Every finding on record at Salmon Creek Post Acute & Rehabilitation

Based on interview and record review, the facility failed to ensure a comprehensive individualized care plan was developed with specific information for that resident for 4 of 7 sampled residents (1, 4, 5, and 6) reviewed for care plans. This failure placed residents at risk for unmet care needs and a diminished quality of life.Findings included . Resident 1Resident 1 was admitted to the facility on [DATE] with diagnoses including spinal stenosis (narrowing of the spaces within the spinal canal), osteoarthritis (a chronic, degenerative joint disease leading to pain, stiffness, and reduced mobility), and presence of an artificial knee joint. Review of Resident 1's 5-Day Minimum Data Set (MDS, an assessment tool), dated 02/11/2026, showed Resident 1 was cognitively intact.Review of Resident 1's Care Plan, initiated 02/05/2026, showed the following segments were incomplete and/or not individualized:--Focus: Communication: the resident has risk for complications related to communication impairment due to (Areas to fill in were left blank.)-- Focus: Risk for Falls: the resident is at risk for falls related to: (Areas to fill in were left blank.)-- Focus: Anticoagulants: the resident is at risk for bleeding and bruising related to use of an anticoagulant for diagnosis of (Areas to fill in were left blank.) Resident 4Resident 4 was admitted to the facility on [DATE] with diagnoses including hypertension (a condition where pressure in the blood vessels is too high, potentially leading to heart failure) and chronic heart failure (a chronic condition where the heart cannot pump enough blood to meet the body's needs leading to fluid buildup in the lungs and legs). The admission MDS assessment, dated 01/27/2026, showed Resident 4 had severe cognitive impairment. Review of Resident 4's Care Plan, initiated 01/21/2026, showed the following segments were incomplete and/or not individualized:--Focus: Diuretics: the resident is at risk for complications secondary to diuretic use due to diagnosis of (areas to fill in were left blank.)--Focus: Opioids: the resident is at risk for complications related to the use of opioid secondary to (areas to fill in were left blank.) Resident 5Resident 5 was admitted to the facility on [DATE] with diagnoses including type two diabetes mellitus (a chronic metabolic leading to high blood glucose levels which can cause significant vision changes). The admission MDS assessment, dated 01/27/2026, showed Resident 5 had moderate cognitive impairment and required moderate assistance with ambulation. Review of Resident 5's Care Plan, initiated 01/21/2026, showed the following segments were incomplete and/or not individualized:--Focus: [Resident 5] has vision impairment related to (areas to fill in were left blank.) RESIDENT 6Resident 6 was admitted to the facility on [DATE] with diagnoses including traumatic subdural hemorrhage (bleeding inside the brain, usually caused by a head injury, potentially leading to dizziness, confusion, and weakness). The admission MDS assessment, dated 02/28/2026, showed Resident 6 was cognitively intact. Review of Resident 6's Care Plan, initiated 01/21/2026, showed the following segments were incomplete and/or not individualized:--Focus: the resident is at risk for falls related to (areas to fill in were left blank.)--Focus: the resident has been admitted to the facility to rehabilitation and requires assistance with their activities of daily living due to (areas to fill in were left blank.)--Focus: the resident is at risk for constipation related to (areas to fill in were left blank.)On 04/02/2026, Staff B, Director of Nursing Services and Registered Nurse, said the Unit Managers are tasked with writing the comprehensive care plans pertaining to nursing services. After reviewing the segments of incomplete care plans for Residents 1, 4, 5, and 6, Staff B said they each should have been completed and stated, We recognized that was an issue and we have been working on hiring and positions being filled, so our team is really coming together and now we are looking at systems. Reference WAC 388-97-1020 (1), (2)(a)(c)

Based on interview and record review, the facility failed to ensure residents were free from significant medication errors when medications were not administered in accordance with provider orders and/or within the standard practice administration parameters for 3 of 7 sampled residents (Resident 1, 2, and 6) reviewed for significant medication errors. This failure placed residents at risk of adverse medical conditions, a change in health conditions, and a diminished quality of life.Findings included.Review of the facility policy, Medication Administration Section 7.1, General Guidelines, dated January 2023, showed, Medications are administered in accordance with written orders of the prescriber . The individual who administers the medication dose records the administration on the resident's MAR [Medication Administration Record, comprehensive records of physicians' orders and the medications and treatments administered to a resident] immediately following the medication being given.medications are administered within 60 minutes of the scheduled time. Resident 1Resident 1 was admitted to the facility on [DATE] with diagnoses including spinal stenosis (narrowing of the spaces within the spinal canal), post-traumatic stress disorder (PTSD, a mental health condition caused by an extremely stressful or terrifying event), and chronic kidney disease (a long-term condition where the kidneys are damaged). Review of Resident 1's 5-Day Minimum Data Set (MDS, an assessment tool), dated 02/11/2026, showed Resident 1 was cognitively intact.Review of Resident 1s' February 2026 MAR and Treatment Administration Record (TAR, comprehensive records of physicians' orders and the medications and treatments administered to a resident), showed the following medications or treatments were omitted/not administered:-02/10/2026 at 8:00PM Ketoconazole (medicated cream to treat skin), for wound care.-02/10/2026 Evening. Monitoring bruising area; arms bilateral, knees, abdomen.-02/10/2026 Evening. Sedative/Hypnotic. Monitor for insomnia.-02/10/2026 Evening. Anticoagulant (blood thinning medication) medication monitoring.Review of Resident 1's Medication Administration Audit Report, dated 02/05/2026 through 02/16/2026, showed the following medications were not administered within the nursing standard of practice window of one hour prior to the ordered administration time to one hour after the ordered administration time (a two-hour timeframe):-Acetaminophen, for pain, was administered outside of the two-hour parameters four times out of 12 opportunities. -Estradiol, for hormone regulation, was administered outside of the two-hour parameters one time out of 12 opportunities. -Fluticasone propionate, for allergies, was administered outside of the two-hour parameters six times out of 12 opportunities. -Furosemide, for fluid retention, was administered outside of the two-hour parameters four times out of 12 opportunities. -Heparin (blood thinner) was administered outside of the two-hour parameters five times out of 12 opportunities. -Hydromorphone, for pain, was administered outside of the two-hour parameters four times out of 12 opportunities. -Ketoconazole, for wound care, was administered outside of the two-hour parameters 10 times out of 12 opportunities. -Losartan potassium, for hypertension (high blood pressure), was administered outside of the two-hour parameters four times out of 12 opportunities. -Phentermine, for weight loss, was administered outside of the two-hour parameters four times out of 12 opportunities. -Prazosin, for anxiety (feelings of fear, tension or uneasiness) and PTSD nightmares, was administered outside of the two-hour parameters two times out of 12 opportunities. -Rosuvastatin calcium, for hyperlipidemia (high cholesterol), was administered outside of the two-hour parameters five times out of 12 opportunities. -Senna, for constipation, was administered outside of the two-hour parameters six times out of 12 opportunities. -Sertraline, for depression (persistent feelings of sadness, hopelessness, and loss of interest), was administered outside of the two-hour parameters 10 times out of 12 opportunities. -Topiramate, for weight loss, was administered outside of the two-hour parameters one time out of 12 opportunities. Resident 2Resident 2 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD, a lung and airway disease), chronic pain syndrome (pain lasting longer than three months), type 2 diabetes mellitus (a chronic metabolic disorder leading to high blood sugar), and a psychotic disorder (a severe mental disorder causing abnormal thinking and perceptions). The quarterly Minimum Data Set (MDS) assessment, dated 12/31/2025, showed Resident 2 was cognitively intact.Review of Resident 2's January 2026 MAR and TAR showed the following medications or treatments were omitted/not administered:-01/04/2026 at 8:00PM Arnuity ellipta (mediation for asthma), for wheezing.-01/04/2026 at 8:00PM Cymbalta, for chronic pain syndrome.-01/04/2026 at 8:00PM Melatonin (sleep aid), for supplement.-01/04/2026 at 8:00PM Olanzapine, for psychotic disorder.-01/04/2026 at 8:00PM Omega-3, for supplement.-01/04/2026 at 8:00PM Vitamin C, for supplement.-01/04/2026 at 8:00PM Zetia, type 2 diabetes mellitus.-01/04/2026 at 8:00PM Zinc, for supplement.-01/04/2026 at 8:00PM Potassium chloride, for supplement.Review of Resident 2's Medication Administration Audit Report, dated 01/13/2026 through 01/28/2026, showed the following medications were not administered within the nursing standard of practice window of one hour prior to the ordered administration time to one hour after the ordered administration time (a two-hour timeframe):-Arnuity ellipta, for wheezing, was administered outside of the two-hour parameters two times out of 16 opportunities. -Cymbalta, for chronic pain syndrome (CPS), was administered outside of the two-hour parameters six times out of 16 opportunities. -Furosemide, for fluid retention, was administered outside of the two-hour parameters six times out of 16 opportunities. -Incruse ellipta, for COPD, was administered outside of the two-hour parameters three times out of 16 opportunities. -Insulin glargine, for Diabetes mellitus type II, was administered outside of the two-hour parameters six times out of 16 opportunities. -Levothyroxine sodium, for autoimmune thyroiditis (inflammation of the thyroid), was administered outside of the two-hour parameters six times out of 16 opportunities.-Melatonin, for supplement, was administered outside of the two-hour parameters one time out of 16 opportunities. -Olanzapine, for psychotic disorder, was administered outside of the two-hour parameters one time out of 16 opportunities. -Omega-3, for supplement, was administered outside of the two-hour parameters one time out of 16 opportunities. -Potassium Chloride, for supplement, was administered outside of the two-hour parameters four times out of 16 opportunities. -Vitamin C, for supplement, was administered outside of the two-hour parameters one time out of 16 opportunities. -Zetia, for type 2 Diabetes Mellitus, was administered outside of the two-hour parameters one time out of 16 opportunities. -Zinc, for supplement, was administered outside of the two-hour parameters one time out of 16 opportunities. Resident 6Resident 6 was admitted to the facility on [DATE] with diagnoses including traumatic subdural hemorrhage (bleeding inside the brain, usually caused by a head injury, potentially leading to dizziness, confusion, and weakness). The admission MDS assessment, dated 02/28/2026, showed Resident 6 was cognitively intact.Review of Resident 6's Medication Administration Audit Report, dated 02/24/2026 through 03/11/2026, showed the following medications were not administered within the nursing standard of practice window of one hour prior to the ordered administration time to one hour after the ordered administration time (a two-hour timeframe):-Acetaminophen, for pain, was administered outside of the two-hour parameters one time out of 16 opportunities. -Amlodipine, for hypertension, was administered outside of the two-hour parameters three times out of 16 opportunities. -Aspirin, for Cerebral Vascular Accident (stroke) prevention, was administered outside of the two-hour parameters one time out of 16 opportunities. -Atorvastatin, for Hyperlipidemia (high levels of fat in the blood), was administered outside of the two-hour parameters three times out of 16 opportunities. -Donepezil, for Alzheimer's disease (a brain disorder that affects memory, thinking, and behavior), was administered outside of the two-hour parameters three times out of 16 opportunities. -Levetiracetam, for spasms, was administered outside of the two-hour parameters two times out of 16 opportunities. -Lisinopril, for hypertension, was administered outside of the two-hour parameters three times out of 16 opportunities. -Multi-Vitamins, for supplement, was administered outside of the two-hour parameters two times out of 16 opportunities. -Senna, for constipation, was administered outside of the two-hour parameters three times out of 16 opportunities. -Zinc, for supplement, was administered outside of the two-hour parameters three times out of 16 opportunities. On 04/02/2026 at 11:00AM, Staff B, Registered Nurse and Director of Resident Services, said if there was a blank spot on the MAR or TAR, it meant the medication or treatment was omitted or not charted. While reviewing the January 2026 and February 2026 MAR and TAR for Residents 1 and 2, Staff B noted the blank spots and said those should not be blank. In an interview on 04/06/2026 at 2:00PM with Staff B, after review of the omissions and medication administration times of concern, they stated the administration times were outside of the permitted two hour timeframe and stated, We are making a change to the scheduling of medication administration but there is a lot that goes into it so we have not been able to do it yet. Reference WAC 388.97.1060 (3)(k)(iii)This is a recurring deficiency previously cited on 01/05/2026, 11/18/2025, and 07/31/2025.

Based on interview and record review, the facility failed to consistently conduct and document pre and post dialysis (a life sustaining treatment for kidney failure) assessments designed to ensure consistent ongoing communication and collaboration with the dialysis facility and failed to follow physicians' orders pertaining to dialysis treatment, for 1 of 1 resident (Resident 3) reviewed for dialysis. This failure had the potential to place residents who receive dialysis at risk for unmet care needs and dialysis related complications.Findings included .Review of the facility service agreement with the dialysis service provider, dated 01/05/2026, showed the dialysis service provider would, provide services to designated residents and will provide no other services, medical or otherwise, except as such services relate to or are an integral part of the provision of dialysis service.facility [Skilled Nursing Facility, SNF] shall ensure all appropriate medical, social, administrative, and other information accompany all designated residents at the time of transfer.facility [SNF] will provide for the interchange of information useful or necessary for the care of the designated resident.RESIDENT 3Resident 3 was admitted to the facility on [DATE] with diagnoses to include end stage renal disease (ESRD, the final, permanent stage of chronic kidney disease signifying fatal kidney failure necessitating regular dialysis.) and dependence on renal dialysis (signifies that a resident requires dialysis for survival.). Review of the 5-Day Minimum Data Set (an assessment tool), dated 01/29/2026, showed Resident 3 had severe cognitive impairment, the resident had a diagnosis of ESRD, and dependence on renal dialysis.Review of Resident 3's physician orders, dated 01/31/2026, showed an order for the Pre HD (hemodialysis) Assessment form to be completed before transporting the resident to dialysis, stating, Complete under Pre/Post HD [hemodialysis] Assessment in PCC [Point Click Care, An Electronic Medical Record, EMR] and provide a copy of HD paper form to transport upon arrival for center [dialysis service provider] to complete and return.Review of Resident 3's physician orders, dated 01/29/2026, showed an order for the Post HD Assessment form to be completed upon resident return from dialysis, stating, Complete under pre/post HD assessment in PCC and place a copy of HD paper form into HD [binder] after each session and update weight on return.Review of Resident 3's physicians' orders, dated 02/05/2026, showed an order to premedicate with Norco (A prescription medication used to treat moderate to severe pain.) prior to dialysis, ensure dentures were in, and to send a donut seat and a blanket with the resident to dialysis.Review of Resident 3's physicians' orders, dated 01/29/2026, showed an order to obtain the residents' weight daily.Review of the EMR for Resident 3 showed the following omissions on the Pre/Post HD Assessment:01/31/2026 Incomplete Pre HD Assessment.01/31/2026 Incomplete Post HD Assessment.02/03/2026 Incomplete Post HD Assessment.02/05/2026 Incomplete Pre HD Assessment.02/10/2026 Incomplete Pre HD Assessment.02/14/2026 Incomplete Pre HD Assessment.03/26/2026 Incomplete Post HD Assessment. Review of Resident 3's Comprehensive Care Plan, initiated 01/28/2026, showed the resident required hemodialysis related to their diagnosis of ESRD, interventions included dialysis at every Tuesday, Thursday, and Saturday. The Care Plan did not address Pre and/or Post Dialysis Assessments or documentation and did not address communication and coordination with the dialysis service provider after each dialysis visit.Review of Resident 3's Medication Administration Record (MAR), dated February 2026, showed Resident 3 did not consistently receive Norco prior to dialysis, as ordered by the physician. The MAR had the following entries for administration of Norco on the following dates the resident was scheduled to attend dialysis:02/07/2026 9 indicating see Progress Notes.02/10/2026 Blank/ no documentation.02/12/2026 9 indicating see Progress Notes.02/17/2026 Blank/ no documentation.Review of Resident 3's Progress Notes for the dates of 02/07/2026, 02/10/2026, 02/12/2026, and 02/17/2026 show no documentation pertaining to the physicians' order for Norco to be administered prior to dialysis treatment.Review of Resident 3's Nursing: Hemodialysis Communication Observation/Assessment, dated 02/05/2026, a recommendation from the dialysis center states, Pt. [patient] needs to come with snack/lunch, blanket, donut cushion, dentures in. He [Resident 3] states he isn't getting pain meds there [at the SNF] but complains of severe pain.Review of Resident 3's dialysis facility Patient Note, dated 02/05/2026, stated, Pt. [patient] expressed frustration.regarding care at [SNF]. Called facility and spoke with RN [registered nurse]. Pt. is given Tylenol TID [three times per day] and pain medication is available but not being given. Discussed pt. being in pain at tx [treatment] and on ride to dialysis. RN reported often dialysis pt.'s are premedicated to help with this and she was unsure why this was not happening but would discuss with her team. Requested there additionally be a note that says pt. should always have teeth put in and donut sent.Review of Resident 3's dialysis facility Patient Note, dated 02/10/2026, states, .Pt. was visibly cold and had been sent from SNF without a blanket, jacket or shoes.told pt. he seemed confused. Pt. agreed and said he has been for a few days.Called RN at SNF again and reviewed importance of sending warm clothes, blanket, shoes.Spoke with pt.'s [family member-name redacted] by phone and reported above concerns. She also felt pt was more confused and felt this was d/t [due to] missed tx [treatment] on Saturday [02/07/2026] . this is the second time [dialysis staff member] has called the facility to alert them to need for having warm clothes and having his teeth put in.Review of Resident 3's EMR showed Resident 3 did not attend their scheduled dialysis appointment on 02/07/2026.In an interview on 03/05/2026 at 3:40PM, Collateral Contact 1, dialysis staff member, said Resident 3 often arrived for dialysis in pain, without their communication binder, not properly clothed, and they were often sent without food, their dentures, or a blanket.In an interview on 04/02/2026 at 11:00AM, Staff B, Director of Nursing Services and Registered Nurse said a blank spot on the MAR indicated a medication omission or lack of charting. After review of the Pre and Post Dialysis Assessments that were blank and/or incomplete, Staff B said, That information should have been in the communication binder and then entered in the Pre and Post Assessments. Reference WAC 388-97-1900 (1)(6)(a-c)

Based on observation, interview and record review, the facility failed to ensure expired and/or BUE (beyond-use date) medications were discarded when expired from 2 of 5 medication carts (Cart B & Cart E) reviewed. The facility also failed to store medication in residents' room in a locked container for 1 of 1 resident reviewed (Resident 80). This failure placed residents at risk of not receiving the full benefits of the medication, equipment, supplies, and at risk for accessing unsecured medication. Findings included . Expired medications During an observation and review of the E Wing medication cart on 01/09/2026 at 10:22 AM, the cart had two pill packs with expired medication packs. Torsemide (diuretic, or water pill, used primarily to treat fluid retention) 20 mg (milligrams) expiration date 09/21/2025 and Hydralazine (used to treat high blood pressure) 10 mg expiration date 10/11/2025. The cart also had one Ondansetron (used to prevent and treat nausea and vomiting) 4 mg BUE 10/13/2025. During an observation and review of the B Wing medication cart, on 01/09/2026 at 10:58 PM, the cart had two packages of Ondansetron 4 mg's one BUE date 10/30/2025 and the other 12/05/2025. In an interview on 01/09/2026 at 10:22 AM, Staff P, Licensed Practical Nurse (LPN), said expired medication should not be kept in the cart. Staff P said the pharmacist would go through the cart once a month to get rid of the expired medications. In an interview on 01/09/2026 at 10:58 PM, Staff C, Assistant Director of Nursing/Registered Nurse (RN), said expired medications should be removed from the medication cart and destroyed. Unsecured medications Resident 80 was admitted to the facility on [DATE] with diagnosis including unspecified visual field defects. The Annual Minimum Data Set (MDS), an assessment tool, dated 10/13/2025, documented Resident 80 was alert and oriented. Record review of facility's policy, titled, Self-Administration of Medications and Treatments undated, documented . 8. Self-administered medications and/or treatment supplies will be stored in a safe and secure place, which is not accessible by other residents. lf safe storage is not possible in the resident's room, the medications of residents permitted to self-administer will be stored on a central medication cart or in the medication room.Nursing will transfer the unopened medication to the resident when the resident requests them. Record review of Resident 80's electronic health record did not show a care plan or assessment for medication self-administration and/or storage. In an observation on 01/06/2026 at 12:14 PM, Resident 80 was observed to have a plastic basin with medication bottles on the shelves near the front of his bed. Resident 80 showed the medications that were in the plastic basin which included bottles of: Super Enzymes for digestion, Alpha lipoic 100mg (milligrams) (anti-oxidant), Multivitamin pure food capsules, Melatonin 3mg (sleep aid), Niacin 500mg (Vitamin), Cranberry capsules 500mg (Vitamin), and Vitamin d3 gummies. In an interview on 01/06/2026 at 12:19, Resident 80 said he occasionally took the medications in his room. When asked where he typically kept his medications, Resident 80 said he kept them in the plastic basin on the shelves. In an observation and interview on 01/06/2026 at 12:28 PM, Staff N, Unit Manager/LPN, observed the basin of medications on Resident 80's shelf and said Resident 80's medications should have been kept in a lockbox that could only be accessed by Resident 80 and licensed staff. In an interview on 01/08/2026 at 12:44 PM, Staff B, Director of Nursing/RN, said it was the expectation that Resident 80 received education on having his own medications in his room and the facility provided Resident 80 with a lock box to store his medications. Reference WAC 388-97-1300(2)

Based on observation and interview, the facility failed to ensure staff performed hand hygiene during the lunch hallway meal pass for 1 of 5 hallways (C-Wing) reviewed for lunch meal pass. This failure to perform proper hand hygiene placed residents at risk of cross-contamination, food borne illness and a diminished quality of life. Findings included.During the lunch time dining observation on 01/06/2026 at 1:03 PM, Staff Q, Nursing Assistant (NA), took a meal tray into room [ROOM NUMBER]-B put the tray on the bedside table and pulled the table up to the resident. Staff Q left the room but did not wash or sanitize her hands.In an observation on 01/06/2026 at 1:04 PM, Staff Q grabbed another tray from the cart and took it into room [ROOM NUMBER]. Staff Q placed the tray on the bedside table and pulled the table closer to the resident. Staff Q left the room but did not wash or sanitize her hands.In an observation on 01/06/2026 at 1:06 PM, Staff Q grabbed another tray from the cart and took it into room [ROOM NUMBER]. Staff Q placed the tray on the bedside table. Staff Q left the room but did not wash or sanitize her hands.In an observation on 01/06/2026 at 1:08 PM, Staff Q grabbed another tray from the cart. Staff Q placed the tray on the bedside table and asked another NA for assistance to reposition the resident. Staff Q washed her hands.In an observation on 01/06/2026 at 1:10 PM, Staff Q grabbed another tray from the cart and took it into room [ROOM NUMBER]. Staff Q placed the tray on the bedside table. Staff Q left the room but did not wash or sanitize her hands.In an observation on 01/06/2026 at 1:14 PM, Staff Q grabbed another tray and delivered it to room [ROOM NUMBER].During an interview on 01/06/2026 at 1:15PM, Staff Q stated she was supposed to wash her hands before delivering trays. Staff Q said if she took a tray to a room and touched the bedside table or anything not clean, she was supposed to sanitize or wash her hand. When asked about moving the bedside table in several rooms she stated she was supposed to sanitize her hands. Staff Q said she realized she did not perform hand hygiene.During an interview on 01/08/2026 at 12:29 PM, Staff K, Infection Preventionist/Licensed Practical Nurse, said staff were supposed to wash or sanitize their hands after delivering trays to resident rooms.Reference WAC 388-97-2980

Based on interview and record review, the facility failed to ensure residents who had personal fund accounts established, received accrued interest on those accounts for 3 of 3 sampled residents (Residents 16, 76, and 98) reviewed for Trust Funds interest accrued. This failure placed residents at risk not to receive or have access to monies owed to them.Findings included .Record review of Resident 16's Resident Fund Statement, quarterly statement for the period of 10/01/2025 thru 12/31/2025, showed four credits totaling $7,140.40, four debits totaling $6,801.64, and an ending balance of $381.58. The Statement further showed, YEAR-TO DATE INTEREST PAID. 0.00.Record review of Resident 76's Resident Fund Statement, quarterly statement for the period of 10/01/2025 thru 12/31/2025, showed four credits totaling $2,761.00, three debits totaling $2,343.66, and an ending balance of $852.02. The Statement further showed, YEAR-TO DATE INTEREST PAID. 0.00.Record review of Resident 98's Resident Fund Statement, quarterly statement for the period of 10/01/2025 thru 12/31/2025, showed three credits totaling $6,789.00, five debits totaling $6,671.66, and an ending balance of $123.12. The Statement further showed, YEAR-TO DATE INTEREST PAID. 0.00.In an interview on 01/09/2026 at 2:40 PM, Staff L, Business Office Manager (BOM), said Resident 16, Resident 76, and Resident 98 had their money in an interest-bearing account. When asked why it did not show any interest paid to Residents 16, 76, and 98 on their last quarterly statement, Staff L said over the last quarter they were not dispersing the interest accrued properly.In an interview on 01/09/2026 at 3:23 PM with Staff A, Administrator, Staff D, Regional Director, and Staff M, Regional BOM, Staff M said the interest was not divided correctly to the residents and they needed to fix it. Staff M said every resident account that had over fifty dollars in it accrued interest. Staff M said they did it wrong at the facility, stating, .I've already told them they need to fix it.Reference WAC 388-97-0340 (a)

Based on interview and record review, the facility failed to provide a Medicare Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN - a notice of Medicare non-coverage and residents assumption of financial responsibility) to 1 of 3 residents (Resident 16) reviewed for beneficiary notification. This failure placed residents at risk of not being informed of services and related changesFindings included.Resident 16 was re-admitted to the facility on [DATE]. The Annual Minimum Data Set, an assessment tool, dated 12/31/2025, documented Resident 16 was severely cognitively impaired.Record review of Resident 16's Notice of Medicare Non-Coverage (NOMNC) form, dated 09/03/2025, showed Resident 16's representative received a call on 09/03/2025, informing them that Resident 16's Medicare Part A coverage would end on 09/05/2025. Record review of Resident 16's electronic health record did not show a SNF ABN was issued.In an interview on 01/09/2026 at 2:36 PM, Staff I, Social Services Director, said Resident 16 was not issued a SNF ABN because staff were unclear about which facility department was responsible for addressing Medicare Part A services which included issuing SNF ABNs. In an interview on 01/09/2026 at 2:47 PM, Staff D, [NAME] Director, said social services was responsible for issuing SNF ABNs and said Resident 16 should have received a SNF ABN notice but did not.Reference WAC 388-97-0300(1)(e)(5)(6)

Based on interview, observation and record review, the facility failed to maintain a clean homelike environment by not ensuring resident rooms were cleaned for 1 of 11 rooms (C Wing, room [ROOM NUMBER]) reviewed for environment. This failure placed residents at risk for a diminished quality of life.Findings included. Review of the Environmental Services Department. In-Services: Daily Resident Room Cleaning, dated 03/09/2015, showed 7. Dust Mop. The entire floor is to be dust mopped; especially behind, under beds and behind dressers.During an observation on 01/06/2026, in room [ROOM NUMBER] a hospital wristband was on the right side of the bed and on the left side of the bed next to the dresser was a tied-up plastic bag with trash in it on the floor.During an observation on 01/07/2026 at 10:03 AM, in room [ROOM NUMBER] the wristband and the bag were in the same location as the day before on the floor.During an observation on 01/08/2026 at 8:40 AM, in room [ROOM NUMBER] the wristband and the bag were in the same location as the day before on the floor.During an interview and observation on 01/08/2026 at 8:49 AM, Staff R, Housekeeping Aide (HA), said she cleaned all rooms daily. Staff R said part of her cleaning included sweeping and mopping the floors. When we went to room [ROOM NUMBER] Staff R was shown and observed the wristband and plastic bag on the floor, Staff R said HA was supposed to sweep and pick up the stuff around and under the bed.During an interview on 01/08/2026 8:56 AM, Staff S, Housekeeping Supervisor Director, said trash should be picked up and the floor should be dust mopped daily. Staff S said the HAs had a guidance checklist to follow.Reference WAC 388-97-0880 (2)

Based on interview and record review, the facility failed to complete an AIMS (Abnormal Involuntary Movement Scale) test (a rating scale used to assess the severity of involuntary movements that sometimes develop as a side effect of treatment with antipsychotic medications [drugs used primarily to treat symptoms such as hallucinations and delusions]) for 2 of 5 sampled residents (Resident 4 &118) reviewed for unnecessary medications. This failure placed residents at risk for adverse medication side-effects, medical complications, and a diminished quality of life.Findings included . Resident 4 was admitted to the facility on [DATE] with multiple diagnoses to include a psychotic disorder ([other than schizophrenia] a severe mental illness where a person loses touch with reality). The 5-Day Minimum Data Set (MDS, an assessment tool), dated 12/08/2025, showed Resident 4 was alert and oriented. Review of Resident 4's physician order, dated 12/19/2025, showed Resident 4 was prescribed quetiapine fumarate 25 mg (milligrams) at bedtime. The December 2025 and January 2026 electronic medication administration record (EMAR) showed Resident 4 was receiving quetiapine fumarate at bedtime. Review of Resident 4's care plan, dated 12/13/2025, showed the focus Antipsychotics: the resident is at risk of adverse reactions related to the use of antipsychotics. The care plan's intervention AIMS (abnormal involuntary movement scale) assessment as indicated. Review of the Consultant Pharmacist's Medication Regimen Review dated 12/01/2025 and 12/20/2025, Pt's [patient] on quetiapine (Seroquel), an antipsychotic. I was unable to locate a Current AIMS test in chart. Review of Resident 4's electronic health record (EHR) did not show documentation of an AIMS test completed for the administration of quetiapine fumarate. During an interview on 01/09/2026 at 8:34 AM, Staff H, Unit Manager/Licensed Practical Nurse, said an AIMS assessment was needed for a resident on an antipsychotic medication. While reviewing Resident 4's electronic records, Staff H said she could not find an AIMS for Resident 4 but one should have been completed. Resident 118 was admitted to the facility on [DATE] with multiple diagnoses to include depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and dementia (a general term for loss of memory, language, problem-solving and other thinking abilities). The admission MDS, dated [DATE], showed Resident 118 was severely cognitively impaired and was taking antipsychotic medication. Record review of Resident 118's physician orders, dated 12/31/2025, showed Resident 118 was prescribed quetiapine fumarate (an antipsychotic medication) 37.5 mg at bedtime. The December 2025 and January 2026 EMAR showed Resident 118 was receiving quetiapine fumarate at bedtime. Review of Resident 118's EHR did not show documentation of an AIMS test completed for the administration of quetiapine fumarate. In an interview on 01/09/2026 at 10:34 AM, Staff E, Regional Nurse Consultant/Registered Nurse (RN), said there was not an AIMS test done for Resident 118 and there should have been. In an interview on 01/09/2026 at 12:44 PM, Staff B, Director of Nursing/RN, said an AIMS test should be done upon admission for a resident taking an antipsychotic medication, or when a new antipsychotic medication was started. Reference WAC 388-97-1060 (3)(k)(i)

Based on interview and record review, the facility failed to ensure a written transfer/discharge notice was provided to the resident or the resident representative in a language and manner they understood for 1 of 1 residents (Resident 115) reviewed for hospitalization. This failure placed the resident at risk for not knowing the reason for their transfer or have the opportunity to make decisions about their transfer/discharge rights.Findings included .Record Review of the facility's undated Bed Hold Policy, documented, .Prior to a transfer, written information will be given to the residents and the resident representatives that explains in detail: .The details of the transfer (per the notice of transfer).Record review of Resident 115's admission Minimum Data Set (MDS, an assessment tool), dated 12/05/2025, documented Resident 115 was admitted on [DATE] and had moderate cognitive impairment.Record review of Resident 115's Nursing Note, dated 12/03/2025, stated, .At 0002 [12:02 am], the patient's granddaughter, present in the room, spoke with the patient's daughter, who requested the patient be transferred to a hospital for evaluation of potential sepsis [the body's extreme response to an infection. It is a life-threatening medical emergency]. Emergency services were called at 0005 [12:05 am], and the patient was subsequently transferred to Legacy Hospital. The on-call provider was notified.Record Review of Resident 115's Electronic Medical Records showed no documentation of a written transfer/discharge notice.Record Review of Resident 115's Nursing Home Discharge MDS, dated [DATE], documented Resident 115 had an unplanned discharge on [DATE].In a joint interview on 01/08/2026 at 2:27 PM, Staff B, Director of Nursing and Registered Nurse (RN) and Staff E, Regional Nurse Consultant and RN, said they were unable to find a Discharge/Transfer notice form for Resident 115. In a joint interview on 01/09/2026 at 11:04 AM, Staff B and Staff E said when a resident was transferred to the hospital they should be sent with an Interact SNF/NF [Skilled Nursing Facility/Nursing Facility] to Hospital Transfer Form. When asked if a resident was transferred emergently how they notified the resident or their representative in writing of the reason for their transfer, they stated it's done verbally over the phone and sent in writing the next business day. Staff B and Staff E confirmed Resident 115 did not have a Hospital Transfer Form filled out, given in person, or mailed to them or their representative. Reference WAC 388-97-0140 (1)(a)(b)(c)

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, an assessment tool) was completed accurately to reflect a resident's health status and/or care needs for 2 of 2 sampled residents (Residents 39 and 22) reviewed for resident assessment. This failure placed residents at risk for unidentified and/or unmet care needs and a diminished quality of life. Findings included . Dialysis Resident 39 was admitted to the facility on [DATE] with multiple diagnosis to include acute kidney failure (the sudden loss of the kidneys' ability to filter waste and balance fluids in your body) and chronic kidney disease, stage 4 (severe kidney damage). The Quarterly MDS, dated [DATE], showed Resident 7 was cognitively intact, had acute kidney failure, and was not on dialysis (a life sustaining medical treatment that filters waste products and excess fluid from your body when your kidneys fail). Record review of Resident 39's physician orders, dated 07/01/2025, showed Resident 39 was ordered to have dialysis every Tuesday, Thursday, and Saturday at 3:30 PM at a dialysis center. Record review of Resident 39's care plan, dated 07/01/2025, documented a Focus area, COMMUNITY DIALYSIS: [Resident 39] is at increased risk for complications secondary to requiring hemodialysis [dialysis using an external machine that requires a pathway into the bloodstream] secondary to ESRD [End Stage Renal Disease, the final permanent stage of chronic kidney disease]. Record review of Resident 39's progress notes, dated 10/23/2025, showed Resident 39 went to her dialysis appointment on 10/23/2025. Record review of Resident 39's October 2025 Electronic Treatment Administration Record (ETAR), showed Resident 39 went to dialysis on October 23rd and October 25th, 2025. In an interview on 01/09/2026 at 9:53 AM with Staff F, MDS Nurse/Registered Nurse (RN), and Staff G, MDS Nurse/Licensed Practical Nurse, Staff F said they gathered information for completing the MDS through interviews with the resident and Electronic Health Record (EHR) review. When asked about how Resident 39's dialysis was coded on the Quarterly MDS, dated [DATE], Staff G looked at Resident 39's EHR and said Resident 39 went out to dialysis on October 23, 2025. Staff F said dialysis should have been captured on the MDS and it was not. In an interview on 01/09/2026 at 11:19 AM, Staff B, Director of Nursing/RN, said it was her expectation the MDS was completed to accurately reflect the resident and their care needs. Hospice Resident 22 was admitted to the facility on [DATE] with multiple diagnosis to include Alzheimer's disease (brain disorder). The Annual MDS dated [DATE], documented Resident 22 was severely cognitively declined. Record review of Resident 22's physician order, dated 08/06/2025, showed Resident 22 was admitted to hospice services. Record review of Resident 22's care plan, dated 01/26/2025, documented Resident is admitted to hospice services .with expected decline in condition due to terminal progressive disease related to advanced age, debility and failure to thrive. Record review of Resident 22's Annual MDS, dated [DATE], showed Resident 22 was not receiving hospice care. In an interview on 01/08/2026 at 12:55 PM, Staff F and Staff G said Resident 22 was receiving hospice services. When asked if hospice was coded in the Annual MDS, dated [DATE], Staff G said hospice was not captured on the MDS and it should have been. Reference WAC 388-97-1000 (2)(n)

Based on interview and record review, the facility failed to develop a comprehensive care plan for 1 of 1 sampled resident (Resident 116) reviewed for comfort care (medical focus shifts from curing an illness to providing relief from pain and symptoms).This failure placed residents at risk of unmet care needs and a diminished quality of life.Findings included.Resident 116 was admitted to the facility on [DATE]. The Significant Change Minimum Data Set, an assessment tool, dated 11/18/2025, documented Resident 116 was moderately cognitively impaired. Record review of Resident 116's Portable Orders for Life-Sustaining Treatment, dated 11/11/2025, documented Resident 116 was on comfort care. Record review of Resident 116's care plan, dated 12/11/2025, showed a care plan for comfort care was developed a month after Resident 116 was placed on comfort care.In an interview on 01/08/2026 at 12:50 PM, Staff B, Director of Nursing/Registered Nurse, said it was the expectation that Resident 116's care plan was updated when Resident 116 level of care changed to comfort care. Reference WAC 388-97-1020(1)(2)(a)(b)

Based on observation, interview and record review, the facility failed to provide assistance with grooming for 1 of 4 residents (Resident 80) reviewed for activities of daily living. This failure placed residents at risk of unmet care needs and a diminished quality of life. Findings included.Resident 80 was admitted to the facility on [DATE] with diagnosis including unspecified visual field defects. The Annual Minimum Data Set (MDS), an assessment tool, dated 10/13/2025, documented Resident 80 was alert and oriented. Record review of Resident 80's electronic health record, showed resident was scheduled for and received showers on Tuesday, Friday and Sunday. In an interview on 01/06/2026 at 12:45 PM, Resident 80 said the facility staff did not help him shave his facial hair. Resident 80 was observed with unkempt facial hair during the interview. Resident 80 said he was unable to shave himself and needed assistance from staff. In an observation on 01/08/2026 at 1:59 PM, Resident 80 was observed with unkempt facial hair. Resident 80 said staff did not assist him with shaving. He stated, they keep saying I have an electric shaver, it has never worked.In an interview on 01/08/2026 at 2:14 PM, Staff O, Certified Nurse Assistant, said Resident 80 received showers in the evening and the staff were to assist him with shaving. Staff O said Resident 80 required assistance with shaving due to his visual impairment. Staff O said Resident 80 used to have an electric shaver, but it might have broken. In an observation on 01/09/2026 at 9:20 AM, Resident 80 was observed with unkempt facial hair.In an interview on 01/09/2026 at 10:09 AM, Staff B, Director of Nursing/Registered Nurse said it was the expectation that staff were to assist residents with shaving. Reference WAC 388-97-1060(2)(c)

Based on interviews and record reviews, the facility failed to ensure bowel interventions were initiated for 1 of 8 sampled residents (Resident 74) reviewed for quality of care and failed to perform ordered weights for 1 of 5 residents (Resident 13) reviewed for weights. This failure placed residents at risk for discomfort, health complications and a diminished quality of life.Findings included . Resident 74 was admitted to the facility on [DATE]. The Modification of Quarterly Minimum Data Set (MDS, assessment tool), dated 12/16/2025, documented the resident was alert and oriented. Review of Resident 74's Electronic Health Record (EHR) order, dated 06/04/2025, documented, Polyethylene Glycol Powder [laxative]. Give 17 grams by mouth as needed for Constipation. Dissolve in 8oz [ounce] fluid and drink daily as needed. Review of Resident 74's EHR order, dated 06/29/2025, documented, Bisacodyl [laxative] Rectal Suppository 10 MG [milligrams]. Insert 1 suppository rectally every 24 hours as needed for constipation. The Bowel and Bladder Elimination task sheet showed Resident 74 had a Bowel Movement (BM) on 01/01/2026 at 08:33 PM, and did not show another BM until 01/06/2026 at 06:00 PM, over 117 hours (five days) since his previous documented BM.Review of Resident 74's January 2026 Medication Administration Record (MAR) showed the bowel protocol was not initiated between the dates of 01/01/2026 and 01/06/2026.In an interview on 01/09/2026 at 10:57 AM, Staff H, Unit Manager/ Licensed Practical Nurse, said nursing staff received daily BM reports in the morning, and administer bowel medications per orders. Staff H said the administration of bowel interventions should be documented, including refusals, and stated, I would expect something administered on the 4th.In an interview on 01/06/2026 at 02:33 PM, Staff E, Regional Nurse Consultant/ Registered Nurse, said the BM protocol should have been initiated and documented as ordered. Staff E said Resident 74 routinely refused care, including BM medications. Staff E was unable to produce documentation of bowel interventions for Resident 74. Resident 13 was admitted to the facility on [DATE]. The 5-day MDS, dated [DATE], indicated that Resident 13 was renal insufficient and required dialysis treatment (a life sustaining medical treatment that filters waste products and excess fluid from your body when your kidneys fail). Resident 13 was alert and oriented Review of Resident 13's EHR order, weight one time a day. Review of Resident 13's Medication Administration Record (MAR), dated December 2025, had no documented weights for 12/01/2025, 12/02/2025, 12/06/2025, 12/09/2025, 12/11/2025, 12/13/2025, 12/15/2025, 12/18/2025, 12/20/2025, 12/21/2025, 12/29/2025 and 12/30/2025. Review of Resident 13's MAR, dated January 2026, had no documented weights for 01/01/2026, 01/02/2026, 01/04/2026, 01/05/2026 and 01/07/2026. Review of Resident 13's dialysis communication log had no documentation for 12/01/2025, 12/02/2025, 12/06/2025, 12/11/2025, 12/13/2025, 12/15/2025, 12/18/2025, 12/20/2025, 12/21/2025, 12/29/2025, 12/30/2025, 01/01/2026, 01/02/2026, 01/04/2026, 01/05/2026, and 01/07/2026. During an interview on 01/08/2026 at 10:57 AM, Staff K, Unit Manager/Licensed Practical Nurse, said weights should be documented in the EHR. Staff K said if the resident refused the refusal should be documented. While reviewing the EHR, Staff K said she could see several weights were not completed. Reference WAC 388-97-1060 (1), (3)(c)

Based on observation, interview, and record review, the facility failed to obtain physician orders for oxygen use for 1 of 2 sampled residents (Resident 83) reviewed for respiratory care. This failure placed residents at risk for worsening health complications, unmet care needs, and a diminished quality of life.Findings Included. Record review of the facility's policy titled, Oxygen Administration, undated, documented .1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Resident 83 was admitted to the facility on [DATE], discharged return anticipated on 12/19/2025, and re-admitted on [DATE] on hospice. The admission Minimum Data Set, (an assessment tool) dated 11/11/2025, showed Resident 83 was cognitively intact and was on oxygen therapy. In an observation on 01/06/2026 at 10:52 AM, Resident 83 was observed lying in bed with oxygen on per nasal cannula (NC) running at 3 liters per minute (lpm). In an observation on 01/07/2026 at 10:01 AM, Resident 83 was observed lying in bed with oxygen on per NC running at 3 lpm. Record review of Resident 83's care plan, dated 12/24/2025, documented a Focus, RESPIRATORY DISEASE: [Resident 83] is at risk for respiratory complications secondary to supplementary oxygen requirement.Oxygen 2L [2 liters] via NC for comfort. Record review of Resident 83's readmission progress note, dated 12/23/2025, documented, .on oxygen. Record review of Resident 83's progress note, dated 01/06/2026, documented, .Resident uses continuous oxygen via nasal canula. Record review of Resident 83's progress note, dated 01/07/2026, documented, .Resident uses continuous oxygen via nasal canula. Review of Resident 83's Electronic Health Record (EHR) showed no physician's order related to use of oxygen. In an interview on 01/09/2026 at 11:01 AM, Staff H, Unit Manager/Licensed Practical Nurse, said a physician's order was needed for residents using oxygen. After looking at Resident 83's EHR, Staff H said she did not see an order for oxygen use after the readmission to the facility and there should have been. In an interview on 01/09/2026 at 11:10 AM, Staff B, Director of Nursing/Registered nurse, said it was her expectation residents using oxygen had physician's orders in place for oxygen use. Reference WAC 388-97-1060 (1)(3)(vi)

Based on interview and record review, the facility failed to ensure resident census and nursing hours were accurately posted and/or updated daily for 30 of 30 days reviewed for nurse staff postings. This failure placed residents, resident representatives, and visitors at risk of not being fully informed of the current staffing levels and resident census information.Findings included.Record review of facility's policy titled, Posting Nursing Staffing Information Policy dated 10/06/2022, documented, I. The facility will post the following information daily, at the beginning of each shift. The posting shall include:. d. The information should reflect staff absence on each shift due to call-outs and illness.e. Resident Census.Record review of the daily nursing staffing information postings, from 12/07/2025 to 01/06/2026 did not show resident census posted daily.In an interview on 01/09/2026 at 11:05 AM, Staff H, Staffing, reviewed the Daily Nursing Staffing Information postings from 12/07/2025 to 01/06/2026 and said they did not include resident census on them. Staff H said the nurse staffing data reflecting staff absence or changes at the beginning of each shift was updated the next day and not on the actual date/shift the changes occurred. In an interview on 01/09/2026 at 1:08 PM, Staff B, Director of Nursing/Registered Nurse, said it was the expectation that staffing changes were adjusted every shift and the resident census was updated daily on the Daily Nursing Staffing Information postings.Reference WAC 388-97-1620(2)(b)(i)

Based on observation, interview, and record review, the facility failed to ensure staff properly donned (putting on) personal protective equipment (PPE) for 1 of 3 sampled resident rooms (room [ROOM NUMBER]) reviewed for infection prevention and control. This failure placed residents at risk for the spread of infection transmission in the facility and a diminished quality of life.Findings included. Record review of the facility's policy titled, Transmission-Based Precautions [TBP, extra infection control measures used in healthcare settings for people with known or suspected infections that spread easily], dated 02/01/2022, documented: .Contact Precautions [infection control measures used to prevent the spread of infections that are transmitted through direct contact with an infected person or their environment]. 2. Personal Protective Equipment (PPE)A. Glovesa. Staff and visitors will wear gloves when entering the room for all interactions that may involve contact with the resident and/or the resident's environment.b. Staff and visitors will remove gloves and perform hand hygiene prior to leaving the resident's room.B. Gownsa. Staff and visitors will wear a gown when entering the room for all interactions that may involve contact with the resident and/or the resident's environmentb. Staff and visitors will remove the gown and perform hand hygiene prior to leaving the resident's room. In an observation on 01/08/2026 at 12:46 PM, a sign was observed posted on the wall to the left of the door entrance to room [ROOM NUMBER] that showed: Contact PrecautionsEVERYONE MUST: clean their hands, including before entering and when leaving roomPROVIDERS AND STAFF MUST ALSO Put on gloves before room entry.Discard gloves before room exit.Put on gown before room entry.Discard gown before room exit . In an observation on 01/08/2026 at 12:50 PM, Staff J, Certified Nursing Assistant, entered room [ROOM NUMBER] with a lunch tray. Staff J did not don gloves or a gown prior to entering room [ROOM NUMBER]. Staff J set the lunch tray down on the bedside table placed over the bed and talked to the resident lying in bed. A visitor was observed in room [ROOM NUMBER] sitting next to the bed with a gown and mask on. Staff J then picked the lunch tray up off the bedside table, exited the room without cleaning her hands, and placed the lunch tray back in the food cart. In an interview on 01/08/2026 at 12:53 PM, when asked Staff J what the process was for entering and exiting a room for a resident on contact precautions, Staff J said she would put on gloves or a gown when providing one on one care or changing a resident. Staff J then looked at the contact precautions sign on the wall outside of room [ROOM NUMBER] and said they should have gowned and gloved whenever they went into the room. In an interview on 01/08/2026 at 12:50 PM, Staff K, Infection Preventionist (IP)/Licensed Practical Nurse, said she expected staff to put on a gown and gloves when they entered the room for a resident on contact precautions, even when delivering a food tray. Staff K said Staff J should have put on a gown and gloves when she entered room [ROOM NUMBER]. In an interview on 01/08/2026 at 3:06 PM, Staff B, Director of Nursing/Registered Nurse, said she expected staff followed the TBP, such as contact precautions, indicated for a resident and room per the IP's directions and directions posted at the door. Reference WAC 388-97-1320 (1)(a)

Based on interview and record review, the facility failed to obtain a signed consent before administering a psychotropic medication (medications capable of affecting the mind, emotions, and behaviors) for 1 of 5 residents (Resident 6) reviewed for unnecessary medications. This failure placed the resident at risk of not being fully informed of the risks and benefits before making decisions about medications, and a diminished quality of life.Findings included .Record review of Resident 6's Annual Minimum Data Set (an assessment tool), dated 12/18/2025, documented Resident 6 was admitted on [DATE], alert and oriented, and was treated for multiple diagnoses to include anxiety disorder (excessive and persistent fears or worries that interfere with daily life) and bipolar disorder (a mental health condition with significant mood swings of extreme highs and lows that affect the ability to function in daily life). Record review of Resident 6's Order Summary Report documented the following medication ordered on 11/27/2025: Sertraline (an antidepressant and psychotropic medication) 25 MG (milligrams). Give 2 tablet by mouth one time a day for MDD [Major Depressive Disorder, a persistent sadness, irritability, and a loss of interest in activities that once brought joy].Record review of Resident 6's Electronic Medical Records did not show documentation of an informed consent completed for the administration of Sertraline.In a joint interview on 01/08/2026 at 2:27 PM, Staff B, Director of Nursing and Registered Nurse (RN) and Staff E, Regional Nurse Consultant and RN, said Resident 6 did not have a consent for Sertraline in their records. In a joint interview on 01/09/2026 at 11:04 AM, Staff B and Staff E said it was their expectation residents on psychotropic medications had consents signed prior to administration of the medication. Reference WAC 388-97-0260

Based on interview and record review, the facility failed to ensure residents were free from significant medication errors when medications were not administered in accordance with provider orders for 2 of 5 sampled residents (Residents 2 &4) reviewed for significant medication errors. This failure placed residents at risk of adverse medical conditions, a change in health condition, and a diminished quality of life.Findings included.Review of the facility policy, Medication Administration Section 7.1, General Guidelines, dated January 2023, showed, Medications are administered in accordance with written orders of the prescriber . The individual who administers the medication dose records the administration on the resident's MAR [Medication Administration Record, comprehensive records of physicians' orders and the medications and treatments administered to a resident] immediately following the medication being given.Resident 2Resident 2 was admitted to the facility on [DATE] with diagnoses including metastatic cancer (cancer that spreads from where it started to a distant part of the body), chronic respiratory failure (a condition where the lungs can't adequately oxygenate the blood or remove carbon dioxide), hypertension (high blood pressure), reduced mobility, and weakness. Review of Resident 2's admission Minimum Data Set (MDS, an assessment tool), dated 10/03/2025, showed Resident 2 had severe cognitive impairment.Review of Resident 2's October 2025 and November 2025 MAR and Treatment Administration Record (TAR, comprehensive records of physicians' orders and the medications and treatments administered to a resident), showed the following medications or treatments were omitted/not administered:-10/09/2025 Night Shift. Catheter (a thin flexible tube used to drain urine from the bladder) care every shift. Document output every shift, for Foley care.-10/10/2025 Evening Shift. Catheter care every shift. Document output every shift, for Foley care.-10/10/2025 Complete skin observation weekly on Friday evening shift.-10/15/2025 Evening Shift. Triad (a skin barrier cream used to protect skin from moisture), apply to bilateral buttock every day and night shift for skin breakdown.-10/15/2025 Night Shift. Wound care: barrier cream to buttocks every shift and as needed every shift.-10/16/2025 0000 Bladder scan every 6 hours, straight catheter for PVR>350cc (for management of urinary retention the bladder scanner first checks urine volume; if it's high, a sterile straight catheter is inserted to drain the bladder, then removed.).-10/16/2025 6:00AM Bladder scan every 6 hours, straight catheter for PVR>350cc.-10/17/2025 6:00AM Bladder scan every 6 hours, straight catheter for PVR>350cc.-10/22/2025 Evening Shift. Triad, apply to bilateral buttock every day and night shift for skin breakdown.-11/13/2025 Evening Shift. Complete skin observation weekly on Thursday evening shift.-11/17/2025 Night Shift. Posterior thigh redness-apply a thin layer of barrier cream every day and night shift for wound care.-11/17/2025 Night Shift. Triad, apply to bilateral buttock every day and night shift for skin breakdown.-11/17/2025 Night Shift. Catheter care every shift for retention.-11/24/2025 Evening Shift. Catheter care every shift for retention.-11/24/2025 Night Shift. Catheter care every shift for retention.-11/24/2025 Night Shift. Posterior thigh redness-apply a thin layer of barrier cream every day and night shift for wound care.-11/24/2025 Night Shift. Bilateral heel boots (cushioned heel protectors that relieve pressure and prevent sores). Ensure placement while in bed. Resident 4Resident 4 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a group of neurologic disorders characterized by an alteration in mental status) and a urinary tract infection. The admission Minimum Data Set (MDS) assessment, dated 10/17/2025, showed Resident 4 had severely impaired cognition.Review of Resident 4's October 2025 and November 2025 MAR and Treatment Administration Record (TAR, comprehensive records of physicians' orders and the medications and treatments administered to a resident), showed the following medications or treatments were omitted/not administered:-11/20/2025 at 5:00AM Levothyroxine Sodium (thyroid medication) Oral Tablet 112MCG (micrograms). Give 1 tablet by mouth, one time a day. For thyroid, take before breakfast.-11/07/2025 at 6:00AM Acetaminophen Oral Tablet 325MG (milligrams). Give 2 tablet by mouth four times a day.-11/20/2025 at 6:00AM Acetaminophen Oral Tablet 325MG. Give 2 tablets by mouth, four times a day.-11/07/2025 Day Shift. Document orthostatic blood pressure.-11/07/2025 Day Shift. Document orthostatic blood pressure.-11/07/2025 Weekly weight every Friday day shift.-11/02/2025 Night Shift. Barrier cream to be applied to coccyx every shift and as needed with soilage/incontinence episodes r/t [related to] redness until resolved.-11/03/2025 Evening Shift. Barrier cream to be applied to coccyx every shift and as needed with soilage/incontinence episodes r/t [related to] redness until resolved. -11/06/2025 Night Shift. Barrier cream to be applied to coccyx every shift and as needed with soilage/incontinence episodes r/t [related to] redness until resolved.-11/07/2025 Day Shift. Barrier cream to be applied to coccyx every shift and as needed with soilage/incontinence episodes r/t [related to] redness until resolved.-11/02/2025 Night Shift. Elevate head of bed to alleviate/ prevent shortness of breath while lying flat, every shift for preventative measures.-11/03/2025 Evening Shift. Elevate head of bed to alleviate/ prevent shortness of breath while lying flat, every shift for preventative measures.-11/06/2025 Night Shift. Elevate head of bed to alleviate/ prevent shortness of breath while lying flat, every shift for preventative measures.-11/07/2025 Day Shift. Elevate head of bed to alleviate/ prevent shortness of breath while lying flat, every shift for preventative measures. On 01/05/2026 at 11:01AM, Staff B, Registered Nurse and Director of Resident Services, said if there was a blank spot on the MAR or TAR, it meant it was not done or was not documented. While reviewing the October 2025 and November 2025 MAR and TAR for Residents 2 and 4, Staff B noted the blank spots and said those should not be blank. Reference WAC 388-97-1260 (3)(k)(iii)

Based on interview and record review, the facility failed to provide activities of daily living (ADL's) for resident's dependent on staff assistance related to bathing for two of three sampled residents (Resident 1 & 2) reviewed for ADLs. This failure placed residents at risk for unmet needs, poor hygiene, and a diminished quality of life.Findings included.Review of the facility's undated Shower/Tub Bath policy showed, At a minimum, the resident will be offered at least 2 full baths or showers per week. Resident 1Resident 1 admitted to the facility on [DATE] with diagnoses including end stage renal disease (permanent kidney failure), weakness, and reduced mobility. Review of Resident 1's 5-day Minimum Data Set (MDS) assessment, dated 11/20/2025, showed Resident 1 had moderate cognitive impairment and was dependent upon staff for bathing assistance.During an interview on 11/25/2025 at 1:50PM, Resident 1 said they frequently were not assisted with bathing because they were at their regularly scheduled dialysis appointments.Review of Resident 1's Care Plan , dated 09/23/2025, showed Resident 1 required assistance with their personal hygiene and they were frequently incontinent of bowel and bladder.Review of Resident 1's Treatment Administration Record (TAR) , dated October 2025, showed Resident 1 was scheduled to receive bathing assistance every Wednesday and Sunday of the month but only received assistance with bathing five (5) out of the nine (9) times bathing assistance was scheduled. The TAR further showed Resident 1 was scheduled to be out of the facility every Monday, Wednesday, and Friday at a medical center providing dialysis services (an artificial process for removing waste products and excess fluids from the body, a process that is needed when the kidneys are not functioning properly). Because the facility scheduled showers for a time that they were at their scheduled dialysis appointments, Resident 1 did not receive four (4) showers.Review of Resident 1's TAR , dated November 2025, showed Resident 1 received assistance with bathing two(2) out of the eight (8) times bathing assistance was scheduled . The TAR further showed Resident 1 was scheduled to be out of the facility every Monday, Wednesday, and Friday at a medical center providing dialysis services. Because the facility scheduled showers for a time that they were at their scheduled dialysis appointments, Resident 1 did not receive six of their scheduled showers. Resident 2Resident 2 admitted to the facility on [DATE] with diagnoses including cancer, reduced mobility, and weakness. Review of Resident 2's admission MDS assessment, dated 10/03/2025, showed Resident 2 had severe cognitive impairment and was dependent upon staff for bathing assistance.Review of Resident 2's Care Plan, dated 10/02/2025, showed Resident 2 required assistance with their personal hygiene.Review of Resident 2's Treatment Administration Record (TAR) , dated October 2025, documented Resident 2 did not receive their scheduled shower assistance on 10/10/2025.Review of the Progress Notes, dated October 1, 2025 through October 31, 2025, for Resident 2 showed no documentation stating why they had not received their scheduled shower assistance. During an interview on 12/05/2025 at 11:01AM, Staff B, Registered Nurse and Director of Nursing Services, said residents were scheduled for bathing assistance twice per week and if a resident was not assisted to bathe, the nurses were expected to document in the Progress Notes. Staff B reviewed the electronic medical records for Residents 1 & 2 and acknowledged that Resident 1 had their bathing assistance scheduled for the same day of the week as their dialysis appointments. Reference WAC 388-97-1060 (2)(c)

Based on interview and record review, the facility failed to implement their written abuse prevention policies and procedures for timely identifying and investigating potential allegations of abuse/neglect when facility staff failed to recognize potential abuse for one of three sampled residents (#1) reviewed for investigations and grievances. This failure placed residents at risk for abuse, psychosocial harm and a decreased quality of life. This caused harm to Resident #1 when three unidentified and uninvestigated incidents occurred and the resident reported the incidents saying they felt embarrassed and ashamed. Findings included . The facility's policy entitled Patient Protection Abuse, Neglect, Exploitation, Mistreatment and Misappropriation Prevention, issued 11/2016, documented the following: - Definitions: Sexual Abuse is non-consensual sexual contact of any type. - The most critical step toward detecting and preventing abuse is acknowledging that no one should be subjected to violent, abusive, humiliating, exploitive or neglectful behavior. -Reporting: The administrator is responsible for the investigating, reporting and coordinating of the investigation process of any alleged or suspected abuse regardless of the source of the concern. -Identify: Any allegation requires an investigation. -Protection: Patient protection actions include immediately removing the patient from contact with the alleged abuser during the investigation. If the incident involves a center employee, the employee is suspended immediately after obtaining their statement, pending completion of the investigation. -Report/Respond: All alleged violations involving abuse, neglect . are reported immediately BUT not later than 2 hours after the allegation is made IF the events that cause the allegation involve abuse . Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's Minimum Data Set, an assessment tool, dated 02/24/2021, documented the resident was cognitively intact, required extensive assistance with dressing, and limited assistance with toilet use, bed mobility, and transfers. The February 2021 Concern Log had an entry for Resident #1, dated 02/15/2021, which documented a concern with therapy. The log documented the concern was resolved on 02/17/2021. Facility Concern Form, dated 02/15/2021, documented Resident #1 said Staff D, Occupational Therapist, had his hands next to her breast when working with her and it made her uncomfortable. The form documented Resident #1 told Staff D No, the last time it happened and Staff D stopped touching the resident. The resolution of the concern showed Resident #1 (the complainant) was satisfied with the resolution. The form was not signed by Resident #1. The form was signed by Staff A, Administrator, on 02/17/2021. This concern was not included on the accident/incident log and investigated as an allegation of abuse until 03/04/2021. The March 2021 Accident/Incident Log showed Resident #1's allegation of abuse was added to the log on 03/04/2021, 17 days after the staff were made aware of the incident. The facility investigation, dated 03/04/2021, documented the following allegations: Staff D touched the side of Resident #1's breast and Staff D placed his leg between Resident #1's legs. Staff D and Staff E, Physical Therapist, made Resident #1 uncomfortable when they stripped and dressed Resident #1 for an appointment. On 03/11/2021 at 10:34 AM, Resident #1 said she reported the incident of Staff D and Staff E stripping her on 12/28/2020 to Staff G, Registered Nurse (RN) and Nurse Supervisor. Resident #1 said during the incident when Staff D put his hand on her breast, .it wasn't like he just brushed up against my breast, his hand was curved in a cupping like manner on the side of my breast, and he kept it against my breast for an uncomfortably long amount of time until I said, No. Resident #1 said she reported another incident with Staff D in which he straddled my thigh, his knee was very close to my crotch, I would say about 1 centimeter away from my vagina . I would have to rub up against his privates the whole way up. I, again, said, No. Resident #1 said initially she did not want Staff D to get into trouble, she just wanted it to stop. Resident #1 stated, I never said I didn't want [the incident] reported as sexual abuse. Nobody ever even asked me that question. Resident #1 stated, I didn't tell anyone because . I was embarrassed. The fact that it happened again and again made me feel ashamed . Record review of progress notes, dated 02/15/2021 to 03/17/2021, did not show Resident #1 was monitored by social services and/or nursing for psychosocial harm related to the resident's allegations of abuse. On 03/17/2021 at 2:44 PM, Staff C, Assistant Director of Nursing Services and RN, said Resident #1 reported to her a concern about Staff D and how he placed his hands between her arm and her breast. Staff C said she considered unwanted touching of a resident's breast to be sexual abuse. Staff C said Resident #1's concern was not investigated as an allegation of sexual abuse because Resident #1 never mentioned the word breast when she spoke with me. Staff C said she wrote a statement for Resident #1 on the Concern Form, dated 02/15/2021, A couple of times now Staff D had his hand next to my breast when working with me; it makes me uncomfortable . Staff C said she was a mandatory reporter and she should report any allegation of sexual abuse, even if she suspected it might not be true. On 03/18/2021 at 3:32 PM, Staff B, Director of Nursing Services and RN, said he was aware of Resident #1's concern about Staff D and how Staff D had made inappropriate contact with her breast during care. Staff B said it was the expectation of the staff that if they received an allegation that was or could be considered sexual abuse, they reported it to a manager on call immediately. Staff B said Resident #1's concern was not investigated as an allegation of sexual abuse from the beginning based on Staff C's report to Staff B that Resident #1 was not making an allegation. Staff B said the purpose of an investigation was to find out if an allegation was true, and stated, Looking back, knowing what I know now, I would have done an investigation right away. Staff B stated, .If I would have known [Resident #1] was making an allegation, all of the things we did on 03/04/2021, we would have done right then [02/15/2021] . On 03/30/2021 at 11:12 AM, Staff A said she was first notified of Resident #1's concern about Staff D touching her breast with his arm on 02/15/2021. Staff A said she did not investigate the concern as an allegation of sexual abuse because of the way Staff C said Resident #1 was reporting it, as a concern and not an allegation. Staff A said she never spoke directly with Resident #1 about the incident and just took the word of Staff C. Staff A said she was not aware of any interventions, such as counseling, taken to assist Resident #1 after her report of the abuse. Reference WAC 388-97-0640(2)(a)(b)(6)(a) .

Based on interview and record review, the facility failed to ensure residents were free from significant medication errors when diabetic medication was given outside of the physician ordered parameters for 1 of 6 sampled residents (#2) reviewed for significant medication errors. This failure placed residents at risk for medical complications, adverse side effects, and a diminished quality of life. This caused harm to Resident #2 when insulin was administered when the physician orders [REDACTED]. Findings included . Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2's endocrine system related to insulin dependent diabetes care plan, initiated 06/04/19, documented interventions including, Administer medication per physician orders. A review of physician orders, dated 07/25/19, documented an order for [REDACTED]. (Insulin [MEDICATION NAME] is a fast-acting, manmade insulin, which has onset of 5 to 15 minutes, peak effect in 1 to 2 hours and duration of action that lasts 4-6 hours.) The (MONTH) 2019 Medication Administration Record, [REDACTED]. The facility investigation report, dated 11/14/19, documented Resident #2 was admitted to the hospital for [MEDICAL CONDITION] (absence of enough oxygen in the tissues) and low blood sugar. The investigation documented Resident #2's blood sugar at 12:00 PM was 81 and the resident received 20 units on regular insulin in error. Resident #2 had orders for blood sugars less than 100 to hold the insulin. Resident #2's oral intake was 25% and blood sugar levels was not rechecked. A witness statement, dated 11/14/19 by Staff G, Licensed Practical Nurse, documented, I assumed since it was lunch time that it would be ok to give it to her as she was going to be eating. Apparently, I did not read it correctly and administered the insulin. A nurses progress note, dated 11/14/19, documented Resident #2 seemed off, blood sugar was checked and it was 66. Orange juice was given. The progress note noted, Patient slow to respond grips present but very weak. Speech was noted to be gargled and breathing rapid with shortness of breath. The progress note documented blood sugar was checked at 3:50 PM and it was 27. Documentation showed the physician was notified and family were notified of change in condition and altered mental status. Resident #2 was sent to emergency room . Resident #2's hospital records showed the resident arrived at the hospital on [DATE] at 4:04 PM. Resident #2's hospital history and physical, signed and dated 11/14/19 at 10:44 PM, documented the assessment as Acute metabolic [MEDICAL CONDITION]-acutely due to [DIAGNOSES REDACTED] (low blood sugar). The hospital records documented the resident was admitted to intermediate intensive care unit with a [DIAGNOSES REDACTED]. On 11/21/19 at 11:30 AM, Resident #2 said she recalled staff attempting to wake her up several times and was not able to be fully alert. The resident said she was told her blood sugar was 27 and paramedics were transferring her to the hospital. Resident #2 said she had one bite of her salad for lunch. Resident #2 said she felt neglected as staff should have been aware of her insulin orders. On 12/17/19 at 1:15 PM, Staff B said he expected staff to follow physician orders. Staff B said Resident #2's insulin orders were clearly written, and parameters to hold for blood sugars of 100 or less were on MAR. Staff B said Staff G should have understood the orders and should not have given the insulin. Staff B said Staff G did not follow the order and had misread it. Reference WAC 388-97-1060 (3)(k)(iii)

Based on observation, interview and record review, the facility failed to implement recommendations made by the registered dietician concerning an significant weight loss for 1 of 4 sampled residents (#23) reviewed for nutrition. This failure placed residents at risk for impaired nutrition, weight loss, and a diminished quality of life. This caused harm to Resident #23 who experienced a 8.13 % weight loss in 34 days. Findings include . Resident #23 was admitted to the facility on [DATE] with multiple diagnoses. The Minimum Data Set (MDS), an assessment tool, dated 12/18/18, indicated the resident was severely cognitively impaired, required extensive assistance with activities of daily living and required set up and supervision for eating. The MDS documented a significant weight (defined as 5% in one (1) month, 7.5% in three (3) months or 10% in six (6) months). The MDS did not document swallowing, mood, behavior or rejection of care issues. On 02/06/19 at 9:06 AM to 9:30 AM, Resident #23 was observed sitting up in her wheelchair (w/c) in the doorway to her room. An over bed table was placed in front of her with frosted flakes with milk, yogurt and a drink. The resident slowly attempted to feed herself, then placed her head in her hand and leaned to one side. Several Nursing Assistants (NAs) walked past the resident and did not stop to engage or assist her. At 1:07 PM to 1:20 PM, Resident #23 was observed sitting in her w/c in her room next to her bed, with her head leaning on her hand. The over bed table was placed in front of her with ½ a tuna sandwich, a bowl of mandarin oranges, a bowl of chocolate pudding and a 7-up on it. No staff assisted the resident. On 02/07/19 at 8:15 AM to 8:30 AM, Resident #23 was observed in her w/c in the doorway to her room. An over bed table was placed in front of her with a bowl of cereal, a glass of juice and a Canada Dry on it. No staff assisted the resident to eat. On 02/08/19 at 8:30 AM, the resident was observed in the dining room in her w/c. An unidentified staff member asked the resident if she wanted to eat and the resident did not respond. A few moments later, a second staff member held a spoon of food to the resident's mouth and asked if she wanted a bite. The resident did not respond. Staff did not engage or assist the resident further. The resident was returned to her room without having eaten anything. A Nutritional Assessment, dated 10/19/18, documented in the summary, Will trial meals in the dining room for cueing and 1:1 physical assistance w/eating. Will continue to monitor and (adjust) interventions as (resident) allows. The Kardex (tool that directs staff on care), undated, documented the following instruction to staff: *Dining Location: Willamette Dining room (FYI) *Cue/Encourage fluid intake frequently at and between meals *Restorative Dining Record review of Resident #23's weight record documented the resident's weight. On 01/02/19 - 125.4 pounds. On 02/05/19 - 115.2 pounds, a weight loss of 8.13% in one month. The meal intake log, dated 01/08/19 to 02/06/19, showed the following documentation: *35 of 90 opportunities for meals the intake was documented as between 0-25% *28 of 90 opportunities for meals the intake was documented as 50% On 02/11/19 at 3:45 PM, Staff Q, Registered Dietician, said she had done the nutritional assessment, and it would be her responsibility to chart in the care plan and kardex the recommendations she would like implemented. Staff Q said when she made the recommendation for 1:1 (assistance of one staff directly assisting resident) cueing, she had documented it on the kardex listed as resident to eat in dining area and not specifically to have 1:1 assistance. Staff Q stated, It would be assumed if the resident was in the dining room, she would get the help she needed. Staff Q said it was not on the kardex or the care plan for the resident to have 1:1 assistance with eating, so technically the staff did not specifically know to do that. Staff Q stated, I know the resident refuses to go to the dining room a lot so (staff) could assist her in her room. When asked how staff would know to assist the resident in her room with eating, Staff Q stated, It was assumed. When asked how long a trial would last for 1:1 cueing/assistance, Staff Q stated, Usually a couple of weeks. When asked where that would be documented as to how long it was, how it went and what adjustments need to be done, Staff Q said she would document that under her dietary/nutrition notes. Staff Q was unable to provide that documentation. When asked if the resident had continued to lose weight, Staff Q stated, Yes, she did. At 4:00 PM, Staff B, Registered Nurse and Director of Nursing Services, said staff would use the kardex/care plans to direct their care. If it was not on the kardex, the aides would not know the resident required 1:1 assistance with eating. Reference WAC 388-97-1060(3)(h)