Social Services Director, stated they gave a NHTDN to all resident's at discharge as they were part of the discharge packet. After review with the resident/family the form was uploaded into the resident's electronic record. RESIDENT 2In an interview on 01/13/2026 at 4:39 PM, the Admitting Facility (AF) DNS stated they were aware that Resident 2's Power of Attorney (POA) was not notified of the move.In an interview 01/15/2026 at 10:54 AM, Resident 2's representative stated they did not know Resident 2 was moved until they received a call from the admitting facility asking them to go sign papers. Up and moving her without letting us know was not acceptable. Resident 2's representative stated it was a shock to Resident 2. During an interview on 01/15/2026 at 1:38 PM, Resident 2's sister stated they were called by the facility around 6:30 PM saying they had found a LTC facility for Resident 2 who would be moved the next day. Resident 2's sister stated they asked the facility if they were aware that Resident 2 had a POA, and they said yes they were aware.Review of progress notes showed a 01/02/2026 entry that the Social Worker called Resident 2's sister and informed them they had an accepting long term facility that had accepted resident. Resident sister was in agreeance of transfer to {another nursing facility.] A 01/03/2026 Nurses Notes showed Resident 2 was discharged from the facility. During an interview on 01/21/2026 at 10:25 AM, Staff C, stated the prior organization did not list that Resident 2 had a POA, and listed Resident 2 as their own responsible party. Staff C stated they found out later the resident had a POA. RESIDENT 4During an interview on 01/21/2026 at 12:39 PM, Resident 4 stated they were not given a notice of discharge, they were not notified of their right to appeal the discharge. Resident 4 stated they had not been told anything other than they were moving. Review of a Discharge summary, dated [DATE], showed Resident 4 was discharged to another SNF on 01/21/2026. Review of Resident 4's electronic health record (EHR) did not show written notification was given to the resident prior to the date of discharge. RESIDENT 5Review of a Nurses Note, dated 01/13/2026, showed Resident 5 was discharged to a SNF in Tacoma. During an interview on 01/23/2026 at 10:11 AM, Resident 5 stated they did not receive a notice of transfer, they did not receive anything in writing and did not receive much notice. During an interview on 01/23/2026 at 11:38 AM, Resident 5's friend stated they were told they would be moved sometime that week, but then suddenly the coordinator came and took them that night. Review of Resident 5's EHR did not show written notification was given to the resident prior to the date of discharge. RESIDENT 6Review of a Discharge summary, dated [DATE], showed the facility transported Resident 6 to another SNF. During an interview on 01/23/2026 at 10:19 AM, Resident 6 stated they did not even know they were moving until the morning they moved. Resident 6 stated they received no written notice, and was not given a choice of discharge location. Review of Resident 6's EHR did not show written notification was given to the resident prior to the date of discharge. RESIDENT 7Review of the Discharge summary, dated [DATE], showed Resident 7 was transferred to another SNF. During an interview on 01/23/2026 at 9:53 AM, Resident 7 stated they were not given prior written notice.During an interview on 01/23/2026 at 10:02 AM, Resident 7's POA said they were given verbal notice on the day of discharge and they received nothing in writing. RESIDENT 8Review of the Discharge summary, dated [DATE], showed Resident 8 was transported in the facility bus to another SNF. During an interview on 01/23/2026 at 9:43 AM, Resident 8 stated they received no written transfer notification, they came in and told them they were going to move them and the next day someone came in, boxed them up and took them to another facility. RESIDENT 11Review of Resident 11's Care Plan, dated 08/06/2025, showed Resident 11 was a LTC resident of the facility and the goal was LTC at current facility. During an interview on 01/21/2026 at 12:52 PM, Resident 11 stated they wanted to return to their own house and be with their dog. They said facility staff approached them regarding discharge planning the week prior, but did not provide anything in writing. During an interview on 01/21/2026 at 3:55 PM, Resident 11's POA stated the social worker called them and stated they had talked to Resident 11 alone, offered them other placements, and Resident 11 picked one. Resident 11's POA stated Resident 11 was highly confused and not able to make these decisions. During an interview on 01/22/2026 at 2:31 PM, Resident 11s POA stated Resident 11's house was sold and their dog had passed away. Resident 11's POA stated the facility had recently started the discussion to discharge, they received no written notice. Resident 11 had been in the facility around three years and their spouse/partner was also in the facility with the hope they would share a room. During an interview on 01/21/2026 at 11:01 AM, Staff C stated they spoke with the POA and they wanted a care conference with another resident prior to discharge. RESIDENT 13On 01/21/2026 at 1:16 PM, Resident 13 was observed seated in a wheelchair, next to the bed, eating lunch with a visitor at the bedside. In an interview at that time the visitor stated Resident 13 did not speak English and the family was told the facility was going to apply to three nursing homes and they would move Resident 13 to whichever accepted them. The visitor stated, It wasn't a choice, They don't agree. The visitor stated they were told over the phone and received no written notice.In an interview on 01/21/2026 at 1:21 PM, Resident 13's POA stated Resident 13 admitted to the facility in January 2024 and planned to stay at the facility LTC. On Monday (01/19/2026) they received a call from Staff C that they were turning the facility into post acute care and Resident 13 could not stay there as she was not receiving any services. Staff C called again 01/20/2026 saying that she found a place for Resident 13 that accepted them. The POA asked Staff C regarding an Adult Family Home (AFH) that spoke their language, and was told Resident 13 would not be able to due to their level of care. Resident 13's POA said they received no written notice, and were not offered an assessment for community placement. Resident 13's POA stated the resident's care needs had not changed. NOTIFICATION OF STATE LONG-TERM CARE (LTC) OMBUDSMANDuring an interview on 01/21/2026 at 10:25 AM, Staff C, stated they send the LTC Ombudsman's office notification of discharges at the end of the month. Staff C stated they were creating an audit and would send the notices then. Staff C stated they were working on a system where all of the NHTDN would be kept in a binder. Staff C stated they had not sent any notices since they started working at the facility a month prior. Refer to F621 Equal Practices Regardless of Payment Source and F627 Inappropriate Discharge. REFERENCE: WAC 388-97-0120 (2)(5)(a), -0140(1).

Based on interview and record review, the facility failed to have a system in place to address grievances/concerns raised by the Resident Council group for 4 of 8 months (January, March, April and September 2025) when reviewed for resident council. Failure of the grievance official to report back to the resident or council in writing with a response, rationale and action taken on grievances, placed residents at risk for continued concerns, unmet needs and a diminished quality of life.Findings included . During an interview on 09/10/2025 at 9:26 AM, Resident 40 stated when a concern was brought up in Resident Council, Resident 40 would be the one to take initiative and resolve the concern. Resident 40 stated they were unaware if the concerns were documented as a grievance. Review of the Resident Council meeting minutes for January, March, April and September 2025 showed there were a total of eight concerns voiced by residents that required a resolution. Review of the facility's Resident/Family Grievance Log from January 2025 through September 2025 showed there were no grievances related to the eight concerns discussed in Resident Council. During an interview on 09/11/2025 at 2:53 PM, Staff A, Administrator, stated grievances should have been filled out by the facilitator at the Resident Council meeting, logged and followed up on. Reference WAC 388-97-0920(1-6).

Based on record review and interview, the facility failed to provide written bed hold notice at the time of transfer to the hospital for 4 of 4 sampled residents (Residents 1,11,39 and 52) when reviewed for hospitalization. This failure placed the residents at risk for lacking knowledge regarding their right to hold their bed while in the hospital and diminished quality of life.Findings included . Resident 1Review of the electronic health record (EHR) showed Resident 1 admitted to the facility on [DATE] with diagnoses that included dementia (a decline in mental ability that interferes with daily life) and diabetes (too much sugar in the blood). Resident 1 was unable to make needs known. Review of Resident 1's EHR showed hospitalization on 08/31/2025, with no documentation that the resident or resident representative were provided with written copies of the bed hold notice or transfer form. Resident 11Review of the EHR showed Resident 11 admitted to the facility on [DATE] with diagnoses that included rheumatoid arthritis (disease that primarily affects the joints, causing inflammation, pain, stiffness, and damage) and chronic obstructive pulmonary disease (COPD, a condition caused by damage to the lungs). Resident 11 was able to make needs known. Review of Resident 11's EHR showed hospitalization on 08/29/2025, with no documentation that the resident or resident representative were provided with written copies of the bed hold notice or transfer form. Resident 39Review of the EHR showed Resident 39 admitted to the facility on [DATE] with diagnoses that included COPD and diabetes. Resident 39 was able to make needs known. Review of Resident 39's EHR showed hospitalization on 02/22/2025, with no documentation that the resident or resident representative were provided with written copies of the bed hold notice or transfer form. Resident 52Review of the EHR showed Resident 52 admitted to the facility on [DATE] with diagnoses that included hip pain, depression and degenerative disc disease (condition that effects discs in the spine). Resident 52 was able make needs known. Review of Resident 52's EHR showed hospitalization on 08/10/2025, with no documentation that the resident or resident representative were provided with written copies of the bed hold notice or transfer form. During an interview on 09/11/2025 at 2:50 PM, Staff A, Administrator, stated the expectation was for bed hold and transfer forms to be provided to residents when transferred to the hospital. Reference WAC 388-91-0120(4)

Based on interview and record review, the facility failed to promptly screen residents for additional mental health supports through the Preadmission and Resident Review (PASARR, a mental health screening tool) for 4 of 7 sampled residents (Residents 2, 5, 3, and 9) when reviewed for PASARR. This failure placed residents at risk of lack of mental health support, increasing behaviors, decrease in mental health, and a diminished quality of life. Findings included.Resident 2 Review of the electronic health record (EHR) showed Resident 2 admitted to the facility on [DATE] with diagnoses to include dementia (a group of conditions that cause a decline in cognitive abilities, memory, and thinking skills that interfere with daily life) and depression. Resident 2 was able to make needs known. Review of the level 1 PASARR showed it was completed on 08/28/2025, 15 days after admission. Resident 5 Review of the EHR showed Resident 5 admitted to the facility on [DATE] with diagnoses to include depression, hemiplegia (difficulty moving one side of the body), and diabetes (too much sugar in the blood). Resident 2 was able to make needs known. Review of the level 1 PASARR showed it was completed on 07/23/2025, 1 month and 29 days after admission. Resident 3 Review of the EHR showed Resident 3 admitted to the facility on [DATE] with diagnoses to include psychotic disorder and hemiplegia. Resident 2 was able to make needs known. Review of the level 1 PASARR showed it was completed on 07/09/2025, 4 months and 8 days after admission. During an interview on 09/12/2025 at 1:56 PM, Staff N, Social Services Director, stated the facility would receive the PASARR from the hospital and re-complete it in the first few days of admit if inaccurate. During an interview on 09/15/2025 at 12:05 PM, Staff N, Social Services Director, stated Resident 2, Resident 5, and Resident 3’s PASARR were not completed timely, and this did not meet expectation. During an interview on 09/15/2025 at 2:10 PM, Staff A, Administrator, stated the facility would receive the PASARR from the hospital on admitting to the facility and correct it, if inaccurate, within the first seven days. Resident 9 Review of the EHR showed Resident 9 was admitted to the facility on [DATE] with diagnoses to include arthritis (joint pain and inflammation), depression, bipolar disorder (disorder with episodes of mood swings ranging from depressive lows to manic highs) and heart failure. Resident 9 was able to communicate needs. Review of a PASRR level one, dated 08/08/2023 showed no level two evaluation indicated. During an interview on 09/15/2025 at 11:18 AM, Staff B, Director of Nursing Services, stated Resident 9 not having a level two evaluation referral required for mental illness did not meet expectations. Reference WAC 388-97-1915(1)(2)(a-c)

Based on interview and record review the facility failed to implement non-pharmacological interventions (NPI) prior to providing as needed (PRN) pain medications for 4 of 5 residents (Residents 5, 39, 30 and 3) and failed to implement parameters for use of pain medications for 1 of 5 residents (Resident 30) when reviewed for unnecessary medications. This failure placed the residents at risk of receiving unnecessary pain medications, and a decreased quality of life. Findings included .Resident 5 Review of the electronic health record (EHR) showed Resident 5 admitted to the facility on [DATE] with diagnosis of stroke (when blood supply to part of the brain is blocked or reduced. causing loss of function), and diabetes (too much sugar in the blood). The resident was unable to make their needs known. Review of the provider orders showed Resident 5 received a PRN narcotic pain medication on 08/06/2025 and 09/10/2025. Review showed a provider order for nursing staff to attempt nonpharmacological interventions (NPI) such as repositioning prior to administering as needed pain medications. Review of the medications administration record (MAR) showed no NPI were attempted prior to administering the as needed pain medications. Resident 39 Review of the EHR showed Resident 39 admitted to the facility on [DATE] with diagnosis of chronic obstructive pulmonary disease (COPD, a lung disease). The resident was able to make needs known. Review of the provider orders showed an order for a narcotic pain medication as needed (PRN). Review of the EHR showed the resident received a narcotic pain medication PRN on 09/08/2025, 09/09/2025 and 09/10/2025. There was no documentation found that NPI were offered/attempted prior to the as needed pain medications. During an interview on 09/11/2025 at 3:17 PM, Staff E, Licensed Practical Nurse (LPN/RCM) stated staff should have documented NPI attempted prior to administering as needed pain medications in the EHR for Residents 5 and 39 but did not. During an interview on 09/12/2025 at 9:31 AM, Staff B, Director of Nursing Services (DNS) stated it was their expectation staff attempt NPI prior to administering as needed pain medications and document them in the EHR. Resident 30 Review of the EHR showed Resident 30 admitted to the facility on [DATE] with diagnoses to include fracture of the right leg, hypertension (high blood pressure), anxiety, and depression. Resident 30 was able to make needs known. Review of provider’s orders showed Resident 30 received acetaminophen (an over-the-counter pain medication) PRN, dated 08/04/2025, lidocaine external patch (a topical pain medication) PRN, dated 08/04/2025, and received oxycodone (a narcotic pain medication) PRN from 08/04/2025 to 08/08/2025. Review showed none of these orders for PRN pain medications included instructions to nurses on which medication to use for what level of pain. Review showed an order for staff to provide NPI prior to the use of PRN pain medications. Review of the August 2025 MAR showed Resident 30 received acetaminophen without NPI on three occasions, received oxycodone without NPI on 3 occasions, and never received the lidocaine patch. During an interview on 09/15/2025 at 1:14 PM, Staff E, LPN/RCM, stated the facility ensured PRN pain medications were needed by monitoring the pain scale (a scale of 1-10) and providing NPI prior to their use. Staff E stated Resident 30 had orders for NPI to be used but had received PRN pain medications without NPI. Staff E stated the facility’s nursing staff would know which PRN pain medications to provide by using a pain scale. Staff E stated Resident 30’s PRN medication did not include a pain scale for facility nursing staff to use to determine which PRN pain medication to use. Staff E stated the expectation was Resident 30 would have NPI prior to PRN pain medications and PRN medications would include pain scale for use. During an interview on 09/15/2025 at 2:05 PM, Staff B, DNS, stated NPI should be provided prior to the use of PRN pain medications and PRN pain medications should include a pain scale of when to use. Staff B stated Resident 30’s lack of NPI prior to PRN pain medication use and lack of pain scale for PRN medications did not meet expectations. Resident 3 Reviews of the EHR showed Resident 3 was admitted to the facility on [DATE] with diagnoses to include hemiplegia following stroke (conditions that cause paralysis or severe weakness on one side of the body) end stage renal disease with dialysis (treatment that removes waste products and excess fluid from blood when kidneys are not functioning) and depression. Resident 3 was able to communicate needs. Review of Resident 3’s MAR for August 2025 showed an order for Oxycodone (narcotic pain medicine) to be given every eight hours PRN for severe pain, and for nurses to document NPI prior to the use of the medicine. Records showed Resident 3 had oxycodone medication on 08/10/2025,08/11/2025,08/12/2025,08/18/2025,08/20/2025,08/22/2025, 08/23/2025 and 08/25/2025 without documentation of any NPI attempted prior to the use of the medication. Review of the September 2025 MAR showed Resident 3 had been administered oxycodone on 09/03/2025, 09/07/2025 and 09/08/2025 without documentation of NPI’s attempts. During an interview on 09/15/2025 at 10:16 AM, Staff J, Nurse Manager/Patient Care Coordinator, stated the process is for NPI’s to be tried and documented prior use of PRN pain medications. During an interview on 09/15/2025 at 11:18 AM, Staff B, Director of Nursing Services, stated documentation for Resident 3’s pain medication administration did not meet expectations. Reference WAC 388-97-1060(3)(k)(i)

Based on observation and interview, the facility failed to ensure a resident's bed fit them for 1 of 1 sampled resident (Resident 84) when reviewed for accommodation of need. This failure placed residents at risk of inability to sleep, decreased condition, and a diminished quality of life. Findings included.Review of the electronic health record showed Resident 84 admitted to the facility on [DATE] with diagnoses to include hemiplegia (difficulty moving one side of the body), repeated falls, and diabetes (too much sugar in the blood). Resident 84 was able to make needs known. Observation on 09/10/2025 at 9:53 AM showed Resident 84 laid in bed. Observation showed the footboard of the bed had been removed and Resident 84's feet hung off the bed with the back of the ankles resting on the bed. Observation on 09/15/2025 at 12:40 PM showed Resident 84's representative speaking with Staff M, Maintenance Director. Resident 84's representative stated Resident 84 had been waiting three weeks for a longer bed and Staff M stated they had been trying to locate a longer bed, but they were a hot commodity. Staff L stated the facility had bariatric beds (a specialized hospital bed designed for patients who are overweight or obese), but they were for patients that needed them so Resident 84 would have to wait. During an interview on 09/15/2025 at 1:10 PM, Resident 84's representative stated they had told the facility that Resident 84's bed was too short, and the facility had removed the footboard of the bed. Resident 84's representative stated Resident 84 would slide down in bed and they had to help them reposition in bed. Resident 84's representative stated Resident 84 was 6'3. During an interview on 09/15/2025 at 1:57 PM, Staff L, Licensed Practical Nurse/Resident care Manager, stated the facility provided beds that fit a resident by looking at their height and weight, and could rent additional bariatric beds if none were available. Staff L stated the expectation was that all residents would fit in their bed. Staff L stated Resident 84 could not reposition themselves in bed. During an interview on 09/15/2025 at 2:14 PM, Staff B, Director of Nursing Services, stated the expectation was all residents would fit in their bed, and this expectation was not met for Resident 84. Reference WAC 388-97-0860(2)

Based on observation, interview and record review, the facility failed to thoroughly investigate and notify law enforcement for a physical abuse allegation with injuries for 1 of 3 sampled residents (Resident 45) reviewed for abuse and neglect. This failure placed residents at risk of physical and emotional harm, feelings of rejection and impaired quality of life. Findings included.Review of the Electronic Health Record (EHR) showed Resident 45 was readmitted to the facility on [DATE] with diagnoses to include acute respiratory failure, malnutrition (lack of sufficient nutrients in the body), depression, anxiety and seizure disorder (uncontrolled jerking, loss of consciousness, and other symptoms caused by abnormal electrical activities in the brain). Resident 45 was able to communicate needs. Observation and interview on 09/10/2025 at 9:45 AM showed Resident 45 in their room sitting on their wheelchair with worried facial expression and furrowed eyebrows. Resident 45 stated My knee hurts and they are not doing anything about it. Observation and interview on 09/11/2025 at 9:49 AM showed Resident 45 with a purple bruise to their right knee extending from below the knee to the upper thigh area, and stated the staff hurt them by hitting them for no reason. Review of a progress note, dated 09/06/2025, showed Resident 45 reported pain in their right thigh and stated a staff member punched them. Documentation showed a raised bruise on the right thigh area. Interventions were to start providing care in pairs and Tylenol as need it. Review of the admission minimum data set (MDS), an assessment tool, dated 07/22/2025 showed Resident 45 had no behaviors. Review of the social history and discharge plan dated 04/01/2025, showed Resident 45 had no history of trauma and under mental health needs were documented as not applicable. During an interview on 09/12/2025 at 11:32 AM, Staff G, Certified Nursing Assistant, stated Resident 45 experiences pain and was crying on the morning of 09/06/2025. Staff G assisted Resident 45 to use the bathroom (usually Resident 45 goes by their self) and observed fresh raised bruised and swollen area on the right thigh. Staff G stated the resident reported a staff member hitting them. Staff G stated additional bruises on the right knee and right inner thigh were not there on the morning of 09/06/2025, but Resident 45 had them the next day and was related to a different event. During an interview on 09/12/2025 at 12:24 PM, Staff K, Licensed Practical Nurse, stated Resident 45 had a bruise on the right thigh, and now Resident 45 has a bruise on the right inner thigh and right knee. Staff K stated Resident 45 was reporting that they were getting hit by a lady. Staff K was not sure how the bruises occurred and was not aware of any falls. Review of EHR showed Resident 45 was seen by Psychiatry (medical specialty dedicated to diagnose, treatment and prevention of mental, emotional and behavioral disorders) on 09/12/2025 at 12:24 PM and notes stated Impression [they] appears to continue to suffer harm from reported harm. Recommendation [their] report should be investigated and taken seriously. [They] does not appear psychotic or confused and appears to have suffered significant injury. Review of the incident log for September 2025, showed Resident 45 had an occurrence on 09/06/2025 with injury of small bruises and it was reported to the state hot line, and a second occurrence on 09/10/2025 with injuries of bruises that are in an area not generally vulnerable to trauma reported to state hot line. Review of Resident 45 ‘s allegation of physical abuse investigation of 09/06/2025 showed the root cause of the Injuries were related to cognition and diagnoses and Resident 45 having untrue statements, and abuse and neglect was ruled out. Review of Resident 45's second physical abuse investigation of 09/10/2025 showed purple bruise on right knee measuring four and a half inches and purple bruise on the right inner thigh measuring two inches by four inches, and root cause of the injuries were from Resident 45 throwing themselves onto the bed on the right side and abuse and neglect was ruled out. The investigation did not have witness statements of any staff member observing Resident 45 throwing themselves to the bed or chair. During an interview on 09/15/2025 at 08:54 AM, Resident 45 stated they were still afraid of the staff because they could come back and hurt them again. During an interview on 09/15/2025 at 10:01 AM, Staff J, Nurse Manager /Patient Care Coordinator, stated after reviewing facility policy that law enforcement should have been notified. During an interview on 09/15/2025 at 11:26 AM, Staff B, Director of Nursing Services, stated Resident 45 had allegations and was placed on care in pairs (2 staff members with all interactions) for staff protection, and law enforcement was to be notified only when abuse was confirmed per facility policy. Staff B stated there were no environmental interventions put in place despite the claims that Resident 45 was throwing themself onto the bed or chair. Reference WAC 388-97-0640(6)(a)(b)

Based on observation, interview and record review the facility failed to provide quality of care related to the following: medication parameters, non-pressure skin management, bowel management and anticoagulation management for 5 of 22 sampled residents (Residents 30,3, 9, 45 and 5) when reviewed for quality of care. These failures placed the residents at risk for poor clinical outcomes and a decreased quality of life. Findings included .Resident 5 Review of the electronic health record (EHR) showed Resident 5 admitted to the facility on [DATE] with diagnosis of stroke. The resident was unable to make their needs known. Review of the EHR showed an order for coumadin (a blood thinning medication) for blood clot prevention daily. Review of the plan of care on 09/10/2025 showed no active care plan for anticoagulant therapy. During an interview on 09/12/2025 at 9:20 AM, Staff E, Licensed Practical Nurse/Resident Care Manager (LPN/RCM) stated Resident 5 should have had a care plan for anticoagulation therapy but did not. During an interview on 09/12/2025 at 9:34 AM, Staff B, Director of Nursing Services (DNS) stated Resident 5 should have had a care plan in place for anticoagulant therapy but did not and this did not meet expectations. Resident 30 Review of the EHR showed Resident 30 admitted to the facility on [DATE] with diagnoses to include fracture of the right leg, hypertension (high blood pressure), anxiety, and depression. Resident 30 was able to make needs known. Review of the provider’s orders showed Resident 30 received metoprolol tartrate (blood pressure medication) with instructions to hold if the systolic blood pressure (SBP, top blood pressure reading) was less than 105, dated 08/04/2025, and furosemide (a water removing medication) with instructions to hold if the SBP was less than 100, dated 08/12/2025. Review of the August 2025 medication administration record (MAR) showed Resident 30 received metoprolol tartrate with an SBP less than 105 on 6 of 51 opportunities and furosemide with an SBP less than 100 on 2 of 20 opportunities. Review of the September 2025 MAR showed Resident 30 received metoprolol tartrate with an SBP less than 105 on 4 of 21 opportunities and furosemide with an SBP less than 100 on 2 of 11 opportunities. During an interview on 09/15/2025 at 1:14 PM, Staff E, LPN/RCM, stated nursing staff should review and follow parameters associated with medications. Staff E stated Resident 30 received metoprolol tartrate and furosemide outside of parameters. During an interview on 09/15/2025 at 2:05 PM, Staff B, Director of Nursing Services, stated nursing staff should review and follow parameters associated with medications. Staff B stated Resident 30 receiving blood pressure medications outside of parameters did not meet expectation. Resident 3 Review of the EH) showed Resident 3 was admitted to the facility on [DATE] with diagnoses to include hemiplegia following stroke (condition that causes paralysis or severe weakness on one side of the body), end stage renal disease with dialysis (treatment that removes waste products and excess fluid from blood when kidneys are not functioning) and depression. Resident 3 was able to communicate needs. During an interview on 09/11/2025 at 12:08 PM, Resident 3 stated they have chronic constipation (when a person passes less than three bowel movements a week or has difficult bowel movements), and they require assistance to use the bathroom. Review of the bowel documentation from 08/12/2025 through 09/12/2025 showed, Resident 3 did not have bowel movements on the dates 08/12/2025, 08/13/2025, 08/14/2025 and 08/15/2025 for a total of four days and 08/29/2025, 08/30/2025, 08/31/2025, 09/01/2025 and 09/02/2025 for a total of five days. Review of the MAR for August and September 2025, showed no documented laxatives (medications that promote bowel movements) were administered. During an interview on 09/11/2025 at 12:40PM, Staff K, Licensed Practical Nurse, stated the facility has a bowel protocol that is initiated after 72 hours of no bowel movements, and the night shift usually initiates the protocol, and next shift is to follow up on it. During an interview on 09/15/2025 at 11:22 AM, Staff B, Director of Nursing Services, stated the bowel management for Resident 3 did not meet expectations. Resident 9 Review of the EHR showed Resident 9 was admitted to the facility on [DATE] with diagnoses to include arthritis (joint pain and inflammation), depression, bipolar disorder (disorder with episodes of mood swings ranging from depressive lows to manic highs) and heart failure. Resident 9 was able to communicate needs. During an observation and interview on 09/10/2025 at10:44 AM, Resident 9 stated their band aid keeps falling out, and Resident 9 was pointing towards skin- tear with a bruise on left hand. Review of weekly skin check dated 09/03/2025 showed Resident 9 had their right hand with scattered bruising and the back of left hand with scattered bruising. Review of a weekly skin check dated 09/10/2025 showed Resident 9 had a red area on their coccyx (tail bone) from shearing, left hand scratch, left forearm scattered bruising and right forearm scattered bruising. There was no clear description of the skin injuries. During an interview on 09/12/2025 at 10:30 AM, Staff K, LPN, stated the bruises are usually monitored daily with orders, and the sizes and description should be documented in the record. Resident 45 Review of the EHR showed Resident 45 was readmitted to the facility on [DATE] with diagnoses to include acute respiratory failure, malnutrition (lack of sufficient nutrients in the body), depression, anxiety and seizure disorder (uncontrolled jerking, loss of consciousness, and other symptoms caused by abnormal electrical activities in the brain). Resident 45 was able to communicate needs. Observation and interview on 09/11/2025 at 9:49 AM showed Resident 45 with a large purple bruise on their right knee. Review of weekly skin check dated 07/21/2025 showed Resident 45 had no skin issue present. Review of weekly skin check dated 08/28/2025 showed Resident 45 had an old bruise on the front of the left thigh and scattered bruises to the back of their right hand, there was no color description or sizes/ measurements included. Review of weekly skin checks dated 08/29/2025 showed Resident 45 had a red/purple bruise on the right forearm, a purple bruise on the right elbow, four small yellow bruises on the left antecubital (inner surface of elbow), scabs on the right ear next to their face, a bruise on the right ankle and scattered yellow bruising on the right front thigh. There were no documented sizes for any of the bruises. Review of weekly skin check dated 09/05/2025 and locked date 09/11/2025, showed Resident 45 had scattered bruising up and down the right leg, with a bruise on the front of left knee, a bruise on the front of the right knee and a bruise on the back of the right thigh. There was no description or sizing of the skin injuries. During an interview on 09/12/2025 at 12:24 PM, Staff K, Licensed Practical Nurse, stated the bruises are usually monitored daily with orders, and the sizes and description should be documented in the record. During an interview on 09/12/2025 at 12:27 PM, Staff H, Registered Nurse, stated the bruises are to have description and sizing documented at the weekly skin checks. During an interview on 09/15/2025 at11:19 AM, Staff B, Director of Nursing Services, stated the skin checks documentation for Residents 45 and 9 did not meet expectations. Reference WAC 388-97-1060 (1)

Based on observation, interview, and record review, the facility failed to provide oxygen services per provider's orders for 1 of 3 sampled residents (Resident 48) when reviewed for respiratory services. This failure placed residents at risk of oxygen poisoning, decline in condition, and a diminished quality of life. Findings included.Review of the electronic health record (EHR) showed Resident 48 admitted to the facility on [DATE] with diagnoses to include heart failure, chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), and diabetes (too much sugar in the blood). Resident 48 was able to make needs known. Review of the provider’s orders showed Resident 48 received oxygen at 2 liters per minute (L/m), dated 08/25/2025, and nursing staff was to verify the flow rate three times a day, dated 08/25/2025. Observation on 09/09/2025 at 12:43 PM, 09/11/2025 at 9:45 AM, and 09/15/2025 at 9:20 AM showed Resident 48 was receiving oxygen at 5 L/m. Review of the medication administration record for 09/09/2025 through 09/15/2025 showed the facility’s nursing staff had marked Resident 48 was receiving oxygen at 2 L/m. During an interview on 09/15/2025 at 1:41 PM, Staff L, Licensed Practical Nurse/Resident Care Manager, stated the facility ensured oxygen was provided per provider’s order by reviewing the order and the expectation was it would be followed. Staff L observed Resident 48’s oxygen and stated it was being provided at 5L/m, which did not meet expectations. Staff L stated facility nursing staff had marked Resident 48 was receiving oxygen at 2L/m on multiple occasions. During an interview on 09/15/2025 at 2:05 PM, Staff B, Director of Nursing Services, stated the expectation was for residents to receive oxygen per provider’s orders and Resident 48 receiving oxygen at 5 L/m did not meet expectations. Resident 81 Review of EHR showed Resident 81 was readmitted to the facility on [DATE] with diagnoses to include respiratory failure, COPD, and asthma (when airways are inflamed and makes it difficult to breathe). Resident 81 was able to communicate their needs. During an observation and interview on 09/09/2025 at 2:54 PM, Resident 81 was in bed receiving oxygen via nasal cannula (thin tubing in nose) at two liters per minute. Resident 81 stated they have been using oxygen since coming back from the hospital and they need it. Review of the providers orders for September 2025 showed no order for the use of Oxygen. During an interview on 09/15/2025 at 10:01 AM, Staff J, Nurse Manager/Patient Care Coordinator, stated the expectation was for oxygen to be administered with a provider order and descriptions of the rate and to document oxygen saturation levels. During an interview on 09/15/2025 at 11:16 AM, Staff B, Director of Nursing Services, stated documentation for Resident 81’s oxygen administration did not meet expectations. Reference WAC 388-97-1060(3)(j)(vi)

Based on observation, interview, and record review, the facility failed to provide dental services to increase residents' ability to eat for 1 of 3 sampled residents (Resident 4) when reviewed for dental services. This failure placed the resident at risk of decreased nutritional intake, oral discomfort, and a diminished quality of life. Findings included.Review of the electronic health record showed Resident 4 admitted to the facility on [DATE] with diagnoses to include enterocolitis (inflammation of the intestines), malnutrition (insufficient nutritional intake), and adult failure to thrive. Resident 4 was able to make needs known. Observation and interview on 09/09/2025 at 10:24 AM showed Resident 4 had 2 teeth. Resident 4 stated the facility did not offer any dental services to them. Review of Resident 4's care plan, initiated 08/19/2025, showed no focus area related to dental. Review showed a focus area related to Resident 4 being at risk for nutritional problems, had a mechanically altered diet (a dietary modification designed for individuals with difficulty chewing or swallowing), and was at risk for inadequate oral intake. Review of a Dietitian Consulting Services - Nutrition Assessment, dated 08/29/2025, showed Resident 4 had a Dysphagia texture - Moist and Minced (modifications in food and liquid consistency to make them easier and safer to swallow for individuals with swallowing difficulties). Review showed the question Resident has dental or mouth problems that make it hard to chew or swallow was answered None noted. During an interview on 09/15/2025 at 1:41 PM, Staff L, Licensed Practical Nurse/Resident Care Manager, stated the facility conducted an oral exam on admission to determine which residents required dental services. Staff L stated residents missing teeth would be referred to a dentist or denturist. Staff E stated Resident 4 had one tooth and would like to have an upgraded diet. Staff E stated Resident 4 had not been referred to dental services and this did not meet expectations. During an interview on 09/15/2025 at 2:05 PM, Staff B, Director of Nursing Services, stated residents would have an oral assessment on admission and be referred to dental services if they had broken or missing teeth. Staff B stated Resident 4 should have been referred to dental services. Reference WAC 388-97-1060 (3)(j)(vii)

Based on observation and interview, the facility failed to maintain a homelike environment in 2 of 2 halls (East and [NAME] Halls) when reviewed for environment. This failure placed residents at risk of decreased mood, feelings of worthlessness, and a diminished quality of life. Findings included.Observation on 09/09/2025 at 2:22 PM showed the closet door in room [ROOM NUMBER] without a closet door for bed A. Observation on 09/09/2025 at 12:50 PM showed a plastic bag tied to the overbed light cord in room [ROOM NUMBER] bed A. Observation on 09/09/2025 at 1:47 PM showed a plastic bag tied to the overbed light cord in room [ROOM NUMBER] bed B. Observation on 09/09/2025 at 3:18 PM showed a sock tied to the overbed light cord in room [ROOM NUMBER] bed A. Observation on 09/10/2025 at 9:42 AM showed a plastic bag tied to the overbed light cord in room [ROOM NUMBER] bed A and B. Observation on 09/10/2025 at 9:57 AM showed the baseboard molding near the bathroom peeling away from the wall in room [ROOM NUMBER]. Observation on 09/15/2025 at 11:45 AM showed a plastic bag tied to the overbed light cord in the following rooms: 153 bed B, 127 bed B, 119 bed A, 136 bed A, and 141 bed B.Observation showed the following rooms with overbed light cords less than three inches long: 186 bed B and 127 bed A. Observation showed a plastic bag braided into a cord and affixed to the back of the bathroom door in room [ROOM NUMBER]. During an interview on 09/15/2025 at 12:28 PM, Staff M, Maintenance Director, stated there were maintenance books at each nursing station where floor staff could inform maintenance of needed repairs. Staff M stated plastic bags should not be tied to overbed light cords and they were unaware of the peeling baseboard molding in room [ROOM NUMBER] or the missing closet door in room [ROOM NUMBER]. During an interview on 09/15/2025 at 2:17 PM, Staff A, Administrator, stated there were maintenance books at each nursing station where floor staff could inform maintenance of needed repairs. Staff A stated plastic bags should not be used to extend overbed light cords and the observations of needed maintenance did not meet expectations. Reference WAC 388-97-0880

Based on interview and record review, the facility failed to obtain laboratory services according to professional standards of practice for 6 of 18 Residents (Residents 3, 9, 10, 11, 12 & 13 ) reviewed for COVID-19 testing. The facility failure to obtain Physician Orders to conduct COVID-19 testing placed residents at risk of delayed identification/diagnosis of COVID-19. Findings included . COVID-19 is an infectious virus which causes respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death. <Resident 3> Review of the June 2025 COVID-19 Reporting Line Listing showed Resident 3 tested positive for COVID-19 on 06/10/2025. Review of Progress Notes showed on 06/10/2025 at 4:54 AM, Resident was administered Tylenol for a fever of 101.9 degrees Fahrenheit (dF). A 06/10/2025 5:59 AM Nursing Note showed the resident had been coughing all night. Although the positive results were documented, the COVID-19 test was not documented when it was done or by who. Review of the June 2025 orders and Medication Administration Record (MAR) showed no orders for COVID testing, and no documented testing. <Resident 9> Review of progress notes showed on 06/22/2025 Resident 9 started feeling crummy late last night, requested cough medicine. A COVID-19 test was done at that time due to symptoms and tested positive. Review of the June 2025 MAR showed there were no PRN (as needed) orders for COVID-19 testing in the event of symptoms. <Resident 10> Review of progress notes showed on 06/22/2025 Resident 10 had a low temp beginning evening shift at 99.2 dF, resident was administered Tylenol and reported feeling tired. According to the note, a COVID-19 test was negative. Review of the June 2025 Treatment Administration Record (TAR) showed there were no PRN orders for COVID-19 testing in the event of symptoms. <Resident 11> On 06/25/2025 at 2:28 PM, Emergency Medical Technicians were observed taking Resident 11 out of the facility. Resident 11's room was posted with Aerosol Contact Precautions (ACPs) and the resident was heard coughing. During an interview on 06/25/2025 at 2:33 PM, Staff L, Licensed Practical Nurse (LPN), stated they tested Resident 11 for COVID-19 three times during the day, with one result that was iffy and two that were negative. Review of Resident 11's electronic health record showed no order for PRN COVID-19 testing. None of the three COVID-19 tests were documented as done. <Resident 12> Review of a 06/24/2025 Nursing Note showed Resident 12 was coughing overnight, the RN (Registered Nurse) swabbed for COVID and the test was positive at 3:10 AM. Review of the MAR/TAR showed no PRN COVID-19 testing orders. <Resident 13> Review of a 06/25/2025 12:20 PM Nursing Note, showed Resident 13 was noted with restlessness, runny nose and coughing, no fever or shortness of breath. COVID-19 test was done and was positive. Review of the June 2025 MAR/TAR showed no PRN COVID-19 testing orders. On 06/25/2025 at 1:43 PM, Staff C, Licensed Practical Nurse (LPN), Infection Preventionist, stated there should be physician orders for COVID-19 testing PRN symptoms and staff would document testing and results on the administration records and/or the progress notes. During an interview on 06/25/2025 at 2:03 PM, Staff D, LPN, Resident Care Manager (RCM), stated if residents showed signs and symptoms of COVID-19, they were tested. If tested, the floor nurse documented the test and results in the progress note or in the PRN COVID testing order. On 06/27/2025 at 2:04 PM, Staff B, Director of Nursing, stated the facility previously had standing orders to conduct COVID-19 testing and they planned to re-implement them. REFERENCE: WAC 388-97-1340 (1)(2)(3) .

Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases, including COVID-19 and other infections for 18 of 32 Residents, (1, 2, 3, 4, 5, 6, 7, 8, 9. 10, 11, 12, 13, 14, 15, 16, 17 & 18) reviewed for infection control. COVID-19 is an infectious disease by a virus causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death. The facility failed to do contact tracing, to identify those who may have been exposed to COVID-19. For those residents (2, 4, 5, 6, 7, 8 & 11) identified as exposed, the facility failed to initiate exposure testing and place those exposed on Transmission Based Precautions (TBPs). The facility failed to conduct broad-based testing when they were unable to identify all exposed contacts. The facility failed to take precautions to prevent potential spread of COVID-19 when they continued concurrent therapy (the treatment of two residents at the same time, who are performing different activities) in the therapy gym, which placed Residents 15, 16, 17 & 13 at risk of contracting COVID-19. The facility failed to implement universal source control on the unit or area for both staff and residents. The facility failed to ensure the staff followed the posted precautions including wearing a fit tested N95 respirator (a filtering facepiece that can filter out at least 95% of airborne particles) and eye protection. Failure of the facility placed residents and staff at risk of illness, isolation and hospitalization. Findings included Review of the facility COVID-19 Precautions and Outbreak Procedure updated 05/17/2024 showed recommendation to staff to visit the Department of Health (DOH) website for the COVID-19 toolkit. Asymptomatic patients with close contact with someone with SARS-CoV-2 infection (the illness caused by COVID-19) should have a series of 3 viral tests for COVID-19. Testing is recommended immediately (but not earlier than 24 hours after the exposure), and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the 2nd negative test. This will typically be at day 1 (where day 0 is day of exposure), day 3 and day 5. If an employee tests positive begin contact tracing, identify all residents and staff members that employee was in contact with in less than 6 feet distance, for greater than 15 minutes (cumulative in 24 hours) in the last 48 hours before symptoms started, or if asymptomatic in the 48 hours prior to positive test results. The April 2024 DOH COVID-19 Preparedness and Outbreak Control Checklist for Long Term Care Facilities Outbreak interventions included identifying asymptomatic residents and/or staff members who had been exposed to COVID-19 and take precautions to prevent potential spread including tested on post exposure day 1, day 3, and day 5 if they had not recovered from COVID-19 infection in the last 30 days. Identify new cases by testing all residents and staff who have been in close contact with a COVID-19 positive individual. If all potential contacts cannot be identified, then broad based testing is recommended (unit wide). Continue re-testing all appropriate residents and staff who previously tested negative every 3-7 days for a minute of 14 days from most recent positive result, or until the Local Health Jurisdiction (LHJ) recommends ending outbreak. Residents who tested positive for COVID-19 should be placed on Aerosol Contact Precautions (ACP) for at least 10 days. Staff entering the resident's room should follow the posted precautions including wearing a N95 respirator, a gown, gloves and eye protection. Ensure all staff members that provide care to residents are fit tested and trained in appropriate N95 respiratory use. Implement universal source control on the unit or area for both staff and residents, source control for healthcare providers can be a NIOSH (National Institute for Occupational Safety and Health) approved N95 respirator or a well-fitting face mask. For N95s to be effective, fit testing and training are needed. Surgical masks may be more appropriate source control for residents <Resident 1> Review of progress notes showed Resident 1 was sent to the Emergency Department on 06/09/2025 with increased confusion, lethargy and abnormal laboratory results. A 06/10/2025 progress note showed the hospital alerted the facility that the resident tested COVID-19 positive at the hospital. The facility obtained orders to place Resident 1 on ACPs upon their return, through 06/20/2025. Review of the facility investigation, June 2025, showed the facility failed to identify that Resident 1's roommate was exposed. On 06/25/2025 at 11:21 AM, Resident 1 was observed self propelling themselves down the [NAME] 1 unit hallway, through doors off the unit and into a common area towards the reception area. Resident 1 was not wearing a mask. During an interview at that time, Resident 1 denied they tested positive for COVID-19, I never had it. I don't know why they keep saying it. <Resident 2> Review of the facility census showed Resident 2 moved into Resident 1's room on 06/06/2025, three days before Resident 1 tested positive for COVID-19. Review of Resident 2's electronic health record (EHR) showed a 06/07/2025 order for a COVID-19 test one time only for Post 7 days admission, which was done as ordered on 06/07/2025 with negative results. When the facility became aware on 06/10/2025 that Resident 1 exposed Resident 2 to COVID-19, they failed to place Resident 2 on documented monitoring, ACPs, or other Transmission Based Precautions (TBPs), or schedule recurrent COVID-19 testing post exposure. Further record review showed a 06/10/2025 order that Resident 2 was cleared to ambulate with SPC (single point cane) without supervision in their room and the west unit every shift. Review of a 06/12/2025 progress note showed Resident 2 ambulated around the facility. <Resident 3> Review of the COVID-19 Reporting Line Listing showed Resident 3 tested positive for COVID-19 on 06/10/2025. Review of Progress Notes showed on 06/10/2025 at 4:54 AM, Resident was administered Tylenol for a fever of 101.9 degrees Fahrenheit (dF). A 06/10/2025 5:59 AM, Nursing Note showed the resident had been coughing all night. Although the positive results were documented, the COVID-19 test was not documented when it was done or by who. Review of the orders and Medication Administration Record (MAR) showed no orders for COVID-19 testing, and no documented testing. Review of physician's orders for June 2025, showed Resident 3 was placed on ACP precautions from 06/10/2025 through 06/21/2025. On 06/25/2025 at 12:14 PM, Resident 3 was in their room, wearing a surgical mask. During an interview at that time, Resident 3 stated they had COVID-19 and it had resolved. <Residents 2, 4, 5, 6, 7, and 8> On June 10, 2025 a letter to the facility residents, family members and responsible parties was written by Staff A, Administrator. The letter was notified them the facility had another resident test positive with COVID-19 and they were symptomatic with common cold symptoms. Presently we have two in-house acquired cases which is considered by the Department of Health to be an outbreak. Operationally, we have implemented universal masking on our [NAME] wing. Our staff wear N-95 masks . Review of the COVID-19 Reporting Line Listing showed on 06/12/2025 Staff F, Nursing Assistant Certified (NAC), tested positive for COVID-19. Review of the facility investigative summary, June 2025, showed that Staff F cared for a resident who had a positive COVID-19 test result on 06/10/2025. The facility investigation identified the resident's who were assigned to Staff F's care on 06/12/2025, (Residents 2, 4, 5, 6, 7 & 8) and obtained orders to monitor for signs and symptoms of COVID-19 due to recent exposure, every shift for five days. The investigation did not include contact tracing to identify other residents and/or staff that may have been exposed in the 48 hours prior to Staff F testing positive. On 06/25/2025 at 10:34 AM Staff C, Licensed Practical Nurse (LPN), Infection Preventionist, stated those (Residents and Staff) who were exposed were tested. When asked, Staff C stated they did not have a surveillance line list, or record of residents or staff who were tested. Staff C stated residents exposed were put on monitoring and should have been put on ACP for 5 days as a precaution. Review of the records of those identified as exposed, showed no TBPs, and no exposure testing were implemented for Residents 2, 4, 5, 6, 7, and 8. During an interview on 06/25/2025 at 2:03 PM, Staff D, LPN, Resident Care Manager (RCM), stated they don't test for COVID-19 unless the resident is symptomatic. <Resident 9> Review of census records showed Resident 9 was admitted into Resident 8's room on 06/12/2025. Review of progress notes showed on 06/22/2025 Resident 9 started feeling crummy late last night, requested cough medicine. A COVID-19 test was done at that time due to symptoms and tested positive. The resident was placed on TBPs and interested parties notified. Review of the 06/23/2025 orders showed the resident was placed on ACP with instructions to staff to use appropriate PPE, including N95. All services provided to be provided in the room, including meals, therapy, activities, and nursing until 07/01/2025. On 06/27/2025 at 10:47 AM Resident 9's room was observed with posted ACP and the door was closed. <Resident 10> Review of census records showed Resident 10 admitted to the west wing on 06/14/2025. Review of the Treatment Administration Record (TAR) showed day 1 post admission COVID-19 Testing was conducted and negative on 06/15/2025, and day 7 post admission on [DATE]. Review of progress notes showed on 06/22/2025 Resident 10 had a low temp beginning evening shift at 99.2 dF, resident was administered Tylenol, and reported feeling tired. According to the note a COVID-19 test was negative. A 06/23/2025 3:33 PM Physician Note showed Resident with a fever and cough, tested positive for COVID-19 just now. Orders for medications and TBP were written. On 06/25/2025 at 11:09 AM, Resident 10's room was observed with posted TBPs. <Resident 11> Review of census records showed Resident 11 was readmitted to the facility into a room with Resident 10 on 06/16/2025. After Resident 10 tested positive for COVID-19, orders were obtained 06/23/2025 to monitor Resident 11 for for signs and symptoms of COVID-19 due to exposure on 06/23/2025. Review of the record showed no TBPs, and no exposure testing was implemented. Resident 11 was moved to a private room on 06/24/2025 at their family's request. On 06/25/2025 Resident 11 was transferred to the hospital at the resident's family's request. On 06/25/2025 at 12:24 PM, Resident 11's room was observed with posted ACPs. The door was closed with an Infection Control cart observed outside the door. <Resident 12> Review of census records showed Resident 12 readmitted to the facility on [DATE]. Review of a 06/24/2025 Nursing Note showed Resident 12 was coughing overnight, the RN (Registered Nurse) swabbed for COVID-19 and the test was positive at 3:10 AM. The resident was placed on TBPs at that time. Orders for posted ACP to start 06/24/2025 until 07/05/2025. On 06/25/2025 at 10:47 AM Resident 12's room was observed with posted ACP and the door was closed. <GROUP THERAPY, Residents 15, 16, 17 & 13> On 06/25/2025 at 10:53 AM, Staff I, Physical Therapy Assistant (PTA) was observed assisting Resident 15, without a mask, from their room, off the unit into a therapy room. Posted on the exit door was a sign directing staff to discard mask prior to leaving the unit. On the other side of the door was a posted Stop sign directing staff to to discard their masks in the garbage can. Staff I did not remove their mask and did not discard the mask in the garbage as directed. On 06/25/2025 at 10:58 AM, Staff I was observed ambulating down the hall and out the unit doors with Resident 16. Again Staff I did not remove and discard their mask. On 06/25/2025 at 11:00 A.M., Resident 17 was observed in the gym. At 11:01 AM, two other therapy staff brought another resident (Resident 13) into the gym, to work on the parallel bars. Resident 13 was not wearing a mask and was observed to cough at 11:06 AM. On 06/25/2025 at 11:05 AM there were four residents (Residents 15, 16, 17 & 13) and four therapy staff observed in the therapy room, at the same time. In an interview on 06/25/2025 at 10:53 AM, Staff I stated they were doing concurrent therapy. Staff I stated they were told by their director and the director of the building that concurrent therapies were still okay, as long as they were different activities. On 06/25/2025 at 1:43 PM, Staff C stated for resident who tested positive for COVID-19 therapy was conducted in their rooms. The therapy gym was dedicated to west side of the building so the facility kept the gym open for non COVID-19 positive residents. <Resident 13> Resident 13 admitted to the facility on [DATE]. The admission day 1 COVID-19 test was negative. On 06/25/2025 at 11:01 AM, two therapy staff were observed assisting Resident 13 to stand up from their wheelchair and walk on the parallel bars in the gym. Neither staff was wearing gowns or gloves. On 06/25/2025 at 11:14 AM, posted outside Resident 13's door was a sign that the resident was on Enhanced Barrier Precautions (EBP). Review of the sign showed staff were directed do wear gloves and gowns for high-contact resident care activities, including transfers. There was no Infection Control Cart with Personal Protective Equipment (PPE - gowns, gloves, masks, etc.) in the immediate area within reach of staff. At 11:15 AM, Resident 13 was brought back to their room by a therapy staff. The staff positioned Resident 13 in their wheelchair with a pillow from the resident's bed, clipped the call light to the resident, rearranged the linen on the bed, moved the bedside table, and turned on the television, all without gloves or a gown. Prior to exiting the room, the staff washed their hands in the sink, turned off the water without a barrier, and then dried their hands. Review of a 06/25/2025 12:20 PM Nursing Note, showed Resident 13 was noted with restlessness, runny nose and coughing, no fever or shortness of breath. COVID-19 test was done and was positive. Resident was immediately placed on TBPs. <Resident 14> Record review showed Resident 14 admitted to the facility on [DATE] with diagnoses including COVID pneumonia. On the day 1 post admission COVID-19 Testing scheduled for 06/07/2025, Resident 14 tested positive. According to the progress notes, the facility placed the resident on ACP starting 06/07/2025, but review of the Physician Orders showed a start date of 06/09/2025. On the day 7 post admission COVID-19 testing, Resident 14 tested negative, and the facility discontinued TBPs. On 06/25/2025 at 10:50 AM, Staff G, NAC, entered Resident 14's room which was located on the dedicated COVID-19 unit without a N95 or wearing any mask. <Resident 15> On 06/25/2025 at 12:21 PM, Resident 15 was observed seated in the hallway, without a mask, next to the nurses medication cart. Staff had served the resident their lunch meal and prepared them to eat in the hallway. <Resident 18> Review of a 06/19/2025 Nursing Notes showed Resident 18 was up in wheelchair out in the hall working with therapies. Similar notes on 06/20/2025. Resident continued working with therapies on 06/22/2025, 06/23/2025, and 06/24/2025. Review of a 06/26/2025 Physician Note showed Resident 18 was one among other residents tested positive for COVID-19 in the building today., Resident 18 claimed they started having some cough three days ago . On 06/25/2025 at 10:47 AM, three staff were observed in the unit's activity room seated at a table. The staff were holding masks in their hands, not wearing masks. During an interview on 06/25/2025 at 1:59 PM, Staff C stated they were holding Orientation in the Activity Room. Staff C stated they noted the staff were not wearing masks and they corrected them. On 06/25/2025 at 10:51 AM, Staff H, Registered Nurse, was observed wearing a KN95 (respirator not approved for use in healthcare settings). On 06/25/2025 at 1:43 PM, Staff C, stated they checked the daily staffing on the unit to ensure they were fit tested. Staff C stated Staff H was up to date with their fit testing. Review of the paperwork showed Staff H was fit tested on [DATE]. When informed Staff H was not wearing the N95 they were fit tested for, Staff C stated they would take care of that. On 06/25/2025 at 2:16 PM, Staff H, was observed wearing a N95, but not the one they were fit tested for. On 06/25/2025 at 1:43 PM, Staff C stated staff on the unit were expected to wear a N95 when they entered and exited the unit. Staff were also expected to replace their N95 respirators when they entered and exited COVID-19 positive rooms (on posted ACPs). Staff C stated when the outbreak started broad based testing on the unit should have been performed on days one, three and five. On 06/25/2025 at 2:16 PM, Staff J, NAC, was observed sitting at the nurses station wearing a KN95. On 06/25/2025 at 2:18 PM, Staff K, RN, was observed at the medication cart with Staff H. Staff K was wearing only a surgical mask. In an interview at that time, Staff K stated they just walked onto the unit and found out they needed a N95. Staff K stated they entered the unit from an outside door in the activity room. On 06/25/2025 at 2:22 PM, the door from the unit activity room to the outside was observed in the company of Staff D. The door had a key pad for a code to enter and exit. The door opened and an alarm sounded when Staff D entered the building. There was no sign posted informing staff that they were entering a COVID-19 unit and/or that they would need to put on Personal Protective Equipment (PPE) prior to entering. On 06/25/2025 at 2:33 PM, Staff L, LPN, was observed wearing a N95, but not the one they were fit tested for. When questioned, Staff L stated they would change it and left the unit looking for a different N95. On 06/25/2025 at 2:46 PM, Staff B, Director of Nursing stated they facility would start monitoring and training all staff immediately. REFERENCE: WAC 388-97-1320 (1)(a), (2)(b). .

Based on observation, interview and record review, the facility failed to provide the required care planned supervision to prevent accidents/falls for 3 of 4 sample residents (Resident 1, 3 & 4) reviewed for two person assists with transfers. This failure placed residents at risk for falls, injury and a diminished quality of life. Findings included . Review of the facility Mechanical Lift Re-training dated 03/07/2025 showed Utilization of a Mechanical Lift to transfer dependent residents from one surface to another surface (Bed to wheelchair to bed, bed to shower chair, etc.) is a common occurrence in healthcare settings. It is never acceptable to use a lift with only one staff member. When using a lift, there must always be two staff members present to perform a mechanical lift transfer. This ensures safety during a resident transfer. <Resident 1> Review of the Annual Minimum Data Set (MDS), an assessment tool, dated 03/03/2025, showed Resident 1 was assessed as alert, oriented, and dependent on staff for transfers. Review of the ADL Self-care performance deficit and/or limited physical mobility Care Plan (CP), initiated 12/16/2023, showed Resident 1 required max assist by two staff transfers with Hoyer lift (a mechanical transfer assist device). Review of the facility incident reporting log showed on 03/07/2025 at 10:50 AM, Resident 1 was involved in an equipment related incident and sustained a superficial laceration. Review of the facility investigation showed during transfer from bed to shower chair, the mechanical lift leg got caught under the bed. As the staff pulled the resident toward the shower chair, the lift tipped toward the shower chair and the shower chair tipped rearward as well. The staff supported the resident for a controlled fall to the ground. In the process, the overhead bar struck the resident in the head causing a 2 centimeter (cm) by 2 cm wound. The facility investigation confirmed the staff was aware that all mechanical lift transfers were to be performed by two people, and they still transferred the resident without assistance. Review of the After Visit Summary from the emergency room , dated 03/07/2025, showed the resident was diagnosed with a small laceration on their forehead which was repaired with dermabond (a liquid skin adhesive that holds wound edges together). During an interview on 03/19/2025 at 10:50 AM, Resident 1 stated that a staff member transferred them in the Hoyer by themselves and then they were on the floor with the Hoyer on top of them. Resident 1 stated they hit their head on the floor, which was very scary. <Resident 3> Review of the Quarterly MDS, dated [DATE], showed Resident 3 was with moderate cognitive impairment, and dependent on staff for transfers. Review of the ADL self-care performance deficit CP, revised 11/24/2023, showed Resident 3 was dependent with two person mechanical Hoyer for all transfers. During an interview on 03/19/2025 at 11:13 AM, Resident 3 stated the staff did not consistently transfer them with two staff persons. Resident 3 stated they had been hit in the nose, twice, within the last year, but had not sustained severe injuries. <Resident 4> Review of the 02/03/2025 Quarterly MDS showed Resident 4 was with cognitively intact, and dependent on staff for transfers. Review of the ADL self-care performance deficit CP, initiated 01/28/2025, showed Resident 4 required two person assist with transfers using Hoyer. During an interview on 03/19/2025 at 11:21 AM, Resident 4 stated the staff did not consistently use two people when they transferred them with the Hoyer. Resident 4 stated they had been hit in the head a couple of times, they were not injured so they did not report it. During an interview on 03/19/2025 at 1:06 PM, Staff A, Administrator, stated they would provide additional staff training and supervision. REFERENCE: WAC 388-97-1060(3)(g).

Based on observation, interview, and record review, the facility failed to provide the necessary supervision to prevent falls with injury when 1 of 5 residents (Resident 1) reviewed for accidents and supervision exhibited increased wandering and verbalized wanting to leave the facility. This failure resulted in harm when the resident fell in an unsupervised area of the facility and sustained a head injury that required a transfer to the hospital and suturing (stitching) of the injury. Findings included . Review of the facility's policy and procedure titled, Accidents and Incidents, dated 11/01/2017, showed that the facility was to assure residents were kept safe while allowing them to be at their highest practicable level of care. Review of Resident 1's progress note, dated 05/18/2023 at 1:48 PM, showed Resident 1 admitted on [DATE] with diagnoses to include closed head injury from a fall, dementia, stroke, and atrial fibrillation (abnormal heart rhythm) that required use of an anticoagulant (blood-thinner) medication. Review of Resident 1's care plan initiated 05/18/2023, showed Resident 1 exhibited self-care performance deficit that required one-person assistance with activities of daily living (ADLs). The care plan identified Resident 1 as a risk for falls related to the resident's cognitive loss, decreased safety awareness, gait and balance problems and history of falls. Also addressed in Resident 1's care plan was the use of anticoagulation therapy (medications that increase bleeding). Interventions included taking precautions to avoid falls, avoiding activities that could result in injury, and monitoring the resident for signs and symptoms of bleeding. Review of the facility's incident reporting log for June 2023 showed Resident 1 fell and sustained an injury on 06/05/2023 at 7:10 PM in the facility's courtyard. Review of the facility's incident investigation report, dated 06/05/2023, showed that around 7:10 PM staff noticed Resident 1 missing from their room. Facility staff conducted a search and found the resident in the courtyard lying on the left side with the wheelchair directly behind the resident. Staff noted that the resident was bleeding from a left eyebrow laceration (cut) approximately 1 centimeter (cm) to 1.5 cm in size. In an interview on 06/13/2023 at 2:13 PM, Collateral Contact (CC) stated that Resident 1 wandered through an unsecured door and fell on the concrete sustaining injury to the head that required to be sutured. According to CC, for the resident to be able to get into the courtyard, the resident had to go past the nurses' station. CC stated that Resident 1 needed close monitoring for being a high risk for falls and being on an anticoagulant medication and the facility failed to watch the resident. An observation on 06/15/2023 at 12:35 PM showed there were five doors that led to the facility's courtyard. Three of the doors were secured with alarms. One door that was unsecured could be accessed from the activity room and the other unsecured door could be accessed from the [NAME] Wing dining room located right across the [NAME] Wing nurses' station and Resident 1's room. In an interview on 06/15/2023 at 12:45 PM, Staff E, Resident Care Manager (RCM), stated that on the day of the fall they overheard the nursing aides talking about Resident 1 missing from their room. Staff E stated that, together with other staff, they went to look for the resident and found the resident down in the courtyard. In an interview on 06/15/2023 at 2:19 PM, Staff C, Licensed Practical Nurse (LPN), stated that on 06/05/2023 they were returning from break at approximately 7:10 PM when the nursing aide notified them that Resident 1 was missing from their room. Staff conducted a search in the building and one of the nurses found the resident in the courtyard lying on the ground and bleeding from a laceration on the eyebrow. According to Staff C, they assessed the resident and provided first aid to stop the bleeding. In an interview on 06/15/2023 at 3:04 PM, Staff D, Nursing Assistant Certified (NAC), stated that on 06/05/2023 earlier that afternoon, Resident 1 exhibited increased wandering behavior that led to staff closing the double doors of the [NAME] Hall to prevent the resident from wandering out towards the front main entrance. According to Staff D, Resident 1 kept verbalizing they wanted to go home and expressed finding the means to get out of the facility. Staff D stated that they repeatedly redirected and brought the resident back to the room. According to Staff D, they left the resident in the room sitting in the wheelchair and proceeded to help the other nursing aide provide care to another resident. Staff D further stated that as soon as they finished providing care to the other resident, they checked Resident 1 and found the resident missing from their room. Review of the witness statement obtained from Staff F, NAC, dated 06/05/2023, showed that on 06/05/2023 Resident 1 was very upset that day and tried several times to leave the building. According to the statement, Staff D and F were giving care to another resident, when Resident 1 left their room again and went out to the courtyard. Review of Resident 1's hospital records, dated 06/05/2023, showed that Resident 1 presented to the emergency department with a left eyebrow laceration actively bleeding after a ground-level fall onto concrete that was unwitnessed. Resident 1 had a left eyebrow hematoma (injury caused blood to pool under skin) and the laceration was sutured in the emergency room . According to the hospital records, the hospital obtained computed tomography (CT, a diagnostic imaging procedure) scan of the Resident 1's head and cervical spine and admitted the resident for further observation. In an interview on 06/29/2023 at 11:50 AM, Staff A, Administrator, stated that as much as the facility wanted the residents to freely move around in the facility, the expectation was to keep the doors to the courtyard secure and provide the necessary supervision for residents that go to the courtyard. Reference WAC 388-97-1060(3)(g)

Based on observation, interview and record review, the facility failed to ensure each resident received enough supervision to prevent accidents for one of five residents reviewed (#1). The failed practice caused Resident #1 to fall from bed and sustain injuries, thus causing harm. Findings included . Observations on 03/27/18 at 2:50 PM showed Resident #1 in bed. Resident #1 had protective sleeves on both arms from her hands to elbows. Further observations showed Resident #1's left arm was bruised from the elbow to her shoulder with a bandage on her shoulder. Additionally, Resident #1's left temporal area had bruising and a skin abrasion. During an interview on 03/27/18 at 2:50 PM, Resident #1 stated a staff member was standing next to her bed providing care and rolled her to the opposite side of the bed. Resident #1 stated when the staff member rolled her she fell off the other side of the bed, landing on the floor. Resident #1 stated she had pain after the fall, and she is now scared when staff roll her onto that side of the bed. Review of Resident #1's In Room Care Plan, dated 01/10/18 showed she had been identified as being at high risk for falls and that she required extensive assistance from two staff with bed mobility and toileting. Review of a facility incident investigation dated 03/19/18 showed at 9:00 PM, Staff C, Nursing Assistant Certified, NAC, was providing peri care to Resident #1 and rolled her onto her right side. While Resident #1 was on her right side she fell off the right side of the bed. The investigation indicated the bed was at waist height. Additionally the investigation showed the following injuries; *A red abrasion measuring 5 centimeters (cm) long by 0.5 cm wide on her left temple *A skin tear measuring 7 cm long by 2 cm wide on her left biceps *A bruise measuring 10 cm long by 8 cm wide on her left upper arm *A hematoma measuring 2.5 cm long by 0.5 cm wide on her left forearm The investigation showed Staff C, NAC, was the only staff member present at the time of the fall. During an interview on 03/27/18 at 2:45 PM, Staff B, Director of Nursing, DNS, confirmed Resident #1 was care planned to have two staff present while providing peri care and repositioning in bed. Staff B, DNS, further confirmed Staff C, did not request assistance from a second staff member prior to providing care. Failure to have two staff present, one on each side of the bed, as directed in the care plan, resulted in Resident #1 falling from one side of the bed and causing injuries to her face and arm. WAC 388-97-1060(3)(g) .

Based on observation, interview and record review, it was determined the facility failed to consistently and accurately document resident clinical condition, define and implement interventions consistently, recognize standards of practice, monitor and evaluate the impact of interventions and/or revise interventions appropriately to provide timely necessary treatment and services to ensure that a resident without a pressure ulcer did not develop one, and to promote healing when a pressure ulcer did develop in 1 of 3 residents (#17) reviewed for pressure ulcers. This failure resulted in the development of a painful, ongoing Stage 3 pressure ulcer causing physical and psychosocial harm to the resident. Findings include: Facility Policy and Procedure for Skin Breakdown indicated residents at risk of skin breakdown would receive weekly full body skin assessments by a licensed nurse using the Admission/Weekly Skin Observation Tool. Upon discovery of a pressure ulcer, licensed nursing staff were to do the following: 1) describe the pressure ulcer on the body outline, including color, size and pain; 2) notify the physician, obtain a treatment order and document treatments on the Treatment Administration Record; 3) document the pressure ulcer on the Skin Grid for Pressure Ulcers and continue to document weekly; 4) identify interventions to promote skin healing/resolution of skin impairment; 5) implement interventions and document on the resident's care plan; 6) document all previous actions in progress notes; 7) conduct weekly rounds to evaluate the pressure ulcer, plan of care, the resident's compliance with plan of care, and review with the resident the risks and benefits of non-compliance with plan of care; 8) when non-compliance occurs, complete a Deviation of Care Form; and 8) update the resident's care plan to include noncompliance with the treatment plan. The facility tool for weekly monitoring and documentation of pressure ulcers, "Skin Grid for Pressure (and other) Ulcers," defined staging of pressure ulcers as follows: Stage 1: reddened areas of tissue that do not turn white or pale (in light skinned people such as Resident #17) when firmly pressed. Stage 2: partial thickness skin loss presenting as a shallow open ulcer with a pink-red wound bed, without slough (dead tissue: yellow, tan, gray, green or brown). Stage 3: full thickness skin loss. Bone, tendon, muscle not exposed. Slough may be present but does not obscure depth of tissue loss. May include tunneling. Stage 4: full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (tan, brown, or black covering) may be present on some parts of the wound bed. Often includes tunneling. Resident #17 was originally admitted to the facility from the hospital with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE], indicated Resident #17 was alert, oriented and able to make needs known. The resident was non-ambulatory, used a wheelchair for locomotion and required extensive assistance of 2 persons with bed mobility and transfers. The MDS indicated the resident was at risk of developing pressure ulcers but did not currently have any pressure ulcers. The progress note, dated 9/11/13, documented "two open areas" on Resident #17's "left buttock, with some dark red area around open areas." There was no indication of any intervention or action taken in response to the open areas on the resident's "left buttock" until 9/24/13. A progress note, dated 9/24/13, documented a facsimile was sent to Resident #17's physician requesting an "air bed to prevent skin breakdown, awaiting response." The progress note, dated 9/25/13, indicated Resident #17's physician was called on 9/24/13 requesting "treatment on Stage 2 coccyx. ... Awaiting call back from MD, also processed order for air mattress." The next documentation related to the condition of Resident #17's skin in the coccyx/sacral/buttock area was an assessment on 9/28/13, when the resident returned from the hospital. The resident was sent to the hospital for a minor procedure on 9/26 and returned on 9/28/13. Resident #17's "Admission and Weekly Skin Observation Tool (AWSOT)," dated 9/28/13, documented a red, blanchable area over the left sacrum, measuring 3 x 3 cm. In contradiction to the AWSOT, Resident #17's "Skin Condition Sheet," dated 9/28/13, indicated a 3 x 3 centimeter (cm) Stage 2 "pressure sore" over the left sacrum. Resident #17's physician's orders [REDACTED]. Documentation for Resident #17's left sacral pressure ulcer on the weekly Skin Grid for Pressure Ulcers (SGPU) reflected the following: Spaces for indicating the date the ulcer was first identified and whether or not the ulcer was present on admission were left blank. The earliest documentation on the SGPU was on 10/2/13, indicating the ulcer was identified as Stage 3, measuring 2 x 3 centimeters (cm) and 0.05 cm deep. The resident was not experiencing pain from the ulcer. On 10/16/13: Stage 2, measuring 1.8 x 1.5 cm and 0.05 cm deep. The resident was not experiencing pain from the ulcer. On 10/24/13: Stage 2, measuring 1.5 x 1.5 cm and 0.1 cm deep with 25% slough. The resident was experiencing pain from the ulcer. On 10/31/13: Stage 3, measuring 3.0 x 2.0 cm and 0.1 cm deep. The resident was experiencing pain from the ulcer. On 11/6 and 11/13/13 the ulcer remained at Stage 3 and the resident continued to experience pain from the ulcer. On 11/20/13, after the surveyor began asking about the resident's pain related to the ulcer, the SGPU documented the wound was Stage 3, measuring 1.8 x 1.6 cm and 0.2 cm deep. The space for documenting pain was left blank even though the resident reported pain during the dressing change observed by the surveyor that day. On 11/22/13: Stage 3, measuring 2.0 x 1.5 cm and 0.1 cm deep, 80% pink/red with 20% thin yellow slough. The resident was not experiencing pain from the ulcer. The physician was notified of changes. Until the SGPU dated 11/22/13, no documentation was found to reflect that the physician was notified of changes in the ulcer condition: that the ulcer had advanced from Stage 2 to Stage 3. Resident #17's Comprehensive Care Plan, dated 8/30/13, identified the resident at high risk for pressure ulcers. Interventiions included "Use cushion for pressure reduction when resident is in chair." On 9/26/13, the Comprehensive Care Plan identified a "pressure ulcer on coccyx," 15 days after 2 open areas were noted on the resident's "left buttock" on 9/11/13. Interventions for the ulcer included an "air bed for pressure reduction" and "cushion for pressure reduction when resident is in chair." The care plan did not include to reposition the resident every 2 hours. Resident #17's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident received Tylenol 650 mg for pain on November 3, 6, 10, 16, 21, and 22. The Restorative Nursing Assessment and Referral (RNAR), dated 10/2/13, documented Resident #17 received Occupational Therapy (OT) and Physical Therapy (PT), reached his/her maximum potential and was referred for restorative nursing services for upper and lower extremity range of motion (ROM) exercises to "prevent losses." The referral stated Resident #17 required use of a Hoyer (hydraulic lifting device) with assistance of 2 persons for all transfers and used a wheelchair for locomotion. Additional PT services were initiated for Resident #17 on 10/8/13 for stand and pivot transfers. The PT Discharge Summary, dated 10/30/13, indicated the resident was discharged from PT on 10/29/13 because s/he was unable to progress with transfers, requiring 90-100% maximum assistance. During this period, restorative nursing provided services only for upper extremity ROM. The RNAR, dated 11/6/13, indicated PT had again referred Resident #17 for restorative nursing services for both upper and lower extremity ROM. The RNAR again stated the resident required use of a Hoyer with assistance of 2 persons for all transfers. Progress notes indicated a Hoyer lift was consistently used for transfers with Resident #17. Beginning on 10/30/13, Resident #17's progress notes indicated the resident was refusing to lie down between meals in order to relieve pressure on the sacral ulcer, instead remaining in his/her wheelchair from breakfast until going to bed sometime after dinner. Resident #17's Comprehensive Care Plan did not address transfers, use of a Hoyer lift, or the resident's noncompliance with repositioning every 2 hours. Each day of the survey, 11/17 through 11/23/13, Resident #17 was observed spending the entire period between breakfast and dinner sitting in his/her wheelchair. Each observation revealed the resident was sitting on the nylon sling used with the Hoyer lift. On 11/20/13 at 3:04 p.m., Staff Y stated Resident #17 usually got out of bed at 7:30 a.m. and preferred to spend the entire day in his/her wheelchair, declining to go back to bed until after dinner. Staff Y said s/he tried to convince the resident to spend time each day repositioned in bed so as to take pressure off the left sacral ulcer but the resident refused, choosing to spend the entire day in the wheelchair. Staff Y said the resident "hates to go in and out of bed because he hates the Hoyer lift." On 11/21/13 at 7:30 a.m., Resident #17 was observed lying in bed, on a motorized air mattress with alternating cycles and pressure settings. The resident was lying on a Hoyer sling, leaning slightly to the left. Staff Y agreed with the surveyor that it appeared that the thick nylon webbing edges of the Hoyer sling, which were crisscrossed under the resident's pelvis, appeared to press against the area where the pressure ulcer was located. The resident yelled out loudly to Staff Y to hurry and get him/her up because the resident's "bottom hurts." Staff Y stated s/he gave the resident Tylenol for the pain a half hour earlier and said Tylenol did not effectively treat the resident's pain. During the dressing change, the ulcer on Resident #17's left sacrum was observed to be red/pink with yellow/white slough, measuring approximately 2 x 1.5 cm. Staff Y said the amount of slough had increased over the past 3 weeks. When asked if s/he would spend time during the day out of the wheelchair, lying in bed to keep pressure off his/her "sore bottom," the resident said, "No, because of that thing they use (the Hoyer). It drives me nuts; I can't stand it." The resident said it was hard to explain why s/he hated the Hoyer so much and said, "There's something about it I can't stand. It's mostly the hook-up part." The resident said s/he wished PT had not terminated services to work on stand/pivot transfers. Staff Y said, "I think if (the resident) was able to transfer without the Hoyer (s/he) would agree to spend time in bed during the day. But (s/he) won't do it because of the Hoyer." As Resident #17 was transferred from bed to wheelchair with the Hoyer lift, the resident was observed to appear tense, grimacing and silent as staff hooked the sling to the lift, raised the resident off the bed in a horizontal position, and swung the resident away from the bed. Then, after the resident was adjusted in the sling to a sitting/upright position, the resident said, "See, now this part is okay." On 11/22/13 at 9:43 a.m., Staff K, the Charge Nurse, said Resident #17's sacral ulcer was not healing because the resident refused to spend time in bed during the day to take pressure off the ulcer. Staff K said s/he was not aware the resident had an aversion to the Hoyer lift "until yesterday." Staff K said, "Yesterday, Staff Y told me (Resident #17) told you s/he hated the Hoyer lift. If I had known this sooner, I would have asked PT to assess the resident for transfer methods." Staff K said yesterday Resident #17 self-propelled in the wheelchair to the therapy room and asked PT to evaluate the resident for transfers. PT evaluated the resident and wrote a communication to nursing saying Resident #17 could now use a sit to stand lift device instead of the Hoyer. The "Communication to Nursing on Ambulation/Transfer Level," written by PT staff, dated 11/21/13, indicated Resident #17 demonstrated an ability to tolerate a "sit to stand" lift for transfers and requested nursing to modify the plan of care accordingly. At 10:11 a.m., Staff C, the Resident Care Manager (RCM), said Resident #17 had been non-weight bearing and required a Hoyer lift for transfers throughout the resident's entire stay at the facility. Staff C said after 10/25/13, when the resident was informed s/he would not be able to discharge to a more independent setting, the resident became depressed, less compliant with the plan of care and more resistant to spending time in bed during the day to relieve pressure on the sacral ulcer. Staff C said Resident #17 told Staff C the resident did not want to use the Hoyer lift and Staff C did not explore the reason why with the resident. Staff C said s/he assumed it was because the resident wanted to be able to do standing transfers, to be more independent. No one told Staff C it was because the resident hated the Hoyer itself. Staff C said staff should have informed Staff C the resident hated the Hoyer. Staff C said when the resident refused to go to bed during the day to relieve pressure from the sacral ulcer, Staff C should have asked the resident the reason for the refusal and explored alternative interventions. Staff C said, "(Resident #17) did tell me (s/he) didn't want the Hoyer. I didn't explore that with (the resident)." Staff C said s/he never observed Resident #17 during a transfer in the Hoyer lift. When asked if Resident #17 had a pressure relieving device on the seat of his/her wheelchair, Staff C said, "No, (s/he) should have one, but I think it's just a regular cushion." At 11:55 a.m., Staff JJ, a physical therapist, said s/he worked with Resident #17 previously and was not able to advance the resident functionally. Staff JJ said once PT has discharged a resident, it was up to nursing to determine when a reassessment is needed and make a referral. Staff JJ said, "(Resident #17) came in yesterday and asked about getting back on therapy. I noticed a Hoyer sling on the wheelchair. I asked (the resident) to stand and (s/he) stood, had the range of motion and strength to stand. I thought adding a standing frame activity to the resident's restorative nursing regimen might help increase or maintain strength. If (Resident #17) improves with that, I would like to pick (him/her) up for more functional rehab. But just standing/sitting is not skilled. Transfers can be worked on through restorative nursing." At 1:50 p.m., Staff HH, a restorative nursing assistant, said Resident #17 received restorative nursing for ROM 6 days per week. Staff HH said the resident actively participated and "always looks forward to it." Staff HH said s/he always worked with Resident #17 in the wheelchair, "never in bed because (s/he) is always in the wheelchair." Licensed staff documented on Resident #17's Treatment Flowsheet for November 2013 that the resident was consistently repositioned every 2 hours each day. At 2:05 p.m., when presented with documentation on the Treatment Flowsheet indicating Resident #17 was being repositioned every 2 hours, Staff Y stated it was not accurate. Staff Y said the resident was only repositioned while in bed and usually spent nearly the entire day in the wheelchair. When asked if s/he had ever instructed Resident #17 to shift position while in the wheelchair, Staff Y said, "No, but I guess I could try that." On 11/23/13 at 3:34 p.m., Staff E and Staff KK, both licensed nurses, were asked what was meant by instructions on Resident 17's Treatment Flowsheet to "monitor air mattress." Both agreed it meant to make sure the air mattress was turned on and functioning properly. Neither was able to identify how to determine if the pressure and cycle settings were correct or if there were any specific instructions for pressure and cycle settings. At 3:43 p.m., the surveyor asked Staff LL, a physical therapist, if the cushion on Resident #17's wheelchair had functional pressure relieving properties. The surveyor observed as Staff LL and the physical therapy aide assisted Resident #17 to a standing position at the parallel bars in order to remove the cushion from the wheelchair. The resident appeared to tolerate this well, bearing weight with assistance at the parallel bars for about 20 seconds. Staff LL removed the outer casing from the cushion to reveal a yellow, foam pad with a thin blue plastic pad lying on top of the foam. The plastic pad was completely flat, about 1/4 to 1/3 inch thick. Staff LL said it was a gel cushion but looked "nearly empty" of gel. Staff LL said, "It's too flat. It needs more gel. You can tell it has disintegrated. (Resident #17) needs a pad with more gel but the facility has a limited supply. This one, the gel is depleted or evaporated or something and has no pressure reducing function. We need one with a good gel cushion. This doesn't have that." At 3:57 p.m., Staff Q, the Restorative Nursing Manager, said today s/he received a rehab recommendation for Resident #17 to work with a sit to stand lift for 30 seconds to one minute in 3 to 5 minute intervals. Staff Q said s/he would conduct an evaluation, write orders and develop a plan for the resident on 11/25/13. At 4:29 p.m., Staff B said when residents were receiving PT services, it was up to PT staff to monitor wheelchair cushions to assure they had functional pressure relieving properties, and when residents were not receiving rehab services, it was up to the Resident Care Managers. The facility failed to provide care and services necessary to prevent the sacral pressure ulcer from developing when Resident #17 was assessed to have high risk for pressure ulcers, yet no weekly skin assessments were conducted and a functional pressure reducing device was not placed in the resident's wheelchair. The facility failed to provide care and services to promote healing in the sacral pressure ulcer when the first evidence of skin breakdown was not timely reported to the physician, interventions were delayed, monitoring and documentation was inconsistent, the physician was not timely notified of changes in the ulcer and alternative interventions were not explored when the resident was unwilling to transfer using the Hoyer lift. These failures caused physical and psychosocial harm to Resident #17. Refer to F155.

Based on observation, interview and record review the facility failed to provide the necessary care and services to identify, implement and ensure timely treatment was provided for 1 of 1 sampled resident (#43) reviewed for hospice services. This failure resulted in actual harm when Resident #43 had delayed treatment for [REDACTED]. The facility also failed to correlate assessment findings as end of life changes that required a more thorough assessment to address the resident's physical, mental and psychosocial needs for 1 of 1 sampled resident (#82) reviewed for care and services related to death issues. Failure to correlate assessment findings with end of life for Resident #82 resulted in unmet physical, mental and psychosocial needs. Findings include: RESIDENT #43 Resident #43 had resided in the facility for 8 months with multiple medically disabling conditions including a dysfunctional bladder that required an indwelling Foley catheter (a tube inserted through the urethral opening into the bladder). Resident #43 started hospice services in January 2013. A Minimum Data Set (MDS-an assessment tool) dated 1/08/13, documented the resident had a Brief Interview of Mental Status (BIMS) score 15 of 15 indicating he had no cognitive impairments. He was listed as being able to understand conversation, he had clear speech and staff had no difficulty understanding him. Resident #43's care plan dated 1/20/13, documented the resident had a urinary tract infection. The resident's catheter care plan documented he was to receive cath (catheter) care each shift and as needed by staff. On 1/30/13 at 2:50 p.m., LN C stated Resident #43 did all of his daily catheter care except to empty the urine bag. Refer to F-tag 272. A mental health consultation dated 12/20/12, documented Resident #43 had clear cognition with significant medical issues, suffering from anxiety and depression due to his significant loss of independence. On 1/10/13 Resident #43's chart documented the facility received an order to obtain a urinalysis after the resident complained of urinary tract pain. A chart note dated and timed 1/11/13 at 5:00 a.m., documented Resident #43, "refused to have Foley changed to obtain UA (urinalysis). Resident #43 requested pain medication for pain in his back and legs on a scale of 10 (highest level of pain) ... possibly related to urinary." The UA was not obtained until 1/15/13 when the resident had his scheduled catheter change for the month. On 1/17/13 a lab report documented Resident #43 had a bladder infection. An antibiotic was started on 1/18/13, nine days after the initial order to obtain a urine sample was received by the facility to treat the infection. On 1/30/13 at 2:00 p.m., Resident #43 was observed in his bed. He was alert and able to complete an interview regarding his care. Resident #43's catheter and port for collecting a urine sample were observed. Resident #43 said on 1/11/13 around 4:00 a.m., a licensed nurse came to his room and said she was going to change his Foley catheter because she had to get a urine sample. Resident #43 said he told the nurse he was in pain after being awakened, he needed pain medication and to sleep. He was not going to have his Foley changed at 4:00 a.m. Resident #43 stated he did not know why the nurse insisted on changing the entire catheter. The resident demonstrated the location of the port and said staff could have cleansed the port with an alcohol wipe and aspirated a sample of urine. Resident #43 said he purchased his own brand of catheter bags and equipment he had used at home to provide his own care for years. Resident #43 said he did his own catheter care in the facility with aseptic technique. Resident #43 said his pain medication was increased when he had symptoms of a bladder infection. He also reported he felt anxious when the nurse told him his physician had ordered the Foley to be changed for a urine sample. It was an invasive procedure and he was already on a schedule to have the catheter changed once a month not during the middle of the night. Resident #43 stated he never refused to have a urinalysis, rather, he refused to have his entire catheter changed at 4:00 a.m. On 1/30/13 at 1:30 p.m., Licensed Nurse A (LN A, the unit manager) said she had been told Resident #43 had refused to allow the nurse to get the UA on 1/11/13. LN A said she had not spoken to Resident #43 directly nor talked with the night nurse who reported the resident's alleged refusal. There was no plan in place to address getting the urine sample for another 5 days. On 1/30/13 at 1:40 p.m., LN B said she was she was aware Resident #43 "refused" to have the catheter changed on 1/11/13. LN B said she notified the resident's physician but she had not documented her call. LN B said she had also discussed the matter with the contracted hospice nurse but had not documented the information. LN B said there was no other plan or option to get the UA except to wait until 1/15/13 when Resident #43 had his scheduled catheter change. On 1/30/13 at 1:45 p.m., the hospice nurse said the resident was known to "pull apart" his catheter tubing and "might not trust it would be clean". The hospice nurse had no other options to obtain the UA except to wait another 5 days for the scheduled catheter change. During further interview with LN B She reprted she had never observed or noted Resident #43 pulling apart or handling his catheter to cause contamination. The DNS said she did not know why staff would insist on changing the entire catheter to get a urine sample. The DNS said nursing staff were to refer to the facility Lippincott Manual of Nursing Practice for guidance in getting a urine sample for residents with catheters other than changing the entire catheter. The Manual documented staff were to, "Clamp the drainage tubing below the aspiration port for a few minutes to allow urine to collect, cleanse the aspiration port with 70% alcohol and insert a sterile needle to obtain the urine..." Record review of a current physician order [REDACTED]." There was no order from the physician, directing staff to obtain a UA by changing the entire catheter. Record review of physician orders [REDACTED]. According to Medication Administrator Records (MARs) dated between 1/11/13 and 1/15/13, Resident #43 requested and received 23 doses of the pain medication during the time he was waiting for the UA to be obtained. From 1/20/13 to 1/24/13 his requests for the same pain medication was reduced to 13 doses after he received treatment for [REDACTED]. The facility further failed to assess or implement a plan regarding the resident's ability to do self-catheter care to ensure he was able to complete this care without complications or risk of infection. The facility failed to obtain a physician ordered urine sample for 6 days when Resident #43 had pain and discomfort from a bladder infection that required antibiotic therapy. RESIDENT #82 Resident #82 admitted on [DATE] with multiple [DIAGNOSES REDACTED]. The resident had a physician's orders [REDACTED]. According to the records the resident was bedridden at home for 4-5 months and had deteriorated a couple of weeks prior to going to the emergency room . After the residents hospital stay, s/he admitted to the nursing home for skilled physical therapy, occupational therapy and speech therapy. The plan was for the resident to discharge home with spouse and son after the nursing home stay. Record review revealed that on the dates of 12-22-12 through 12-24-12 the resident had blood pressures between 98/50 and 98/60. A nursing note dated 12-23-12 with a time of 10:00 p.m., documented the resident to be combative with staff during a.m. care. Further review of the record revealed a nurse's note dated 12-25-12 with a time of 3:30 a.m., documented that the resident had diminished lung sounds at the bases and a nurse note dated 12-15-12 at 8:00 p.m. documented that the residents lung sounds were clear. A nurses note dated 12-25-12 with a time of 2:00 p.m., documented that the resident had diminished lung sounds at the bases with slight lower lobe crackles and was agitated, anxious, and moaning. A nurse note dated and timed for 12-28-12 at 4:30 p.m., documented that a care conference was held with the family. The note documented that the resident had a decline in condition, and would be comfort care. Record review revealed that the resident passed away on 12-29-12. In an interview on 1-3-13 at 9:24 a.m., Staff L stated that she spoke to the physician about the residents decline in condition prior to receiving comfort care orders. Staff L was unable to provide documented evidence that the physician was notified and unable to provide a documented plan of care related to the residents change of condition prior to 12-28-12. Staff L was also unable to provide documented evidence that the family was made aware of the resident's end of life changes prior to 12-28-12. Staff L stated that the resident was "clearly" end stage prior the care conference and request for comfort care. Although the resident had experienced low blood pressures over several days with lung sound changes, anxiety and combativeness, staff did not correlate assessment findings as end of life changes that required a more thorough assessment in an effort to address the resident's physical, mental and psychosocial needs until six days after the first noted change in condition. Failure to correlate assessment finding to end of life changes placed Resident #82 at risk of not having optimal end of life care and services. .

Based on observation, interview and record review it was determined that the facility failed to ensure residents received the necessary treatment and services to promote healing of pressure ulcers and prevent new pressure ulcers from developing for 1 of 3 sample residents (#1) reviewed for pressure ulcers. Failure to prevent pressure ulcers from developing and failure to monitor and treat existing pressure ulcers resulted in Resident #1 to have three facility acquired pressure ulcers and one which increased in depth causing pain and therefore causing harm to the resident. Findings include: FAILURE TO PREVENT PRESSURE ULCERS FROM OCCURRING Resident #1 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review indicated Resident #1 was non-ambulatory, and used a wheelchair when not in bed. Resident #1 was hospitalized during survey date. Review of facility "Pressure ulcer care area assessment" dated 12/7/12 indicated Resident #1 had risk factors for pressure ulcers that included confined to bed or chair, needs special mattress, and required a special mattress. Record review revealed Resident #1 had no pressures ulcers identified on 7/5/12 when admitted to the facility. Further record review revealed a Braden skin assessment (an assessment tool used to identify residents at risk for developing pressure ulcers) dated 7/5/12 which scored Resident #1 at 16, indicating she was at risk for developing pressure ulcers. Record review also revealed a pressure ulcer care plan dated 7/5/12. The care plan was a template with blanks and boxes to be filled in. The intervention mobility box that identified the Braden score of 16 was checked, however all remaining boxes were left blank. The care plan did not have documentation to identify goals or identify interventions to prevent pressure ulcers from occurring. The care plan had a box to mark actual ulcer sites, but that was also left blank. Review of skin records indicated Resident #1 developed three pressure ulcers while in the facility. On 9/6/12, Resident #1 developed a Stage 2 (partial thickness of skin loss) sacral pressure area. On 10/17/12 staff discovered a Stage 2 pressure wound on Resident #1's left upper buttock, and on 10/26/12 staff discovered a Stage 1 (persistent redness that does not go away when pressure is relieved, no opening in skin) pressure area on the resident's right heel. Record review revealed a physician's orders [REDACTED]. During an interview on 12/14/12 at 1:15 p.m., Staff B confirmed Resident #1 frequently refused to wear the heel protecting boots and that there was no documentation of physician notification of refusals. A progress note dated 12/2/12 indicated Resident #1's right heel had an opening in the skin, a decline from the previous notes that indicated the heel was closed. Observations on 12/14/12 revealed the boots ordered by the physician were cushioned over the foot and lower legs with a cut out around the heel designed to elevate the heel, therefore reducing contact and pressure to the heel when in bed. The foam boot was also indicated to reduce pressure from the foot rests when sitting in a wheelchair. Further record review revealed no documentation to evidence facility staff had informed the physician who ordered the heel protecting boots that Resident #1 refused to comply with the prescribed treatment or that the treatment of [REDACTED]. The record did not have a signed risk and benefit form for refusal to wear the protective boots until 12/7/12, after Resident #1 had already developed a heel pressure ulcer. Failure to have a comprehensive pressure ulcer care plan with interventions in place had potential to place Resident #1 at a higher risk for developing pressure ulcers. RIGHT HEEL PRESSURE ULCER A progress noted dated 10/26/12 indicated Resident #1 had a "dark purple colored pressure sore" on her right heel. The progress note described the sore as soft and painful to the touch. The note indicated heel float boots were applied. A progress noted dated 10/28/12 identified a Stage 1 pressure ulcer on Resident #1's right heel. The note indicated Resident #1's physician was notified via fax on 10/28/12, two days after staff identified the pressure area. Four days after the pressure area was identified, on 10/30/12 the facility received a physician's orders [REDACTED].#1. Review of Weekly Ulcer Measurement Tool dated 10/26/12 indicated the right heel wound measured 3 cm by 3 cm and had no loss of skin thickness. The ankle wound was measured weekly after the initial assessment on 11/3/12, 11/10/12, 11/17/12, 11/25/12, and 12/7/12, none of the listed assessments had documentation to show the depth, if any, of the wound. A progress note dated 12/2/12 described the right heel wound as "open", "mushy", and "painful". The documentation indicated the wound had increased in depth with partial loss of skin. The same progress note indicated the physician had been notified of the condition of the wound. During an interview on 12/14/12 at 1:50 p.m., Staff C confirmed the facility had looked through the documents that had been faxed on 12/2/12 and was unable to confirm that the physician had been notified of the wound progression or the ineffectiveness of the treatment for [REDACTED]. During an interview on 12/14/12 at 1:50 p.m., a family member of Resident #1 reported when she visited the facility on 12/7/12 Resident #1 had what appeared to be an old, bloody Band-Aid on her right heel. Review of the facility Record of Concern form revealed a statement dated 12/9/12 in which Staff D indicated the heel wound had progressively gotten worse every week. The written statement also indicated staff had put a specialized dressing over Resident #1's right heel and that staff would need to contact the physician to get an order for [REDACTED]. Review of the December 2012 Treatment Administration Record (TAR) revealed no documentation of staff putting the specialized dressing on Resident #1 on 12/2/12. The December 2012 TAR indicated the order for treatment was not received until 12/7/12. The only documentation of a dressing change for Resident #1's right heel was on 12/7/12, indicating the dressing that was placed on 12/2/12 was not removed for 5 days, and the underlying wound had not been assessed since 12/2/12. During an interview on 12/14/12 at 1:00 p.m. Staff C reported the facility did not have a policy allowing nurses to administer treatments without a physician's orders [REDACTED]. Resident #1 had pressure ulcers develop, and increased in depth while at the facility. Failure to have wound prevention interventions in place, failure to notify the physician when the wound worsened, and failure to obtain treatment orders placed Resident #1 at risk for a decline in wound healing.

Based on observation, interview and record review it was determined that the facility failed to provide the care and services according to the physician's orders [REDACTED]. This failure potentially placed Resident #1 and Resident #2 at increased risk of skin breakdown. Findings include: RESIDENT #1 Resident #1 was admitted to the facility 9/6/12. Review of Resident #1's record revealed an admitting skin assessment dated [DATE] which indicated the resident had a history of [REDACTED]. Further review of Resident #1's medical record revealed a physician's orders [REDACTED]. Review of the care directive dated 9/6/12 for staff located in Resident #1's room directed staff to use Bilateral heel lifts. Observations on 1/22/13 at 8:40 a.m. revealed Resident #1 lying in bed wearing socks with both heels lying directly on the mattress. Resident #1 was not wearing protective heel boots, had no intervention in place to elevate her feet from the surface of the bed, and did not have a special pressure reducing mattress. During an interview on 1/22/13 at 8:45 a.m. Resident #1 pointed to a protective heel boot lying in a chair in the corner of her room. Resident #1 reported she only has one boot that she wears on her left foot. During an interview on 1/22/13 at 9:05 a.m. Staff C reviewed Resident #1's care directive and confirmed the resident should have been wearing protective boots while in bed and was not. Staff C also confirmed Resident #1 only had one protective boot instead of two. Review or Resident #1's care plan dated 9/18/12 indicated Resident #1 was to wear heel protectors at all times when in bed. Review of Resident #1's record revealed no documentation of Resident #1 refusing to wear heel protectors. Observations on 1/22/13 at 9:40 a.m. revealed Resident #1's skin over her left heel was intact, but reddened. Staff D who was present during the observations confirmed the reddened heel. Failure to implement the interventions put in place and physician's orders [REDACTED]. RESIDENT #2 Resident #2 admitted to the facility on [DATE]. Review of Resident #2's medical record revealed an admitting skin assessment dated [DATE] indicated there were no areas of concern on the resident's heels. Further review of Resident #2's medical record revealed a physician's orders [REDACTED]. Review of Resident #2's care plan dated 12/27/12 indicated Resident #2 was to wear heel protectors at all times when in bed. Observations on 1/22/13 at 8:45 a.m. revealed Resident #2 was lying in bed with his heels directly on the mattress. Resident #2 did not have on protective heel boots and did not have a special pressure reducing mattress. During an interview on 1/22/13 at 9:054 a.m. Staff C confirmed the protective heel boots should have been on Resident #2 while he was in bed. During an interview on 1/22/13 at 9:45 a.m. Staff E confirmed Resident #2 had a pressure ulcer on his left heel measuring 5.7 cm by 7.9 cm. which started as a blister. During an interview on 1/22/13 at 10:33 a.m. Staff B confirmed blisters are considered pressure areas. Staff B additionally reported Resident #2 does not like the heel boots and frequently refuses to wear them. Review of Resident #2's medical record revealed no documentation to support Resident #2's refusals or that staff had notified the ordering physician that Resident #2 had refused the treatment. Failure to implement physician ordered treatments to protect Resident #2's skin and as directed in the care plan placed Resident #2 at potential risk for skin breakdown and/or delayed healing of skin that has already broken down.

Based on observations, record review, and interviews, the facility failed to provide consistent supervision for 1 of 4 residents (former Resident #1) reviewed for falls. Resident #1 was outside and known to staff to have exited the sidewalk into the parking lot. Supervision was not sufficient to prevent the resident from falling from the sidewalk onto the street surface in the parking lot after staff relocated Resident #1 to the side walk once. Actual harm occurred when Resident #1 sustained a fractured arm as a result of the fall. Findings include: Resident #1 was readmitted to the facility during 8/2010 with multiple medical [DIAGNOSES REDACTED]. Review of Resident #1's comprehensive assessment dated [DATE] revealed the resident had intact memory and was independent with daily decision making skills. The facility's assessment of the resident's functional ability for wheel chair mobility on the unit was independent and she required limited assistance of one staff when off the unit. Review of a facility investigation dated 9/7/10 revealed on 9/7/10 at approximately 2:50 p.m., Resident #1 fell from her wheel chair while outside on the sidewalk in front of the facility. Review of a witness statement dated 9/8/10 revealed a visitor notified the receptionist that a resident was on the ground with a wheel chair tipped over on top of the resident. The facility concluded Resident #1 apparently rolled off the edge of the sidewalk curb and fell on to the ground in the parking lot. The resident was taken to the hospital for evaluation and subsequently diagnosed with [REDACTED]. Further review of the investigation revealed Resident #1 had been upset earlier in the afternoon and went outside. The report indicated the resident was found in the parking lot and refused to come inside; Staff E (licensed nurse on evening shift) encouraged the resident to move from the parking lot onto the sidewalk and reportedly checked on her 15 minutes later at which time the resident remained on the sidewalk. Approximately five minutes after that check, facility staff were notified the resident had fallen. On 9/16/10, the investigator observed the sidewalk and parking lot located in the front of the facility with Staff A (administrator) and Staff B (investigation nurse).The curbed sidewalk extended across the entire front of the building with a few areas that were level to the parking lot surface to accommodate wheel chairs. Portions of the sidewalk had curbed sides on the interior side adjacent to the landscaped areas. Staff A pointed to an area to the left of the front door where he had on at least two previous occasions observed former Resident #1 seated in her wheel chair, watching the activity in the front of the building. Staff A and Staff B stated Resident #1 being outside on the date of the fall was not unusual. Staff B was not aware of any other residents currently using manual wheel chairs that independently wheeled outside on the sidewalk. On 9/16/10 at 2:10 p.m., interview with Staff F (licensed nurse evening supervisor) revealed she recalled on 9/7/10, prior to change of shift report around 2:00 p.m., Resident #1 was attempting to leave the facility from the dining room adjacent to the nurses' desk area. Staff F stated the resident was pushing on the door to get out, alleging staff were cooking inside with a barbecue grill which was "a death trap" and she (Resident #1) had to leave. Staff F stated they calmed the resident and redirected her to the nursing desk area. Staff F stated Resident #1 was not placed on close supervision after trying to exit the facility from the dining room. Staff F stated when she came out from report at approximately 2:20 p.m., Resident #1 was not around the desk area; she thought someone probably took the resident to an activity. At 2:30 p.m., Staff E (evening shift licensed nurse) reported to her that Resident #1 was outside in front and was moved to the sidewalk from the parking lot but refused to come inside. Staff F stated she was not excited about the resident being outside but the resident was adamant about not coming in, so she decided they would go outside and check on her frequently; the resident fell within 5 minutes of the first check. On 9/16/10 at 2:00 p.m., Staff E told the investigator she located Resident #1 in the parking lot after being informed by Staff D (off going licensed nurse on day shift). She stated Resident #1 was angry and yelling at her, but did allow her to move her to the sidewalk. According to Staff E, that was not normal behavior for the resident. Staff E stated she was concerned about the resident's safety and informed the evening supervisor (Staff F) that the resident was outside and refused to come in. Staff E stated she checked on the resident within 15 minutes and she was still on the sidewalk; approximately 5 minutes later she was informed Resident #1 fell . Review of nursing progress notes dated 9/2/10 through 9/6/10 revealed documentation Resident #1 was intermittently confused and having delusions. During that time period the resident was treated for [REDACTED]. There was evidence of physician notification and treatment for [REDACTED]. Review of nursing notes dated 9/7/10 prior to the resident's fall did not address the resident's physical or mental status. Review of physical therapy documentation on 9/7/10 revealed Resident #1 adamantly refused therapy and yelled at the therapist. Review of occupational therapy notes dated 9/7/10 revealed the resident was confused at times during the session. During interview on 9/16/10 at 12:25 p.m., Staff G (physical therapist) stated the behavior described in the physical therapist's notes on 9/7/10 was not baseline behavior for Resident #1 according to his knowledge and previous observations of the resident. The facility failed to provide consistent supervision for Resident #1 while the resident was outside demonstrating unsafe behaviors of leaving the sidewalk and going into the parking lot. The unsafe behavior followed the resident's witnessed attempt to leave the facility earlier while emotionally upset and exhibiting delusional behaviors.