Every finding on record at Royal Park Health and Rehabilitation

Based on observation, interview and record review, the facility failed to establish and maintain a system of accounting for controlled drugs (substances or medications that had a high potential for abuse, misuse and addiction) in sufficient detail to enable an accurate reconciliation in 3 of 3 medication room emergency medication kits (Medication room [ROOM NUMBER] - Oak, Medication room [ROOM NUMBER] - Evergreen, and Medication room [ROOM NUMBER]- Transitional Care Unit -TCU), reviewed for medication storage. This failure created a risk of potential undetected drug diversion. Findings included.During an observation and interview on 05/04/2026 at 10:46 AM, the refrigerator in Medication room [ROOM NUMBER] - Oak unit medication room was observed with Staff D, Registered Nurse (RN). The refrigerator contained a clear plastic emergency medication kit (e-kit) that separated medications into multiple compartments. Review of the paper inventory sheet attached to the front of the kit documented the kit was to contain two vials of injectable lorazepam (a controlled medication that treated anxiety) and two 30 milliliter (ml) bottles of liquid lorazepam. Two 30 ml bottles of liquid lorazepam were observed in the kit. The pharmacy label on the back of the e-kit documented the lorazepam was delivered on 04/29/2026. The e-kit was sealed with a red tag labeled 00087. Staff D stated the e-kit red tag seal number was not tracked and the lorazepam was not logged into a narcotic tracking book (a book where two licensed nurses counted and verified controlled medications each shift). Staff D further stated all three medication rooms contained a similar refrigerated e-kit.During observation and interview on 05/04/2026 at 11:36 AM, the refrigerator in Medication room [ROOM NUMBER] - Evergreen unit medication room was observed with Staff F, Resident Care Manager, and Staff E, RN. The refrigerator contained a clear plastic e-kit, similar to Medication room [ROOM NUMBER] - Oak unit. Review of the paper inventory sheet attached to the front of the kit documented it was to contain two vials of injectable lorazepam, and two 30ml bottles of lorazepam liquid. The two bottles of lorazepam liquid were observed through the clear tote. Staff E acknowledged the e-kit contained two 30 ml bottles of lorazepam liquid but no vials. The pharmacy label on the back of the e-kit documented it was delivered on 04/29/2026. The e-kit was sealed with a white tag labeled 3739935. Staff F stated when staff accessed the e-kit, they were to unseal it, complete a white emergency box sign-out record, fax the completed record to the pharmacy, place the record into the e-kit box, and place a new tag with a new number on the e-kit to reseal it. Staff E stated the e-kit was not logged into a narcotic tracking book unless lorazepam was removed for a particular resident. Then it would be logged into a narcotic tracking book to be counted each shift as required. Both Staff F and Staff E stated they were unsure how staff accounted for the e-kit lorazepam.During an observation and interview on 05/04/2026 at 11:36 AM, the refrigerator in Medication room [ROOM NUMBER] - TCU was observed with Staff F. The refrigerator contained a clear plastic e-kit, similar to Medication room [ROOM NUMBER] - Oak and Medication room [ROOM NUMBER] - Evergreen units. The e-kit was unsealed, contained no tag number, and was easily opened by Staff F. The e-kit contained two vials of injectable lorazepam and two 30 ml bottles of lorazepam liquid. Staff F stated they were unsure when the e-kit was accessed and by whom, or what was removed. They acknowledged the e-kit should have been resealed with a new red tag labeled 00081 on the kit. In an interview on 05/04/2026 at 12:35 PM, with Staff B, Interim Director of Nursing, and Staff C, Regional Director of Clinical Operations, Staff C stated a nurse would typically verify the lorazepam e-kit tag number was unchanged when they monitored the temperature of the medication refrigerator. Staff C stated the lorazepam e-kit was to be sealed. Both Staff B and C stated they expected staff to maintain a system of records with sufficient detail to enable an accurate reconciliation of controlled drugs. A policy for medication storage was requested and none was provided.During an interview on 05/05/2026 at 12:54 PM, Staff A, Administrator, stated they expected staff to maintain a system of records with sufficient detail to ensure an accurate reconciliation of all controlled drugs.Reference WAC 388-97-1300(1)(b)(ii)(c )(ii)-(iv)

Based on observation, interview and record review, the facility failed to assess and implement a care plan for a positioning device (wedge to keep head raised) that was provided to 1 of 3 sampled residents (Resident 16) reviewed for positioning and mobility. This failure placed the resident at risk for unsafe conditions, risk of poor body alignment and improper positioning. The 04/06/2026 quarterly assessment documented Resident 16 had diagnoses that included dementia and difficult swallowing. Resident 16 was severely cognitively impaired and required substantial assistance for rolling to their left or right side then returning to their back when in bed.The 04/27/2023 care plan documented Resident 16 required assistance with activities of daily living, had esophageal reflux (a disease where the stomach acid flows back up into the esophagus and casues heartburn - a burning chest pain near the sternum), and was at risk for pressure ulcers and falls. Staff were instructed to wait at least one hour after meals, then lay the resident down between meals, keep the head of bed elevated, and encourage and assist with turning and repositioning. One staff member was required for bed mobility and staff were to use pillows to elevate the resident's heel off the mattress to prevent pressure ulcers. Resident 16 had no other positioning devices documented in their plan of care for use when they were in bed. On 04/27/2026 at 10:56 AM, Resident 16 was observed sleeping in bed. Signage hung on the wall above the headboard instructed Head of bed to be elevated at all times. Resident 16's bed was observed positioned flat. A foam wedge was positioned behind Resident 16's back. The wedge was as wide as the bed and went from the resident's head to their mid-back in length. Resident 16 was positioned on their back. Their head and lower part of their body leaned to the left with their head and shoulder area partially on the edge of the wedge. On 04/28/2026 at 9:19 AM, Resident 16 was observed in the same position, awake, resting in bed leaning towards the left edge of the wedge.On 04/29/2026 at 10:24 AM, Resident 16 was napping in bed on their back. Their head rolled off the positioning wedge to the left with their neck bent forward in an awkward position. The resident's eyeglasses were skewed off their nose hanging to the left side of their face. On 04/30/2026 at 10:15 AM, Resident 16 was awake, resting in bed. The resident was cued by an unidentified Nursing Assistant (NAC) to scoot back over on the wedge and was positioned back in the center of the bed and wedge. During an interview on 05/05/2026 at 1:20 PM, Staff G, Director of Therapy, stated the positioning wedge on Resident 16's bed was not something that the therapy department had implemented. Staff G stated it might have been something the nursing staff implemented. During an interview on 05/05/2026 at 1:55 PM with Staff H, NAC, and Staff I, NAC, Staff H stated the wedge on Resident 16's bed would have to be care-planned for the resident either by the Resident Care Manager or the therapy department and it was to keep Resident 16's head elevated because of risks related to swallowing. Staff I stated they had been employed at the facility for three months, and the wedge had been in place since they began working there. Staff H stated the wedge had been in place as far back as they could remember. Staff H and Staff I acknowledged Resident 16 leaned over to the left when in bed. They stated if they saw Resident 16 lean towards the edge, they were able to reposition the resident but would not be allowed to remove the wedge. On 05/05/2026 at 2:17 PM, Resident 16's bed was observed with Staff C, Regional Director of Clinical Services. Staff C stated they were not aware the positioning wedge was used for Resident 16 and was unsure how long it had been there. Staff C was unsure why the wedge was necessary as the same effect could be achieved by raising the head of the bed. Resident 16's roommate spoke up at that time and stated Resident 16's family brought it in and it had been there for months. Staff C stated, devices used for positioning were assessed to make sure they were appropriate and safe, and if so, were added to a resident's plan of care. Staff C stated they were going to have the device evaluated. Reference: WAC 388-97-1020(5)(b)

Based on observation, interview and record review, the facility failed to ensure nail care was provided to a resident per providers orders for 1 of 5 residents (Resident 42) reviewed for Activities of Daily Living (ADL's). This failure placed residents at risk of unmet care needs. Findings included. A quarterly assessment dated [DATE], showed that Resident 42 had severely impaired cognition and diagnoses of Congested Heart Failure (CHF, a long-term condition where the heart cannot pump blood effectively) and Osteoarthritis (a degenerative joint disease.) The resident was fully dependent on facility staff for their grooming and bathing. On 04/28/2026 at 10:43 AM, Resident 42 was observed sleeping in bed with their feet visible. Their toenails were long, thickened, and curved over the end of the toes and onto the skin. There was red polish on the ends, that had grown out over a quarter of an inch. Additionally, there was a scabby, dried, greenish area next to the right big toenail. The April 2026 Treatment Administration Record (TAR) showed a physician order, started on 04/25/2025, to perform fingernail and toenail care weekly on Fridays. It was signed as completed on 04/03/2026, 04/10/2026, 04/24/2026 and refused on 04/17/2026. Review of Resident 42's care plan, updated 12/23/2025, showed they preferred a shower or bed bath one or two times a week. As of 04/29/2026 Resident 42's medical record showed no entries about toenail care, refusals for nail care, podiatrist (a provider that specialized in all aspects of footcare) notes or referrals.In an interview of 05/05/2026 at 9:29 AM, Staff N, Licensed Practical Nurse (LPN) stated that nail care was done by the shower aide on their bath days unless the resident had diabetes. Staff N confirmed that Resident 42 was not diabetic and the shower aides did their nail care. Staff N agreed to look at Resident 42's feet together once the resident was awake. During an interview on 05/05/2026 at 9:48 AM, Staff O, Shower Aide, stated that nail care was done by the aides on shower days, unless the resident was diabetic or on blood thinners. They stated that Resident 42's toenails were too thick with fungus for the shower aides to do the nail care and previously it was done with a Dremel (a battery-operated tool used to file and smooth nails) by a podiatrist. During an observation and subsequent interview on 05/05/2026 at 11:26 AM with Staff N, Resident 42's toenails were observed unchanged from 04/28/2026. Staff N asked the resident if the facility could contact a podiatrist about their toenails, and the resident immediately agreed. Staff N stated they did not know when toenail care was last done for the resident, and the care should be done by a podiatrist. They further stated that since a referral to podiatrist was already a part of the facility's standing orders, Staff N would add Resident 42 to the list of residents to be seen by podiatry. During an interview on 05/05/2026 at 3:03 PM, Staff B, Director of Nursing and Staff C, Regional Director of Clinical Operations, acknowledged that nail care for Resident 42 was not done as ordered and that a referral to the podiatrist was appropriate. Reference: WAC 388-97-1060(2)(c)

Based on interview and record review, the facility failed to consistently monitor a resident for latent injuries after numerous falls for 1 of 4 sampled residents (Resident 4), reviewed for accidents. Specifically, the facility did not complete vital signs (VS- temperature, heart rate, respiratory rate and blood pressure) and neurological checks (neuro checks, an assessment used to evaluate the residents' level of consciousness, movement, hand grasps, pupil size and reaction) after unwitnessed falls. This failed practice placed residents at risk for unidentified injuries and diminished quality of life.Findings included.Review of the facility policy titled Fall Management and Neurological Check, updated January 2025, showed that the facility implemented a fall management plan based on medical history and the resident evaluation. Review of the facility document titled Neurological Evaluation Flow Sheet, updated January 2025, showed when initiated, neuro checks and vital signs (VS) were to be completed hourly for four hours, then every four hours for 24 hours. A 04/23/2026 comprehensive assessment documented that Resident 4 had diagnoses of dementia and paralysis on one side of the body after a stroke. The resident had severe cognitive impairment and required staff assistance with transfers to and from their wheelchair. The resident had an 03/19/2026 order for Eliquis (a blood-thinner) twice a day. Review of the facility incident log showed that Resident 4 had five falls since 03/19/2026, including four unwitnessed falls on 03/24/2026.Review of the facility investigations, which included neurological evaluation flow sheets, for the four unwitnessed falls on 03/24/2026 showed the following:At 12:15 AM, the resident was found kneeling in the bathroom, attempting to get up. A scrape on their left leg was noted. Hourly neuro checks and VS were started. At 3:00 AM, the resident was found on the floor, next to their bed. The resident had a large bump on the right temple area on their head. The resident was sent to the hospital for evaluation, as they were on blood thinners. They returned to the facility at 9:30 AM, and neuro checks and VS were resumed. At 4:00 PM, the resident was found sitting in the hallway with their wheelchair in front of them. They had a new abrasion to their left arm. Neuro checks were not restarted and the next neuro check and VS check was done at 6:00 PM, two hours later.At 6:15 PM, the resident was found sitting on the floor, next to a table and their wheelchair, in the dining room. No injuries were found. A neuro check was done at 10:00 PM and no additional neuro checks were completed after that. During an interview on 05/05/2026 at 8:58 AM, Staff K, Licensed Practical Nurse (LPN) stated that if a fall was unwitnessed, the staff needed to do neuro checks at the frequency written on the flowsheet, then give the sheet to the Resident Care Manager (RCM.) If a resident had a second fall while still on neuros, staff should restart the neuro checks as a new fall. During an interview on 05/05/2026 at 12:13 PM, Staff L, RCM, stated that after a fall, the resident should be put on neuro checks if they hit their head or may have hit their head. If the resident had another fall while on neuros, they would restart the neuros if that fall was not witnessed. During an interview on 05/05/2026 at 3:03 PM, Staff B, Director of Nursing and Staff C, Regional Director of Clinical Operations, reviewed findings regarding monitoring Resident 4 following their falls. Staff C initially stated that facility policy was that neuro checks were not always required for an unwitnessed fall in certain instances. It could be based on nursing judgement. After reviewing that Resident 4 had four unwitnessed falls that day, was on blood thinners and one of the earlier falls had resulted in a lump on their head and a hospital visit, Staff C and Staff B acknowledged that the resident should have had neuro checks for the last two falls as directed on the neuro sheet.Reference: WAC 388-97-1060 (3)(g)

Based on observation, interview and record review, the facility failed to ensure medications were administered as ordered for 1 of 5 sampled residents (Resident 2) reviewed for medication administration. Specifically, two medications for Resident 2 were not held or administered when indicated according to parameters ordered by the provider. This failure placed residents at risk for adverse health complications and diminished quality of life. Findings included.The 02/05/2026 comprehensive admission assessment documented Resident 2 had diagnoses that included Heart Failure (ineffective pumping of the heart that caused fluid build-up, swelling of limbs and difficult breathing) and low blood pressure. Resident 2 was severely cognitively impaired. Resident 2's medication orders included the following: - 02/16/2026: Metoprolol twice daily for heart failure, hold for systolic blood pressure (SBP, the top number of a blood pressure reading) less than 110, and heart rate (HR) less than 60 beats per minute.-02/27/2026: Midodrine three times daily for low blood pressure. On 03/20/2026, the order was changed and added to hold the medication for SBP greater than 130. <Metoprolol> A review of the April and May Medication Administration Records (MAR) from 04/01/2026 to 05/03/2026, showed Metoprolol was scheduled in the morning (between 6:00 AM and 10:00 AM) and evening (between 6:00 PM and 10:00 PM). There was no documentation of the BP or HR on the MAR. Review of the April and May Treatment Administration Record (TAR) from 04/01/2026 to 05/03/2026, showed that vital signs (VS, which included BP and HR readings) were done every dayshift. The TAR showed the morning SBP was less than 110 on 18 of the 33 days reviewed from 04/01/2026 to 05/03/3036. Per the April and May 2026 MAR, Metoprolol was held on four days (04/04/2026, 04/09/2026, 04/14/2026, and 04/15/2026). There was no documentation of the VS on the MAR on the evening shift. Additional vital signs were documented in the Weights and Vitals tab of the facilities charting system. When reviewed, the times the evening VS were documented for April and May 2026 did not correlate with times the metoprolol was ordered to be given. Additionally, there were no afternoon or evening VS recorded for 04/09/2026. <Midodrine>The April and May 2026 MAR from 04/01/2026 to 05/03/2026, showed Midodrine was scheduled in the morning (between 6:00 AM and 10:00 AM), afternoon (between 2:00 PM and 7:00 PM) and in the evening (between 7:00 PM and 10:00 PM). There was no documentation of the BP on the MAR when Midodrine was administered. Additional vital signs were documented in theWeights and Vitals tab of the facilities charting system. Comparison of April and May 2026 VS to the April and May 2026 MAR showed 3 times when a dose of the Midodrine should have been held, and was given (04/14/2026, 04/19/2026 and 04/28/2026). Additionally, there were 2 times when the dose of Midodrine should have been administered but was held (04/01/2026 and 04/25/2026). 28 of the 33 days reviewed had BP readings only once or twice a day.No documentation was found in the medical record that showed the provider was notified of frequent instances when the blood pressure readings were outside of ordered parameters. During an interview on 05/04/2026 at 11:13 AM, Staff J, Registered Nurse (RN) stated that the day shift nursing assistants (NA's) obtained VS daily for all residents on the unit. They stated that the NA's documented results on paper, then put them into the computer when they were able. Staff J further stated that the nurse should have checked or obtained VS before giving any medication that had orders to hold them if outside of the parameters. During an interview on 05/05/2026 at 8:58 AM, Staff K, Licensed Practical Nurse (LPN) stated that when charting a medication given in the computer, there was an optional tab for supplemental documentation the nurse could click on. Staff K showed when that tab was opened, the most recent BP results were displayed, and the nurse could click on one of them to use this or add another reading. They further stated if a BP was added in this way, the result flowed to the resident's VS tab. Additionally, when staff documented VS results in the VS tab, the first entry of the day flowed onto the TAR as well. During an interview on 05/05/2026 at 12:13 PM, Staff L, Resident Care Manager (RCM) stated that the nurse was to obtain the VS and document results before giving those medications. After reviewing Resident 2's record, Staff L acknowledged that the VS should have been obtained and charted prior to each dose of metoprolol and midodrine. Staff L stated the documentation on the MAR, TAR and VS tab did not clearly indicate which blood pressure and heart rate readings were used to determine if medications were to be given or held. During an interview on 05/05/2026 at 3:03 PM, Staff B, Director of Nursing, and Staff C, Regional Director of Clinical Operations, acknowledged that the documentation of VS timing and frequency was not adequate to determine if metoprolol and midodrine were or were not given as ordered according to the parameters. Reference: WAC 388-97-1060(3)(k)(iii)

Based on observation, interview and record review, the facility failed to ensure a particular type of drinking cup was consistently provided as care planned and ordered for 1 of 1 sampled residents (Resident 16) reviewed for assistive devices. This failure placed the resident at risk of swallowing difficulties and unintended health consequences.Findings included.On 02/06/2025, the physician's order noted, Resident 16 to use a sippy cup (drink aid designed to control liquid flow and promote safe swallowing with lid) for all drinks, no straws. The 04/06/2026 quarterly assessment documented Resident 16 had diagnoses that included dementia and dysphagia (difficulty swallowing). Resident 16 had severe cognitive impairments, required moderate assistance from staff for eating, and received daily eating/swallowing skill practice during the assessment look back period. The 04/27/2023 care plan documented Resident 16 had activities of daily living (ADL) self-care deficits. On 04/16/2025, the care plan was updated to show Resident 16 used 2-handled cups for assistive devices. On 04/17/2025, the care plan was updated to show Resident 16 required staff cues to wake up and take bites/drinks throughout each meal and was to use sippy cups for beverages. Resident 16 was also at nutritional risk related to difficult swallowing. The 08/06/2025 diet list included soft and bite-sized textures, and mildly thick liquid consistencies. On 09/16/2025, interventions included aspiration precautions (safety measures designed to prevent foods or liquids from entering the airway and lungs) and no straws. On 04/27/2026 at 1:10 PM, Resident 16 was observed in their room, seated in their wheelchair next to their bed. The overbed table was positioned across Resident 16's lap. Two brown plastic coffee mugs were on the table. One had remains of a drink in the bottom, the other was half full of coffee that was thickened. The cups had no lids on them, and only one handle. There were no sippy cups present. Three signs were hanging on the wall above the head of the bed. One read Head of bed elevated at all times; a second read Thicken liquids and the third read Sippy cups only. On 04/28/2026 at 9:39 AM, Resident 16 was observed resting in bed. The overbed table next to the bed had a coffee mug on it that was half full with thickened water in it. The signage that read Sippy cups only hung above the head of the bed.On 04/29/2026, the physician's order noted, Resident 16 to use a lipped up (directs the flow of liquid smoothly onto the tongue, provides a comforting resting spot for the mouth, and prevent drips running down the outer walls) for all drinks, no straws. During an interview on 05/05/2026 at 1:55 PM with Staff H, Nursing Assistant (NAC), and Staff I, NAC, Staff H stated Resident 16 ate their meals in the main dining room with Restorative Nursing staff and Staff H did not assist with that. Staff H stated Resident 16 was allowed drinks at their bedside. They stated Resident 16 had to have thickened liquids, a spouted cup, and had to be sitting up. When asked, Staff I stated Resident 16 was not allowed to have a regular coffee mug as this was a choking risk. Staff H stated a regular coffee mug should never be given to the resident.During an interview on 05/05/2026 at 2:17 PM with Staff B, Director of Nursing, and Staff C, Regional Director of Clinical Operations, they reviewed Resident 16's orders and were uncertain if a sippy cup and a lidded cup (as ordered on 04/29/2026) were the same type of cup. They acknowledged that a regular coffee mug was not the correct type of cup for Resident 16 to drink from.Reference: WAC 388-97-1140(2)(4)

Based on observation and interview, the facility failed to follow professional standards for food service safety regarding cleanliness, hand hygiene and facial hair being covered for 3 of 3 food preparation areas (Kitchen, Main Dining Room and Steam Table). These failures placed residents at risk for food-borne illnesses.Findings included .<Kitchen cleanliness>During the initial Kitchen tour on 04/27/2026 at 9:00 AM with Staff P, Dietary Supervisor, crumbs and food debris were observed on counters, stove, steam table and the toaster area. The stovetop had dried, crusted food debris and a large, dried, crusted spill on the stovetop. Additionally, there was dried splatter on the backsplash behind the stove and dried drips down the right side of the stove. There was a large pot of soup simmering on the stove, over the dried spill. While this surveyor was inspecting the dry storage area, Staff P returned to the kitchen, moved the soup to another burner, removed the stovetop tray with the spill, and brought it to the dishwashing area. Staff P then began to wipe off the counters. <Hand Hygiene> On 05/01/2026 at 7:24 AM, Staff Q, Cook, was observed at the tray line plating food and wearing gloves in the Kitchen. Staff Q stopped placing food on plates and went to the stove to fry an egg, touched the burner knob, the frying pan handle, and an egg. When they cracked the egg, they got raw egg on their gloves. Staff Q removed their gloves and put on new ones, then returned to plating food. Staff Q did not wash hands or use hand sanitizer with the glove change. <Facial Hair Coverings> On 04/27/2026 at 1:04 PM, the lunch meal service was observed in the Main Dining Room. Staff R, Dietary Aide, was observed wearing a beard net, that partially covered their short beard. Their mustache and sides of their beard were uncovered. Staff S, Dietary Aide wore a beard net that covered their chin. Staff S's facial hair on their cheeks, neck and mustache were not covered. Both Staff R and Staff S plated food from the Steam Table, then handed the food to other staff, who brought it to the residents. On 05/01/2026 at 6:43 AM during food preparation in the kitchen, Staff R was observed toasting and buttering the bread. They then went to the Steam Table to add covers to the plates and, placed trays in the meal carts. Staff R was wearing a beard net over their chin, that did not cover their mustache or the facial hair on their cheeks. During an interview on 05/01/2026 immediately following the morning food preparation, Staff P stated that the dietary staff was required to keep their hair covered, including all facial hair. When informed that Staff R and Staff S's facial hair was not fully covered by their beard nets, Staff P stated two beard nets could have been used to fully cover their facial hair. Staff P also acknowledged that hand hygiene was to be completed anytime gloves were changed in the kitchen. Staff P further acknowledged that food preparation surfaces were to be kept clean when food was prepared. During an interview on 05/05/2026 at 3:03 PM, Staff B, Director of Nursing and Staff C, Regional Director of Clinical Operations acknowledged that the kitchen should be maintained in a clean manner, staff should perform hand hygiene with all glove changes and facial hair should be fully covered during food preparation.Reference: WAC 388-97-1100(3)

Based on interviews and record review the facility failed to ensure pharmacy services were provided to meet the needs of 1 of 3 sampled residents (Resident 1) reviewed for medication management. The failure placed residents at risk for adverse events related to missed medications.Findings included .<Resident 1>Review of Resident 1's care plan, dated 02/06/2025 showed they had a diagnosis of a shoulder fracture and chronic pain. The same care plan had interventions, dated 02/11/2025, that included: the resident's pain is alleviated/relieved by rest and medications and administer analgesia (pain medication) as per orders.Review of the resident's admit orders, dated 02/06/2025, showed the following narcotic pain medication:-Morphine 30 mg (milligram) immediate release (IR) (a short acting, strong narcotic pain medication): Take 1 tablet by mouth twice daily. Review of Resident 1's Medication Administration Record (MAR) for August 2025 showed an order dated 02/06/2025, for Morphine 30 mg to be given two times daily at 7:00 AM and 7:00 PM. On 08/07/2025 at 7:00 PM the MAR shows code OO (on order). On 08/08/2025 at 7:00 AM the MAR shows code 9 (other/see progress note). On 08/08/2025 at 7:00 PM the MAR shows code OO.Review of Resident 1's progress notes showed on 08/07/2025 at 9:20 PM, Staff D, Licensed Practical Nurse (LPN), wrote the residents Morphine 30 mg was on order from the pharmacy. On 08/08/2025 at 8:04 AM, Staff E, Registered Nurse (RN), wrote, med not available, pharmacy called and [stated] need new script provider called, waiting for script to be sent to pharmacy. Further review showed that on 08/08/2025 at 3:22 PM, Staff D, wrote, called pharmacy to check on status of Morphine order, was told that 60 tabs would arrive on the morning run. On 08/09/2025 at 2:41 PM Staff F, RN, wrote Pt endorsed withdrawal from morphine. Had missed 2 doses before MSER (morphine extended release) arrived from pharmacy on 8/9.Review of the medical provider communication book showed an untimed note dated 08/06/2025, that indicated Resident 1 needs MS (morphine) renewal order.Review of pharmacy records showed a prescription written by Staff C, Nurse Practitioner, on 08/06/2025 for Morphine 30 mg IR. A pharmacy communication was then returned to the facility at 1:52 PM which indicated Resident1's previous Morphine prescription had been for Morphine Extended Release (ER) and checking to see if the NP now wanted Morphine IR. A response was sent back to the pharmacy at 2:56 PM which stated the NP intention was to provide new rx (prescription) to continue same order. Void this rx for IR tab, [they] will send new surescript (electronic prescription) for ER formulation. The pharmacy responded on 08/06/2025 at 2:59 PM with dc' d (discontinued). The next pharmacy communication found was dated 08/08/2025, with a fax time at the top of the scanned page of 11:55 AM, marked urgent, for Resident 1's Morphine 30 mg ER, written by Staff C.Review of the Food and Drug Administration (FDA) package insert/prescribing information for Morphine ER showed under the heading Morphine ER dosage and Administration, provided direction Do not abruptly discontinue morphine sulfate extended-release tablets in physically dependent patient because rapid discontinuation of opioid analgesics has resulted in serious withdrawal symptoms, uncontrolled pain, and suicide.Review of the publication Pain Management in the Post-Acute and Long-Term Care Setting, Copyright 2021, indicates on page 63, that opioid dependence (i.e., the body's physical dependence on opioids to function normally) is common. A withdrawal syndrome can result from abrupt cessation, rapid dose reduction.During an interview with Resident 1 on 09/09/2025 at 11:50 PM, with their spouse also present in the room, Resident 1 stated that there was a day, last month, when I did not get my Morphine in the evening or the next day. They further stated that they had been on the same dose of Morphine for several years, related to chronic pain, and were dependent on the medication for pain relief. They stated that when they did not get the Morphine in the evening the nurse told them that the medication had not come from the pharmacy, and it would come the next day. On the next day it still did not come, and the nurse told them that they would get their as needed Hydrocodone (a narcotic mixed with Tylenol) until the Morphine arrived. They stated that they went through that day and experienced unrelieved pain and felt that they experienced withdrawal symptoms in the form of body aches and flu-like symptoms until the medication arrived from the pharmacy the next day. They further stated that they did not feel as if the nursing staff took the situation seriously and discounted their complaints of pain and withdrawal.In an interview on 09/09/2025 at 1:14 PM with Staff B, Resident Care Manager (RCM) and LPN, they stated that the facility policy for reordering medication was for the nurse to notify the pharmacy when there was a seven-day supply of the medication remaining. They further stated that if the floor nurse did not have an ordered medication for a resident, they should notify them so they could communicate with the medical provider. They further stated that they were the RCM responsible for oversight for Resident 1 and they had no knowledge of the resident missing their prescribed twice daily Morphine.In an interview with Staff A, Director of Nursing, on 09/09/2025 at 1:40 PM, they stated that the facility policy for reordering medications was for the nurse to notify the pharmacy when there was a three-day supply of the resident's medication remaining. They stated that if a medication was reordered too soon the pharmacy would not send it. They further stated that they had no awareness of Resident 1 having missed doses of their prescribed Morphine. In a later communication via email, on 09/11/2025 at 3:16 PM, Staff A stated that the nurse was to reorder the resident medication when the resident supply hit the blue line on the medication card, indicating the last seven doses of the medication were remaining.During an e-mail conversation with Staff C, Nurse Practitioner, on 09/11/2025 at 10:15 AM, they wrote that, this situation of not having the morphine was not planned or recommended. Later in the same email chain, at 10:31 AM, Staff C indicated that Resident 1 was very aware of [their] pain management and all of the medications included in [their] pain management plan. Staff C further stated that they did not speak with Resident 1 about their prescribed Morphine not being available nor had they written a progress note related to the situation.In an interview with Staff D, LPN, on 09/09/2024 at 2:48 PM, they stated that they had verbally spoken to the Medical Provider, Staff C, on the same day Resident 1 was out of their prescribed Morphine. They further stated that they had not noticed Resident 1 was almost out of their Morphine until the day before they ran out and Staff D thought they had communicated with Staff C then too but could not remember clearly. They stated that the medication should have been reordered when the remaining supply was at the blue line, with seven days of the medication remaining. They stated that during the time Resident 1's Morphine was not available that Resident 1 had asked them several times when it was coming from the pharmacy and indicated that they wanted the medication. Reference: (WAC) 388-97-1300 (1)(a)(b)(i)(ii)

Based on interview and record review, the facility failed to ensure provider orders were consistently followed to track ostomy (a surgically placed opening [stoma] in the abdomen to allow body waste to pass into a collection bag) output, teach the resident to manage their ostomy independently, consistently assess and monitor skin around the stoma and provide and document ostomy care consistent with professional standards for 1 of 1 resident (Resident 1) reviewed for ostomy care. Resident 1 experienced harm when they developed excoriation (skin breakdown), redness and weeping, around their ostomy so facility staff were unable to securely adhere the ostomy bag to the skin and required the resident's transfer to the hospital for evaluation and treatment. Findings included:The 2022 article titled Living with an Ileostomy, published by United Ostomy Associations of America (a nonprofit organization that supports and educates people who have ostomies) at www.ostomy.org, documented that the output/stool from an ileostomy contained digestive enzymes (stomach acid) which caused skin breakdown, so it was important to address skin issues right away by changing the ostomy wafer and treating the irritated skin. As the discharge may be more liquid or watery, the risk for dehydration was higher, since the large intestine (which was bypassed) is where most of the fluid and electrolytes were absorbed. Since liquid stool increased the likelihood of dehydration, the physician may suggest foods or medications to thicken it, and liquids to drink, to replace lost fluids and electrolytes. The article further suggested to seek medical advice for the following issues: Watery discharge lasting more than five to six hours, chronic skin irritation, rash, weeping skin or if unable to wear the pouching system for two or three days without leaking.The New Ostomy Patient Guide 2024, published by United Ostomy Associations of America at www.ostomy.org, under the heading Basic Ileostomy Care documented to treat skin irritation by dusting the irritated skin with a powder designed for use around the stoma, then apply No-Sting skin prep and allow it to dry, before placing a new ostomy appliance on.The undated Peristomal Skin Assessment Guide, published by the Wound, Ostomy and Continence Nurses Society (a recognized professional nursing organization, dedicated setting national standards in expert ostomy care, WOCN) at www.wocn.org documented that if unable to maintain a pouch seal for 24 hours, may try a convex pouching system, barrier ring, stoma powder, barrier swab/spray or an ostomy belt. The guide documented in bold letters to change pouch when leaking; do not reinforce with additional tape.According to an admission assessment dated [DATE], Resident 1 admitted to the facility on [DATE] with diagnoses of ulcerative colitis (inflammatory disease of the bowel that causes ulcers within the colon and rectum) and had a new ileostomy (a type of ostomy that allows the waste to exit from the small intestine into a pouch adhered to the abdomen, bypassing the colon and rectum.) The resident was alert, made their needs known and required moderate assistance with managing their ostomy.<Provider Orders>Resident 1's Electronic Medical Record (EMR) provider orders included the following:1) Document ileostomy output every shift, initiated on 06/02/2025.2) Document ileostomy training provided (to resident) every day and night shift, for Ileostomy care, initiated on 06/06/2025. A WOCN consultant nursing note from 05/30/2025 was included with the resident's documents from the hospital. The note described the ileostomy products used and recommended, which included a two piece system (the convex shaped wafer, that adhered to the skin around the stoma, and pouch that snapped onto the wafer), ostomy belt, skin barrier ring, skin sealant and antifungal and ostomy powder. The note also described application tips used, such as crusting (process to alternate layers of powder and barrier spray on irritated skin around the stoma, until the skin is dry so a pouch can adhere.) The note also documented how the wafer was applied in diamond fashion, crimped on the sides and how an ostomy belt helped maintain the seal to prevent leaking. None of these WOCN consultant recommendations were documented in the nursing or therapy notes about patient education.A review of the 06/02/2025 transfer orders from the hospital included the surgeon's discharge instructions. Under the heading Caring for an Ileostomy, the document showed the following:- It was important to keep track of how much output your ileostomy is producing. Your colon absorbs salt and water; since your colon may have been removed or is out of circuit, the concern is that your body will become dehydrated and low on salt - this can hurt your kidneys and make you very ill.- Your output should be less than [PHONE NUMBER] ml (milliliter, a measurement) over a 24 hour period. If it is more than this, you should try eating foods to bulk your output. You may also add soluble fiber (Metamucil, Citrucel or generic equivalent) twice daily.- If your output is still liquidy or high output, you should take Imodium (antidiarrheal medication) 2-4 mg (milligrams, a measurement) four times a day before meals and at bedtime. - You will need to drink greater than two liters of fluid per day. The best thing is to drink Gatorade, G2 or Pedialyte. Avoid sodas and large volumes of water. Drinking a large amount of water can actually affect the salt balance in your body and make things worse.- Watery stoma output and dark urine are the FIRST signs of dehydration. Do not wait until you are feeling lightheaded, have dry mouth or headache. These are late signs and you are probably already dehydrated and may need to be admitted to the hospital.None of these orders were found in the facility EMR.A review of the June 2025 Treatment Administration Record (TAR) showed the order to document ileostomy output every shift, on day and night shift. A check mark and nurses initials were documented from 06/02/2025 through 06/10/2025 with one blank/omission on 06/05/2025 for night shift. The amount of output was not documented. A progress note dated 06/03/2025 at 7:35 PM, documented that the ileostomy output was 150 ml. A progress note dated 06/11/2025 at 6:19 PM, documented that they were unable to obtain measurements of the ileostomy output. There was no further documentation found of ileostomy output amounts found for the resident's 10 days in the facility.Review of a Bowel Monitor from 06/04/2024 through 06/11/2024, showed the daily bowel movement (BM) output. Of the 17 responses, seven were checked under the heading of loose BM.Review of Resident 1's care plan, dated 06/02/2025, documented two areas related to the ileostomy. Goals included that the resident would remain free from discomfort, complications or signs and symptoms related to their ileostomy, and the resident would maintain or develop clean and intact skin. Interventions included were to give medications as ordered, monitor/document side effects and effectiveness, obtain and monitor lab/diagnostic work as ordered and report result to the provider, follow up as indicated, educate resident/family/caregivers of causative factors and measures to prevent skin injury and to follow facility protocols for treatment of injury. The care plan showed no specific needs of the resident related to the presence of the ileostomy and did not include what type of ostomy products were used, recommendations from the hospital ostomy consultant or the ostomy orders from the surgeon.<Patient Education>A review of the June 2025 TAR showed a 06/06/2025 order for Ileostomy training, scheduled to occur daily on every day and evening shift. A check mark and nurses initials were documented twice daily from 06/06/2025 through 06/11/2025.A review of progress notes from 06/02/2025 through 06/11/2025 showed the following related to resident teaching:- 06/03/2025 at 9:35 PM, patient teaching done for ileostomy training, verbalized understanding.- 06/05/2025 at 2:38 AM, understands ileostomy teaching.-A social services progress note dated 06/10/2025 at 8:55 AM showed that Resident 1 had requested nursing to train them on ostomy care prior to discharge, and Staff C, Resident Care Manager (RCM) was informed.Review of the progress notes showed no documentation of what specifically the staff taught Resident 1 related to ileostomy management. Additionally, no documentation was found about if the resident did any step of the bag change independently or how much assistance they required. During an interview on 07/08/2025 at 12:24 PM, Staff C, RCM stated that therapy staff completed the ostomy teaching with the resident but was unsure if it was the Physical Therapist (PT) or Occupational Therapist (OT). During an interview on 07/08/2025 at 12:35 PM, Staff D, OT stated that OT did ostomy training with the nursing staff, provided teaching pamphlets and referred to a teaching sheet on ostomy care.A review of the OT notes for Resident 1 showed the following:-On 06/03/2025, the goals of therapy included the resident would be moderately independent for burping (opening pouch to allow air to escape) and emptying the ileostomy bag and would demonstrate 100% understanding of the ileostomy bag change. The note showed that training was initiated with burping and emptying the bag and demonstration by the OT with minimal assistance.- 06/04/2025, the resident was provided a handout of new education. It did not show the name of the handout. The note also showed the resident had a leak on the side of the colostomy bag and the OT consulted the nursing staff to use paper tape on the leak, to hopefully last until a bag change the next day.Review of the medical record showed no further teaching documentation was provided, such as handouts given, checklist of subjects reviewed or resident response to education.<Ostomy Care/skin breakdown>Review of a provider progress note, dated 06/09/2025 at 2:17 PM showed the resident's ileostomy bag was leaking earlier, and the nurse had helped them to change it.Review of a nursing progress note, dated 06/09/2025 at 11:57 PM showed the Ileostomy bag was changed twice after it started to leak. The note did not document if the resident performed any part of the bag changes.Review of weekly skin evaluations did not show any documentation of the skin condition around the stoma.On 06/09/2025, the provider wrote an order for an outside wound consulting agency to Evaluate and treat the resident.Review of the wound consulting agency progress note, dated 06/10/2025 at 8:02 AM showed the Physician Assistant (PA) was asked to see the Resident 1 about a small open area on their buttock. The note showed no documentation of the ostomy or skin condition around the stoma.Review of a late entry nursing progress note dated 06/11/2025 at 2:00 PM showed the resident had issues with the ostomy appliance adhering to the skin. The note further showed the previous night shift nurse reported they changed the bag several times for the same reason. The OT then reapplied the appliance, and it leaked again after two hours. The note described the resident used toilet paper and paper towels to catch the bile which made the skin more irritated. The nurse cleansed the area with soap and water, then applied powder and made several more attempts to get the appliance to adhere, without success. The surgeon's office and on-call provider were contacted.Review of a late entry nursing progress note dated 06/11/2025 at 2:35 PM showed that another nurse was asked to assist with the ostomy pouch placement. The note described the surrounding skin was excoriated and constantly weeping, preventing the ostomy pouch from adhering despite using skin prep and a stoma ring.Review of a nursing progress note, dated 06/11/2025 at 2:21 PM showed a third nurse assisted with attempts to place and secure the ostomy bag.Review of a nursing progress note, dated 06/11/2025 at 6:38 PM showed the staff sent Resident 1 to the hospital for further evaluation due to the appearance of the skin around the stoma.Review of an emergency room provider note, dated 06/12/2024, showed Resident 1 arrived at the emergency room the previous day with concerns of redness around their ostomy site. The provider described the skin around the stoma with notable skin breakdown and redness three centimeters around the stoma, that likely was the result of poor ostomy care. The provider further documented that the resident was admitted to the hospital with a wound care/ostomy team consult.Review of a 06/16/2025 discharge summary documented the resident discharged home from the hospital five days later.During an interview on 07/08/2025 at 12:24 PM, Staff C, RCM stated that hospital admissions were done by either the RCM's, Staff B, Director of Nursing (DON) or the floor nurses. They would review the documents sent from the hospital, input the provider orders into the computer system and have the original documents scanned into the chart. When asked if there was a doctors order to measure the ostomy output, Staff C stated they had never seen such an order but imagined it would be on the Medication Administration Record (MAR). They further stated that specific details of ostomy care (type and size of pouch, shape of the wafer, stoma ring/powder/paste or if a belt were used) wouldn't necessarily be documented in the chart or in the care plan if the doctor didn't write an order for it. It would also depend on what products were available in the facility.In an interview on 07/16/2025 at 10:42 AM, Staff E, Registered Nurse (RN) stated they would know what products to use for an ostomy pouch change by what supplies were in the resident's room.In an interview on 07/16/2025 at 10:55 AM, Staff F, RN stated that a Physician Assistant (PA) from an outside wound consulting agency came to the facility weekly, and could be a resource for ostomy issues, since they specialized in skin and wound care. During an interview on 07/08/2025 at 12:57 PM, Staff A, Administrator verified that different nurses may share the tasks on the admission. They further stated that they did not have any policy and procedure for ostomy care and just went by the provider orders.During an interview on 07/08/2025 at 1:37 PM, Staff B, DON stated that the discharge instructions from the surgeon were orders, that should have been put in as admission orders in the EMR. The staff did not follow the order to document the amounts of ostomy output or ostomy patient education, as required. Staff B further stated that the staff who changed the ostomy bag should have documented the condition of the surrounding skin, and details of patient involvement with the bag change (needed supervision, some assistance or independent.) When asked why it might be important to track the amount and consistency of the output from an ileostomy, Staff B stated the doctor probably just wanted to make sure if there was output at all.During a telephone interview on 07/08/2025 at 4:13 PM, Resident 1 stated that their experience with their ostomy care was Terrible. They stated the pouch broke several times, was changed three to four times on the last day and it only lasted for two hours. The resident described the surrounding skin as deep red, raw and bleeding for over two inches around and looked like raw meat. They further stated it was so painful, and staff was not gentle, just ripped the ostomy wafer off. I was screaming. The resident said three nurses trying to get the pouch to stick on and They didn't know what they were doing. The resident stated that they ended up going back to the hospital without a pouch on, the nurse just had them hold a wad of wet towels over their ostomy. Resident 1 concluded by stating that they refused to go back to the facility and instead went home with home care after five days.During a telephone interview on 07/10/2025 at 11:51 AM, the Nurse Practitioner (the provider who evaluated Resident 1 in the hospital emergency room on [DATE]) stated that it was clear that Resident 1's skin condition around the stoma did not deteriorate to that extent in just a few hours, it was at least a couple of days.Reference: WAC 388-97-1060(3)(j)(iii)

Based on observation, interview, and record review, the facility failed to ensure 2 of 4 dependent residents (Resident 1 and 3), reviewed for Activities of Daily Living (ADL's), received the appropriate number of baths per week. This failure placed residents at risk for poor hygiene and a diminished quality of life. Findings included . <Resident 1> Review of a facility assessment, dated 05/14/2025, showed the resident was admitted with diagnoses to include a stroke with one sided weakness. The resident had aphasia (affects the ability to produce spoken or written language, even though the individual may understand language). Resident #1 had difficulty making their needs known. The resident's care plan, dated 02/19/2025, showed the resident was to be showered twice a week. It was noted the resident preferred bed baths but staff should continue to offer for the resident to use the shower. Review of Resident 1's shower record from 05/09/2025 to 06/09/2025 showed the resident received a bed bath on 05/09/2025 and not again until 05/19/2025, 10 days later. The next bed bath was 7 days later on 05/26/2025 and an additional 7 days on 06/02/2025. On 06/09/2025 at 12:28 PM, Resident 1 was laying in bed. The resident had difficulty answering questions. When asked if they received bathing twice a week they shook their head no. When asked if they like showers, they nodded no and nodded yes they preferred bed baths in their room. <Resident 3> Review of a facility assessment, dated 05/06/2025, showed the resident was admitted with diagnoses to include dementia. The resident had difficulty making their needs known and required partial to moderate assistance for personal hygiene. Review of Resident 3's shower record from 05/09/2025 to 06/09/2025 showed the received a shower on 05/12/2025 and not again until 05/20/2025, 8 days later. On 06/09/2025 at 11:20 AM, Staff A, Nursing Assistant (CNA), stated they had a shower aide for the unit but they had called off for the day. Staff A was asked how showers were made up if there wasn't a shower aide and they replied they weren't sure. On 06/09/2025 at 12:22 PM, Staff B, CNA, stated they were a shower aide but had been taken off showers for the day to help on the floor. Staff B stated they would be pulled if too many CNA's called off sick. If Staff B couldn't do showers, they would try and make them up the next day they worked. On 06/09/2025 at 12:25 PM, Staff C, Resident Care Manager (RCM), stated if a shower aide was pulled onto the floor, they would make up the showers the following day. Staff C stated showers were to be given twice a week. On 06/09/2025 at 1:18 PM, Staff E, Director of Nursing (DNS), stated on occasion the shower aides would be pulled to the floor. If that was done, the floor staff should help get the showers done that had been missed. Reference WAC 388-97-1060(2)(ac)

Based on observation, interview, and record review, the facility failed to provide adequate staff supervision for the bed mobility and reassess a resident's ability to assist after a room change and level of consciosness to prevent accidents for 1 of 3 sampled residents (Resident 2), reviewed for falls. Resident 2 experienced harm when they were rolled toward the edge of their bed by a staff member during a bed linen change, rolled off the bed headfirst onto the floor, required transfer to the hospital and sustained a subdural hematoma (a serious condition where blood collects between the skull and the surface of the brain, usually caused by a head injury). Findings included . Review of a facility assessment, dated 02/07/2025, showed Resident 2 had diagnoses to include heart failure, below the knee amputation, and obesity. Resident 2 was able to make their needs known. The Care Area Assessment summary (CAA), for functional ability, showed the resident had impaired functional mobility and was dependent on staff to transfer, toilet, and for bed mobility. During an observation and interview on 04/14/2025 at 12:50 PM, Resident 2 was lying in bed. The resident's bed was in an elevated position, the resident said they controlled their own bed. The resident had red areas around their left and right eye and yellow/black bruising on the left side of their forehead. Resident 2 was asked if they had pain and stated they had a headache which they have had since the fall. The resident stated they were rolled to be changed and fell off the bed. Resident 2 stated they went head first onto the floor. I woke up as I was falling to the floor. Resident 2's care plan, dated 08/23/2024, showed the resident required extensive assistance of one - two staff for bed mobility. On 04/02/2025 the resident's care plan was updated to have extensive assistance of two staff, one on each side of the bed. Review of the facility investigation, dated 04/01/2025, showed the nurse went to Resident 2's room around 4:30 AM after Staff D (nursing assistant certified - NAC) had called for assistance. The resident was lying on the floor, next to the bed, and the bed was in an elevated position. The resident stated they fell headfirst out of their bed. Emergency personnel were called and the resident was transferred to the hospital. The cause of the fall was determined to be related to the resident went to sleep during care, was rolled to their side towards the edge of the bed, and the size of the resident. The NAC needed assistance of another staff member to prevent a fall and injury. Review of a statement by Staff D, dated 04/01/2025, showed the Resident 2 was incontinent of bowel so needed changed. Staff D documented they asked the resident to stay awake during care but the resident went back to sleep. When Staff D rolled the resident towards them, they rolled off the bed. During an interview on 04/08/2025 at 10:30 AM, Staff C, NAC, was asked if a resident's bed mobility was an extensive assistance of one - two staff, how would they determine the number of staff needed. Staff C stated it would depend on if the resident could assist or not. If they could, they would do care with one, if not, they would have a second staff member assist. When asked about Resident 2, Staff C stated they always used two staff, even though the resident could grab onto the mattress, for safety. During an interview on 04/14/2025 at 10:22 AM, Staff E, NAC, stated if they needed to do care for a resident, they would determine how well the resident could assist them in order to determine if they needed a second staff member. When asked about Resident 2, Staff E stated prior to the resident's room move, the resident's bed was against the wall. The resident was able to grab the mattress to roll and then put their hand on the wall to brace themselves. On 04/14/2025 at 11:30 AM, Staff F, Resident Care Manager (RCM), stated when a resident was a one - two extensive assist with bed mobility, the staff would determine what the resident could do to help. Staff F stated Resident 2 was a one - two assist before the fall. Prior to the resident's room move, the resident's bed was against the wall and when rolled, the resident would put their hand on the wall. In their current room, the resident chose not to have the bed against the wall which could make it less safe to use one staff member. The resident's care plan was updated to have 2 staff, one on each side of the bed. On 04/14/2025 at 2:15 PM, Staff B, Director of Nursing (DNS), stated if a resident was a one - two extensive assist in bed, staff would determine the extent the resident could help. Resident 2 could usually help some when rolled in bed. Resident 2 was rolled toward Staff D during care and rolled out of the bed. Staff D was not able to hold the resident when they started to fall because of the resident's size. On 04/17/2025 at 9:45 AM, Staff D was interviewed and stated when they went to check on the resident, about 4:00 AM, the resident had been incontinent and needed changed. Staff D stated Resident 2 was able to help roll in bed but at times the resident would not comprehend what was going on and it was more difficult to keep the resident awake, like the night of the fall. Staff D stated they tried to keep the resident awake, rolled the resident toward them, and the resident rolled off the bed. Staff D was not able to stop the resident due to their size. Reference: WAC 388-97-1060(3)(g)

Based on interview and record review, the facility failed to administer the correct dose of pain medication for 1 of 3 sampled residents (Resident 1), reviewed for medication errors. Resident 1 experienced experienced harm when they had uncontrolled pain that required hospital transfer when Staff administered 50 mg of Tramadol (an opioid medication used for moderate to severe pain) instead of 100 mg, as ordered. Findings included . Review of a facility assessment, dated 03/17/2025, showed Resident 1 was admitted with diagnoses to include sciatica (a condition where a nerve root in the lower back was compressed or irritated which could cause pain and radiated down the leg along the affected nerve) and a progressive neurological disorder that affected movement. Resident 1 was able to make their needs known. Review of the Resident 1's care plan, dated 03/13/2025, identified the resident was on pain medication therapy. Saff were to administer the pain medications as ordered by the physician, monitor for side effects and effectiveness of the medication. Review of a facility investigation, dated 03/25/2025, showed the resident had only received one 50 milligram (mg) tablet of Tramadol instead of two 50 mg tablets (total of 100 mg) which was ordered. The resident had severe pain that was not fully alleviated with the 1 tablet. The resident was sent to the hospital later in the evening for uncontrolled pain. Review of Staff A, Licensed Practical Nurse (LPN) interview during the investigation showed the resident was medicated with Tramadol at 9:30 PM, the nurse followed up with the resident who continued to complain of severe pain. The resident was given Tylenol and continued to rate their pain as a 10 (scale 0 - 10; 0 no pain, 10 worst pain possible). The provider was called and the resident was sent to the hospital. Review of the resident's Medication Administration Record (MAR) for March 2025 showed the Resident 1 had an order for Tramadol 50 mg every six hours as needed and 100 mg scheduled at bedtime. The resident was also taking a muscle relaxant and a medication for nerve pain. Review of hospital records showed the resident arrived at the emergency room (ER) at 12:40 AM on 03/26/2025, complained of right leg pain, and rated it an 8 out of 10 (8 - intense pain, physical activity is severely limited). During an interview on 04/14/2025 at 1:30 PM, Staff B, Director of Nursing (DNS), stated Staff A no longer worked at the facility and confirmed Resident 1 had an order to give 100 mg of Tramadol in the evening and only received 50 mg. Staff B stated the facility reviewed ER transfers and that was how they discovered the medication error. On 04/15/2025 at 2:15 PM, Resident 1 was interviewed. The resident stated they asked the nurse to start with only 50 mg of Tramadol and if the pain continued, they would ask for the other 50 mg. When Resident 1 realized they needed the second tablet for pain, the nurse refused to give it to them, and told the resident they didn't not have an order for more. Resident 1 told Staff A they only had half the ordered amount and Staff A stated they were not getting more. The resident was then sent to the hospital with uncontrolled pain. Reference: WAC 388-97-1060(1)

Based on interview and record review the facility failed to ensure the facility had enough staff to provide care according to facility acuity (the level of severity of residents' illnesses, physical, mental, and cognitive limitations, and conditions) and/or care plans for 5 of 9 sampled resident's (Resident 40, 31, 27, 24 and 28), reviewed for sufficient staffing. This failure placed all residents at risk for potentially avoidable accidents, unmet care needs, and diminished quality of life. Findings included . Review of the facility assessment reviewed 08/15/2024, showed staffing levels were determined at the facility level to ensure there were enough staff with appropriate competencies and skill set necessary to care for the residents' needs as identified through resident assessments and plans of care. The facility would consider staffing needs for each shift and would adjust as necessary based on any changes to its resident population. The assessment further showed the facility average daily census was 105 over the last six months with an average of 70 long term care and 35 short term/rehabilitation residents. The facility reviewed resident acuity levels to understand potential implications regarding the intensity and complexity of care and services needed. The assessment showed the facility contingency staffing plan included the use of on-call managers who would come into the building to provided coverage as needed and the use of staffing agencies for immediate and long-term staffing needs when needed. <Resident 40> According to the 11/02/2024 quarterly assessment, Resident 40 was cognitively intact, understood others, made themselves understood, and was able to clearly verbalize their needs. Review of July 2024 through December 2024 grievance log showed Resident 40 filed the following grievances: -08/06/2024 staff ignored call lights and played on their mobile phones. -09/03/2024 still having issues with staff ignoring call light never had any follow up from prior grievance in August. -12/03/2024 night shift staff using Oak activity room as break room and ignoring call lights. In an interview on 01/08/2025 at 10:38 AM, Resident 40 stated staff were still not answering call lights timely. Resident 40 further stated they received medications around 3:30 AM and would often come out in search of the nurse to find staff using the Oak activity room as a breakroom while residents had call lights on in the halls. <Resident 31> According to the 11/19/2024 quarterly assessment, Resident 31 had diagnoses including chronic (occurring for long period of time or repeatedly) respiratory failure (lungs not working properly to get enough oxygen into the body) with hypoxia (low oxygen levels in body), chronic pulmonary embolism (blood clot that blocks blood flow to lungs), and muscle weakness. Resident 31 was cognitively intact, understood others, made themselves understood, and was able to clearly verbalize their needs. Review of the 04/17/2024 self-care performance deficit care plan showed Resident 31 required extensive assistance of staff to perform most activities of daily living (ADLs) including toileting hygiene. A 04/17/2024 fall risk care plan showed Resident 31 was at risk for falls and instructed staff to encourage call light use, ensure appropriate footwear was worn, keep the bed at an appropriate transfer level, and anticipate Resident 31's needs. A 04/17/2024 respiratory care plan showed Resident 31 had difficulty breathing and instructed staff to elevate the head of the bed and provide oxygen therapy per provider order, changing from an oxygen mask to a nasal cannula during meals. Review of July 2024 through December 2024 grievance log showed Resident 31 filed the following grievances: -07/02/2024 the night Nursing Assistant was rude, rough and pinched Resident 31's skin when they assisted with a brief change. -11/05/2024 they waited 45 minutes for staff to assist with personal hygiene after an episode of incontinence. In an interview on 01/08/2025 at 10:38 AM, Resident 31 stated staff were still not answering call lights timely. Resident 31 further stated they should not be taking themselves to the bathroom but did because staff would not respond to their call light timely. Resident 31 explained they typically did not wear their oxygen when in the bathroom, last week they pressed their bathroom call light, after waiting 35 minutes without staff response, Resident 31 began to yell out because they needed their oxygen. Resident 31 stated they left the door to their room open, in case of emergencies, because staff did not response to call lights timely. <Resident 27> According to the 12/19/2024 quarterly assessment, Resident 27 admitted to the facility on [DATE] with diagnoses including muscle weakness. Resident 27 required substantial staff assist to transfer onto the toilet and was dependent of staff for toileting hygiene. The assessment further showed Resident 27 did not sustain any falls prior to admission and sustained three falls after their admission. Resident 27 had moderate cognitive impairment and was able to verbalize their needs. Review of the 11/18/2024 self-care deficit care plan showed Resident 27 required extensive assistance of one to two staff to use a mechanical lift for transfers. A 11/18/2024 care plan showed Resident 27 was a risk at risk for falls related to being legally blind and instructed staff to anticipate Resident 27's needs, encourage call light usage, keep bed at a safe transfer level, offer toileting with each interaction, and not to leave Resident 27 unattended on the toilet. Review of the November 2024 through December 2024 facility incident log showed Resident 27 sustained falls on 11/12/2024, 11/17/2024, 12/05/2024, and 12/28/2024. Review of the 11/17/2024 fall incident report showed Resident 27 was found sitting on the floor in the bathroom. A 11/19/2024 incident summary showed Resident 27 was left on the toilet unattended and attempted to self-transfer back into their wheelchair. Review of the 12/05/2024 fall incident report showed Resident 27 was found lying on the bathroom floor holding the back of their bleeding head. A 12/06/2024 incident summary showed Resident 27 recently had their diuretic (medication that helps the body get rid of excess fluid) increased and fell when they attempted to transfer onto the toilet independently. During observation on 01/10/2025 at 11:51 AM, the call light above Resident 27's room came on. A visitor stuck their head out of the room and said Where is an aide at? [Resident 27] needs to go to the bathroom, last time [Resident 27] fell , [staff] better get down here, we will see how long this takes. At 11:52 AM, Resident 27 now sat in the doorway to their room with the call light still on. At 11:53 AM, the visitor flagged staff down and informed them Resident 27 needed to go to the bathroom. In an interview on 01/14/2025 at 10:10 AM, Resident 27's family friend stated residents had excessively long call light wait times, and they reported their concern to nursing. Resident 27's friend explained they had seen multiple call lights on with no staff around. The friend continued to explain Resident 27 had weakness in their legs and had their diuretic increased which caused Resident 27 to urinate more often. Resident 27's friend further stated Resident 27 attempted to self-transfer because they waited too long for staff to answer their call light. In an interview on 01/14/2025 at 10:13 AM, Resident 27 stated they sustained at least three falls in the facility. Resident 27 explained they took themselves into the bathroom because they did not want to have incontinence accidents while waiting for staff to answer their call light. Resident 27 further stated there was not enough help because they had excessive call light wait times. <Resident 24> According to the 11/16/2024 quarterly assessment, Resident 24 was cognitively intact, understood others, made themselves understood, and was able to clearly verbalize their needs. Review of the functional abilities care plan revised 12/05/2023 showed Resident 24 required substantial up to dependent staff assistance to perform most ADLs and instructed staff not to rush Resident 24 during ADL cares. Review of July 2024 through December 2024 grievance log showed Resident 24 filed the following grievances: -11/05/2024 the resident waited one and a half hours for staff assistance. In an interview on 01/07/2025 at 2:43 PM, Resident 24 stated the facility did not have enough staff because they often had excessively long call light waiting times. <Resident 28> According to the 12/16/2024 quarterly assessment, Resident 28 was cognitively intact, understood others, made themselves understood, and was able to clearly verbalize their needs. In an interview on 01/07/2025 at 11:29 AM, Resident 28 explained they approached the nurses' station after waiting 50 minutes for their call light to be answered and observed staff sitting around while call lights were going off. In an interview on 01/17/2025 at 12:28 PM, Staff G, Nursing Assistant (NA), stated they were unsure how the facility determined staffing levels. Staff G explained when a NA called in the facility pulled staff from another unit or placed the restorative staff on the floor. Staff G acknowledged residents had excessively long call light wait times when not enough staff. In an interview on 01/17/2025 at 12:52 PM, Staff E, Registered Nurse, stated they were unsure how the facility determined staffing levels. Staff E explained when a nurse called in, sometimes the resident care manager (RCM) came in to help. When a NA called in staff would be pulled from another unit or from the restorative nursing program. Staff E stated restorative nursing staff wore dual hats sometimes they were restorative aides and other times they were a floor aide. Staff E further stated the restorative program did not have a big pool of staff to pull from, only 2 or 3 restorative aides, but pulling from restorative staff was the last resort because that staff was not replaced when pulled to the floor. Staff E acknowledged residents had to wait a long time to get help when there was not enough staff. In an interview on 01/17/2025 at 12:59 PM, Staff D, RCM, stated in theory staffing should be based on census and acutely level. Staff D explained when staff called in, they were to call the facility to get the on-call managers number and call the on-call manager. The on-call manager was to attempt to call staff in and if unable to fill the vacancy, the facility would pull the shower aides to the floor or place restorative nursing staff on the floor. Staff D explained if the bathe aide was pulled to the floor each NA would be responsible for completing their own bathes, if the restorative aide was pulled to the floor, no staff replaced restorative because they did not have the training, there was no restorative program. A tracking log of attempts to fill call ins was requested from Staff D. Staff D acknowledged the facility had no tracking log of who was called in an attempt to fill staffing call ins when they occurred. Staff D was asked about facility acuity. Staff D explained Oak hall was long-term care residents, rooms 101 through 120 had lighter care needs while rooms 128 through 146 had heavier care needs with higher use of full body lifts for dependent residents. Staff D explained as the resident care manager they had attempted to readjust the NA section assignments based on resident acuity, but floor staff did not honor managements changes and readjust the assignments. Staff D acknowledged some residents had excessively long call light wait times, especially the back of Oak hall, rooms 128 through 146. During interview and record review on 01/17/2025 at 1:20 PM, Staff U, Staffing Coordinator, explained they followed a handwritten staffing guide. Staff U provided a copy. Review of the form provided by Staff U showed staffing assignments for Oak hall for staffing from three up to eight direct care staff and instructed nurses to adjust assignments based on resident behaviors and use of transfer lifts. Staff U explained Oak hall was long-term care, residents in the front part of Oak required less assistance than the residents toward the back of Oak hall. Staff U stated staff assigned to the front of Oak sometimes cared for more residents because they required less assistance, but that was not consistent. Staff U acknowledged staff who worked the back of Oak hall had voiced concerns about needing more staff in that area. In an interview on 01/17/2025 at 1:46 PM, Staff B, Director of Nursing, stated staffing was based on calculations according to the company guidance that determined how many direct care staff were needed based on census. Staff B further stated management also attempted to keep the facility acuity into consideration. Staff B acknowledged residents on the back part of Oak hall were heavier care and attempted to adjust section assignments accordingly. In a confidential interview on 01/17/2025 at 2:00 PM, an anonymous staff stated the back part of Oak hall was heavy care related to a high use of transfer lifts, it was too much for one person to handle. The anonymous staff further stated they had informed management, but nothing had been done yet; the section assignments did not get adjusted. The staff added sometimes it took them 20 minutes to find a peer to assist them with full body mechanical lift transfers because those should not be done with only one staff for safety. In an interview on 01/17/2025 at 4:07 PM, Staff A, Administrator, stated staffing levels were determined based on the facility population. Staff A further stated section assignments were readjusted based on resident acuity nightly. Reference WAC 388-97-1080 (1), -1090 (1) Refer to F585, F676, and F727 for additional information.

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety. Specifically, expired foods were not discarded for 1 of 2 refrigerators, 1 of 1 dry storage areas, and food items in the refrigerator and freezer were not dated when opened. The facility further failed to maintain a clean cooking environment. These failures placed residents at risk for food-borne illnesses. Findings included . <Expired/undated food> During an initial tour of the kitchen on [DATE] at 8:47 AM, the dry storage area revealed a container of French salad dressing and two containers of Caesar salad dressing with no received or expiration date, six cartons of thickened cranberry cocktail that expired [DATE], a bag of coconut that expired [DATE], and twelve containers of a vanilla nutritional drink that expired on [DATE]. The refrigerator in the main kitchen contained a bag of brown, wilted salad, two bags of brown wilted lettuce and a bag of spinach that was brown that had no received or expiration dates. The freezer contained a bag of ham with a use by date of [DATE], a bag of tortillas with a use by date of [DATE], a bag of zucchini with a use by date of [DATE], two pecan pies with a use by date of [DATE], three bags of meatballs that expired on [DATE], a bag of opened egg rolls and chicken breasts with no open or expiration date, and an opened bag of beef fritters and uncovered wheat rolls that were freezer burned. During an interview on [DATE] at 9:34 AM, Staff S, Registered Dietician, stated there needed to be a date on all food items and it was important for quality, safety and to prevent food borne illnesses. <Food Temperatures> During observation of a lunch tray line on [DATE] at 11:19 AM, Staff Q, Dietary Manager, had checked the temperatures of the cold items.The salad was 52.1 degrees Fahrenheit (F), cottage cheese was 44 degrees F, and the Jello was 64.6 degrees F., all above the recommended food temperature of 41 degrees. Staff Q placed the cottage cheese, salads, and sandwiches on an ice bath. At 11:39 AM, Staff Q served the items from the ice bath, no further temperatures of the food were obtained. At 11:58 AM, Staff Q served a chicken breast from a warmer and no temperature was obtained. At 12:02 PM, Staff Q served a sandwich from the refrigerator and no temperature was obtained. At 12:19 PM, Staff Q served another chicken breast and no temperature was obtained. In an interview on [DATE] at 12:21 PM, Staff Q stated they were not sure if the items from the ice bath were at an appropriate temperature because they had not rechecked them. Staff Q stated it was important to check the temperatures of the food to prevent food borne illnesses. <Sanitary Environment> During an observation on [DATE] at 10:03 AM, the oven was unclean with food debris on the outside of the oven and thick burned food debris covered the bottom of the inside of the oven. The food warmer was unclean with food debris. Staff Q initially stated it was from spilled food and the outside of the oven was cleaned once a month and the inside every three months. Staff S stated the oven warmer, and oven needed to be cleaned, and Staff Q stated the outside of them gets cleaned every evening. Staff S stated the oven and oven warmer needed to be kept clean to ensure safety. During a second observation of the kitchen seven days later on [DATE] at 1:25 PM, the thick layer of burned food debris remained on the bottom of the oven and the outside of the warmer and oven were unclean. Reference: WAC [DATE] (3), 2980

Based on observation, interview and record review, the facility failed to ensure staff were offered the COVID-19 vaccine (COVID-19, a viral illness that caused fever, difficult breathing, and other viral symptoms that included possible hospitalization or even death), were provided education regarding the risks/benefits and potential side effects of the vaccine, and maintained documentation related to vaccine education, declination,or administration of the vaccine as required for 3 of 3 sampled staff (Staff G, H, and I) reviewed. This failure placed residents and staff at risk of illness or exposure to the COVID-19 virus and potential unintended health consequences. Findings included . The Centers for Disease Control and Prevention (CDC) Recommended Adult Immunization Schedule 2025 for ages [AGE] years or older retrieved from www.cdc.gov/acip-recs/hcp/vaccine-specific/ documented adults age 19-[AGE] years or adults age 65 or older who were unvaccinated for COVID-19 were recommended to receive 1 or 2 doses (dependent on the vaccine brand) of COVID-19 vaccine unless contraindicated. Those previously vaccinated before 2024-2025 were recommended to receive 1 or 2 doses (dependent on the vaccine brand) of 2024-2025 COVID-19 vaccine unless contraindicated. On 01/15/2025 at 12:58 PM, room [ROOM NUMBER] on Evergreen Unit was observed to have a new aerosol precaution sign (signage that notified staff of important measures to implement prior to entering a resident room such as donning personal protective equipment, PPE, or performing hand hygiene, for example) on their door and the door was closed. A bin of PPE was positioned at the doorway, and Staff F, Nursing Assistant, NA, was observed putting on a disposable gown, gloves and a respirator-type mask. When interviewed, Staff F stated the resident in room [ROOM NUMBER] had been at the facility for 6 days and had just tested positive for COVID-19 that morning when they developed symptoms of respiratory illness. During an interview on 01/17/2025 at 9:27 AM, Staff G, NA, stated they had been vaccinated for COVID-19 probably two years prior when the vaccine first came out and was unaware there were additional COVID-19 vaccines available. Staff G stated they had never received any education regarding the vaccine and had not been offered one recently. During an interview on 01/17/2025 at 10:33 AM, Staff H, NA, stated they did not remember being offered a COVID-19 vaccine recently unless it was offered as part of their initial employment onboarding paperwork. A review of staff COVID-19 vaccinations documented the following: -Staff G received two doses of the COVID-19 vaccine on 05/07/2021 and 06/08/2021 and signed a declination for an additional vaccine on 07/26/2023. -Staff H received two doses of the COVID-19 vaccine on 09/12/2021 and 10/11/2021. -A third staff, Staff I, NA, was added to the review and had received two doses of COVID-19 vaccine on 08/25/2021 and 09/16/2021. During an interview on 01/17/2025 at 1:13 PM, Staff J, Licensed Practical Nurse and temporary acting Infection Prevention Nurse, stated the facility did not offer COVID-19 vaccines to staff. They encouraged the staff to see their primary care provider or pharmacies that offered discounted vaccinations and bring in their proof of vaccination. Staff J was uncertain when the facility stopped offering COVID-19 vaccines. They stated if staff did not bring in evidence of their vaccine, the facility had no documentation. Staff J stated they did not keep track of staff education or who had received or declined the COVID-19 vaccine. Reference: WAC 388-97-1320

Based on interview and record review the facility failed to ensure residents could file grievances without reprisal or fear of reprisal, report grievances consistent with alleged abuse to the State Survey Agency as required, and repeatedly promptly resolve grievances for 4 of 5 sampled residents (Resident 40, 31, 10, 24), reviewed for grievances. This failure placed residents at risk of feelings of powerlessness, unmet care needs, and diminished quality of life. Findings included . Review of the facility policy title, Grievance Procedure revised November 2016, documented residents and resident representatives were informed of their right to voice a grievance orally, in writing, and anonymously regarding the care and treatment/lack of treatment, behavior of staff and of other residents, and other concerns during their stay. The policy further documented residents had the right to voice grievances without discrimination or reprisal and without fear of discrimination or reprisal. Grievances were to be resolved immediately, when possible. If a grievance involved an allegation of abuse, neglect, exploitation, or misappropriation of resident property the executive director was to be notified, an investigation started and the abuse prohibition procedure was to be followed. <Resident 40> According to the 11/02/2024 quarterly assessment, Resident 40 was cognitively intact, understood others, made themselves understood, and was able to clearly verbalize their needs. Review of July 2024 through December 2024 grievance log showed Resident 40 filed the following grievances: -08/06/2024 the beef tips taste like sawdust with a 08/15/2024 resolution of facility returned to the previous food supplier. -08/06/2024 staff ignored call lights and played on their mobile phones. A 08/26/2024 resolution of staff was educated on leaving phones in lockers and notifying the nurse all resident cares were provided by the end of the shift. -09/03/2024 still having issues with staff ignoring call light never had any follow up from prior grievance in August and staff did not perform hand hygiene prior to handling resident items. A 09/10/2024 resolution of 1:1 staff education on hand hygiene. -12/03/2024 night shift staff using Oak activity room as break room and ignoring call lights. A 12/10/2024 resolution of staff education and signage posted on activity room staff were not to use the resident area as a breakroom. In an interview on 01/08/2025 at 10:38 AM, Resident 40 stated staff still had not answered call lights timely. Resident 40 further stated they received medications around 3:30 AM and often came out in search of the nurse to find staff using the Oak activity room as a breakroom while residents had call lights on in the halls. In a follow-up interview on 01/08/2025 at 11:11 AM, Resident 40 stated they felt staff retaliated against them when they previously voiced concerns. Resident 40 explained Staff F, Nursing Assistant (NA), approached them once and stated Why did you say that? You threw me under the bus and then would not talk to Resident 40 for a while. Resident 40 further stated they felt staff talked down to them and this made them feel they needed to move out. Resident 40 was unaware they could file a grievance anonymously and felt grievances were not addressed timely because they had the same concerns month after month. Review of additional grievances provided by the facility on 01/20/2025 showed: -06/04/2024 an identified nursing assistant (not Staff F, NA) wore their pants low with their underwear exposed. Resident 40 recommended the staff use a belt and staff responded, I don't have one, you are just looking at my **s. -06/10/2024 Resident 40 felt retaliated against when the staff identified in the 06/04/2024 grievance approached the resident and stated, I hope everyone can see that I am doing my job right. <Resident 31> According to the 11/19/2024 quarterly assessment, Resident 31 had diagnoses including chronic (occurring for long period of time or repeatedly) respiratory failure (lungs not working properly to get enough oxygen into the body) with hypoxia (low oxygen levels in body), chronic pulmonary embolism (blood clot that blocks blood flow to lungs), and muscle weakness. Resident 31 was cognitively intact, understood others, made themselves understood, and was able to clearly verbalize their needs. Review of July 2024 through December 2024 grievance log showed Resident 31 filed the following grievances: -07/02/2024 the night NA was rude, rough and pinched Resident 31's skin when they assisted with a brief change. A 07/03/2024 resolution included staff education and verbal disciplinary action. The grievance did not describe what type of staff education was provided. Review of the July 2024 through December 2024 facility mandatory reporting log showed no entries for this allegation of potential abuse. -09/03/2024 the clam chowder smelled and tasted bad with a 09/04/2024 resolution switched out soup for replacement item. -11/05/2024 waited 45 minutes for staff to assist with personal hygiene after an episode of incontinence. A 11/12/2024 resolution included a staff reminder to answer call lights as soon as possible. In an interview on 01/08/2025 at 10:38 AM, Resident 31 stated staff were still not answering call lights timely. Resident 31 further stated they were not to be taking themselves to the bathroom but did because staff would not respond to their call light timely. Resident 31 explained they typically did not wear their oxygen when in the bathroom, last week they pressed their bathroom call light, after waiting 35 minutes without staff response, Resident 31 began to yell out because they needed their oxygen. Resident 31 stated they left the door to their room open, in case of emergencies, because staff did not response to call lights timely. In a follow-up interview on 01/08/2025 at 11:11 AM, Resident 31 stated they felt ignored, and staff talked down to them. Resident 31 further stated they did not know how to file a grievance until their child informed them how. <Resident 10> According to the 10/19/2024 annual assessment, Resident 10 was cognitively intact, understood others, made themselves understood, and was able to clearly verbalize their needs. Review of the July 2024 through December 2024 grievance log showed Resident 10 filed the following grievances: -09/03/2024 Teriyaki beef was too tough with a 09/04/2024 resolution of staff were educated on roasting meat. In an interview on 01/08/2025 at 10:55 AM, Resident 10 stated they rarely ate meat served because they could not chew it. Resident 10 further stated the facility did not follow-up on grievances. <Resident 24> According to the 11/16/2024 quarterly assessment, Resident 24 was cognitively intact, understood others, made themselves understood, and was able to clearly verbalize their needs. Review of July 2024 through December 2024 grievance log showed Resident 24 filed the following grievances: -11/05/2024 waited one and a half hours for staff assistance with a 11/12/2024 resolution of staff re-education on call light response times. In an interview on 01/07/2025 at 2:43 PM, Resident 24 stated the facility did not have enough staff because they often had excessively long call light wait times. In an interview on 01/17/2025 at 9:09 AM, Staff G, Nursing Assistant, stated residents could submit grievances without fear of retaliation and informed residents about the Ombudsman (a person who investigated and resolved complaints, and advocated for resident's rights) if retaliation concerns arose. Staff G further stated staff were not to confront a resident as to why a concern was reported because that could be considered retaliation. In an interview on 01/17/2025 at 9:50 AM, Staff E, Registered Nurse, stated residents could file grievances without fear of retaliation. Staff E explained if they received a grievance that was a potential allegation of abuse, they followed the facility's abuse prohibition policy. Staff E acknowledged staff should not tell a resident they were thrown under the bus when a concern was voiced, that was unprofessional behavior that could potentially be considered retaliation or harassment. In an interview on 01/17/2025 at 10:26 AM, Staff T, Social Service Director, stated Staff A, Administrator was the grievance official. Staff T further stated residents should be able to submit grievances without fear of retaliation, staff should not approach a resident saying they were thrown under the bus as that could be considered retaliation. Staff T explained grievance information was confidential, and some details were not be shared with staff involved. Staff T further stated if they received a grievance that rose to the level of a potential abuse allegation, they followed the abuse prohibition policy. In an interview on 01/17/2025 at 11:33 AM, Staff B, Director of Nursing, stated residents could submit grievances without fear of retaliation and protected residents by not disclosing persons involved to maintain confidentiality. Staff B was unsure the time frame a grievance should be resolved by. Staff B further stated if a grievance sounded like a potential allegation of abuse, they followed the facility's abuse prohibition process. Staff B acknowledged staff should not approach a resident saying they were thrown under the bus when a concern was voiced because it could be considered retaliation that would need to be investigated. In an interview on 01/17/2025 at 3:56 PM, Staff A, Administrator, stated they reviewed grievances for potential allegation of abuse and followed the abuse policy if a grievance appeared to rise to the level of a potential allegation of abuse or neglect. Staff A further stated the facility attempted to resolve grievances within five days, but some grievances might take longer. Staff A acknowledged staff should not approach residents asking them why they were thrown under the bus as that could be considered potential retaliation. Reference WAC 388-97-0460 Refer to F607, F725, and F804 for additional information.

Based on interview and record review, the facility failed to implement its Abuse and Neglect Policy and Procedure to include the identification of potential allegations of abuse, responding to and reporting the allegation to the State Survey Agency (SA) as required, and thoroughly investigating allegations for 5 of 8 sampled residents (Resident 98, 10, 58, 40, and 31), reviewed for abuse. This failure placed residents at risk for abuse, unmet care needs, and a diminished quality of life. Findings included . Review of the facility policy titled, Freedom from Abuse, Neglect, Corporal Punishment, Involuntary Seclusion, Mistreatment, Misappropriation of Resident Property, and Exploitation, updated [DATE], defined different forms of abuse. The policy defined mental abuse as the use of verbal or nonverbal conduct which caused or had the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. The policy further showed new and existing staff would be trained regarding the facility's abuse policies to include identification of abuse and/or neglect, immediately report all suspected and/or allegations of abuse as required, and thoroughly investigate potential, suspected and/or allegations of abuse. <Resident 98> According to the [DATE] admission assessment, Resident 98 admitted to the facility on [DATE] with diagnoses including muscle weakness, reduced mobility, lack of coordination, and chronic pain. Resident 98 required touch assistance to transfer onto the toilet and moderate staff assistance to perform toileting hygiene. Resident 98 had severe cognitive impairment. Review of a [DATE] facility incident report showed Resident 98 experienced an unanticipated death. Resident 98 was found at 6:30 PM slumped over on the toilet with a laceration above their left eyebrow. The incident report further showed Resident 98 was last seen sitting on the edge of their bed at 5:25 PM, on hour and five minutes prior. The incident report only contained two staff interviews and no resident interviews. A [DATE] investigation summary showed Resident 98 had been compliant with use of their call light, but the call light was not on at the time Resident 98 was found on the toilet. The investigation summary did not rule out abuse and/neglect. Review of [DATE] nursing progress notes showed Resident 98 required moderate assistance for toileting. On [DATE] Resident 98 was found sitting on the toilet unresponsive, staff called emergency medical services and initiated cardiopulmonary resuscitation (CPR) per Resident 98's wishes. Resident 98 expired and the medical examiner (ME) was notified of the laceration to the left upper eyebrow. The progress notes further showed the ME was sent pictures of Resident 98's facial laceration and Resident 98 would need to be picked up for further testing. Further review of Resident 98's medical record showed no pictures of Resident 98's facial laceration were found. In an interview on [DATE] at 11:00 AM, Staff GG, Nursing Assistant (NA), stated they looked into resident rooms as they walked down the hall to check on residents. Staff GG further stated abuse and/or neglect was ruled out by management interviews of residents and staff interviews on the unit. In an interview on [DATE] at 11:16 AM, Staff LL, LPN, stated they constantly checked on residents as they walk down the hall. Staff LL explained incident investigations were completed by management, everyone filled out statements, and management ruled out abuse and/or neglect by reviewing staff and resident interviews conducted. In an interview on [DATE] at 11:53 AM, Staff Y, Resident Care Manager (RCM), explained investigations were completed by management staff depending on the allegation or incident. Staff Y further stated social service staff conducted interviews of residents in the general vicinity and staff, the interdisciplinary team (IDT) discussed the incident and ruled out abuse by asking questions. In an interview on [DATE] at 3:02 PM, Staff B, Director of Nursing (DNS), explained when an allegation of abuse was received, the staff receiving the report ensured resident safety and started the investigation process. The RCM and/or DNS would then interview staff and resident involved and social service staff would conduct extended interviews that included other resident in the area and staff working the unit at the time. Staff B further stated interviews were reviewed by the IDT to rule out abuse and/or neglect. In an interview on [DATE] at 4:17 PM, Staff A, Administrator, explained the facility ruled out abuse and/or neglect by interviewing residents and staff, if appropriate other staff beyond who was involved would be interviewed to try to get a clear picture of an incident. Staff A stated the facility ruled out abuse and/or neglect related to Resident 98's unanticipated death. Staff A was asked how abuse was ruled out if the investigation only contained two staff statements and no resident interviews. Staff A stated, no other residents were involved in that situation, so why would we interview other residents? <Resident 58> The [DATE] quarterly assessment documented Resident 58 had severe cognitive impairment but was able to understand others and make their needs known. On [DATE] at 8:14 AM, Resident 58 was observed lying in bed, waiting for breakfast. When asked about the care at the facility, the resident stated they did not care for Staff X, Licensed Practical Nurse (LPN). The resident stated Staff X was rude and not nice when they interacted with them. In a follow up interview at 1:14 PM that same day, Resident 58 stated that about two or three weeks ago, they had observed Staff X sleeping at the nurse's station, and when they had mentioned it to Staff X, they denied being asleep, and their manner was rude and condescending. Resident 58 further stated it made them feel terrible, and they would not feel comfortable in approaching Staff X if they needed assistance or had a medical concern. When Resident 58 was asked if they had told any of the other staff of their concern, Resident 58 stated they had kept quiet because they did not want to cause a ruckus and were afraid of retaliation. Resident 58 was then asked if they were comfortable with the surveyor informing the facility of their concerns regarding Staff X, and Resident 58 stated yes. In an interview on [DATE] at 2:16 PM, Staff A, Administrator, was informed of the conversation with Resident 58 and the resident's concerns regarding Staff X. On [DATE] a review of the State Agency incident reporting program, STARS, found no documentation that the facility had reported the allegation of possible abuse concerning Resident 58. A report was then made by the surveyor to the SA. An additional review of STARS on [DATE] at 11:49 AM, eight days after the facility was notified of the allegation, found no documentation to show the facility had reported the allegation to the SA as required. Review of the [DATE] facility grievance log which had been provided to the survey team on [DATE] found no entries related to Resident 58. On [DATE] at 12:00 PM, Staff A, Administrator was asked to provide the facility investigation related to Resident 58's allegation, an updated grievance log and the facility reporting log for [DATE]. On [DATE] at 2:38 PM, the updated facility reporting log for [DATE] was reviewed and no entries had been made regarding Resident 58. On [DATE] at 2:39 PM, review of the updated grievance log for [DATE] found an entry dated [DATE] was now present related to Resident 58 which documented the issue as a staff concern which was resolved on [DATE]. On [DATE] at 3:38 PM, a grievance form for Resident 58 was received via email correspondence from Staff A related to the staff concern on [DATE]. The form documented the nature of the concern was expressed by the surveyor and stated Staff X was mean. The form did not include all the information that had been reported to the facility. The form further documented the only steps taken to investigate were to interview the resident. No other documentation or a facility investigation was received. In an interview on [DATE] at 6:14 PM, Staff B, Director of Nursing, was asked if an investigation had been completed regarding the concerns expressed by Resident 58. Staff B stated it was their understanding that the concern was more how Staff X talked, and it was not identified as potential abuse. 47328 <Resident 40> According to the [DATE] quarterly assessment, Resident 40 was cognitively intact, understood others, made themselves understood, and was able to clearly verbalize their needs. Review of [DATE] through [DATE] grievance log showed Resident 40 filed the following grievances: -[DATE] staff ignored call lights and played on their mobile phones -[DATE] still having issues with staff ignoring call light never had any follow up from prior grievance in August and staff did not perform hand hygiene prior to handling resident items. -[DATE] night shift staff using Oak activity room as break room and ignoring call lights. In an interview on [DATE] at 10:38 AM, Resident 40 stated staff were still not answering call lights timely. Resident 40 further stated they received medications around 3:30 AM and often came out in search of the nurse to find Staff X, LPN, sleeping at the nurses' station and other staff using the Oak activity room as a breakroom, while residents had call lights on in the halls. In a follow-up interview on [DATE] at 11:11 AM, Resident 40 stated they felt staff retaliated against them when they previously voiced concerns. Resident 40 explained Staff F, NA, approached them once and stated Why did you say that? You threw me under the bus and then would not talk to Resident 40 for a while. Resident 40 further stated they felt staff talked down to them and this made them feel they needed to move out. In an interview on [DATE] at 12:03 PM, Staff A, Administrator, was informed Resident 40 voiced an allegation of potential abuse related to how staff communicated with them and how it made them feel. In an interview on [DATE] at 12:19 PM, Resident 40 was informed the surveyor reported their concerns about how staff communicated with them and how it made them feel to the facility because it was a potential allegation of abuse the facility needed to investigate. In a follow-up interview on [DATE] at 12:55 PM, Resident 40 stated social services spoke to them. Review of the State Survey Agency Secure Tracking And Reporting System, STARS, on [DATE], showed no entries for Resident 40's [DATE] allegation of potential abuse. The investigation for Resident 40's [DATE] allegation of potential abuse was requested from Staff A, administrator, on [DATE] at 12:00 PM. No documentation was provided. <Resident 10> According to the [DATE] annual assessment, Resident 10 was cognitively intact, understood others, made themselves understood, and was able to clearly verbalize their needs. In an interview on [DATE] at 11:11 AM, Resident 10 stated staff had poor social skills and ignored residents. Resident 10 explained this made them feel ignored and depressed. Review of the [DATE] depression screening assessment showed Resident 10 scored a one, indicating minimal depression symptoms. Review of the [DATE] depression screening assessment showed Resident 10 scored an eight, indicating mild depression symptoms. In an interview on [DATE] at 12:03 PM, Staff A, Administrator, was informed Resident 10 voiced an allegation of potential abuse related to how staff communicated with them and how it made them feel. In an interview on [DATE] at 12:19 PM, Resident 10 was informed the surveyor reported their concerns about how staff communicated with them and how it made them feel to the facility because it was a potential allegation of abuse the facility needed to investigate. The investigation for Resident 10's [DATE] allegation of potential abuse was requested from Staff A, administrator, on [DATE] at 12:00 PM. Review of the [DATE] facility incident report showed Resident 10 stated staff was mean and they wanted staff to make them feel like a human being. The investigation contained a [DATE] grievance filed by Resident 58 related to Staff X, LPN, being mean, no staff or other resident interviews were included. A [DATE] investigation summary showed abuse and/or neglect was ruled out through residents' interviews conducted by social services. <Resident 31> According to the [DATE] quarterly assessment, Resident 31 had diagnoses including chronic pulmonary embolism (blood clot that blocks blood flow to lungs) and muscle weakness. Resident 31 was cognitively intact, understood others, made themselves understood, and was able to clearly verbalize their needs. Review of [DATE] through [DATE] grievance log showed Resident 31 filed the following grievances: -[DATE] night NA was rude, rough and pinched Resident 31's skin when assisting with a brief change. A [DATE] resolution of staff education and verbal disciplinary action. The grievance did not describe what type of staff education was provided, did not include staff or resident interviews, and did not rule out abuse and/or neglect. Review of the [DATE] through [DATE] facility mandatory reporting log showed no entries for the [DATE] allegation of potential abuse. In an interview on [DATE] at 11:11 AM, Resident 31 stated they felt ignored by staff and staff talked down to them. In an interview on [DATE] at 12:03 PM, Staff A, Administrator, was informed Resident 31 voiced an allegation of potential abuse related to how staff communicated with them and how it made them feel. In an interview on [DATE] at 12:19 PM, Resident 31 was informed the surveyor reported their concerns about how staff communicated with them and how it made them feel to the facility because it was a potential allegation of abuse the facility needed to investigate. Review of the State Survey Agency Secure Tracking And Reporting System, STARS, on [DATE], showed no entries for Resident 31's [DATE] or [DATE] allegations of potential abuse. The investigation of Resident 31's [DATE] allegation of potential abuse was requested from Staff A, administrator, on [DATE] at 12:00 PM. Review of documentation provided showed a single piece of paper with Resident 31's vague interview. Resident 31's interview showed they could perform most cares independently, staff thought they did not need to help them but Resident 31 voiced they could use more staff assistance. Abuse and/or neglect was not ruled out. In an interview on [DATE] at 9:13 AM, Staff G, NA, stated if they received a report of a potential allegation of abuse, they would ensure resident safety then report the allegation to the nurse and up the chain of command so an investigation could be started. Staff G further stated a report of staff being rude and so rough they pinched a resident's skin, would be considered a grievance, not a potential allegation of abuse. In an interview on [DATE] at 9:54 AM, Staff E, Registered Nurse, stated if a resident reported staff was rude and so rough they pinched a resident's skin, Staff E would complete a skin assessment, speak with the identified staff 1:1, and notify management. Staff E further stated they would ask the resident if they would like to file a grievance with an incident resolution. In an interview on [DATE] at 10:32 AM, Staff T, Social Service Director, explained when an allegation of potential abuse was reported they would ensure resident safety by removing any identified staff from providing resident care, start an investigation, and rule out abuse and/or neglect by completing resident and staff interviews. Staff T acknowledged if a resident reported staff was rude, rough, and pinched their skin, it would be considered a potential allegation that needed to be reported to the State Survey Agency and all steps followed to investigate the potential allegation. In an interview on [DATE] at 11:38 AM, Staff B, Director of Nursing, stated all staff were mandatory reporters and should follow the appropriate steps when an allegation of abuse was received. Staff B acknowledged Resident 31's [DATE] grievance of rude staff with rough care and pinched skin should have been reported as an allegation of abuse and investigated as such. In an interview on [DATE] at 3:56 PM, Staff A, Administrator, stated they reviewed grievances for potential allegations of abuse and/or neglect. Staff A further stated if a grievance appeared as a potential allegation, then it would be reported and investigated following all the steps in the abuse policy. In a follow-up interview on [DATE] at 4:01 PM, Staff A, acknowledged if a resident reported staff was rough and pinched their skin, it would be considered an allegation of potential abuse. Reference WAC [DATE] (2) Refer to F585, F730, and F842 for additional information.

Based on observation, interview and record review, the facility failed to provide care according to the person-centered care plans and provider orders for 4 of 8 sampled residents (Residents 27, 36, 54 and 89 ) reviewed for quality of care. Specifically, Resident 27 was on a fluid restriction and their intake was not monitored or maintained, Resident 36's blood sugar monitoring equipment was broken by staff and was not replced timely, Resident 54 did not have their bowel management medications administered to prevent constipation, and Resident 89 had difficulty swallowing and a Speech Therapy evaluation was not completed timely. These failures placed residents at risk for unintended health consequences and decreased quality of life. Findings included . <Resident 36> A review of the 10/25/2024 quarterly assessment documented Resident 36 had diagnoses that included Parkinson's disease (a Central nervous system disease that caused stiffness, tremors and balance difficulty) and diabetes. The resident was cognitively intact and received insulin injections (treated high blood sugar) daily. On 08/07/2024, an order was given by the provider for staff to utilize a continuous glucose monitor (CGM, a sensor inserted under the skin that monitored blood sugar levels continuously and sent the information to a receiver or smartphone application) to monitor Resident 36's blood sugar level twice a day, no finger sticks. During an interview on 01/08/2025 at 11:11 AM, Resident 36 was in their room seated in their recliner. The resident stated they received insulin injections every day to manage their blood sugar. Resident 36 stated they had an implanted blood sugar monitor and it was observed on the back upper portion of the resident's left arm. The resident stated they had a receiver that was held up to their arm and their blood sugar level could be seen. Resident 36 stated their CGM had been broken over a week prior. The resident stated one of the nurses had been unable to get the CGM to work, had tried to replace a cartridge in the sensor and also broke the cartridge. The resident stated ever since, staff were pricking their fingers to obtain their blood sugar and their fingertips were sore. Resident 36 stated their family member had tried to order more cartridges but none had come in yet. Review of the January medication administration record (MAR) documented blood sugar results were obtained twice daily from Resident 36's CGM, with no omissions. There were no progress notes that documented that the CGM was broken, what the status was, or if the provider or other staff had been notified. During a follow up interview on 01/17/2025 at 9:10 AM, Resident 36 stated they were still having their blood sugar results obtained using finger sticks. They stated no one from the facility had talked with them regarding replacing their cartridges or if their family was able to obtain any supplies. During an interview on 01/17/2025 at 9:33 AM, Staff AA, Certified Medication Technician, stated they performed finger sticks to obtain Resident 36's blood sugar result. Staff AA viewed the order that instructed staff to use the monitor and not use finger sticks and stated the resident's CGM was not working and had been broken for several weeks. Staff AA was not sure if the provider had been notified, or if the Resident Care Manager knew the CGM was broken. During an interview on 01/17/2025 at 1:18 PM, Staff D, Resident Care Manager, stated they had not been notified that Resident 36's CGM was not working. The resident's family had been providing the supplies for the monitor. Staff D stated they expected staff to notify the provider so other arrangements or orders for blood sugar monitoring could be obtained, and they expected staff to follow-up and also write a progress note. 46115 CONSTIPATION <Resident 54> Review of the March 2018 facility bowel protocol, documented residents who were at risk of constipation would have a care plan implemented. A licensed nurse reviewed the bowel monitor daily, and if a resident did not have a bowel movement (BM) for three days, the nurse administered the physician ordered bowel program. Per the 12/23/2024 significant change in condition assessment, Resident 54 was unable to make decisions regarding cares, and needed total assistance from staff for activities of daily living, such as toileting. Review of the 04/27/2023 care plan showed there was no care plan for constipation. Review of the December 2024 MAR documented on 12/17/2024, the physician had ordered a laxative (Milk of Magnesia) to be given on day four of no BM as needed, a suppository was to be given the next shift if no BM and an enema the next shift if no results had occurred. Review of the bowel records from 12/12/2024 through 01/08/2025, documented Resident 54 had no BMs from 12/20/2024 through 12/24/2024 (five days). Additional review of the MARS for December 2024, documented the resident had not received the bowel medication as ordered during the above time frames, and no documentation was found in Resident 54's record that stated the reason for the omissions. In an interview on 01/16/2024 at 3:14 PM, Staff B, Director of Nursing, stated the expectation was for bowel medication to be given as ordered and this was important to prevent constipation which could cause pain, discomfort and an obstruction. 47328 FLUID RESTRICTION <Resident 27> According to the 12/19/2024 quarterly assessment, Resident 27 admitted to the facility on [DATE] with diagnoses including heart failure (HF, heart is not strong enough to pump blood well enough to meet the body's needs), atrial fibrillation (irregular and abnormal heartbeat) and malnutrition. Resident 27 had moderate cognitive impairment and was able to verbalize their needs. Review of the 09/24/2024 nutrition care plan showed Resident 27 had nutritional risks and instructed staff to provide diet per provider orders, provide 120 milliliters (mls) of a house supplement with meals, obtain weights per facility protocol, and follow a 1500 ml/24 hours (hrs) fluid restriction per provider orders. Review of provider orders showed a 12/02/2024 order Resident 27 was on a 1500 ml fluid restriction. The provider order broke down the fluids as dietary was to provide 960 mls/24 hrs with meals and nursing was to provide 540 mls/24 hrs, (180 mls each shift in addition to fluid provided by dietary). A 12/02/2024 order instructed night shift to add all fluids provided by the dietary and nursing departments nightly. Review of the December 2024 through January 2025 MAR showed Resident 27 was provided the following fluids by nursing: -12/02/2024 540 mls on evening shift -12/08/2024 240 mls on day shift -12/12/2024 540 mls on night shift -12/15/2024 360 mls on day, evening, and night shifts -01/01/2025 360 mls on day shift and evening shift -01/08/2025 320 mls on evening shift These amounts exceeded the 180 mls allowed per shift. The January 2025 MAR further showed Resident 27 received 1620 mls fluid total on 01/07/2025 and 2480 mls fluid total on 01/08/2025. Review of the December 2024 through January 2025 fluid intake at meals showed Resident 27 was provided: -12/23/2024 488 mls with breakfast, 440 mls with lunch, and 240 mls with dinner (1168 mls) -12/12/2024 360 mls with breakfast, 240 mls with lunch, and 480 mls with dinner (1080 mls) -01/06/2025 420 mls with breakfast and lunch, 240 mls with dinner (1080 mls) During observation on 01/07/2025 at 9:15 AM, Resident 27 sat in their room with a Fluid Restriction 1500mls, NO water at bedside sign posted above their bed. Resident 27 had a large clear cup of ice water with a straw on their bedside table. Similar observations were made on 01/07/2025 at 12:13 PM, on 01/09/2025 at 8:14 AM and 12:13 PM, on 01/13/2025 at 7:44 AM, and 01/15/2025 at 10:05 AM. In an interview on 01/09/2025 at 1:25 PM, Staff R, Nursing Assistant (NA), stated floor staff passed ice water at least twice daily. Staff R was unsure what size the large clear cups used to pass ice water to the residents were. In an interview on 01/14/2025 at 10:13 AM, Resident 27 stated they could get all the juice, coffee, or other fluids they wanted but sometimes staff limited their water. Resident 27 explained staff removed water from the bedside at night. In a follow-up interview on 01/15/2025 at 12:12 PM, Staff R, NA, stated staff could reference a resident's care plan to see what interventions were implemented for the resident, including a fluid restriction. Staff R further stated fluid restrictions were typically in place related to heart issues and not following a fluid restriction could potentially cause increased swelling and medical complications. During observation and interview on 01/15/2025 at 12:25 PM, Staff E, Registered Nurse, explained when a resident was on a fluid restriction, the daily fluid allotment would be divided up into fluids provided by dietary for meals and fluids provided by nursing throughout the day. Staff E stated fluids consumed would be documented in the resident's medical record. Staff E further stated residents were typically on fluid restrictions related to HF and could fill up with fluid if the restriction was not followed. Staff E stated Resident 27 was on a fluid restriction and had signage posted at the bedside to notify staff. Staff E walked into Resident 27's room to point out the fluid restriction sign that read Fluid Restriction 1500mls, NO water at bedside. Staff E removed a large clear cup of water off the bedside table and acknowledged Resident 27 should not have water at their bedside. Staff E reviewed Resident 27's medical record. Staff E stated Resident 27 was on a fluid restriction because they had HF. In an interview on 01/15/2025 at 1:07 PM, Staff D, Resident Care Manager, explained when a resident was on a fluid restriction, the daily fluid allotment would be divided up into fluids provided by dietary for meals and fluids provided by nursing throughout the day. Staff D stated a resident on a fluid restriction should not receive extra water and typically had signage posted at the bedside for staff to follow. Staff D reviewed Resident 27's medical record. Staff D acknowledged Resident 27 was on a fluid restriction because of their HF. In an interview on 01/15/2025 at 2:22 PM, with Staff B, Director of Nursing, and Staff C, Assistant Director of Nursing, they explained when a resident was on a fluid restriction, the daily fluid allotment would be divided up into fluids provided by dietary for meals and fluids provided by nursing throughout the day. Staff B stated the facility typically posted signage at the bedside when a resident was on a fluid restriction and staff should ask the resident's nurse for approval on fluids prior to providing them to a resident on a fluid restriction. The provider should be notified if a resident took in more fluids than ordered. Both Staff B and C stated if a fluid restriction was not followed it could cause fluid overload and/or a potential flare up of the medical condition the fluid restriction was managing. Both Staff B and Staff C were unsure what size the large clear plastic cups used to pass ice water to the residents were. Staff B reviewed Resident 27's medical record. Staff B acknowledged Resident 27 was on a fluid restriction for HF. In an interview on 01/15/2025 at 3:44 PM, Staff A, Administrator, was unsure what size the large clear plastic cups used to pass ice water to the residents were. Staff A stated they expected staff to read signage posted in a resident's room and follow fluid restrictions when implemented. In an interview on 01/17/2025 at 3:28 PM, Staff S, Registered Dietician, was unsure what size the large clear water cups used to pass ice water to the residents were. Staff S further stated they were not aware staff were not following Resident 27's fluid restriction and were concerned. Reference WAC 388-97-1060 (1) This is a repeat deficiency from 11/13/2024 and 05/13/2024.

Based on observation, interview and record review, the facility failed to implement interventions timely to prevent weight loss for 2 of 7 sampled residents (Resident 54 and 77) reviewed for nutrition. This failure placed the residents at risk for further weight loss and a decline in their health. Findings included . <Resident 77> According to the 11/09/2024 annual assessment, Resident 77 admitted to the facility on [DATE] with diagnoses including dysphagia and muscle weakness. The assessment further showed Resident 77 showed no signs and/or symptoms of a swallowing disorder. Resident 77's weight was 159 lbs within the last 30 days. Resident 77 was cognitively intact and able to clearly verbalize their needs. Review of the 01/05/2024 initial nutrition evaluation by the Registered Dietician showed Resident 77's weight was 181.6 lbs on 01/04/2024. The assessment further showed Resident 77 was on a regular texture diet with thin liquids and nourishment supplement ordered at bedtime. Resident 77 consumed 75-100% of all three meals. Nutritional interventions were listed as monitoring with a goal weight of 180 lbs, plus or minus 5%. Review of a 05/01/2024 nutrition hydration skin committee review form showed Resident 77 was reviewed related to weight loss. Resident 77's weight was 165.8 lbs on 04/30/2024 with a 5% weigh loss in the last month from 174.9 lbs on 03/29/2024. Resident 77's average meal intake was 26-100%. An interdisciplinary team evaluation summary showed Resident 77 had an 11 lbs significant weight loss in April 2024 unrelated to intake, no recommendations were made at that time. Review of a 08/22/2024 nutrition hydration skin committee review form showed Resident 77 was reviewed related to weight loss. Resident 77's weight was 158.8 lbs on 08/22/2024 with a 7.5% weight loss in the last three months from 169.2 on 05/09/2024 and a 10% weight loss in the last six months from 179.9 on 02/16/2024. Resident 77's average meal intake was 51-100%. An interdisciplinary team evaluation summary showed Resident 77 had documented weights indicating weight loss, weight were obtained sitting, standing, and in wheelchair and recommended consistent weighing method be used. Review of a 08/23/2024 nutrition note showed Resident 77's body mass index (BMI, calculated weight relative to height) was at the lower end of normal for their age and a calorie dense supplement was added twice daily for calorie and protein support. Review of provider orders showed Resident 77 was ordered a nutritionally enhanced meals (NEM, extra calories added through use of butter, brown sugar and gravy for example) on 08/22/2024 and a calorie dense supplement twice daily on 08/23/2024. Review of the nutrition care plan revised 08/23/2024 instructed staff to provide Resident 77 a diet and calorie dense supplement as ordered, offer liquids between meals, obtain weights per facility protocol, and offer a meal substitute or supplement if 50% or less of a meal was consumed. Review of a 09/24/2024 provider progress note showed Resident 77 was concerned about their weight loss. The note further showed Resident 77 had a 15 lbs weight loss in the last six months, moderate protein-calorie malnutrition with muscle wasting in their abdomen, thighs, and face. Resident 77 stated the food is horrible. Review of the 11/06/2024 annual nutrition evaluation form showed Resident 77's weight was 159.2 lbs on 11/04/2024 and their desired body weight was between 170-180 lbs. The assessment further showed Resident 77 was on regular texture NEM diet with thin liquids and calorie dense supplement twice daily. Resident 77 consumed 26-100% of their meals. The dietician evaluation summary showed between 08/14/2024 through 11/04/2024, Resident 77's weights had been stable between 154 and 160 lbs. Review of a 12/04/2024 provider note showed Resident 77 was seen for follow-up on their protein calorie malnutrition. Resident 77 was on nutritional supplements and their weight had stabilized between 157-158 lbs for the last three months. Resident 77 attributed their weight loss to disliking the facility food. In an interview on 01/07/2025 at 2:53 PM, Resident 77 stated the facility food was terrible. Resident 77 further stated they had lost 30 lbs, from 180 lbs down to 160 lbs, and it bothers me. Resident 77 explained they had lost so much weight they could now pull their pants down without having to undo their belt. In a follow-up interview on 01/17/2025 at 9:04 AM, Resident 77 stated their preferred weight was being in the 180 lbs range. Resident 77 again stated their pants were loose and was concerned they had lost so much weight. In an interview on 01/16/2025 at 1:43 PM, Staff G, NA, explained the facility process for obtaining weights. Staff G explained if a weight showed a potential weight loss, a reweigh would be obtained and they would notify the nurse and resident care manager. Staff G was unsure if Resident 77 had weight loss. In an interview on 01/16/2025 at 1:53 PM, Staff E, Registered Nurse, stated if a resident refused a meal or consumed less than 50% of a meal, they would offer them an alternative like a sandwich or pudding. Staff E further stated if potential weigh loss was identified the provider and RD would be notified. Staff E reviewed Resident 77's medical record. Staff E stated Resident 77's weight upon admission was 182 lbs on 12/29/2023, was not on a prescribed weight loss regimen and had weight loss in the facility, Resident 77's lowest weight was 154.8 lbs on 10/01/2024. Staff E further stated Resident 77 was started on a calorie dense supplement on 08/23/2024 after a 23.2 lbs weight loss. Staff E acknowledged Resident 77's stopped losing weight, their weight stabilized, and they started gaining a few pounds after the supplement was added and increased. In an interview on 01/16/2025 at 2:18 PM, Staff Y, Resident Care Manager, reviewed Resident 77's medical record. Staff Y stated Resident 77's weight upon admission was 182 on 12/29/2023, they lost 23 lbs since at the facility, Resident 77's weight was 159 lbs on 01/10/2025. Staff Y stated Resident 77 was ordered calorie dense supplements on 08/23/2024. Staff Y acknowledged if supplements were ordered sooner, it could have potentially prevented Resident 77 from losing so much weight. In an interview on 01/16/2025 at 2:40 PM, Staff B, Director of Nursing, reviewed Resident 77's medical record. Staff B stated Resident 77's admission weight was on 12/29/2023 and had significant weight loss in May 2024, five months after their admission. Staff B stated Resident 77 was started on a NEM diet and calorie dense supplements in August 2024, after their weight loss. In an interview on 01/17/2025 at 3:03 PM, Staff S, RD, reviewed Resident 77's medical record. Staff S stated Resident 77 began to be followed by the facility nutrition/hydration committee 05/01/2024 for identified weight loss, 165.8 lbs on 04/30/2024, a 16.2 lbs weight loss. Staff S further stated a NEM diet and calorie dense supplements were ordered in August 2024, then their weight stabilized. Staff S reviewed the 09/24/2024 provider progress note that showed Resident 77 had protein calorie malnutrition after a 15 lbs weight loss in six months with muscle wasting. Staff S acknowledged Resident 77's protein calorie malnutrition diagnoses was new during their stay at the facility. In an interview on 01/17/2025 at 4:11 PM, Staff A, Administrator, stated the facility implemented interventions when weight loss was identified, not prior to weight loss. <Resident 54> Per the 12/23/2024 significant change assessment, Resident 54 had diagnoses which included diabetes, high blood pressure, dementia and had severe cognitive impairments. The assessment further showed the resident held food in their mouth or residual food in their mouth after meals, coughed or choked during meals and had no weight loss or gain. A 12/23/2024 physician's order prescribed Resident 54 mildly thickened liquids, supervision for all intake and was to have aspiration precautions [sitting upright at a 90-degree angle, taking small bites and chewing well before swallowing, and eating and drinking slowly] for dysphagia (difficulty swallowing). The order also stated sippy cups (a cup with two handles and a lid that prevented excessive flow of fluids) for all drinks. The 04/24/2024 care plan stated Resident 54 would have no unplanned significant avoidable weight loss or gain, was at risk related to an aspiration event, dysphagia and was on a mechanically altered diet. The interventions included a two handled cup, aspiration precautions, no straws, supervision, refer to the dietician as appropriate and two ounces of no sugar added shakes with lunch and dinner that was added on 12/23/2024. A 10/01/2024 nutritional evaluation by the Registered Dietician showed Resident 54 had a downward trend in weight, lost 10 lbs in the last year but was not significant and food preferences were updated. A 12/23/2024 nutritional evaluation by the Registered Dietician showed Resident 54's weight on 06/12/2024 was 172.4 pounds (lbs), 09/04/2024 170.4 lbs, 11/05/2024 163.2 lbs, and 12/18/2024 157.5 lbs. The resident's average intake was 58 %, current body mass index was 22.6, underweight, and a no sugar added shake was added to meals. Review of Resident 54's record from August 2024 through January 2025 showed a 9.1% weight loss in six months, a 6.57% loss in three months and a 2.3% loss over the past month. During an observation on 01/10/2025 at 12:11 PM, Resident 54 sat alone in their room consuming fluids and eating independently (no supervision as ordered). Subsequent observations of the resident without supervision during the meal service were made on 01/10/2025 at 12:31 PM, 01/13/2025 at 7:23 AM, 7:44 AM, 7:55 AM, 01/15/2025 at 12:28 PM, 12:32 PM, 12:37 PM, and 12:45 PM. In an observation on 01/10/2025 at 12:36 PM, Resident 54 had some regular cups and had consumed fluids from them (not all cups were sippy cups as ordered). In a similar observation on 01/13/2025 at 7:05 AM, the resident had a regular cup, and one cup of the fluids contained ice cubes (resident was prescribed thickened liquids). At 7:55 AM, the resident had three cups of fluids, and none were in a sippy cup. On 01/15/2025 at 12:33 PM and 01/16/2025 at 7:58 AM, the resident had consumed fluids out of a regular cup. In an interview on 01/15/2025 at 1:39 PM, Staff OO, Nursing Assistant, stated supervision for meals meant sitting with the resident but they did not have enough staff to do so when the residents ate in their rooms. Staff OO stated they looked at the resident's care plan or meal tickets to know if they needed adaptive equipment for meals. When asked why it was important for the resident to have a sippy cup, Staff OO stated to prevent choking. Staff OO stated any resident that received thickened liquids should not have had ice in their fluids as they could choke or aspirate. During an interview on 01/16/2025 at 2:19 PM, Staff B, Director of Nursing, stated Resident 54 had not triggered for weight loss, but had lost 15 lbs. Staff B added interventions would be placed prior to weight loss. Staff B stated a resident that requires sippy cups should have them for all liquids and this was important to control the flow of the liquids and stated residents on thickened liquids should not have ice cubes unless they have signed a risk/benefit form, and this could cause aspiration. In an interview on 01/17/2025 at 2:41 PM, Staff S, Registered Dietician, stated Resident 54 had a downward trend in their weight. When asked what interventions were put in place for the resident over the past six months, Staff S stated they had a downgrade in their diet, change in adaptive equipment and aspiration precautions. Staff S added house supplement had been added on 12/23/2024. When asked if interventions should have been placed prior to December 2024, Staff S stated it possibly could have helped to start the house supplement sooner or to have increased it. Staff S acknowledged Resident 54 was diabetic and added they did not have sugar free house supplement in stock, and it had to be ordered when needed. 47328 Reference: WAC 388-97-1060 (3)(h) Refer to F804 for additional information.

Based on interview and record review the facility failed to complete annual staff performance reviews yearly as required and provide education based on the outcome of these reviews for 1 of 5 sampled staff (Staff F), reviewed for performance reviews. This failure placed residents at risk of receiving care from inadequately trained and/or underqualified care staff, and diminished quality of life. Findings included . Review of Staff F, Nursing Assistant, personnel file showed they were hired on 11/03/2022. The personnel file included a 01/10/2023 verbal warning for not completing training as required and a 07/29/2024 written warning for a verbal altercation with a peer which included use of profanity and threatening language at the nurse's station. No documentation of a performance evaluation was found. In an interview on 01/17/2025 at 12:28 PM, Staff G, Nursing Assistant, stated staff evaluations were done yearly. In an interview on 01/17/2025 at 12:52 PM, Staff E, Registered Nurse, stated staff evaluations were done yearly. In an interview on 01/17/2025 at 12:59 PM, Staff D, Resident Care Manager, stated staff evaluations were supposed to be completed yearly. Staff D stated resident care was a priority and acknowledged staff evaluations were not completed yearly as required. In an interview on 01/17/2025 at 1:46 PM, Staff B, Director of Nursing, stated staff evaluations were to be completed yearly. Staff B acknowledged the facility was behind on completing staff evaluations yearly as required. Reference WAC 388-97-1680 (1), (2)(a-c) Refer to F585 for additional information.

Based on interview and record review, the facility failed to provide the necessary care and services to maintain the resident's highest practicable level of well-being for 1 of 3 residents (Resident 1) reviewed for diabetes management. Resident 1 experienced harm when they were found unresponsive from a blood sugar of 39 milligrams (mg)/deciliter (dl) (a normal blood sugar ranges from 80 mg/dl to 130 mg/dl) and Staff administered an oral glucose gel which resulted in Resident 1 aspiration (when food or drink goes into the lung). This failure placed other residents at risk for diminished quality of care. Findings included . Review of the facility assessment, dated 10/28/2024, showed Resident 1 had diagnoses to include diabetes and lung disease. Resident 1 had some difficulty making their needs known. Per the assessment, the resident took insulin (a hormone that helps regulate blood sugar levels) to manage their diabetes. Resident 1 was set up assist for self-care which included eating. Review of a facility policy titled Hypoglycemia [low blood sugar]/Hyperglycemia [high blood sugar] recommended Guidelines, dated May 2016, showed the recommended guidelines for a resident whose blood sugar was below 80 mg/dl, and able to swallow, a nurse was to give the resident food such as fruit juice, crackers, or glucose gel (sugar in gel form). The blood sugar was to be re-checked 15 minutes later. If the resident was unable to swallow, the nurse was to give an injection of Glucagon (a hormone produced by the pancreas that stimulates the liver to release glucose into the bloodstream) and re-check the blood sugar after 15 minutes. This was to be repeated if the blood sugar remained low. Review of the resident's care plan, dated 09/30/2024, showed the resident had diabetes. The resident was to get medication as ordered by the doctor and staff were to monitor and document side effects and effectiveness. Review of Resident 1's Medication Administration Record (MAR) for October 2024, showed the resident received an oral medication twice a day for diabetes, and was to be given 9 units of Insulin Lispro (a fast-acting insulin that starts to work about 15 minutes after injection) with meals and 18 units of Lantus (a long-acting insulin) at bedtime. Blood sugars were ordered to be checked three times a day. On 10/08/2024 at 12:00 PM, it was documented the resident's blood sugar read 189 mg/dl and Resident 1 received 9 units of insulin. Review of nurse progress notes, dated 10/08/2024, showed Staff A, Licensed Practical Nurse (LPN), went into Resident 1's room around 1:10 PM, after it was reported Resident 1 was unresponsive. Staff A documented the resident's first blood sugar was 39 mg/dl and Staff A gave a shot of Glucagon. The second blood sugar taken was 31 mg/dl and Staff A documented they gave a tube of fast acting glucose gel. There was no documentation to show the resident was no longer unresponsive. The next blood sugar was at 1:24 PM and had dropped to 26. Emergency medical personnel (EMS) arrived at the facility and transported the resident to the hospital. On 11/06/2024 at 11:35 AM, during a confidential interview, staff in Resident 1's room were heard yelling to the resident you have to swallow, you have to swallow. On 11/06/24 at 2:40 PM, Staff B, LPN, stated they had worked the morning of Resident 1's incident. Staff B took Resident 1's blood sugar at lunch, which read 189 mg/dl. The resident was then given the 9 unit of insulin, as ordered. Staff B stated the lunch trays were already on the unit and staff had started to deliver them. Staff B was in another room charting when they heard someone yell for help and said Resident 1 was unresponsive. Staff B entered Resident 1's room and Staff A had already arrived in the room. Staff B watched Staff A give the resident a shot of Glucagon. Staff B went on to say Staff A then opened a tube of glucose gel and asked Staff B to give it to the resident. Staff B told Staff A the resident was not responsive and refused to give it. Then Staff A had Staff C, Certified Nursing Assistant (NAC), massage Resident 1's throat as Staff A attempted to give Resident 1 the glucose gel. Staff B observed several empty tubes of the glucose gel next to the resident. After the EMS came, the resident continued with a low blood sugar. The EMS were told the resident was given tubes of glucose gel; they told staff to stop giving the oral gel, and asked for a suction machine. The resident was then transported to the hospital. On 11/13/2024 at 10:40 AM, Staff D, Director of Nursing (DNS), stated there was not a medication error for Resident 1 because the correct dose of insulin, 9 units, had been given to the resident. Staff A stated the resident was on a sliding scale (the amount of insulin given was based on the blood sugar reading) which was changed by the physician to administer 9 units of insulin with meals. Staff D stated Resident 1 had received a lunch tray after the insulin had been administered. When asked if an unresponsive resident should receive glucose gel by mouth, Staff D stated the resident should not receive anything by mouth. Staff D also confirmed if a resident was drowsy and unable to respond to direction, they should not receive anything by mouth. Saff D stated they had received statements from the staff that cared for Resident 1 but no investigation had been done. Review of staff statements about the incident with Resident 1 showed Staff A reported they had given Resident 1 a Glucagon shot because the blood sugar was 39 mg/dl. Staff A stated the resident's blood sugar kept dropping and they gave a tube of glucose. Staff A wrote the resident was swallowing and waking up. Staff B's statement reported Staff A gave a shot of Glucagon. Staff A told Staff B to give the resident glucose gel, and they refused since the resident was still unresponsive. Staff B observed Staff A put glucose gel in Resident 1's mouth and Staff C rubbed the resident's throat. Staff B stated Staff yelled to the resident to swallow, swallow. Staff C reported they had set up Resident 1's lunch tray. At about 1:10 PM another staff member asked if the resident was normally hard to wake up. Staff C went into the resident's room, and they were up in a wheelchair limp and clammy. Staff C stated Staff A arrived, took a blood sugar which was 39 mg/dl and gave a shot to the resident. Staff A then put some pink stuff in the resident's mouth. Staff C massaged the side of the resident's neck to help them swallow. Staff A then repeated the shot and put more pink stuff in the resident's mouth because the next blood sugar read 31 mg/dl. On 11/08/2024 hospital records were reviewed and showed EMS reported to the emergency room (ER) they arrived at the facility and witnessed staff give glucose gel to an unresponsive resident. The EMS instructed staff to stop giving it, asked for a suction machine, and suctioned the resident's airway. The resident was noted to have gurgling sounds while breathing. A note from the ER nurse documented the resident was unresponsive when EMS arrived at the facility. The resident had been given glucose by mouth and was suspected to have aspirated because their oxygen saturation (the measure of how much oxygen is traveling through your body) was low and the resident had raspy lung sounds. The record showed Resident 1 was diagnosed with aspiration pneumonia. Reference: WAC 388-97-1060(1)

Based on observations, interview, and record review, the facility failed to ensure a resident was free from sexual abuse by a staff member for 1 of 3 sampled residents (Resident 1), reviewed for abuse. Resident 1 experienced harm when they reported a staff member had sexual intercourse with them and the sexual assault exam showed abrasions consistent with penile penetration. This failure placed the resident at risk for further abuse and psychosocial harm. Findings included . Review of the facility's policy titled Abuse, Neglect and Misappropriation of Resident Property Prohibition Policy, updated 10/2022, showed each resident has the right to be free from abuse, including verbal, mental, sexual, or physical abuse . Sexual Abuse was defined as non-consensual sexual contact of any type with a resident. Review of the facility assessment, dated 07/02/2024, showed Resident 1 was admitted with diagnoses to include respiratory disease and Diabetes. The resident was alert and oriented and able to make their needs known. Resident 1 required moderate assistance with Activities of Daily living (ADL's). Progress notes from 05/03/2024 through 07/01/2024 were reviewed. There was one entry on 05/03/2024 which showed Resident 1 made inappropriate sexual statements to staff. The resident was diagnosed with a urinary tract infection (UTI) and treated with antibiotics. There was no further documentation of the resident's sexual behaviors. Resident 1's care plan, revised 07/01/2024, showed the resident had a history of sexually inappropriate comments about sex when there was medical changes such as a UTI. Staff were to attempt non-medical interventions, ensure safety, and allow the resident to express experience. Social Services and Licensed Nurses were to be alerted for follow up. Review of the facility investigation, dated 07/01/2024, showed Staff B, Restorative Aide (RA) went to Staff A's, Administrator, office with Staff C, Director of Nursing (DNS), to report Resident 1 had reported engaging in sexual activity with a staff member. Review of the statement by Staff B showed the resident reported there was an inappropriate man that worked the graveyard shift. When asked what the resident meant about inappropriate, the resident sated the staff member had engaged in sexual activity with them. The resident stated they feared retaliation which was why they hadn't reported it prior. Resident 1 explained it had been going on for a while and when asked the last time if occurred, the resident couldn't remember a day but within the last week. Review of the interview between the resident and Staff C and D, Social Services Director (SSD), showed the resident explained they had been sleeping with a man. The resident stated it had been going on for about 4 months on graveyard shift. The resident stated it started out touching and gradually into intercourse. The resident was asked the last time this occurred and the resident responded a couple of days ago. The resident was not able to give a name but described the staff member. Review of hospital records, dated 07/02/2024, showed Collateral Contact 2 (CC2), SANE (Sexual Assault Nurse Examiner) nurse conducted a physical exam with Resident 1. The exam revealed a red linear rectangle like abrasion, on the posterior opening of the vaginal canal, at the 8 o'clock position, and measured 6 millimeters (MM) by 2 mm. There was an additional abrasion in the 5 o'clock position, which measured 1 mm by .25 mm. The resident complained of being tender at both areas of injury. During an interview on 07/03/2024 at 12:20 PM, Staff A and Staff C, stated Staff B immediately reported to them Resident 1 had reported sexual abuse. Staff C and Staff D went and interviewed Resident 1. Three staff members met the description the resident had given and were suspended. Staff A stated they notified the resident's family of the allegation and the family wanted to talk with the resident before they sent the resident to the hospital for a sexual assault exam. The following day, July 2nd, the resident was sent out to the hospital and later that day, Staff A received a call from the hospital and was told trauma had been found on the exam. On 07/03/2024 at 3:04 PM, Collateral Contact 1 (CC1) was interviewed. CC1 stated they were informed by Staff A Resident 1 had made an allegation of sexual abuse. Staff A had explained the process of going to the emergency room for an exam and CC1 wanted to talk with the resident first. The CC1 explained Resident 1 had not made an actual allegation before but a couple of months prior, Resident 1 had commented they wanted to be sexual. CC1 stated Resident 1 was diagnosed with a UTI at that time and after the UTI had been treated, the sexual behavior stopped. CC1 stated when they asked Resident 1 about the sexual abuse, the resident had specific, detailed information about the encounter and CC1 was confident sexual abuse had occurred. After the conversation with the resident, CC1 requested the resident be sent to the hospital for an exam. CC1 accompanied the resident for the exam which showed vaginal abrasions and was told the injuries had happened 2 days or less prior to the exam. On 07/03/2024 at 3:30 PM, Resident 1 was observed lying in bed in their room. Resident 1 stated the encounter had occurred at night. Resident 1 stated they thought the staff member had come into the room to provide care. Resident 1 could not provide a name but described the staff member, which was the description they had provided to the facility. Resident 1 stated the staff member pulled down their brief, touched them, and proceeded to have sex with them. Afterwards, the staff member gave the resident a wash cloth to clean themselves up. Resident 1 went on to say they reported it to Staff B but didn't realize everyone was going to be told. During an interview on 07/30/2024 at 2:40 PM, CC2 stated they examined Resident 1. CC2 had a urinalysis done and it was negative for a UTI. CC2 said they collected evidence and did a physical exam. Resident 1 had two external abrasions on the genitalia. CC2 stated the posterior abrasion was consistent with penile penetration. Reference: WAC 388-97-0640 (1)

Based on interview and record review, the facility failed to ensure supervision was provided as planned 1 of 3 sampled residents (Resident 2) reviewed for falls. Resident 2 experienced harm when they fell out of their bed and sustained a head laceration and skull fracture. This failure placed residents at risk for similar falls, injuries, and adverse outcomes. Findings included . The 02/2000 facility policy titled Fall Evaluation (Morse Scale) and Management documented the licensed nurse completes the Morse Scale, (an assessment tool that helps determine if a resident is at high risk for falls), then implements the appropriate care plan interventions for fall risk management based on the resident's medical history and evaluation. <Resident 2> A review of the record showed Resident 2 had diagnoses including dementia, failure to thrive, and osteoporosis (weak or brittle bones). The 05/01/2024 annual comprehensive assessment documented Resident 2 was severely cognitively impaired, was not understood when speaking, and was totally dependent on staff for activities of daily living (ADLs) including transfers from their bed. The Care Plan revised on 05/15/2024 showed Resident 2 was at risk for falls related to weakness, unaware of safety needs, impaired mobility, and dementia. Staff were instructed to anticipate and meet the resident's needs, attempt to keep the call light in reach and encourage them to use, keep the left side of the bed against the wall, ensure it is snug, and keep the brakes locked, ensure appropriate footwear when out of bed, fall mat at the right side of the bed when the resident is in bed, high/low bed in low position when the resident is in bed, and keep the room free of clutter. Resident 2 was dependent on two staff and a mechanical lift (hoyer) when transferring from their bed to their wheelchair. A review of the 07/15/2024 at 5:00 AM nursing progress notes documented a nursing assistant (NAC) went to the nurse's station and stated Resident 2 had rolled out of bed and was bleeding from their head. When assessed, Resident 2 had a laceration on their scalp at the hairline but had no deformities in their extremities and no change in their level of consciousness. The resident was sent to the emergency room for possible stitches. The progress notes further documented the resident's bed was halfway up, not in the lowest position, and their fall mat was not in use when the NAC went to grab the mechanical lift to get the resident out of bed and the resident rolled out of bed at that time. A review of the 07/15/2024 emergency room visit documented Resident 2 had a ground level fall and struck their head on the floor with no loss of consciousness. The resident was nonverbal at baseline and had dementia. Imaging of the resident's head and spine showed a fracture of their skull. The provider sutured an 8-centimeter scalp laceration and did not attempt to remove a piece of bone that was seated firmly in the area of the laceration. The provider noted that the resident slept throughout the examination. A 07/15/2024 Facility Neurological Evaluation document showed that at 5:00 AM (post-fall), Resident 2 was alert, their pupil response was brisk, they were moving all extremities, and their vital signs were within normal limits. The document further showed that the resident was at the hospital from 5:45 AM until the next entry at 10:45 AM. At this time, Resident 2's level of consciousness was listed as stupor, their pupils reacted sluggishly, they were unable to follow commands, and there was no response to painful stimuli. The 07/15/2024 at 4:17 PM Nurse Practitioner progress note documented that Resident 2 returned to the facility after an evaluation at the emergency room where they were treated for their head laceration. The note documented that upon Resident 2's return to their room, they were pale, unarousable, and had breathing that indicated death was imminent. The NAC had positioned the resident for comfort and exited to retrieve pain medication for the resident. At this time Resident 2 passed away around 12:39 PM. The 07/15/2024 Fall Incident Investigation documented two NACs were assisting Resident 2 in getting ready for the morning and was prepared to be transferred by a mechanical lift, a system that uses a sling under a resident that is attached to a lift that when cranked up raised a resident off their bed. This procedure required two staff to complete. The investigation noted Resident 2 was care-planned to have the bed against the wall with a mat by the bedside because they had unpredictable movements and rolled. Staff G, NAC, positioned Resident 2 on the sling in the center of the bed. The floor mat was moved from the side of the bed to make room for the mechanical lift to fit under the bedframe. The investigation noted that the bed was elevated approximately two feet in the air. Staff G left the bedside, retrieved the mechanical lift from the alcove at the room's entryway and then backed the lift into the room and heard the resident fall on the ground behind them. The investigation concluded that facility protocols were followed at the time of the fall, and abuse was ruled out. During an interview on 07/16/2024 at 4:02 PM, Staff H, NAC, stated they had just started their shift on 07/15/2024 close to 5:00 AM, and was asked to help lift Resident 2 out of bed to their chair. As they approached Resident 2's room, Staff G told them they had turned to get the mechanical lift and heard Resident 2 fall. Staff H stated when the emergency medical services team arrived, Resident 2 was awake and talking. When the resident returned from the emergency room , they assisted Resident 2 into a clean shirt, and positioned them for comfort, but the resident did not make any responses and passed away shortly after this. During an interview on 07/16/2024 at 4:31 PM, Staff F stated they spoke with Staff G and H after the fall. Staff F confirmed that the use of a mechanical lift required two staff and once a resident was in bed with the bed elevated, staff were not to leave the resident and Staff G left Resident 2 only for a few seconds when they went to retrieve the mechanical lift from the entryway. During an interview on 07/16/2024 at 5:03 PM, Staff G, NAC, stated they provided care for Resident 2 often and it was the normal routine to get Resident 2 up first thing in the morning. Staff G stated they had provided care to Resident 2 and positioned them in the middle of the bed with the sling under [NAME] them. They stated they had raised the bed, moved the floor mat and positioned the resident's wheelchair at the head of the bed to get it ready for the resident when they noticed the oxygen tank on the back of the wheelchair was empty. Staff G stated they left the room to tell the nurse that the resident needed another oxygen tank and to ask Staff H to help them transfer Resident 2 with the mechanical lift. Staff G stated they were unsure how long they were away from Resident 2's room, but it might have been 1 or 2 minutes. Staff G returned to the room and was backing into the room with the mechanical lift when they heard the resident fall. Staff G stated the saw that Resident 2's head was bleeding, so they immediately called for help. Staff G stated the looking back, they would not have left the resident's bed elevated but they never thought Resident 2 would be able to roll out of bed and it was an accident. During a follow-up interview on 07/24/2024 at 2:02 PM, Staff F stated they had further discussed the fall with Staff G, and stated they educated Staff G regarding safe transfers and that they were not to leave a resident unattended with their bed elevated. Staff F stated after Resident 2's fall, all staff that helped transfer residents were assigned mandatory education regarding safe transferring techniques. Reference: WAC 388-97-1060(3)(g)

Based on interview and record review, the facility failed to provide needed pain management for 1 of 3 sampled residents (Resident 1), reviewed for pain. Resident 1 experienced harm when the facility did not ensure they had the ordered pain medication, or another effective alternative, to treat the resident timely and the resident had to be transferred to the hospital in order to relieve their pain. This failure placed residents at risk of uncontrolled pain and diminished quality of life. Findings included . According to the facility assessment, dated 11/22/2023, Resident 1 was admitted with diagnoses which included surgery to repair a fracture. The resident was able to make their needs known. Review of nurse progress notes, dated 11/16/2023, showed Resident 1 was admitted to the facility on [DATE] at 1:00 PM. Resident 1 rated their pain as a 8/9 out of 10 (pain scale used where 0 is no pain and 10 is worst pain). It was explained to the resident their pain medication was to be given every six hours and their time would be up after 3:00 PM. Resident 1 was given Tylenol. There was no documentation to show the provider was notified of the resident's reported pain level or that any non-medication interventions were attempted to help alleviate some of the resident's pain. Review of a nurse progress notes on 11/16/2023 at 7:00 PM (six hours after admission) showed the provider was notified the resident requested to be sent to the hospital for pain management. Review of emergency room (ER) notes dated 11/16/2023 showed the resident was brought into the ER for pain management. The ambulance personnel reported Resident 1 had not received pain medication and the facility had explained to them it was because the medication dispensing machine had stopped working and were unable to get the pain medications for the resident. The ER report documented that Resident 1 confirmed this. During an interview on 01/26/2024 at 2:30 PM, Staff F, Administrator, stated around the time of this incident, the dispensing machine wasn't working because the Internet lines had gone down in the building. Staff F stated they would find more information and send it to the investigator. On 01/26/2023 at 3:04 PM, during a telephone interview, Staff F stated when Resident 1 admitted to the facilit was already in pain rated at 8/9. Staff F stated the staff had ordered medication from the pharmacy which could take up to four hours to receive. Staff F stated the resident went to the hospital because they didn't want to wait for the medication to arrive. A document was sent from the facility and reviewed on 01/30/2024 showed a documented statement from Staff G, Registered Nurse (RN) who was the on-call manager on 11/16/2023. On admit, the resident stated they had pain at a 8/9 out of 10. The staff had discovered the medication dispensing machine was not working and it would not allow the resident's narcotic pain medication to be pulled. The resident was given Tylenol to assist in pain management and Staff G was contacted Staff G documented time was spent troubleshooting the medication dispensing machine in the hope that resolution would occur. When it was apparent the machine would not upload data, the pharmacy was asked how long it would take to satellite the medication. Per pharmacy policy, it would take up to four hours to deliver the medication STAT (immediately). On 01/30/2024 at 9:40 AM, Resident 1 was interviewed. Resident 1 stated when they were admitted to the facility in extreme pain. Resident 1 stated they were given Tylenol which did not help. Resident 1 was told by staff they weren't able to get them their pain pills and went to the hospital for pain medication. On 01/30/2024 at 10:10 AM a Collateral Contact (CC) was interviewed. The CC stated they were not with the resident on admit but had received 22 phone calls from Resident 1 on 11/16/2023 who was upset and crying in pain. The CC stated they were on the phone with Resident 1 when a staff member came to talk to the resident. The CC heard the staff member say the medication would take several hours to arrive so their only option was to wait in pain or go to the hospital. This was around six hours after the resident had been admitted . Reference: WAC 388-97-1060(1)

Based on interview and record review, the facility failed to develop and implement an effective discharge plan for 1 of 3 residents (1), reviewed for discharge. This failure resulted in actual harm to Resident 1, when they remained in the facility after their desired discharge date , incurred a several thousand dollar bill, and developed COVID-19 (an infectious disease caused by a new 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), requiring multiple medical treatments. Findings included . According to the 08/03/2021 admission assessment, Resident 1 was cognitively intact and able to make their needs known. The assessment also showed the resident was admitted for therapy, after a fall with hospitalization . Review of a discharge plan initiated on 07/29/2021 showed the resident was to be discharged home with services. Per review of an 08/02/2021 care conference note, with Staff C, Resident Care Manager, Staff D, Social Services, and the resident in attendance, the resident's discharge plan and goals were reviewed. Per the documentation, the goal was to discharge home. The documentation also showed the resident lived alone in their own apartment, with neighbors/friends who assisted with their needs. According to a discharge care plan, initiated on 08/03/2021, the resident's anticipated discharge location was home with services, when rehab and treatment were complete. The care plan did not include any specific information regarding any services or assistance the resident might need, or who would provide it. An 08/05/2021 Social Services progress note showed the resident was making progress, working on overall strengthening, and gaining weight. Per the note, a referral to an outside agency was made to evaluate the resident for placement in an adult family home. Per an 08/09/2021 progress note, the resident had been notified that day that the facility had a COVID-19 outbreak, with one resident testing positive. An 08/12/2021 progress note showed the resident was provided with a notification that Medicare coverage for skilled nursing services would be ending on 08/15/2021. Per the note, the resident wanted to discharge home on 08/16/2021. Review of the resident's record showed the resident remained at the facility beyond 08/16/2021. No documentation regarding why the resident did not discharge home on 08/16/2021, per their wishes, was found. Further review of the resident's record showed the resident tested negative for COVID-19 eight times from 08/09/2021 - 08/24/2021, before testing positive on 08/25/2021 (nine days after the resident was to discharge). According to progress notes for 08/25/2021 - 09/17/2021, the resident experienced COVID-19 symptoms including cough and shortness of breath. The resident received an infusion of fluids due to dehydration, as well as antibiotics, steroids, and monoclonal antibodies (laboratory produced antibodies that help fight an infection), to treat the COVID-19 infection. Per a 09/24/2021 progress note, the resident was well enough to discharge home that day (over a month after the requested discharge date of [DATE]). In an interview by telephone on 12/07/2021 at 1:55 PM, the resident stated that they wanted to discharge from the facility sooner but had not been allowed to, and was unsure why. The resident also stated they had received a bill for several thousand dollars from the facility after discharging, and did not feel that was fair. In an interview on 12/09/2021 at 11:20 AM, Staff D, Social Services, was asked about Resident 1's discharge plan. Staff D stated the original plan was for the resident's neighbor to provide assistance. Staff D added the resident did not discharge on 08/16/2021 because the neighbor was no longer willing to assist the resident. In an interview by telephone on 12/09/2021 at 1:07 PM with Staff E, Business Office Manager, the resident's insurance coverage and billing statements were reviewed. Per Staff E, the resident owed the facility $3,708 for charges incurred after Medicare coverage ended on 08/15/2021, and before the resident re-qualified for coverage on 08/25/2021, after being diagnosed with COVID-19 and requiring several treatments. In a follow-up interview on 12/10/2021 at 10:35 AM, Staff D stated resident discharge plans were discussed during initial care conferences within the first few days after admission. Staff D added discharge goals and destination, financial concerns, as well as any anticipated services or equipment needs, would also be discussed. A resident's progress towards discharge was also reviewed in weekly interdisciplinary team (IDT) meetings. Per Staff D, therapy staff had recommended Resident 1 be discharged to an assisted living facility during one of these meetings, but the resident decided they wanted to discharge home. When asked why the resident did not discharge on 08/16/2021, Staff D stated the resident ended up needing more services than anticipated, and the delay was related to trying to get Medicaid approval for the resident. Staff D was unable to provide any documentation regarding when the approval process started, the services the resident required, discussions with the resident regarding not meeting the anticipated discharge date , or why the resident did not discharge on 08/16/2021. On 12/10/2021 at 11:04 AM, the lack of documentation regarding discharge planning, as well as the reason why the resident did not discharge on 08/16/2021 was discussed with Staff A, Administrator, and Staff B, Director of Nursing. No further documentation was provided. Reference: WAC 388-97-0080(2)(6)

Based on observation, interview, and record review, the facility failed to protect one of 21 cognitively impaired female residents (#34), who resided on a secured dementia unit, from sexual abuse. This resulted in an Immediate Jeopardy situation for Resident #34, when another resident (#60), with a known history of inappropriate interactions with her, placed his hand under her shirt, and grabbed her breast. This placed all female residents who resided on the secured unit, at risk for harm from sexual abuse. Findings included: The State Agency informed the facility on 12/11/17 at 6:40 p.m. of the Immediate Jeopardy situation. The facility initiated 24 hour/one to one supervision of Resident #60, screened all facility residents for risk factors, and provided facility-wide staff education regarding abuse prevention, identification, recognition of risks, and reporting requirements. The screening process completed by the facility identified an additional resident in a separate unit that had risk factors, and initiated an additional twenty four hour/one to one supervision, to protect residents in that area of the facility. On 12/15/17 at 9:00 a.m., the facility was notified of the removal of the immediate jeopardy, effective 12/14/17 at 2:00 p.m Review of Resident #60's record showed he admitted in September 2016, and resided in the secured dementia unit. Per the record, [DIAGNOSES REDACTED]. The resident was alert, able to make his needs known, and was able to propel independently in his wheelchair. The record further showed the facility had knowledge of two previous inappropriate incidents that occurred, nine months prior (in February 2017), between Resident #34 and Resident #60. Resident #34's record showed she had [DIAGNOSES REDACTED]. She was able to ambulate short distances without assistance, and could propel in a wheelchair independently. The record also showed the resident had a history of [REDACTED]. Resident #34 was observed in the dementia unit on 12/04/17, from 9:00 a.m. to 11:45 a.m. The resident wandered in and out of the activity room, and attempted to remove other residents' shoes/socks . Staff XX, Activity Assistant, was observed to stop activities that were in process to intervene, attempting to redirect Resident #34 away from other residents. No other staff were present in the activity room during the observations. In an interview on 12/06/17 at 3:20 p.m. Staff L, Licensed Practical Nurse, said Resident #34 gets very busy when there was a lot of activity, stated the resident can be hard to redirect, and must be kept in line of staff sight, to keep her safe. Regarding the previous incidents in February 2017 (per review of the facility timeline of events), on 02/07/17, Resident #60 and Resident #34 were seated in the hallway of the unit. Resident #60 was observed with his hand under Resident #34's shirt, touching her breast. Care plan interventions were updated to keep Resident #60 in line of sight, when out in common areas. A second incident occurred on 02/14/17, when Resident #34 was found in Resident #60's room, and he was observed with his hands on the outside of her shirt, touching her chest. Resident #60 was initally placed on fifteen minute checks, and on 02/15/17, the facility began one to one supervision during waking hours (as he was assessed to sleep through the night at that time and not wander). Per further record review, additional care plan interventions for Resident #60 were initiated on 02/15/17 by the Interdisciplinary (IDT) Team (which consisted of staff, medical providers, and guardians/family of Resident #60). Care plan interventions included: one to one supervision, a room change (Resident #60 was moved to the opposite end of hallway from Resident #34), and medication changes. The record showed the one to one supervision was discontinued, per recommendation of the IDT on 03/06/17, as Resident #60 had not exhibited any behaviors, and there were no reports of inappropriate interactions with staff or other female residents. The current care plan, portions of which were carried forward from February 2017, was in effect on 12/11/17. Interventions directed staff to be aware of the resident's interactions with female peers, to not seat female residents in proximity of Resident #60 when there were group activities, and to keep Resident #60 in direct line of sight of staff, when he was out in common areas. On 11/29/17 at 11:45 a.m., Resident #60 was observed seated in his wheelchair at the far end of the unit, near rooms occupied by female residents. Staff were observed transporting residents into the dining room for lunch, assisting other residents with medications, and providing activities in the activity room. Resident #60 was not in line of sight of staff, while he sat in his wheelchair, outside of female resident rooms. On 12/11/17, review of the facility reporting log (a documenting tool of facility incidents) showed a resident-to-resident incident occurred between Resident #60 and Resident #34, on 12/09/17 at 8:26 p.m. Per review of the preliminary investigative statement by Staff K on 12/11/17 regarding the incident, on 12/09/17 at 8:26 p.m. Staff K, Nursing Assistant, wrote that Resident #60 and Resident #34 were observed seated next to each other by the nurses's station. Staff K observed Resident #60 with his hand underneath the blouse of Resident #34, groping her right breast. Per Staff K's written statement, she immediately sought assistance from Staff L, Licensed Practical Nurse. The residents were separated, and a one to one supervision was initiated by Staff L for Resident #60. The plan for one to one supervision was until 10:00 p.m., at which time Resident #60 would be in bed. There was no re-assessment, to determine if Resident #60 slept through the night, or to determine if Resident #34 wandered into resident rooms during the night. In an interview on 12/11/17 at 5:19 p.m. Staff WW, Nursing Assistant, was providing one to one oversight to Resident #60. When the surveyor asked why the resident was receiving one to one supervision, Staff WW stated she was not 100% sure. In an interview on 12/11/17 at approximately 5:25 p.m. Staff VV, Registered Nurse, stated Resident #60 was on a one to one supervision because of touching. She stated he could move by himself, and if he was not watched, he could grab anyone. When asked whether there were any instructions in place, to prohibit Resident #60 from being within reach of female residents, prior to the incident on 12/09/17, Staff VV said there were not, and that he would sit next to female residents and hold hands. She stated if staff were watching he would not have incidents (of inappropriate touching), but if we're not watching, probably would. In an interview on 12/12/17 at 11:39 a.m., Staff M, Social Services, said that even though Resident #60 was more of an opportunist (a person who takes advantage of opportunities when they arise), and does not seek out female residents or initiate contact, they still needed to protect the residents. Per interview with Staff O, Registered Nurse, on 12/12/17 at 2:25 p.m., she stated the secured unit staff were aware of Resident #60's behavior, and the need to keep him under observation, when he was around other residents. The 12/13/17 investigative report, when reviewed on 12/14/17, showed Resident #60 had been seated in his wheelchair in the common area, by the nurse's station. There were no staff in line of sight, when Resident #34 entered the common area, and sat down next to Resident #60. Per the record, Staff K observed the incident when she walked down the hallway. The facility failure to implement care plan interventions in place for Resident #60, and re-assess the effectiveness of the interventions, allowed Resident #34 to experience a non-consensual sexual interaction. Reference WAC 388-97-0640(1)

Based on interview and record review, the facility failed to ensure one of four sample residents (#1), was free from a significant medication error. This failure resulted in actual harm to the resident, who was given a medication she was allergic to, and required medical treatment and emergency room evaluation, to counteract the effects. Findings included: The 09/15/17 admission assessment showed Resident #1 had [DIAGNOSES REDACTED]. Per record review, the resident had memory impairments, and severe cognitive impairment. The record also identified the resident was allergic to a specific narcotic medication. According to the facility investigation, dated 09/13/17, Resident #1 was given another resident's narcotic pain medication by Staff A, Registered Nurse (RN). Staff A reported the medication error to Staff B, RN. It was documented Staff A then discovered Resident #1 had an allergy to the narcotic medication she accidentally received. Resident #1's vital signs were taken and went down in numbers, including respirations at 13 (they were previously 22). Per the record, Staff B went into Resident #1's room, rechecked her respirations, and documented they were shallow and at 12 to 13. The physician was notified, and an order was received to administer [MEDICATION NAME] (a medication to reverse the effects of the narcotic). Resident #1 was sent to the hospital for an evaluation. A review of the hospital emergency room notes listed the [DIAGNOSES REDACTED]. The note further documented the resident had decreased respirations as a result of receiving the medication, and has had a catastropic course from narcotic medications and anesthesia in the past. The resident responded to the [MEDICATION NAME], and was sent back to the facility. On 09/22/17 Staff C, Resident Care Manager, confirmed Staff A gave narcotic medication to the wrong resident, and confirmed the resident was allergic to the medication she was given. Staff C stated after the incident, Staff A had received education on the rights of medication administration. (See F 281 for additional information). Reference: (WAC) [PHONE NUMBER](3)(k)(iii)

Based on observation, interview, and record review, the facility failed to ensure one of five residents (#1), reviewed for accidents, was provided supervision as planned when using a powered wheelchair. The lack of supervision placed Resident #1 at risk for continued injury, and caused actual harm, when the resident hit a shelf with the wheelchair, and fractured Resident #2's toe. Findings included: Resident #1 admitted to the facility in 2017 with multiple [DIAGNOSES REDACTED]. According to the most recent facility assessment, dated 06/04/17, the resident required extensive assistance from two people for transfers, and assistance from one person for locomotion on and off the unit. The resident was assessed to require the use of a wheelchair for all mobility. Additional review of the record showed the resident owned two wheelchairs; one manual, and one electric powered. Resident #1 was observed in her room, seated in her manual wheelchair on 07/11/17 at 12:30 p.m. When asked about training on using the powered chair, she stated she no longer used the power chair, because she ran over her friend's foot. Resident #1 stated she had been using the chair on her own, and going up and down the hallways. The record showed physical therapy began training on use of the powered chair, after the resident obtained it, in May 2017. Physical therapy services ended 6/12/17. The record showed the resident met the maximum potential of skilled services, for use of the powered wheelchair. Recommendations were for staff to provide stand-by assistance at all times, and not to leave the resident alone in the chair. In an interview on 07/13/17 at 12:30 p.m. Staff A, physical therapist, stated the process for communicating care plan changes to facility staff, when recommendations were made by a therapist, included a communication care coordination note. The note was completed and given to the managers, and a yellow carbon copy kept in a book in the therapy office. Staff A said there was also a clipboard where the information was written for the managers and others to review. Staff A stated she was unable to find the copy in the communication book, and the clipboard utilized for communications with other disciplines had no entries, regarding the physical therapy recommendation for Resident #1 using the powered wheelchair. A facility investigation on 06/14/17 (2 days after physical therapy's prior recommendations) showed Resident #1 sustained an abrasion and contusion (a bruise) to her leg. Per the investigation, the resident was observed in the hallway, wheeling in circles in the power chair, and caught the chair under the handrail. The investigation showed the resident had been unable to control her chair, and the accident resulted in an injury to her leg. Documentation of the facility response to the incident showed revision of the resident's care plan (no use of the power chair by the resident until safe), and staff were inserviced on not allowing use of the powered wheelchair until it was deemed the resident was safe in operating it. Review of the resident's current care plan, dated 06/13/17-06/19/17, showed the resident was independent when up in the powered wheelchair. A facility investigation dated 06/20/17 showed a second accident occurred between Resident #1 and Resident #2. Documentation of the incident showed the following: Resident #1 was placed by Staff B, nursing assistant, into her powered chair, and was escorted to attend a breakfast event in the activity room. Staff B left after the resident was brought to the room. When breakfast was completed, Resident #1 attempted to back her chair out away from the table, careened (moved swiftly and in an uncontrolled way) into a shelf, which fell to the floor, and landed on Resident #2's foot. The accident resulted in an injury (a fractured toe) to Resident #2's left foot. In an interview on 07/13/17, at 1:20 p.m. Staff C, activity staff member, said she had not received any communication about Resident #1's power chair, and/or her ability to safely use it on her own. In an interview on 07/13/17 at 2:15 p.m., regarding the accidents with Resident #1's wheelchair, Staff A, Director of Nursing, stated that adequate communication had not taken place surrounding Resident #1, and the use of her powered wheelchair. Reference: (WAC) 388-97-1060 (3)g

Based on interview and record review, the facility failed to provide necessary care and services for 1 of 3 sampled residents (#1), with a wound infection. The failure resulted in actual harm, as evidenced by Resident #1 requiring an extended hospital stay for an infection, due to a delay in recieving medical care while at the facility. Findings include: Resident #1 was admitted to the facility on [DATE], and discharged to her home on 11/02/16. She had [DIAGNOSES REDACTED]. According to the admission assessment, dated 08/22/16, Resident #1 was cognitively intact for daily decision-making. She required extensive assistance to total dependence for actitivites of daily living. The assessment further documented the resident had a [MEDICATION NAME] (a surgical procedure which diverts urine from the kidneys and ureter, into a specially created artifical opening in the abdomen) and an old suprapubic catheter site (a flexible tube that is used to drain urine from the bladder through a cut in the abdomen, a few inches below the navel), for which daily dressing changes were performed. A nurse progress note, dated 10/29/16 at 10:50 p.m., documented the resident was having, yellow/green drainage at the old suprapubic catheter site. There was no documentation the physician was notified of the drainage in the clinical record. The next note, on 11/01/16 at 1:47 p.m., documented the resident was having, green drainage with foul odor at the site, and the physician was notified by a note, written in a communication book, which was at the facility. At 11:40 p.m. the same day, another progress note documented the area was, draining copious (large) amounts of green purulent (pus) maleodorous (foul-smelling) drainage. There were no further nursing progress notes regarding the drainage, or the appearance of the wound site after that time. A review of the advanced registered nurse practioner (ARNP) note of 11/01/16 documented, .She will be going home tomorrow .Has f/u (follow-up) with PCP (primary care physician) .She continues to have vaginal leaking/discharge .Sees urology (a branch of medicine studying and treating diseases/conditions of the urinary tract) tommorrow . There was no documentation regarding the green, foul smelling drainage, coming from the old suprapubic catheter site. In an interview on 12/06/16 at 2:39 p.m., Staff A, a licensed practical nurse, stated, I notified the doctor by putting it into the physician information/concern log book at the desk. Any issues we have with patients, that are not emergencies, are addressed in that book. She was asked if vital signs had been taken. She stated, Yes. She did not have a fever however, I don't remember. She further stated, I noted it with the doctors however, I didn't feel like they thought it was an issue. A review of the physician/practioner problem log, dated 11/01/16, documented an information/concern entry for Resident #1: The suprapubic site continues with drainage - green with foul odor. There was a line drawn through the documentation. In an interview on 12/06/16 at 3:03 p.m., Staff C, ARNP, was asked how the staff communicated with her. She stated, In our book or by phone, if we are not here. She was asked if she was aware of the copious amount of green drainage (with a foul odor), coming from the resident's old suprapubic site. She stated, The resident was going to see urology on 11/02/16 so, I was going to leave it to him. Staff C was asked what her intervention and assessment of the drainage was. She stated, I tried to get her to see urology. The next course of action would be left to him. She was asked if she had contacted the urologist, and informed him of her findings. She stated, I don't recall if I did call the urologist, however, I would have documented it had I spoken with him. Staff C was asked what a line through resident's name meant on the communication book. Did it mean the problem had been addressed by you or were you just aware of the problem. She stated, A line through the log page means that we are aware of it. In an interview on 12/07/16 at 9:40 a.m., Staff D, Resident Care Manager, was asked what assessment should be completed by nursing staff, when a resident has copious amounts of green drainage. She stated, There should be an assessment and observation. She further stated, If you do it (assessment), it should be documented. Resident #1 was discharged on [DATE], the day after the nurse progress notes identified a problem with the green, foul odor drainage coming from her suprapubic catheter site. A review of the discharge plan of care, dated 11/02/16, revealed appointments had been made by the facility for the resident's primary care and orthopedic (related to bones/skeletal structure) physicians. The discharge instruction sheet did not include information regarding a previously scheduled appointment with the Urologist, which was made on 10/06/16, for 11/02/16 at 1:30 p.m. In addition, the discharge plan did not contain instructions related to treatment of [REDACTED]. In an interview on 12/08/16 at 10:26 a.m., the resident's daughter was asked if she was aware of the appointment with the urologist on 11/02/16. She stated, Yes, they did tell me when I was leaving the facility. I did not take her to that appointment, as she sees him all the time, and I had no idea why she had the appointment. The daughter was asked if she had been made aware of the green drainage when she came to take her mother home on 11/02/16. She stated, Absolutely not. In an interview on 12/08/16 at 10:30 a.m., Staff E, Director of Nursing, was asked if the resident's daughter had been informed of the need to go to the urology appointment on 11/02/16, due to the large amount of green, foul smelling drainage. She stated, The ward secretary reminded the resident of the doctor's appointment a week prior to discharge, and the resident stated she would tell her daughter. Hospital records were obtained and reviewed. The resident presented to the hospital emergency department on 11/04/16 (2 days after discharge) with pus (a probable sign of infection) coming from the old suprapubic catheter site. Urine cultures from the [MEDICATION NAME] bag, and from the old suprapubic site were obtained. The resident had three different bacteria which grew from the cultures. The resident remained in the hospital for 4 days, and recieved intraveneous antibiotics before going home.

Based on interview, observation, and record review, the facility failed to ensure interventions to prevent falls were implemented as planned for 1 of 5 sample residents (#2). The failed practice resulted in actual harm to the resident who fell and sustained a fracture. Findings include: Resident #2 had [DIAGNOSES REDACTED]. Per record review, the resident required total assistance for all activities of daily living, was a full mechanical lift transfer due to non-weight bearing status, and utilized a wheel chair for mobility. The resident had a history of [REDACTED]. In addition, anti-skid mats were to be positioned underneath and on top of the cushion for further protection against sliding According to the record, on 11/2/14, the resident fell out of her wheelchair and sustained a 6 x 3 centimeter skin tear to her left elbow. Several hours after the fall, the resident was noted to have a deformity of her right lower leg. The resident was transported to the hospital, where she was diagnosed with [REDACTED]. The facility investigation of the fall revealed the resident's wedge cushion was placed incorrectly in the seat of the wheelchair, creating a forward rather than a backwards slant. The facility was unable to determine who put the cushion in the chair, or how long it was improperly positioned. Staff did state they noticed the resident sliding forward in the chair prior to the fall, and checked to make sure the anti-skid mats were in place, but did not check to see if the wedge cushion was positioned in the chair correctly. During observations made on 11/10/14 at 1.30 p.m., it was noted the resident had a new wheelchair that reclined, and was no longer utilizing the wedge cushion for positioning. When interviewed on 11/10/14 at 2:30 p.m., Staff A (Registered Nurse) stated staff should have made sure the wedge cushion was properly placed in the chair when they saw the resident sliding forward. The facility's failure to ensure the wedge cushion was properly placed resulted in significant injury to the resident who fell out of the chair and fractured her leg. Surgical intervention was required to stabilize the fracture and the resident was hospitalized for [REDACTED].

Based on interview and record review, the facility failed to ensure 2 of 6 sample residents (#1, 2) were free of significant medication errors. The failed practice resulted in actual harm to Resident #1 who was hospitalized as a result of the incident, voiced emotional distress, and required interventions/monitoring following incident. Findings include: Resident #1 had [DIAGNOSES REDACTED]. Per record review, the physician orders [REDACTED]. On 4/9/14 a licensed nurse mistakenly gave the resident 100 units of insulin instead of the 18 units ordered by the physician. The error resulted in the resident receiving 5.5 times the prescribed dosage of insulin. To prevent a severe hypoglycemic reaction the resident was given sugar based snacks, intravenous fluids containing glucose, and his blood sugars were closely monitored. To ensure the resident would receive appropriate treatment in the event of complications, the physician had the resident transported to the hospital where he was monitored overnight before returning to the facility the next day. Per the facility investigation, the licensed nurse who made the medication error mistook the concentration of insulin (100 units per milliliter), as the dosage and did not see the physician's orders [REDACTED]. When interviewed on 4/14/14 at 2:10 p.m., the resident stated he no longer trusted the nursing staff and was concerned another medication error would occur. The resident further stated he felt weaker because the incident caused him to miss a day of physical therapy and he worried his discharge from the facility might be delayed as a result. The facility's failure to administer insulin correctly resulted in a significant medication error and actual harm to the resident who endured additional invasive blood sugar monitoring, intravenous therapy, hospitalization , emotional distress, and interruption of therapy services. Due to the medication error identified related to Resident #1, an audit of residents receiving insulin was completed by the facility on 4/10/14. The audit identified a second error on a different unit involving insulin administration. Resident #2 had [DIAGNOSES REDACTED]. Per record review, the physician orders [REDACTED]. Per record review, the resident received 100 units of insulin rather than the 30 units ordered by the physician for 4 days starting on 4/7/14 and extending through 4/10/14. The error resulted in the resident receiving 3.3 times the prescribed dose of insulin for 4 days in a row. The resident, who routinely had extremely high blood sugars, had no adverse effects from the elevated dosage of insulin. During an interview on 4/14/14 at 1:10 p.m. and administrative nurse stated both errors were the result of nursing staffs' failure to read the physician's orders [REDACTED].

Based on interview and record review, the facility failed to administer medications as ordered by the physician for 1 of 9 sample residents (#4). The failed practice resulted in actual harm to the resident who experienced an adverse reaction to the medication. Findings include: Resident 4 had [DIAGNOSES REDACTED]. Per record review, the resident was admitted to the facility with physician orders [REDACTED]. According to the record, on 11/25/10 a licensed nurse erroneously administered 67,000 units of [MEDICATION NAME] (7.4 times the prescribed dose), instead of the 9,000 units ordered by the physician. The error was not discovered for approximately 12 hours, by which time the resident was experiencing nose bleeds, prolonged bleeding from a finger stick, and had a significant amount of blood in his urine. The resident was transported to the hospital where he received Vitamin K to promote blood clotting and reverse the effect of the [MEDICATION NAME]. On 11/26/10 the resident developed extensive bruising on his abdomen, was coughing up small amounts of blood, required a pressure dressing to control the bleeding from a skin tear he sustained the previous evening, and had a progressively decreasing blood pressure. The resident's blood clotting time was tested and found to be at a critical level. The physician ordered Vitamin K to be given immediately, after which the resident was transported to the hospital for further evaluation. On 11/27/10 the resident was coughing up blood, but had no other signs/symptoms of active bleeding. Laboratory results indicated the resident's blood clotting time was still significantly prolonged and Vitamin K was again administered. On 11/28/10 the resident was transported to the hospital where he received a blood transfusion and was admitted for further monitoring and treatment related to the medication error. During an interview on 12/3/10 at 10:45 a.m., an administrative staff member stated the medication error occurred because the licensed nurse miscalculated the dosage. The facilities failure to administer the medication as ordered resulted in harm to the resident who suffered excessive bleeding that required repeated treatments and hospitalization to control.

Based on observations, record review, and interview, the facility failed to provide the necessary supervision and assistance to prevent accidents for 1 of 4 residents (#1), who were at risk for falls, in a sample of 6 residents. Resident #1 fell and sustained right arm fractures. Findings include: Resident #1 had [DIAGNOSES REDACTED]. Per review of the care plan, the resident was to be "escorted" back from the main dining room, offered to use the bathroom, and "lain down" as soon as she was finished with her meal "to prevent self-transfer and falls." Per review of the facility investigation dated 9/17/10, Staff B went on her break and "forgot to lay" the resident down after breakfast. The resident attempted to transfer herself from her wheel chair to bed after breakfast. She fell on to the floor next to her bed and sustained fractures to her right wrist and forearm. An x-ray on 9/17/10 showed the resident had a fracture of the distal radius, the distal ulna, (bones in the wrist area) and a possible fracture of the right elbow. The investigation concluded the nursing assistant did not follow the resident's care plan. During an interview on 9/22/10 at 12:00 noon, Staff A said after a meal she took the resident to the bathroom and then put her to bed, so she would not try to transfer herself to bed. On 9/22/10 at 12:05 p.m. during observations, Staff B helped the resident into the sitting position; put a gait belt on the resident to assist with the transfer; and did a stand pivot transfer from the bed to the wheel chair. She wheeled the resident to the dining room for her lunch. The resident had a splint on her right forearm, so she needed feeding assistance. On 9/22/10 at 4:45 p.m., the Administrator and the Director of Nurses said Staff B did not follow the resident's care plan. They said they counseled the nursing assistant to follow residents' care plans from here on. The Director of Nurses said the resident was going to see the orthopedic physician next week to check on the healing process and determine if the swelling was down enough to put a cast on the resident's arm.