Every finding on record at Shelton Health and Rehabilitation

Based on record review and interview, the facility failed to ensure medications were administered timely for 2 (Residents 1 and 6) of 3 residents reviewed for medication administration. This failure placed residents at risk for increased risk of infection and decreased quality of life.The findings included.Review of the facility policy, titled Medication Administration Policy, dated 01/2023 documented .Medications are administered in accordance with written orders of the prescriber .Medications are administered within 60 minutes of scheduled time .Unless otherwise specified by the prescriber, routine medications are administered according to the established medications administration schedule for the nursing care center . Resident 1Resident 1 was admitted to the facility on [DATE] with diagnoses including dementia with other behavioral disturbance, diabetes, retention of urine (inability to empty urine from the bladder), obstructive and reflux uropathy (damage or structural change in the urinary tract causing urine to flow backward from the bladder into the kidneys) and bladder neck obstruction (blockage or failure of the muscle at the base of the bladder to open properly during urination). A significant change Minimum Data Set (MDS), an assessment dated [DATE] showed Resident 1 was cognitively impaired and was always incontinent with bladder and bowel.Review of Resident 1's physician's order dated 05/19/2026 documented urology referral related to retention.Review of Resident 1's Urology documentation dated 07/24/2026 documented .Chronic Urinary retention.Patient is unable to adequately empty bladder, placing her at risk for recurrent urinary tract infections, sepsis and renal damage.Patient and caregivers educated on signs of infection, and need to complete antibiotics.Start Bactrim 800/160 for 14 days.prescription sent to facility pharmacy.Resident 1's nursing progress note dated 07/24/2026 at 3:31 PM, documented .Resident returned with new orders for a chronic Foley and some orders for treatment to her abdominal folds.Resident 1's provider note dated 07/24/2026 documented.The patient returned from her initial Urology [specialist who focuses on diseases of the urinary tract] follow-up appointment. She has a chronic foley catheter in place and returned with a Bactrim [medication to treat infection] order to treat UTI [urinary tract infection] .Review of Resident 1's physician's order dated 07/27/2026, documented Sulfamethoxazole-Trimethoprim (Bactrim) 800-160 milligrams, give one tablet by mouth two times a day for UTI for 14 days.During an interview on 08/07/2026 at 9:30 AM, Staff A acknowledged Resident 1 did not receive the prescribed antibiotic until 7/27/26 (3 days after the urology appointment). She stated she was unsure why the delay occurred.During an interview on 08/07/2026 at 11:00 AM, Staff B, Advanced Registered Nurse Practitioner (ARNP) was asked if she saw Resident 1 after her return from the urologist appointment? Staff B stated she saw the resident on that day and Resident 1 had returned with a prescription for Bactrim from urology on 07/24/2026. Staff B was asked if Resident 1 was at high risk for developing an infection. Staff B stated .yes the resident was high risk for developing an infection. Staff B stated she reviewed the documentation and handed it off to nursing. Staff B was told the antibiotic was not started until 07/27/2026 and was asked what is your expectation for the administration of antibiotics to residents? Staff B acknowledged the antibiotic should have been administered as soon as possible .there was too long of a delay in receiving the antibiotic.Resident 6Resident 6 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including bilateral below the knee amputations, diabetes and chronic kidney disease. The significant change MDS dated [DATE] showed the resident was cognitively intact and received insulin injections daily.Review of Resident 6's physician order dated 07/23/2026 showed Insulin Glargine (long acting insulin used to treat diabetes) inject 13 units subcutaneously (beneath the skin) daily related to Type 2 Diabetes with Diabetic Chronic Kidney Disease.Resident 6's electronic medication administration record dated 08/09/2026 and 08/10/2026 showed the prescribed 8:00 AM insulin was not administered until 10:23 AM (2 hours and 23 minutes after the ordered administration time).During an interview on 08/12/2026 at 3:07 PM, Resident 6 was asked if they had any concerns with their care. The resident responded that she had concerns about how the facility administers her medication. She stated on 08/09/2026 the nurse checked her blood glucose after she had already eaten her breakfast meal. She stated her insulin was not administered until late morning and should have been given around 8:00 AM.it really messed me up that day.During an interview and review of records on 08/13/2026 at 1:55 PM, Staff C, Resident Care Manager acknowledged medications are to be administered 1 hour before or 1 hour after the administration time. Staff C acknowledged Resident 6's insulin was administered greater than 2 hours after the administration time of 8:00 AM on 08/09/2026 and 08/10/2026.Reference WAC 388-97-1300 (1)(a)(i)(ii)

Based on observation, interview and record review, the facility failed to prevent and limit the spread of a gastrointestinal (GI) illness and Norovirus (a virus causing acute GI outbreaks in long-term care facilities, resulting in symptoms such as nausea, vomiting, and diarrhea, which rapidly spread from person to person) by ensuring GI Contact Precaution(limiting direct or indirect contact with the resident or environment by wearing gown and gloves during resident care for residents requiring transmission based precautions and washing hands with soap and water) were followed for 23 of 34 (1, 2, 5, 6, 7, 8, 9, 11, 13, 15, 17, 18, 19, 20, 24, 25, 26, 27, 30, 31, 33, 35, and 36) residents reviewed for a GI or Norovirus illness. The facility failed to cohort (a group of residents with similar symptoms) and isolate residents with the illness and protect residents exposed to the illness. Residents 1 and 2 experienced harm when they developed nausea, vomiting and/or diarrhea that required treatment with medication when they were not moved to a different location after their roommate showed signs of a GI illness. The facility failed to consistently surveille potential and active illness in resident and staff. The facility failed to notify the local health jurisdiction, residents, families, and the public in a timely manner of the outbreak. The facility failed to remove Resident 1 from isolation in accordance with the facility policy. These failures placed the residents, visitors, and staff at an increased risk of GI illness or Norovirus and diminished quality of life.Findings included.<Room Assignments>The facility policy, Norovirus Prevention and Control, revised 07/16/2025, documented the facility will follow guidelines and established standards of practice observed by the Center for Disease Control and Prevention (CDC) for Norovirus prevention and control.The CDC recommendations, Key Infection Control Recommendations for the Control of Norovirus Outbreaks in Healthcare Settings, undated, documented when a Norovirus infection is suspected, adherence to personal protective equipment (PPE) use according to GI Contact Precautions (CP) when entering the resident care area. Symptomatic residents should be placed in single occupancy rooms. If unable to accommodate single occupancy rooms, efforts should be made to separate the symptomatic residents from asymptomatic residents. These efforts may include placing a cohort of residents in multi-occupancy rooms or in designating care area. Minimize resident movements within a facility during a Norovirus outbreak. Restrict symptomatic and recovering residents from leaving the designated area unless it is for essential care or treatment. Suspend group activities for the duration of a Norovirus outbreak. Place residents with Norovirus on CP for a minimum of 48 hours after the resolution of symptoms. Exclude ill personnel from work for a minimum of 48 hours after the resolution of symptoms. The importance of performing frequent hand hygiene should be reinforced. During outbreaks, use soap and water for hand hygiene after providing care or having contact with residents suspected or confirmed with Norovirus.Resident 1Resident 1 was admitted to the facility on [DATE] with diagnosis of chronic obstructive pulmonary disease (a lung disease which makes it hard to breathe). The quarterly minimum data set (MDS), dated [DATE], documented Resident 1 had no cognitive impairment and was dependent on staff with activities of daily living (ADLs).Resident 24 was admitted to the facility on [DATE] with diagnosis including diabetes mellitus (a condition where the body does not produce enough insulin). The quarterly MDS dated , 05/27/2026, documented Resident 24 had severe cognitive impairment and was dependent on staff with ADLs.On 07/22/2026 at 12:17 PM, Resident 1 said her roommate, Resident 24, became ill two days before they did. Resident 1 said they were not offered a different room once their roommate became ill. Resident 1 said they felt they were bound to get the illness. Resident 1 said they had nausea then vomiting, lasting three days. The resident said this was really tough. They said they were on isolation a long time and it felt like two weeks. Resident 1 said they stayed in their room about four days total. Resident 1 said they were told they had to wear a mask and wash their hands if they left the room. Resident 1 said they felt like the illness was probably spread by staff who did not wash their hands properly. Review of Nursing Progress notes, dated 07/09/2026, documented Resident 24 had a poor appetite, nausea and vomiting.Progress notes, dated 07/10/2026, documented Resident 1 had several episodes of vomiting in the evening.The Medication Administration Record (MAR), dated July 2026, documented Resident 1 required Geri-lanta (a medication used for GI upset) on 07/10/2026 and 07/13/2026.Resident 2Resident 2 was admitted to the facility on [DATE] with diagnosis including a stroke. The annual MDS, dated [DATE], documented Resident 2 had no cognitive impairment and was dependent on staff with ADLs. Resident 17 was admitted to the facility on [DATE] with diagnosis including diabetes mellitus. The admission MDS, dated [DATE], documented Resident 17 had no cognitive impairment and was dependent on staff with ADLs.On 07/22/2026 at 3:13 PM, Resident 2 was observed in her bed. The resident could not answer historical questions. Resident 2 appeared to have limited range of motion requiring dependence on staff with ADLs. On 07/23/2026 at 10:42 AM, Resident 2's family member (FM) said she was not made aware of a GI outbreak at the facility until they went to visit Resident 2 who was sick at that time of the visit. Resident 2 had vomiting and diarrhea. Resident 2's FM was not told when or if the resident had been exposed to the GI illness. A new room was not offered to the resident once her roommate became symptomatic.At 2:23 pm, Staff K, Registered Nurse (RN), said Resident 2 became symptomatic once the outbreak spread to their hall. She was not sure who had the illness first, Resident 17 (Resident 2's roommate) or Resident 2. Resident 2 had started to develop symptoms of vomiting and diarrhea during the night. When the family came into visit during the day, she informed the family Resident 2 was symptomatic.Progress notes, dated 07/09/2026, documented Resident 17 had an episode of diarrhea.Progress notes, dated 07/10/2026, documented Resident 2 had vomiting and diarrhea.The MAR, dated July 2026, documented Loperamide (a medication used to treat diarrhea) was administered to Resident 2 on 07/10/2026. The Daily Census sheet, dated 07/12/2026, showed four unused resident rooms. On 07/22/2026 at 2:54 PM, Resident 15 and Resident 34 were observed talking in their rooms. Resident 15 said they were very ill with the whole works. This included nausea, vomiting, and diarrhea. The resident said, it was really bad and they were really miserable. Resident 15 said it lasted about three to four days. Resident 34 said they did not get ill and they tried to stay on their side of the room during Resident 15's illness. Resident 34 said they were not offered a different room during this time. Resident 15 said CP lasted several days after her symptoms resolved. Resident 15 said they felt the residents near the doorway got sick first and they felt the illness was spread by the staff not washing their hands. On 07/23/2026 at 3:30 PM, Staff E, said the facility had a GI and Norovirus outbreak. They first started seeing symptoms of nausea, vomiting, and diarrhea. This started on 07/07/2026 with more cases on 07/08/2026. Then it spread throughout the facility. Staff E said they did not consider moving residents who were asymptomatic out of the symptomatic residents' rooms. She acknowledged the facility had open rooms they could have used for asymptomatic residents. Staff E said she heard somewhere, she was not sure where, they no longer recommend moving residents out of rooms or cohorting residents. Staff E said she was not familiar with the facilities policy directing staff to move residents who were asymptomatic to another room. Staff E stated that residents become contagious once they show signs of symptoms and they would have had time to move the asymptomatic residents. Staff E said she did not review the facility policy or the CDC Centers for Disease Control recommendations. She said she did discuss the GI outbreak guidance with Staff B, RN/Director of Nursing Services. Staff E acknowledged Resident 1 was out in the common area while on isolation. Staff B agreed both Resident 1 and Resident 2 became symptomatic after their roommates' showed symptoms and would have had time to move the residents out of their rooms and they did not follow the policy of moving roommates or cohorting residents. On 07/28/2026 at 3:25 PM, Staff B stated residents on isolation were in the hallways with other asymptomatic residents. Staff B said they did not follow their policy for Norovirus outbreaks. Staff B said the outbreak did not go as it should have.<Prevention & Observations>On 07/13/2026 at 11:45 AM, Staff C, RN, said they were waiting for results on a Norovirus test to determine if a resident had the virus. At 12:02 PM, Resident 5's room was observed to have a sign directing staff to follow GI CP and another sign directing staff on how to don (apply) a gown, gloves, and a mask.At 12:05 PM, an unknown staff member came to Resident's 5 room entryway carrying the resident's lunch tray. The staff member had a gown, gloves, and mask already on and did not wash their hands or apply clean PPE at the room entryway. The staff did not wash their hands at the sink once they dropped off the tray and left the room.At 12:20 PM, Resident 1, Resident 3, Resident 8, and Resident 37 were all observed in a common area near sitting or standing close to each other.On 07/14/2026 at 12:23 PM, a sign was posted on the front entry indicating the facility was having a Norovirus outbreak and provided visitors with guidance on methods to prevent the spread of the illness.At 12:25 PM, Staff B said masks were not needed in the hallway but I would put one on if you go in the rooms. Staff B said they have a few residents left on precautions but are at the end of the outbreak. At 12:35 PM, Staff J, Physical Therapy Assistant, was observed to enter Resident 30's. Staff J did not perform hand hygiene or don a gown and gloves before entering the room. Staff J had a mask on his face and did not don a clean mask when entering the resident's room. At this time, Staff D acknowledged Staff J entered Resident 30's room without proper PPE or hand hygiene. Staff D pointed to the signs posted outside the resident's door directing staff to wear PPE, including masks. Staff D said there is no reason to wear masks in the hallways because the GI illness is spread by contact with residents or the environment.At 12:40 PM, Staff J pushed Resident 30 out of the room, without changing his mask or hand hygiene. He pushed the resident to a common area in the facility and performed exercises with them.At 12:48 PM, Staff J returned Resident 30 to their room without donning PPE or performing proper hand hygiene.At 12:53 PM, Staff F, Nursing Assistant (NA), entered Resident 30's room donning a clean gown and gloves after hand hygiene. Staff F did not change the mask on her face before entering the room. Staff F obtained a dirty food tray from the room.At 12:54 PM, Staff F removed her gown and gloves and washed her hands with soap and water. She did not change her mask when leaving the resident's room. Staff F was observed adjusting her mask with her hands. At the same time, Staff G, NA, was observed to enter Resident 11's room donning a clean gown and gloves after hand hygiene. Resident 11's room was observed to have a sign directing staff to follow GI CP. Staff G did not change the mask on their face before entering the room. Staff G obtained a dirty food tray from the room. She removed her gown and gloves and washed her hands with soap and water. She did not change her mask. When asked why they were wearing masks, Staff F said there is a a bug going around here. Both Staff said they did not change their mask when they entered the CP rooms. Staff F, Staff G, and Staff H, NA, said they change their masks periodically but not in between each resident's rooms. All three staff said they touch the residents' environment when entering the residents rooms. They said they received education from Staff E, RN and Infection Preventionist (IP), on how the GI illness is spread and what PPE to wear. They said they did not get education on replacing their mask between residents. At 1:49 PM, Staff I, NA, was observed in Resident 13's room with a mask on. Staff I then left the room, used hand sanitizer hanging in the hallway to wash his hands. Staff I did not change his mask and proceeded down the hall. Staff I was observed touching his mask to adjust it with his hands. Staff I said he believed the outbreak started about 3-4 days ago. Residents had symptoms including stomach distress, diarrhea, nausea, and vomiting. Staff I said he is wearing the mask due to the outbreak and changes it a few times a day. Staff I said he did not get education regarding precautions needed during the outbreak but noticed the sign on the door when entering the building. He had been warned earlier to wash his hands with soap and water, however.At 1:52 PM, Staff E said some residents came out of CP today and the GI outbreak was resolving.At 1:59 PM, Staff J said he was wearing a mask due the current GI outbreak. Staff J said he wears the same mask all day without changing it. Staff J was observed to adjust his mask with his hands. Staff J said he did not wash his hands or wear PPE when entering and exiting Resident 30's room which required CP. He acknowledged he had Resident 30 in a common area doing therapy and the resident was on CP. Staff J said he was told there was a stomach bug going around but did not received education on precautions to take during the outbreak or when to change his mask. Staff J said, I may have brought residents to the therapy room who were on precautions, adding I probably did.On 07/23/2026 at 11:56 AM, Collateral Contact (CC) A, Public Health Nurse and Local Health Jurisdiction, said she was notified of the outbreak on 07/13/2026. The facility did not ask for any assistance in managing the outbreak. CC A said masks are not used for a GI outbreak or Norovirus because the illness is not spread through the air or droplets. Masks should not have been used in the hallways, and all PPE should be changed between residents. CC A said residents are contagious as soon as they show signs or symptoms of the illness. At this time, the facility should have moved the asymptomatic residents out of the double rooms. CC A said the facility should have acted promptly. CC A said she was disappointed with the facility's response to the outbreak.On 07/23/2026 at 2:14 PM, Staff AA, Dietary Manager, said staff were given education to wear a mask in the hallways during the GI illness. Staff were instructed to change masks between residents.At 2:37 PM, Staff O, LPN, and Staff P, LPN, said a lot of staff were wearing mask during the GI outbreak, but they were not sure why since the virus is spread by contact. They felt maybe staff felt better wearing masks.On 07/23/2026 at 3:30 PM, Staff E said they first started seeing symptoms of nausea, vomiting, and diarrhea in residents. Staff E said they notified staff of the GI outbreak and instructed them to start monitoring residents. Staff E said all residents were on isolation until 07/14/2026 and 07/15/2026. This included Resident 1 and Resident 8, who were in the common hallways with other residents. Staff E said she educated staff on how the virus was spread and the proper GI CP. Staff E said staff should wear a clean gown and gloves when entering a CP resident's room and use soap and water to wash hands. Staff E said she did not know why so many staff wore masks in the halls. She said she did not education staff to wear masks. Staff E said she educated staff on changing masks between resident rooms, and they have had this education many times in the past. Staff E showed documentation she did not educate housekeeping staff, three of whom were symptomatic, until 07/14/2026 and therapy staff until 07/22/2026. On 07/28/2026 at 3:25 PM, Staff B said she was aware staff did not follow GI CP, proper hand hygiene procedures, or changing of mask between resident rooms.<Surveillance>The LTC Acute Gastroenteritis Surveillance Line List - Resident Only, undated, listed 18 residents with the illness including symptoms of nausea, vomiting, and diarrhea. Seven of the eighteen residents listed did not have an onset date listed. One stool specimen was collected for Resident 19, confirming Norovirus. No other residents were tested for Norovirus. Symptom resolution was noted for 5 residents. The identified space used to confirm if the GI illness was related to the GI or Norovirus outbreak was blank for all 18 residents. Five residents (Resident 2, 20, 33, 35, and 36) with GI symptoms documented in the medical record were absent from the log.Record review and line listing showed the following:07/07/2026 - Resident 7, Resident 11, and Resident 18 had either nausea, vomiting, or diarrhea. Resident 7 was roommates with Resident 6. Resident 8 had a roommate. Resident 11 had a roommate.07/08/2026- Resident 9, Resident 5, Resident 30, and Resident 13 had either nausea, vomiting, or diarrhea. Resident 9 had a roommate and was positive for Norovirus. Resident 30 had a roommate. Resident 13 had a roommate.07/09/2026 - Resident 6, Resident 27, Resident 17, Resident 24, and Resident 20 had either nausea, vomiting, or diarrhea. Resident 17 is roommates with Resident 2. Resident 24 is roommate with Resident 1. Resident 20 is roommates with resident 19. Resident 20 was not represented on the Line List. 07/10/2026 - Resident 31, Resident 2, Resident 1, Resident 25, and Resident 33 had either nausea, vomiting, or diarrhea. Resident 31 had a roommate. Resident 2 and Resident 33 were not represented on the Line List. 07/12/2026 - Resident 15 had diarrhea. Resident 15 is roommates with Resident 34.07/13/2026 - Resident 26 and Resident 19 had either nausea, vomiting, or diarrhea.The LTC Acute Gastroenteritis Surveillance Line List - Staff Only, undated, documented ten staff members were identified as having symptoms including nausea, vomiting, and diarrhea. The onset and resolution date was listed for 4 of the 10 staff. The log did not indicate what unit/residents the staff worked with or when they returned to work. Staff K, RN, worked 07/02/26 -07/04/2026. She had symptoms of nausea, vomiting, and diarrhea on 07/01/2026 with a resolution of symptoms on 07/04/2026. Staff R, LPN, worked 07/07/2026 - 07/09/2026. She had symptoms of nausea, vomiting, and diarrhea on 07/10/2026 with a resolution of symptoms on 07/12/2026. Staff R returned to work 07/13/2026 - 07/15/2026. Staff V, NA, was listed as having symptoms of nausea, vomiting, and diarrhea. No onset date or resolution date was listed for the staff. Staff V worked 07/07/2026 - 07/09/2026 and 07/12/2026 - 07/16/2026. Four housekeeping staff were noted as having nausea, vomiting, and diarrhea with no onset or resolution dates. The surveillance did not identify any trends or patterns with the staff line list. On 07/14/2026 at 1:06 PM, Staff G, NA, said residents have been exhibiting signs and symptoms of vomiting and diarrhea for about 7-9 days. She said the illness started on Team 1 then subsequently spread to each wing, pointing down the hall.On 07/23/2026 at 11:56 AM, CC A, said she was notified of the outbreak on 07/13/2026. The facility did not ask for any assistance in managing the outbreak. Later, after the 13th, the facility provided a line list of residents and staff with missing dates and information. At 2:23 pm, Staff K, RN, said the GI illness started on Team 1 (Rooms 148-169) then later spread to Team 2 (Rooms 129-146) and Team 3 (Rooms 102-127). Residents' symptoms included nausea, vomiting, and diarrhea. Staff were notified to monitor residents for the GI illness. Resident 6 became ill after their roommate Resident 7. Resident 6 has some episodes of poor appetite normally, but they refused food for a couple days, vomiting and required Tylenol (a pain medication). Staff K thought the symptoms Resident 6 experienced were out of the ordinary for them but added it was hard to tell. Staff K said she was off a couple days, and Resident 6 appeared much better after she returned. At 2:37 PM, Staff O, LPN, said the outbreak occurred a couple of weeks ago and initially showed up in rooms on Team 1. These rooms were put on isolation. Slowly, one or two residents showed up with symptoms. The symptoms lasted 24-48 hours. Dining was closed on 2nd day. Signs and symptoms were nausea, vomiting and diarrhea. Others had headaches and body aches. Staff O and Staff P, LPN, stated both Resident 35 and Resident 36 were symptomatic with diarrhea as noted on their saved daily report sheets. These residents did not appear on the LTC Acute Gastroenteritis Surveillance Line List - Resident Only log. Resident 35 and Resident 36 were symptomatic first, then Resident 25 had diarrhea and vomiting. It continued to spread then Resident 24 and Resident 1 became ill. The most active day was 07/09/2026. Resident 20 had nausea, vomiting and diarrhea. Both staff said it was a lot of residents at once. Staff P said Resident 19, Resident 20's roommate, typically has loose stools, adding the resident had some diarrhea and a poor appetite around this time. Staff O said Resident 19 clearly was not themselves and was tired out, not wide awake like normal. Staff O said Resident 19 became ill way after [Resident 20] was sick. Staff P agreed it was later than Resident 20's illness.On 07/23/2026 at 3:30 PM, Staff E, said she was in charge of handling the GI and Norovirus outbreak. Staff E said they first started seeing symptoms of nausea, vomiting, and diarrhea. This started on 07/07/2026 with more cases on 07/08/2026. Staff E acknowledge they knew there was an outbreak by the 8th because residents and staff were having similar symptoms. Staff E said they notified staff of the illness and instructed them to start monitoring residents. She was told who was symptomatic in the morning standup meeting and found cases in the medical records. Staff E said Resident 6 and Resident 19 both have similar symptoms exhibited during the outbreak on a regular basis. Staff E said she did use the standardized case definition to determine if Resident 6 and Resident 19 symptoms met the criteria for infection. Staff E did not know what area staff worked in who became ill, did not know when some were ill, and did not know when they returned to work. Staff E said staff could return to work 24 hours after symptoms were resolved. Staff E said they ask the staff what their sign or symptoms were when calling in but do not push it. Staff E said she found out all staff were ill after the fact. Staff E said she was not familiar with the facility policy. Staff E said she did not review the facility policy or the CDC recommendations. She said she did discuss the outbreak with Staff B. Staff E agreed some residents were not represented on the Line List. <Reporting>On 07/23/2026 at 11:56 AM, CC A, said she was notified of the outbreak on 07/13/2026. CC A said she should have been notified as soon as the facility was aware of a GI outbreak in the facility. CC A estimated this date to be around 07/08/2026. On 07/23/2026 at 3:30 PM, Staff E, said they identified a GI outbreak by 07/08/2026 but did not notify the local public health jurisdiction until 07/13/2026, when they got a positive Norovirus resident for Resident 9. Staff E said she was not aware she was supposed to make the notification until they had a confirmed case. <Notification>On 07/13/2026 at 11:30 AM, upon entering the facility, several staff were observed wearing masks throughout the facility. No sign was posted on the front entrance notifying the public of a communicable disease outbreak.On 07/14/2026 at 12:23 PM, a sign was posted on the front entry indicating a norovirus outbreak was occurring the facility and provided visitors with guidance on methods to prevent the spread of the illness, six days after the facility was aware there was an outbreak.On 07/23/2026 at 10:42 AM, Resident 2's Family Member (FM) said she was not made aware of a GI outbreak at the facility until they went to visit Resident 2. There were no posting alerting visitors to an outbreak in the facility. Resident 2's FM felt the family was not notified timely of the outbreak.At 10:44 AM, Resident 19's FM said they typically visit the facility every Sunday but did not on 07/12/2026. The FM said they were not made aware of an outbreak at the facility, and they were not aware if Resident 19 was exposed to or contracted the illness. When the FM was at the facility on 07/19/2026, no staff mentioned any concerns to them.At 3:30 PM, Staff E, said they knew there was an outbreak by 07/08/2026 because residents and staff were having similar symptoms. Staff E stated she did not put up a posting on the front door for visitors until 07/13/2026 after they got a positive Norovirus test on Resident 9. The GI outbreak was resolved by 07/14/2026. Staff E said family and residents should have been notified of the outbreak.On 07/28/2026 at 3:25 pm, Staff B said families, visitors, and residents were not notified of the GI outbreak. A sign notifying visitors was not posted until 07/13/2026.< Isolation> On 07/22/2026 at 12:17 PM, Resident 1 said they had been symptomatic with GI illness. The nausea and vomiting lasted three days. They said they were on isolation a long time and it felt like two weeks. Resident 1 said they were allowed to leave their room while on isolation.At 2:54 PM, Resident 15 said she had the GI illness for about 3-4 days. Resident 34 said they did not get ill and they tried to stay on their side of the room during Resident 15's illness. Both resident's said they did not leave their room for a week or two. Resident 15 said CP lasted several days after her symptoms resolved.Review of electronic health records showed Resident 8 and Resident 6's medical record lacked evidence of signs or symptoms of a GI illness.The LTC Acute Gastroenteritis Surveillance Line List - Resident List, undated, documented Resident 8 had symptoms of diarrhea. Resident 6 was identified as having symptoms of nausea, vomiting, and diarrhea. On 07/23/2026 at 3:30 PM, Staff E said all residents on The LTC Acute Gastroenteritis Surveillance Line List were on isolation. Staff E said she was aware Resident 8 had no signs or symptoms documented in the record, was out in common areas, but was in isolation. Staff E could not answer why Resident 8 was on CP and did not determine if the resident met the criteria for the illness. Staff E said Resident 8 was on CP but did not know there were no symptoms documented in the resident's medical record. Staff E acknowledged Resident 1 was out in the common area while on CP. Staff E acknowledged Resident 26 and Resident 17 had documented signs and symptoms of the illness on 07/13/2026 but were removed from isolation on 07/14/2026, 24 hours after symptoms resolved. Staff E acknowledge some residents did not have CP removed according to the policy and were on CP for days later. Staff E said her and Staff B discussed the 24 hour removal time frame and was not aware of what the policy stated.On 07/28/2026 at 3:25 PM, Staff B said residents should be removed on isolation 48 hours after symptoms resolved. Staff B was unaware Resident 17 and Resident 26 had symptoms on 07/13/2026 while isolation was removed on 07/14/2026. Staff B acknowledged some residents were in isolation longer than 48 hours after symptom resolution.Reference: WAC 388-97-1320(1)(a)(2)(b)(c)

Based on observation, interview and record review, the facility failed to review, revise and implement a comprehensive plan of care to include resident risk for bruising 3 of 4 (3, 4, 5) resident reviewed for bruising and for infection control measures for 14 of 21 sampled residents (1, 2, 6, 8, 13, 15, 17, 19, 20, 24, 25, 26, 30 & 31) reviewed for care plans. The failure placed residents at risk to receive inappropriate and inadequate care to meet their individualized needs.Findings included.<Bruising>Resident 3 was admitted to the facility on [DATE] with diagnoses including dementia. On 07/13/2026 at 01:05 pm, Resident 3 was observed with two small fading bruises on their forearms. Progress notes dated 05/30/2026 and 07/08/2026 documented Resident 3 had bruises of unknown origin. The Medication Treatment Record (MAR), dated July 2026, documented Resident 3 received Plavix (a medication used to prevent blood clots), Trulicity (an injection used to reduce blood sugars), and naproxen (a medication used to control pain) which all contribute to bruising. The care plan did not show Resident 3 was at risk of bruising. Resident 4 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (a lung disease which causes difficulty with breathing and dry, thinning skin). On 07/23/2026 at 2:28 pm, Resident 4 was observed with thin, fragile skin. Resident 4 had many bruises on their hands, arms, and a small bruise on the forehead. Progress notes, dated 04/20/2026, 05/20/2026, 06/17/2026, and 07/12/2026 documented Resident 4 had episodes of bruising. The MAR, dated July 2026, documented Resident 4 received prednisone (used to reduce inflammation in the lungs) which increases the risk of thin, fragile skin and bruising. The care plan did not show prednisone would increase the risk of Resident 4's bruising. Resident 5 was admitted to the facility on [DATE] with diagnoses including COPD. On 07/13/2026 at 12:02 pm, Resident 5 was observed to have thin, fragile skin. Progress notes, dated 06/03/2026 and 06/29/2026 noted episodes of bruising of unknown origin. The MAR, July 2026, showed Resident 5 received aspirin (used to prevent blood clots), insulin injections (used to control blood sugar), and budesonide (used to reduce the inflammation in the lungs), which all increase the resident's risk of bruising. The care plan did not show Resident 5 was at risk of bruising.On 07/28/2026, 2:50 pm, Staff B, registered nurse (RN) and Director of Nursing (DNS), said the resident's care plans were not updated to reflect their risk of bruising. <Infection Control>Resident 1 room entryway was observed to have a sign directing staff to use gastrointestinal (GI) Contact Precautions (a directive to staff to wear gown and gloves during resident care and washing hands with soap and water). The resident's care plan did not reflect GI Contact Precaution (CP). Resident 2 room entryway was observed to have a sign directing staff to use GI CP. The resident's care plan did not reflect GI CP.Resident 6 room entryway was observed to have a sign directing staff to use GI CP. The resident's care plan did not reflect GI CP.Resident 8 room entryway was observed to have a sign directing staff to use GI CP. The resident's care plan did not reflect GI CP.Resident 13 room entryway was observed to have a sign directing staff to use GI CP. The resident's care plan did not reflect GI CP.Resident 15 room entryway was observed to have a sign directing staff to use GI CP. The resident's care plan did not reflect GI CP.Resident 17 room entryway was observed to have a sign directing staff to use GI CP. The resident's care plan did not reflect GI CP.Resident 19 room entryway was observed to have a sign directing staff to use GI CP. The resident's care plan did not reflect GI CP.Resident 20 room entryway was observed to have a sign directing staff to use GI CP. The resident's care plan did not reflect GI CP.Resident 24 room entryway was observed to have a sign directing staff to use GI CP. The resident's care plan did not reflect GI CP.Resident 25 room entryway was observed to have a sign directing staff to use GI CP. The resident's care plan did not reflect GI CP.Resident 26 room entryway was observed to have a sign directing staff to use GI CP. The resident's care plan did not reflect GI CP.Resident 30 room entryway was observed to have a sign directing staff to use GI CP. The resident's care plan did not reflect GI CP.Resident 31 room entryway was observed to have a sign directing staff to use GI CP. The resident's care plan did not reflect GI CP.On 07/23/2026 at 3:30 pm, Staff E, RN and Infection Preventionist (IP), said she was in charge of handling a recent GI outbreak. The resident's had symptoms of nausea, vomiting, and diarrhea requiring staff to use GI CP when caring for residents. Staff E said not all residents had their care plans updated. She said she dropped the ball on this, it was her responsibility and it should have been done. She said she had more than one job assignment and it takes away from her ability to adequately do infection control tasks.Reference (WAC) 388-97-1020(1), (2)(a)(b)

Based on observations, interviews, and record review the facility failed to thoroughly investigation and implement interventions for allegations of injuries of an unknown origin for 3 of 4 residents (3, 4, 5) residents reviewed with allegation of injuries of unknown origin. The failure left residents at risk for unidentified abuse and/or neglect, recurrence of events, and a decreased quality of life.Findings included.<Resident 3>Resident 3 was admitted to the facility on [DATE] with diagnoses including dementia. The quarterly minimum data set (MDS) dated , 07/13/2026, documented Resident 3 had severe cognitive impairment and required dependence on staff with activities of daily living (ADLs). On 07/13/2026 at 01:05 pm, Resident 3 was observed with two small fading bruises on their forearms. The Medication Treatment Record (MAR), dated July 2026, documented Resident 3 received Plavix (a medication used to prevent blood clots), Trulicity (an injection used to reduce blood sugars), and naproxen (a medication used to control pain) which all contribute to bruising.The care plan, dated 03/20/2026, documented Resident 3 should avoid scratching and keep hands and body parts from excessive moisture, keep fingernails short. The care plan directed staff to use a draw sheet or lifting device to move the resident and use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. The care plan was updated on 04/21/2026 to show Resident 3's wheelchair had a drop seat with a pommel cushion. The care plan did not show Resident 3 was at risk of bruising due to wandering or due to medication which increased the resident's risk of bruising. Progress notes, dated 05/30/2026, document Resident 3 had a 3.5 cm (centimeter) x 3 cm bruise to the thigh, a 2 cm x 1.5 cm bruise to the right knee, and a 2 cm x 1.5 cm bruise to the left inner thigh.Bruise/Skin Tear/Abrasion investigation, dated 05/30/2026, documented Resident 3's developed bruises to the thigh, knee, and left inner thigh. The investigation documented Resident 3 required assistance from staff with ADLs, had a history of falls and impulsiveness, and attempted to be independent with mobility. The staff reported the resident wanders in the hallways and is at risk of bruising due to the risk of Plavix. The resident is seen self-propelling in their wheelchair and go into rooms and offices. It is reasonable the resident bumped into a doorway during a transfer and sustained bruising. The care plan is noted as updated. No staff interviews were included in the investigation to determine the cause of the resident's bruising. Progress notes, dated 07/08/2026, documented Resident 3 had an 8 cm x 5 cm bruise to the left medial knee and a 7 cm x 9 cm bruise to the left lateral upper leg. Bruise/Skin Tear/Abrasion investigation, dated 07/07/2026, documented Resident 3's bruising to the left medial and lateral knee. Resident 3 required assistance from staff with ADLs, had a history of falls and impulsiveness, and attempts to be independent with mobility. The staff reported the resident wanders in the hallways and is at risk of bruising due to the risk of Plavix. Resident 3 has a pommel cushion in their wheelchair which may have contributed to the bruising which will be removed. Staff were interviewed about their awareness of the bruising, but not to the potential causal factors. On 07/23/2026 at 2:17 pm, Staff K, registered nurse (RN), said Resident 3 wanders a lot finding them all over the building and in staff offices. When a resident has a bruise, they are supposed to try and implement interventions related to preventing further bruises. Staff K could not recall interventions for Resident 3 to prevent bruising. Staff K did not think Resident 3 bruises much. Staff K was not aware of bruising Resident 3's forearms. On 07/28/2026, 2:50 pm, Staff B, RN and Director of Nursing (DNS), said Resident 3 does wander throughout the facility. Staff B said the care plan was not updated to remove the pommel cushion at the time of the bruising. Staff B was not aware of bruising Resident 3's forearms and said an incident report should have been completed. Staff B said she did not implement interventions with the 05/30/2026 bruise and has not had a discussion with Resident 3's guardians about additional interventions to prevent bruising. <Resident 4>Resident 4 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (a lung disease which causes difficulty with breathing and dry, thinning skin). The quarterly MDS dated , 07/23/2026, documented Resident 4 had moderate cognitive impairment and required dependence on staff with ADLs. On 07/23/2026 at 2:28 pm, Resident 4 was observed with thin, fragile skin. Resident 4 had bruises on the left hand and wrist, the right wrist, the right arm, and a small bruise on the forehead. Resident 4 said they were bruised on the right wrist during a blood draw. Resident 4 said the remainer of the bruising occurred during personal cares. The left hand was bruised when staff grabbed at their hand when trying to pull them forward. The bruise on their head occurred when staff bumped the resident in the head with the mechanical lift that morning. Resident 4 said they recall the past bruising episodes, and they are typically occurring during transfers with facility staff, often times with when using the mechanical lift. The resident said they hate using the mechanical lift as a result. Resident 4 said the sling pulled on their neck while getting up a while ago and it still hurts. The MAR, dated July 2026, documented Resident 4 received prednisone (a steroid used to reduce inflammation in the lungs) which increases the risk of thin, fragile skin and bruising. The care plan, dated 04/18/2024, documented the resident should avoid scratching and keep hands and body parts from excessive moisture, keep fingernails short, keep skin clean and dry, use lotion on dry skin, and directed staff to use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. The care plan was updated on 05/26/2026 showing staff were educated on proper use of the mechanical lift. The care plan did not document how prednisone would increase the risk of Resident 4's bruising. Progress notes, dated 04/20/2026, documented Resident 4 had a 2.5 cm x 1 cm bruise to the left medial foot and a 0.4 cm x 1 cm bruise to the left medial knee. The resident said their foot slid off the footrest and hit the foot pedal causing the bruise to the foot. The knee bruise occurred when staff were providing personal cares. Bruise/Skin Tear/Abrasion investigation, dated 04/20/2026, documented Resident 4 had bruising to the left foot and knee. The resident said their foot slid off the footrest and hit the foot pedal causing the bruise to the foot. The knee bruise occurred when staff were providing personal cares. Resident 4 has mild cognitive impairment, is dependent on staff for transfers and bed mobility, is on oxygen, and is at risk of bruising due to steroid use, use of Plavix, and diabetes. The bruising was found not to be due to abuse or neglect. The care plan was noted as updated. No interventions were noted and no interviews with staff to determine how the injuries that occurred were included. Progress notes, dated 05/20/2026, documented Resident 4 had a bruise on the left leg measuring 9 cm x 3 cm. The resident said their leg was hit on the mechanical lift during a transfer. Bruise/Skin Tear/Abrasion investigation, dated 05/20/2026, documented Resident 4's bruises to the left shin. Resident 4 has mild cognitive impairment and is at risk of bruising due to Plavix use. Staff did not know how the bruise occurred. An in-service was performed on 05/27/2026 with staff safe use of the mechanical lift. Progress notes, dated 06/17/2026, documented Resident 4 had three red bruises to the left forearm. Measurements were 4.4 cm x 3 cm, 1 cm x 2 cm, and 1 cm x 1 cm. The resident said it happened while the staff were transferring them to their wheelchair.Bruise/Skin Tear/Abrasion investigation, dated 06/17/2026, documented Resident 4's three bruises to the arm. The resident said it happened while the staff were transferring them to their wheelchair about a week ago. Resident 4 has mild cognitive impairment, is dependent on staff for transfers and bed mobility and is at risk of bruising due to use of steroids and Plavix. The investigation determined Resident 4 was likely was bruised in a different situation, while they were transported by emergency medical services (EMS). No interventions were identified. The care plan was noted as updated. Progress notes, dated 07/12/2026, documented Resident 4 had a bruise on the upper right forearm measuring 5 cm x 6 cm. The resident said it occurred when they were asleep. Bruise/Skin Tear/Abrasion investigation, dated 07/12/2026, documented Resident 4 with a bruise to the right forearm. Resident 4 has mild cognitive impairment, is dependent on staff for transfers and bed mobility and is at risk of bruising due to use of steroids and Plavix. A call light clip was determined to be the probable cause of the bruise. Staff interviews noted the resident told staff the bruising occurred when staff were moving them. No care plan interventions were noted on the care plan. Progress notes, dated 07/23/2026, documented Resident 4 had a small red mark 1 cm x 1 cm to the right forehead. The resident said it happened during the transfer from the bed to the wheelchair. The resident is alert and orientated x 2-3 with forgetfulness [they are] not very good at recounting events due to tiredness and forgetfulness. Bruise/Skin Tear/Abrasion investigation, dated 07/23/2026, documented Resident 4 had a small red mark to the forehead which the resident reported occurred during a transfer. The resident is at risk of bruising due to Plavix use. Resident 4 did not report the injury immediately to staff and it is reasonable that staff did not observe [the mechanical lift] come into contact with the resident during transfer. The resident holds onto the sling during transfer and may have adjusted their hands during the transfer, causing the injury. No intervention was identified. Progress notes, dated 07/24/2026, documented Resident 4 had a bruise to the right upper arm, one superior measuring 3 x 3 cm and one distal measuring 3.5 cm x 3 cm. On 07/23/2026 at 1:51 pm, Staff M, nursing assistant, said they have been told to be careful transferring Resident 4 and that bruises may occur during transfers. Staff M did not think this was the cause of the bruises but were unsure of the cause. On 07/28/2026, 2:50 pm, Staff B said they did staff training in May regarding Resident 4's bruising but has not implemented further interventions relate to the ongoing allegations of bruising during care. Staff B said Resident 4 is not always reliable in their recall. Staff B said they did not consistently implemented interventions or update the care plan. Staff B said they have not discussed further interventions to prevent ongoing bruises. <Resident 5>Resident 5 was admitted to the facility on [DATE] with diagnoses including diagnoses of chronic obstructive pulmonary disease. The quarterly MDS dated , 05/27/2026, documented Resident 5 had moderate cognitive impairment and some dependence on staff with ADLs. The MAR, July 2026, showed Resident 5 received aspirin (used to prevent blood clots), insulin injections (used to control blood sugar), and budesonide (a steroid used to reduce the inflammation in the lungs), which all increase the resident's risk of bruising. The care plan did not show Resident 5 was at risk of bruising or received medication which increased the risk of bruising. On 07/13/2026 at 12:02 pm, Resident 5 was observed to have thin, fragile skin. The resident said they were told someone comes and hits her at night causing bruising. Progress notes, dated 06/03/2026, documented Resident 5 had bruises to the left hand measuring 2.2 cm x 2 cm and 1.5 cm x 1 cm to the left forearm.Bruise/Skin Tear/Abrasion investigation, dated 07/23/2026, documented Resident 5 had a bruise to the wrist. The resident did not recall how they received the bruise. The resident has moderate cognitive impairment, is bedfast, and receives aspirin and a steroidal inhaler as medication. It was determined the resident came into contact with the overbed table or bed causing bruises. No interventions were implemented. No staff interviews were obtained. Progress notes, dated 06/29/2026, documented Resident 5 had a bruise to the left eye measuring 3 cm x 1 cm, a bruise to the chest measuring 15.5 cm x 8 cm, and a bruise to the lower left medial arm measuring 4 cm x 2.5 cm. Bruise/Skin Tear/Abrasion investigation, dated 07/23/2026, documented Resident 5 had bruises to the eye, chest, and arm. The resident stated they did not recall what happened, then later stated someone came in the night while they are sleeping and hit them. The resident has moderate cognitive impairment, is bedfast, and receives aspirin and a steroidal inhaler as medication. Resident 5's fingernails were observed to be long. The resident's bruises were determined to be self-inflicted due to rubbing of the eye and scratching of the chest. The bruising on the arm was determined to be due to medication injections. The was plan was noted a updated. On 07/14/2026 at 12:35 pm, Staff D, licensed practical nurse (LPN), said she believes Resident 5's bruising is caused by pulling the bedside table up close to their chest. She has witnessed them do this. Staff D said she reported the bruising on 06/29/2026 and felt the bruising on the chest could have been caused by the table or pulling items close to their chest. On 07/213/2026 at 2:20 pm, Staff L, LPN, said Resident 5 likes to have everything close to her and pulls up her bedside table and fan close to her chest. She thought Resident 5's bruising could be caused by the bedside table. On 07/28/2026, 2:50 pm, Staff B said she did not believe Resident 5's chest bruise could be from the bedside table. Staff B said there were no interventions such as padding of the bedside table when it was thought to cause bruising on 06/03/2026. Reference WAC 388-97-0640(5)

Based on record review and interview the facility failed to ensure discharge planning included providing recent information related to an abuse allegation and recent fall for 1 of 3 (Resident 1) reviewed for admission, transfer and discharge. This failure placed residents at risk for unmet care needs and decreased quality of care. Findings included . Review of the facility policy titled, Transfer and Discharge, updated 06/2025, documented, .When the facility transfers or discharges a resident.the facility documents the transfer or discharge in the medical record and appropriate information is communicated to the receiving care institution or provider. At minimum the following information is provided. Special instructions or precautions for ongoing care.other necessary information including a copy of the discharge summary.Resident 1Resident 1 was admitted to the facility on [DATE] with diagnoses including obesity, T-11 - T-12 spinal cord injury (affecting the mid and lower back), multiple fractured ribs and dislocation of the right ulnohumeral (hinge joint of the elbow) joint. The admission Minimum Data Set (MDS), an assessment, dated 06/08/2026 documented the resident was cognitively intact, had no behaviors, was dependent on staff for bathing and transfers and was frequently incontinent of bladder and bowel.Review of a Social Services progress note dated 06/11/2026 documented had received a call from the accepting facility. Discharge is for 06/15/2026.Review of Resident 1's progress note dated 06/14/2026 at 3:17 PM, documented the resident had a non-injury fall in the activity room.Review of Resident 1's progress noted dated 06/14/2026 at 4:15 PM, documented the resident had inappropriate sexual behavior towards female residents, exposing his genitalia and inappropriate unwanted sexual propositions. The resident was placed on 1:1 observation to keep himself and other residents safe.Review of a progress note dated 06/15/2026 at 12:05 PM, documented Resident 1 was discharged to another skilled nursing facility.During a telephone interview on 06/25/2026 at 4:25 PM, Staff D, Registered Nurse said she was aware of the sexual abuse allegation related to Resident 1. She was asked if she had contacted the accepting facility to provide a verbal report. Staff D said she had not contacted the accepting facility to provide a report for Resident 1 prior to the discharge. During a telephone interview on 06/25/2026 at 2:05 PM, Collateral Contact 1 was asked if she received Resident 1 from this facility. She stated well yes and no.we did get a referral for Resident 1 from this facility pending authorization.we reviewed the referral and we left a voice mail on Friday that we would accept him after authorization . CC 1 said at approximately 9 am on Monday the resident arrived by a transportation service without authorization, without a report or orders. CC 1 said they cannot accept a resident without prior authorization. She stated we thought he was going back to the facility but the transporter took him to the hospital, he was having pain. CC 1 said we wouldn't have known where he went but the resident's son called and told us. She stated the resident will be transferred to this accepting facility after the hospital stay. During an interview on 06/25/2026 at 2:45 PM, Staff C, Social Services Director said she contacted the accepting facility and Resident 1 was discharged on 06/14/2026. She said she received a call from the accepting facility when the resident had arrived and they could not accept the resident without prior authorization. She said the resident complained of pain to the transporter and Resident 1 was transferred to the hospital. Staff C was asked if the accepting facility had been notified of the resident's fall or of the allegation of sexual abuse prior to the discharge. Staff C said they were unsure if the accepting facility had been notified.During an interview on 07/01/2026 at 2:20 PM, Staff B, Director of Nursing acknowledged Resident 1, was transferred to a SNF on 06/15/2026 and the accepting facility did not accept the resident. Staff B stated the resident complained of pain and Resident 1 was transported to the hospital. Staff B acknowledged staff are to provide a report and update on any changes in the residents' functional status to the accepting facility prior to discharge.

Based on interview and record review, the facility failed to ensure the administrator implemented and enforced facility policies and procedures related to the reporting and investigation of allegations and the safeguarding of controlled substances, when the administrator was made aware of potential narcotic diversion but failed to report the allegation, conduct a thorough investigation, or implement measures to prevent ongoing access to controlled substances. This failure resulted in a breakdown in administrative oversight and placed residents at risk for not receiving prescribed medications, unrelieved pain, and decreased quality of life.Findings include.Review of an email sent to Staff A, Administrator by Staff D, Licensed Practical Nurse, dated 02/06/2026, showed .Several alert and oriented residents have confirmed that they did not request or receive medications at the time she documented them as given.There have been multiple occasions in which [Staff C, Registered Nurse (RN)] has arrived to work appearing impaired.with noticeable head-nodding and difficulty staying awake.Specific medication concerns include.Narcotics signed out for residents such as [Resident 2 and 4] that those residents report they do not receive.Medications suddenly being signed out in 1-2 dose increments that are not typically administered at those times.Discrepancies in the narcotic log, including medications signed out earlier than allowed and not in accordance with proper documentation procedures.Additionally, she frequently leaves the building during her shift and is difficult to locate.Review of the facility investigation, dated 03/27/2026, showed Resident 1 had reported to staff she had not received any pain medication on 03/26/2026 on the evening shift. Resident 1 stated she only takes oxycodone prior to therapy. During care on night shift her hip was adjusted and she requested oxycodone for pain and the night shift nurse was unable to administer the oxycodone due to it being documented as administered at 10:00 PM. The resident was given Tylenol (non-narcotic) pain medication. Resident 2 was interviewed and stated he never requests or sees a nurse after receiving his evening medications and does not see the nurse until he gets up for dialysis at 5:00 AM on Monday, Wednesday and Friday. Resident 2 stated he does not request medications/narcotics during the night. The resident was alert and oriented. Review of documentation showed Staff C had administered narcotic pain medication between 12:00 AM and 05:00 AM, which is inconsistent with the resident's statement. Staff C was terminated.During a telephone interview with Staff D, LPN on 04/03/2026 at 3:19 PM, she stated she had reported concerns related to Staff C to the Administrator in February 2026. She stated she had concerns related to Staff C's behavior and concerns related to narcotics being signed out for residents who normally didn't take medications on the night shift.During an interview with Staff A on 04/03/2026 at 3:30 PM, he was asked to provide documentation of an investigation for the allegations from the staff concerns he received by email on 02/06/2026 regarding Staff C. Staff A stated he could not provide documentation. Staff A did acknowledge having received concerns related to Staff C, nodding off and said he came into the facility almost immediately and he had observed Staff C nodding off. Staff A stated the nurse had been working extra shifts and she was counseled on staying alert and being present for shifts. When asked for the investigation from the 02/06/2026 allegation, Staff A said he thought the Director of Nursing checked the narcotic counts.During an interview on 04/07/2026 at 11:30 AM, Staff B, Director of Nursing, was asked if she was aware of an email sent to Staff A by a staff member with concerns related to possible drug diversion on 02/06/2026. Staff B stated she had no knowledge of this email, and she had not reported or investigated it. She acknowledged she was made aware of an allegation that Resident 1 had not received pain medication on 03/26/2026. Staff B stated she completed the investigation. She stated the allegation had been substantiated and Staff C was terminated. She stated she was now initiating an investigation related to the email received.During an interview on 04/08/2026 at 3:58 PM, Staff A acknowledged he received an email on 02/26/2026 from a staff member with concerns related to possible drug diversion and staff behavior and provided a copy of the email as documented above, dated 02/06/2026. He acknowledged he did not complete an incident report. He stated, I don't have any documentation to dispute what [Staff B] said.Reference WAC 388-97-1620 (1)Refer to F602

Based on interview and record review the facility failed to implement a system to consistently and accurately reconcile controlled medications, using acceptable standards of practice for controlled substances for 3 of 6 residents (Residents 1, 5 and 6) reviewed for medication administration. This failure placed residents at risk of unmet care needs, unrelieved pain and decreased quality of life.Findings included.Review of the facility policy, titled CONTROLLED SUBSTANCE, undated, showed When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record [narcotic log] when removing the dose from the controlled storage.a. Date and time of administration.b. Amount administered.c. Signature of the nurse administering the dose.5. Administer the controlled medication and document dose administration on the MAR [Medication Administration Record].Resident 1Resident 1 was admitted to the facility on [DATE] with diagnoses including infection and inflammatory rection due to internal right hip prothesis. The admission Minimum Data Set (MDS), an assessment tool, dated 03/26/2026 showed the resident was alert and oriented, required staff assistance for most activities of daily living and received pain medication as needed.Review of Resident 1's physician's order, dated 03/20/2026, showed an order for oxycodone (narcotic pain medication) 5 milligrams (mg) give 1 tablet every 6 hours as needed for pain.Review of Resident 1's narcotic sign-out log and MAR for oxycodone IR (immediate release) 5 mg tablet every 6 hours as needed was signed out by Staff C as administered, as follows:03/24/2026 signed out as administered on EMAR at 10:57 PM but not signed out on narcotic log.03/27/2026 10:12 AM signed out of the narcotic book but not signed out on the EMAR.Resident 5Resident 5 was admitted to the facility on [DATE] with diagnoses of Dementia with psychotic disorder and lumbar fracture. The quarterly MDS, dated [DATE], showed the resident was cognitively impaired and received scheduled and as needed pain medication.Review of Resident 5's physicians order, dated12/05/2025, showed an order for oxycodone IR (immediate release) 5 mg take one tablet by mouth every 4 hours as needed for pain.Review of Resident 5's narcotic log for oxycodone showed the medication was administered on 02/02/2026 at 6:43 PM and again at 8:11 PM (1 hour and 28 minutes between doses).Resident 3Resident 3 was admitted to the facility on [DATE] with diagnoses including Vascular Dementia (decline in thinking caused by conditions that block or reduce blood flow to the brain) and Spinal Stenosis (narrowing on the spinal canal causing pressure on the nerves and spinal cord). The quarterly MDS, dated [DATE], showed the resident was cognitively impaired and received pain medication as needed.Review of Resident 3's physician's order, dated 10/25/2025, showed an order for Hydrocodone (narcotic pain medication) 5/325 mg take 1 tablet by mouth every 8 hours as needed for pain.Review of Resident 3's narcotic log for Hydrocodone 5/325 mg showed the following:A. The medication was signed out of the narcotic log by Staff C on 03/02/2026 at 12:38 PM and again at 2:53 PM (2 hour and 15 minutes between doses). There was no documentation the medication was wasted.i. Review of Resident 3's EMAR showed 1 tablet of Hydrocodone 5-325 mg was signed as administered on 03/02/2026 at 12:38 PM.B. The medication was signed out by Staff C on 03/25/2026 at 6:01 AM, at the bottom of the page of the narcotic log and on 03/25/2026 at 6:01 AM, signed out again as removed on the top of the following page of the narcotic log. No documentation the medication was wasted.ii. Review of Resident 3's EMAR showed Hydrocodone 5-325 mg 1 tablet was administered on 3/25/2026 at 6:01 AM.During an interview on 04/08/2026 at 2:30 PM Staff G, Resident Care Manager, acknowledged discrepancies were present in the EMARS and narcotic logs for these residents.Reference WAC 388-97-1300 (1)(b)(ii)

Based on observation, interview and record review the facility failed to protect residents receiving narcotic medications from misappropriation on two of three medication carts (Team 2 & Team 3 Carts) from 12/09/2026-03/26/2026, when staff identified concerns that a registered nurse was diverting narcotic medications; however, the facility failed to report, investigate, or take action on the allegations, allowing the suspected diversion to continue. This failure resulted in residents not receiving prescribed pain medications and the potential misappropriation of medications for which residents were financially responsible.Findings included.Review of the facility policy, titled Freedom from Abuse, Neglect, Corporal Punishment, Involuntary Seclusion, Mistreatment, Misappropriation of Resident Property, and Exploitation, updated March 2025, showed Misappropriation of Resident Property.Examples of misappropriation of resident property and exploitation that must be reported include, but are not limited to.Missing prescription medications or diversion of a resident's medications, including, but not limited to, controlled substances for staff use or personal gain.Procedure.Investigation.The Center conducts a thorough investigation of potential, suspected and/or allegations of abuse, neglect, and exploitation of residents, misappropriation of resident property, mistreatment, and injuries of unknown source, in accordance with state and federal regulations.Protection.The Center protects residents from physical and psychosocial harm during and after an investigations.Reporting and Response.The Center immediately reports all suspected and/or allegations of abuse, neglect, and exploitation of resident property, mistreatment, and injuries of unknown source in accordance with state and federal law.Review of an email sent to Staff A, Administrator by Staff D, Licensed Practical Nurse, dated 02/06/2026, showed .Several alert and oriented residents have confirmed that they did not request or receive medications at the time she documented them as given.There have been multiple occasions in which [Staff C, Registered Nurse (RN)] has arrived to work appearing impaired.with noticeable head-nodding and difficulty staying awake.Specific medication concerns include.Narcotics signed out for residents such as [Resident 2 and 4] that those residents report they do not receive.Medications suddenly being signed out in 1-2 dose increments that are not typically administered at those times.Discrepancies in the narcotic log, including medications signed out earlier than allowed and not in accordance with proper documentation procedures.Additionally, she frequently leaves the building during her shift and is difficult to locate.Resident 1 was admitted to the facility on [DATE] with diagnoses including infection and inflammatory rection due to internal right hip prothesis. The admission Minimum Data Set (MDS), dated [DATE], showed the resident was alert and oriented, required staff assistance for most activities of daily living and received pain medication as needed.Review of Resident 1's physician's order, dated 03/20/2026, showed an order for Oxycodone (narcotic pain medication) 5 milligrams (mg) give 1 tablet every 6 hours as needed for pain.Review of Resident 1's narcotic sign out log and EMAR (electronic medication administration record) for oxycodone IR (immediate release) 5 mg tablet every 6 hours as needed was signed out by Staff C as administered as follows:03/21/2026 at 4:30 AM and 10:08 PM03/22/2026 at 4:10 AM and 11:01 PM03/23/2026 at 5:48 AM and 10:37 PM03/24/2026 signed out as administered on EMAR at 10:57 PM but not signed out on narcotic log.03/26/26 at 12:40 AM 3:24 PM and 10:00 PM.Review of Resident 1's progress note, dated 03/27/2026, showed .Resident reported not receiving oxycodone during evening shift on 03/26/2026. She had requested pain medication (Oxycodone) on night shift following cares being provided.During observation and interview with Resident 1 on 04/03/2026 at 2:42 PM, the resident was asked if she recalled an incident when she did not receive pain medicine by a nurse. Resident 1 said Yes I remember.I only want medication given to me when I ask for it. She said on that day I asked for pain medicine and the nurse said that I had my quota of oxy [oxycodone] and tylenol and I said oh no I haven't, I hadn't taken either. She was asked if she had any pain from that incident of not receiving the medication. Resident 1 said she had no pain related to the incident but .they were trying to tell me I had already taken it and I have all my faculties. The resident appeared well groomed without signs of pain or distress.Resident 2Resident 2 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, diabetes, right above the knee amputation and left below the knee amputation. The annual MDS, dated [DATE], showed the resident was alert and oriented, independent for most activities of daily living and received scheduled and as needed pain medication.Review of Resident 2's physician's order, dated 6/19/2025, showed an order for Oxycodone 5 mg give 1 tablet every four hours as needed for pain.Review of Resident 2's EMAR, dated 2/2026 and 3/2026, showed Staff C documented she administered oxycodone 10 mg on twenty-two occasions during the hours of 11 pm and 4:30 AM.During an interview with Resident 2 on 04/07/2026 at 1:17 PM, the resident was asked if they generally requested medications during the night shift. Resident 2 stated he takes medication before he goes to bed in the evening. He said he does not request or receive any medication during night shift until he wakes for dialysis at 5:00 AM on Monday Wednesday and Friday.Resident 3Resident 3 was admitted to the facility on [DATE] with diagnoses including Vascular Dementia (decline in thinking caused by conditions that block or reduce blood flow to the brain) and Spinal Stenosis (narrowing on the spinal canal causing pressure on the nerves and spinal cord). The quarterly MDS, dated [DATE], showed the resident was cognitively impaired and received scheduled and as needed pain medications.Review of Resident 3's physician's order, dated 10/25/2025, showed an order for Hydrocodone (narcotic pain medication) 5/325 mg take 1 tablet by mouth every 8 hours as needed for pain.Review of Resident 3's narcotic log for Hydrocodone 5/325 mg showed the following:The medication was signed out of the narcotic log by Staff C on 03/02/2026 at 12:38 PM and again at 2:53 PM (2 hour and 15 minutes between doses). There was no documentation showing the medication was wasted.Review of Resident 3's EMAR showed Hydrocodone 5-325 mg 1 tablet was signed as administered on 03/02/2026 at 12:38 PM.The medication was signed out by Staff C on 3/25/2026 at 6:01 AM, at the bottom of the page of the narcotic log and on 3/25/2026 at 6:01 AM, signed out again as removed on the top of the following page of the narcotic log. There was no documentation showing the medication was wasted.Review of Resident 3's EMAR showed Hydrocodone 5-325 mg 1 tablet was administered on 3/25/2026 at 6:01 AM.Review of the facility investigation, dated 03/27/2026, showed Resident 1 had reported to staff she had not received any pain medication on 03/26/2026 on the evening shift. Resident 1 stated she only takes oxycodone prior to therapy. During care on night shift her hip was adjusted and she requested oxycodone for pain and the night shift nurse was unable to administer the oxycodone due to it being documented as administered at 10:00 PM. The resident was given Tylenol (non-narcotic) pain medication. Resident 2 was interviewed and stated he never requests or sees a nurse after receiving his evening medications and does not see the nurse until he gets up for dialysis at 5:00 AM on Monday, Wednesday and Friday. Resident 2 stated he does not request medications/narcotics during the night. The resident was alert and oriented. Review of documentation showed Staff C had administered narcotic pain medication between 12:00 AM and 05:00 AM, which is inconsistent with the resident's statement. Staff C was terminated.During an interview with Staff H, Certified Nursing Assistant, on 3/26/2026 at 5:35 AM, when was asked if she had observed any staff who showed signs of impairment while at the facility? .yes [Staff C].we reported it, the administrator came in and saw her.she also leaves the floor at times for a long time.During an interview with Staff A, Administrator, on 3/26/2026 at 11:30 AM, he was asked if he had received any concerns from staff related to night staff showing signs of impairment or concerns related to medication administration. He stated not impairment but he acknowledged he did receive concerns related to Staff C nodding off and did come into the facility that night and did see Staff C nodding off while at the computer. Staff A stated he held a staff meeting and Staff C participated and showed no other signs of impairment. He stated Staff C was counselled on staying alert and present during work hoursDuring an interview with Staff E, LPN on 4/3/2026 at 2:10 PM, she was asked if she was aware of any staff showing signs or impairment or concerns related to medication administration. She stated Staff C had inappropriate behavior and would call or text her demanding she give up her shifts to Staff C.During a telephone interview with Staff D, LPN on 4/3/2026 at 3:19 PM she stated she had reported concerns related to Staff C to the Administrator in February of 2026. She stated she had concerns related to Staff C's behavior and concerns related to narcotics signed out for residents who normally don't take medications on the night shift.During an interview with Staff A on 4/3/2026 at 3:30 PM he was asked to provide documentation of an investigation for the allegations from the staff concerns he received by email on 2/6/2026. Staff A stated he could not provide documentation, and he thought Staff B , Director of Nursing, checked the narcotic counts.During an interview on 4/7/2026 at 11:30 AM, Staff B, Director of Nursing, was asked if she was aware of an email sent to Staff A by a staff member with concerns related to possible drug diversion on 2/6/2026. Staff B stated she had no knowledge of this email, and she had not reported or investigated it. She acknowledged she was made aware of an allegation that Resident 1 had not received pain medication on 3/26/2026. Staff B stated she completed the investigation. She stated the allegation has been substantiated and Staff C was terminated. She stated she was now initiating an investigation related to the email received.During an interview on 4/8/2026 at 2:30 PM, Staff G, Resident Care Manager acknowledged the facility was completing a facility wide audit of residents who received narcotic pain medication and they had found multiple discrepancies related to Staff C.During an interview on 4/8/2026 at 3:58 PM, Staff A acknowledged he received an email on 2/26/2026 from a staff member with concerns related to possible drug diversion and staff behavior. He acknowledged he did not complete an incident report. He stated .don't have any documentation to dispute what [Staff B] said.Reference WAC 388-97-0640 2(a)3(c)(d)

Based on observation, interview and record review the facility failed to provide behavioral health services to 1 resident of 3 residents (Resident 7) reviewed for behaviors. The facility's failure to provide behavioral health services placed residents at risk for increased behaviors and decreased quality of life.Findings included.Review of the facility policy titled Social Services Referrals, updated 07/2015, showed the .Social Services Department responds to or makes appropriate referrals for these and other conditions.Behavioral symptoms.aggression.Resident 7 was admitted to the facility on [DATE] with diagnoses including chronic pain, cellulitis and dementia. The quarterly Minimum Data Set (MDS), an assessment tool, dated 01/04/2026, showed the resident had mild cognitive impairment, exhibited verbal and wandering behaviors, and was independent for mobility.Review of Resident 7's progress notes showed the following:12/06/2026 - Resident 7 was up most of the night. Accusing staff of stealing and made a comment about running over them with her car.12/20/2025- Resident 7 threatening to smash her way out of the facility through the windows. Resident 1 threw a water pitcher at a staff member.12/21/2025 - Resident 7 threatening to smash windows out because she likes the sound of glass breaking. Resident 7 threw a water pitcher towards a staff member.01/07/2026 - Resident 7 attempted to choke a staff member leaving scratches to the staff's neck and hit her knee with the walker. Resident 1 was sent to the hospital for evaluation.01/08/2026 - Resident 7's roommate was removed due to a behavior disturbance of Resident 1.01/27/2026 - Resident 7 became angry and verbally threatening, .you know I can just hit you.02/13/2026 - Resident 7 left the facility unattended and was refusing to return. (Resident 7 was returned to the facility without injury).Review of Resident 7's physician's order, dated 02/18/2026, showed an order for a medication to treat anxiety was ordered for the resident (60 days after first documented behavior)Review of Resident 7's care plan, dated 02/18/2026, showed interventions included as needed mental health referrals.Review of Resident 7's record showed no documentation for a referral for behavioral health or psychiatric services.Observation and interview with Resident 7 on 03/24/2026 at 2:15 PM, showed the resident ambulated in the hallway with a walker. The resident appeared alert and pleasant. No behaviors noted.During an interview with Staff B, Director of Nursing on 03/26/2026 at 12:15 PM, they acknowledged Resident 7 had documented behaviors towards staff and visitors in December 2025 and January 2026 and the facility did not provide behavioral health or psychiatric services for Resident 7. Staff B stated nursing or social services can make recommendations for these services.Reference WAC 388-97-1000(2)(f)(g)

Based on interview and record review, the facility failed to review, revise and implement a comprehensive plan of care to include, resident behavior monitoring and specific interventions, and guardianship for 6 of 16 sampled Residents (6, 7, 54, 9, 45, and 50) reviewed for comprehensive care plans. This failure to establish care plans that were comprehensive placed residents at risk of receiving inappropriate and inadequate care to meet their individualized needs.Findings included.Resident 7 Resident 7 was admitted to the facility on [DATE] with a diagnosis of major depressive disorder (a serious mental health condition characterized by persistent sadness, low mood, and loss of interest in activities for at least two weeks). Resident 7s Quarterly Minimum Data Set (MDS, an assessment tool), dated 12/18/2025, documented the resident was moderately cognitively impaired and required partial to moderate assistance with activities of daily living. The MDS documented Resident 7 was on an antipsychotic and antidepressant. Review of the electronic health record (EHR), showed Resident 7 orders for scheduled psychotropic and antidepressant medications: -Aripiprazole Tablet by mouth one time a day related to Major Depressive Disorder, order dated 04/28/2025 -Venlafaxine one time a day for depression, order dated 08/07/2025 -Venlafaxine one time a day related to Major Depressive Disorder, order dated 12/17/2025 On 03/26/2026 at 12:31 PM, Staff C, Resident Care Manager/Registered Nurse, said Resident 7 had behaviors such as being tearful, sad, and really liked their Pepsi. Staff C said they try to console Resident 7 and redirect them. Staff C said, Resident 7's care plan listed behaviors and interventions but they were not specific to Resident 7 and specify which medications they were for. Resident 45 Resident 45 was admitted to the facility on [DATE] with diagnoses of anxiety, depression, and restlessness and agitation. The admission MDS, dated [DATE], showed Resident 45 was cognitively intact. Review of Resident 45's current orders, showed they were taking an antidepressant, trazodone, ordered on 03/18/2026, and they were no longer taking an antipsychotic. Review of Resident 45's psychosocial well-being care plan, last revised on 01/28/2026, showed Resident 45 had anxiety disorder and depression with target behaviors listed as agitation, anger, cursing, grabbing, hitting, kicking, screaming, yelling, throwing fecal matter at staff, racist slurs, non-complaint with cares, and accusing of others. This care plan listed Resident 45 as taking psychotropic medications that included both an antidepressant/anxiolytic (anti-anxiety) and an antipsychotic. There was no clear distinction of which target behaviors were being treated by which psychotropic medication, nor was there a distinction between observed behaviors not being treated by medication and target behaviors being treated by the psychotropic medication. During an interview on 03/26/2026 at 10:42 AM, Staff C, Resident Care Manager/ Registered Nurse, when asked how the facility knew which behaviors were being treated/monitored for each class of psychotropic medication listed on the care plan, Staff C said they did not know if they were differentiated on Resident 45's care plan. Staff C reviewed Resident 45's chart and confirmed Resident 45 was not currently taking an antipsychotic despite having it listed on their care plan. Staff C said care plans should be updated when there was a new medication change. Resident 54 Resident 54 was admitted to the facility on [DATE] with a diagnosis of dementia. The Annual MDS, dated [DATE], showed Resident 54 had severe cognitive impairment. Review of Resident 54's EHR, showed they had a guardian (court appointed decision maker). Review of Resident 54's care plans, reviewed on 03/27/2026, showed no care plan existed related to the guardianship or family involvement related to information. Review of Resident 54's care conferences on 06/04/2025, 09/08/2025, and 12/11/2025, showed no mention that family was included in the meeting. During an interview on 03/23/2026 at 11:46 AM, Resident 54's family member (CC1), said they were not included in care conferences, they had wanted to be included in them, and wanted to be updated on Resident 54. CC1 said that months ago it had been difficult to get a list of Resident 54's medications. CC1 stated, We felt like they were treating us like nothing because she had a guardian, even though we petitioned for that. We have felt like our hands are tied and don't get updates. During an interview on 03/26/2026 at 4:15 PM, Resident 54's guardian (CC2), said CC1 was allowed to get information on Resident 54 and had been able to the whole time. CC2 said CC1 was able to be present for care conferences, as it would help the family understand the dementia diagnosis and any decline. When asked about the past few care conferences, CC2 said they were not sure CC1 was invited but that they were always welcome. CC2 said it was okay for CC1 to know about upcoming appointments, such as dental or podiatry appointments. During an interview on 03/25/2026 at 2:40 PM, Staff H, Social Services Director, said CC1 has had approval for information since admission, and she can get whatever information the guardian was okay with. When asked what the guardian had specified for CC1 to get information on, Staff H said they had only been in this role since 02/16/2026. Staff H said that if CC1 requested information today, they would call the guardian and get information from them on what they could provide to CC1. Staff H said they were in the process of setting up a care conference for Resident 54 and had not emailed the guardian for permission to invite CC1. During a follow-up interview on 03/27/2026 at 10:03 AM, Staff H said CC1 was allowed to have general information on care, activities and appointments, and could call to check on them. Staff H said this should be care planned, and confirmed it was not. During an interview on 03/27/2026 at 10:09 AM, Staff J, Licensed Practical Nurse, reviewed Resident 54's electronic profile and said they would not give CC1 any information. Staff J said it would be helpful, to have a care plan with information on who could be involved and what kind of contact they could have. During an interview on 03/27/2026 at 10:45 AM, Staff B, DNS, was told about Resident 54's family being unable to get information/updates. Staff B reviewed the past couple of care conferences and said they did not list the family as being present. Staff B said this probably should have been care planned, for staff communication. Staff B said their expectation was for it to have been communicated correctly to staff, so that they would pass information on to those that were allowed to have the information. Resident 6Resident 6 was admitted to the facility on [DATE]. Review of the Quarterly MDS, dated [DATE], showed the resident had moderate cognitive impairment, a diagnosis of anxiety disorder, and received antidepressant and antianxiety medication during the assessment period. Review of the electronic health record showed Resident 6 had the following psychotropic medication (drugs that alter brain chemistry to treat mental health conditions) orders:a) A 03/19/2026 order for alprazolam (an antianxiety medication) every eight hours as needed for 120 days for anxiety disorder.b) A 02/18/2026 order for duloxetine (an antidepressant) daily for dysthymic disorder (a chronic, long-term form of mild-to-moderate depression that lasts for at least two years).c) A 02/11/2026 order for escitalopram (an antidepressant) daily for depression. An impaired psychosocial wellbeing related to depression and anxiety disorders care plan, initiated 01/21/2026, directed staff to monitor for Anxious, Panic, self-isolation and refusal of care, as well as for adverse side effects associated with antipsychotic, antidepressant, anxiolytic and anticonvulsant medications. The care plan did not identify what psychotropic medications Resident 6 was receiving or what target behavior(s) each medication was initiated to treat. Additionally, Resident 6 was not prescribed a anticonvulsant or antipsychotic medication. Resident 50Resident 50 was admitted to the facility on [DATE]. Review of the admission MDS, dated [DATE], showed the resident was cognitively impaired, had diagnoses of depressive disorder (a serious, common mood disorder causing persistent sadness, loss of interest, and low energy that interferes with daily life), psychotic disorder (a mental health condition characterized by a loss of contact with reality, where individuals struggle to distinguish what is real from what is not) and received antipsychotic and antidepressant medication during the assessment period. Record review showed Resident 50 had a 03/05/2026 order for aripiprazole (an antipsychotic) once a day for psychosis, and a 02/10/2026 order for escitalopram (an antidepressant) once a day for depression. An impaired psychosocial well-being related to depression and psychosis care plan, initiated 02/10/2026, showed staff were instructed to monitor for refusals and self-isolation, as well as for adverse side effects associated with antipsychotic, antidepressant, anxiolytic and anticonvulsant medications use. The care plan did not identify which medications Resident 50 was received or the target behaviors they were initiated to treat. Additionally, Resident 50 was not prescribed an anticonvulsant medication. During an interview on 03/27/2026 at 10:44 AM, Staff H, Director of Social Services, said the psychotropic medications a resident received and the specific behavior(s) each medication was initiated to target/treat should be identified/addressed in the care plan. When asked if the care plans should be specific/personalized to the needs of each resident (e.g., only monitor for adverse side effects of medications a resident receives) Staff H stated, yes. Resident 9 Resident 9 was admitted to the facility on [DATE] with diagnoses of depressive disorder (mental health condition characterized by persistent feeling of sadness or loss of interest) and post-traumatic stress disorder (mental health condition that can develop after a person experiences or witnesses a traumatic event). According to the Quarterly MDS, dated [DATE], Resident 9 was moderately cognitively impaired. Resident 9 had a provider order, dated 03/17/2026, for Seroquel (antipsychotic medication that affects brain chemicals and may stabilize mood, thinking and behavior) to be given daily for post-traumatic stress disorder. Resident 9 had another provider order, dated 02/24/2026, for Venlafaxine, (an antidepressant medication), to be given daily for major depressive disorder. Review of Resident 9's impaired psychosocial well-being care plan, revised 02/22/2026, documented the behaviors requiring intervention and psychotropic drug utilization were related to diagnoses of delirium due to known physiological condition, major depressive disorder, PTSD and chronic pain. The target behaviors listed under the diagnoses were sad/tearful. The care plan went on to document that the antidepressant target behaviors were sad/tearful, but did not have any specific target behaviors for the antipsychotic medication. On 03/26/2026 at 12:22 PM, Staff C, Resident Care Manager, Registered Nurse, regarding the lack of differentiation between the target behaviors for the antidepressant and antipsychotic medications on the care plan, Staff C said they did not see that it had been differentiated between the medication classes. Reference F605 Reference WAC 388-97-1020(1), (2)(a)(b)

Based on interview and record review, the facility failed to implement an effective antibiotic stewardship program to promote appropriate use of antibiotics, reduce the risk of unnecessary antibiotic use and decrease the development of adverse side effects and antibiotic resistance for 3 of 5 entries or 2 of 4 residents (Resident 80 & 39) reviewed for antibiotic stewardship. This failure placed residents at risk for potential adverse outcomes associated with the inappropriate and/or unnecessary use of antibiotics.Findings included .Resident 801) Resident 80 was admitted to the facility on [DATE]. Review of the December 2025 infection control (IC) log showed Resident 80 was started on Bactrim DS times seven days for an urinary tract infection (UTI) on 12/24/2025. The line listing showed a urine sample was collected on 12/17/2025 and sent out for a urinalysis with culture and sensitivity (UA with C&S). The UA C&S results, dated 12/17/2025, showed there were greater than three organisms identified, which was consistent with contamination. Recollection of a urine sample was recommended. A Resident Infection Report dated 12/28/2025, showed the residents 12/17/2025 UA was contaminted and needed to be recollected and documented Resident 80 denied symptoms of a UTI. The report determined McGeer's criteria for UTI was not met. The section of the report that asked if the provider was notified and consulted regarding the resident's condition and infection criteria, was left blank. Review of the electronic health record (EHR) showed Resident 80 completed the full seven days course of Bactrim DS despite denying symptoms of a UTI and the infection criteria not being met. During an interview on 03/27/2026 at 12:50 PM, when asked if they could provide documentation to show staff recollected Resident 80's urine sample as recommended, and the provider was notified (prior to completion of the antibiotics) that McGeer's criteria for a UTI was not met, Staff H, Infection Preventionist, said no. When asked if they knew what the causative organism was and whether it was susceptable to Bactrim Staff H said no. 2) Review of the January 2026 IC log showed Resident 80 was started on levofloxacin for seven days for a UTI on 01/14/2026. The line listing showed a UA with C&S was sent on 01/12/2026. The UA C&S results, dated 01/12/2026, showed greater than three organisms were identified, which was consistent with contamination. Recollection of a urine sample was recommended. A Resident Infection Report dated 01/15/2026, showed resident 80 had complained of pain/discomfort with urination but had no further urinary symptoms and documented McGeer's criteria for UTI was not met. The report showed Resident 80 was receiving levofloxacin (an antibiotic) for seven days and documented that another UA was needed. Review of the EHR showed no documentation that staff recollected a urine sample as recommended but did show Resident 80 completed the full seven days of levofloxacin therapy, even though the residents symptoms did not meet the criteria of UTI. During an interview on 03/27/2026 at 12:50 PM, when asked if they could provide documentation that staff recollected Resident 80's urine sample as recommended, and the provider was notified prior to completion of the antibiotics) that McGeer's criteria for a UTI was not met, Staff H, Infection Preventionist said, no. When asked if they knew what the causative organism was and whether it was susceptable to levofloxacin Staff H said no.3) Resident 39 was admitted to the facility on [DATE]. Review of the February 2026 IC log showed Resident 39 was started on Augmentin times seven days on 02/16/2026 for a UTI. The line listing showed a urine sample was collected on 02/08/2026 and sent for a UA with C&S. The UA C&S results, dated 02/08/2026, showed greater than three organisms were identified, which was consistent with contamination. Recollection of a urine sample was recommended. The provider noted the lab result on 02/13/2026 and wrote on the lab re-collect. Progress notes dated 02/05/2026 and 02/08/2026 showed Resident 39 complained of dysuria (pain/discomfort with urination). A urine sample was obtained on 02/08/2026, but the results were contaminated and a urine sample needed to be recollected. Subsequent progress notes dated 02/11/2026, 02/15/2026 and 02/19/2026 all documented Resident 39 denied dysuria. A Resident Infection Report dated 02/19/2026, showed resident 39 had complained of pain/discomfort with urination, no further signs or symptoms of a UTI were noted. The report identified that the 02/08/2026 UA was contaminated and needed to be recollected but attempts to obtain a urine sample via straight catheterization were unsuccessful. The report determined McGeer's criteria for a UTI were not met, but the Loeb criteria was and Resident 39 was treated with a seven-day course of Augmentin.During an interview on 03/27/2026 at 12:50 PM, Staff H explained that the facility used Loeb's criteria in situations of an expected UTI so treatment could be initiated pending UA C&S results. When asked how they knew what the causative organism was and whether is was susceptible to Augmentin, Staff H indicated they didn't and acknowledged in this case there was not a UA with C&S pending.Reference WAC 388-97-1620(2)(b)(i)(ii)

Based on interview and record review, the facility failed to ensure notification to the Office of the State Long-Term Care Ombudsman (resident advocates) occurred for residents transferred to the hospital for 3 of 3 sampled residents (Residents 3, 6, & 67) reviewed for hospitalization and 1 of 1 Resident (Resident 69) reviewed for Against Medical Advice (AMA) discharge. This failure placed residents at risk of a lack of advocacy and possible unidentified or unmet care needs. Findings included .Resident 3 Resident 3 was admitted to facility on 07/13/2022. The Quarterly Minimum Data Set (MDS, an assessment tool), dated 02/23/2026, documented Resident 3 was severely cognitive impaired. Resident 3 was transferred to the hospital on [DATE]. The electronic health record (EHR) showed no documentation the Ombudsman was notified of the transfer. Resident 6 Resident 6 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], documented Resident 6 was severely cognitive impaired. Resident 6 was transferred to the hospital on [DATE]. The EHR showed no documentation the Ombudsman was notified of the transfer. Resident 67 Resident 67 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], documented Resident 6 was severely cognitive impaired. Resident 67 was transferred to the hospital on [DATE]. The EHR showed no documentation the Ombudsman was notified of the transfer. On 03/25/2026 at 10:35 AM, Staff I, Social Services Assistant (SSA), said they started this position in January 2026 and would have to look for the Ombudsman notifications for those specific residents. On 03/26/2026 at 11:06 AM, Staff I said they were not able to locate the Ombudsman notification for the specific residents. When asked if the EHR should have documented the Ombudsman notification for each resident, Staff I, said yes, it should have. On 03/26/2026 at 11:57 AM, in a joint interview with Staff A, Administrator and Staff B, Director of Nursing Services (DNS), both staff said the EHR should have had documentation showing the Ombudsman was notified of the listed residents' transfers. Resident 69 Resident 69 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], documented Resident 69 was moderately cognitively impaired. A review of the EHR showed Resident 69 was discharged AMA on 02/22/2026. On 03/24/2026 at 3:11 PM, Staff H, Social Services Director, said they would follow-up the next day when asked if they had the ombudsman notification from Resident 69. A review of the Nursing Home Transfer and Discharge Notice for Resident 69 documented the resident left AMA on 02/22/2026 and was signed by Staff I, SSA on 03/25/2026. On 03/25/2026 at 11:51 AM, an email from Staff A, Administrator, said Resident 69 was not included in the ombudsman notification because when they ran the report for discharges, the AMA residents were not included. On 03/26/2026 at 8:20 AM, Staff I, said they sent the Ombudsman the Nursing Home Transfer and Discharge Notice for Resident 69 on 03/25/2026. Staff I, said they tried to send them every Friday and this one was sent late. Reference WAC 388-97-0160

Based on interview and record review, the facility failed to ensure psychotropic medications (any drug that affects the brain activities associated with mental processes and behavior) were regularly monitored and documented on, including the interventions, for 5 of 5 sampled Residents (6, 7, 9, 45, and 50) reviewed for unnecessary medications. This failure placed residents at risk of unnecessary medication usage and a diminished quality of life. Findings included .Resident 6Resident 6 was admitted to the facility on [DATE]. Review of the Quarterly minimum data set (MDS, an assessment tool), dated 02/09/2026, showed the resident had moderate cognitive impairment, a diagnosis of anxiety disorder, and received antidepressant and antianxiety medication during the assessment period. Review of the electronic health record showed Resident 6 had the following psychotropic medication (drugs that alter brain chemistry to treat mental health conditions) orders:a) A 03/19/2026 order for alprazolam (an antianxiety medication) every eight hours as needed for 120 days for anxiety disorder.b) A 02/18/2026 order for duloxetine (an antidepressant) daily for dysthymic disorder (a chronic, long-term form of mild-to-moderate depression that lasts for at least two years).c) A 02/11/2026 order for escitalopram (an antidepressant) daily for depression. An impaired psychosocial wellbeing related to depression and anxiety disorders care plan, initiated 01/21/2026, directed staff to monitor for Anxious, Panic, self-isolation and refusal of care. The care plan did not identify what psychotropic medications Resident 6 was receiving or what target behavior(s) each medication was initiated to treat. Review of the March 2026 MAR and TAR showed there was no direction to nurses to monitor target behaviors associated with the resident's use of alprazolam, duloxetine, or escitalopram. Review of Resident 6's Point of Care charting, a program where Certified Nursing Assistants (CNAs) document care, showed CNA's were directed to monitor Resident 6 for the following behaviors: grabbing others; hitting others; kicking others; pushing others; physical aggression towards others; scratching others; accusing others; cursing others; expressing frustration/.anger at others; screaming at others, threatening others; disruptive sounds; disrobing in public; entering others personal space, public sex acts; repetitive motions; rummaging; spitting; throwing/smearing food; throwing body waste; agitation; anxiousness/restlessness; elopement; pacing; panic neglecting self-care; picking at self; refusing care; sad/tearful; self-injury; hoarding; withdrawn/isolation; and wandering. The behavior monitor did not identify what behaviors, if any, were specific to Resident 6 or which behaviors were being targeted by which medication. On 03/26/2026 at 3:09 PM, Staff B, Director of Nursing Services (DNS), explained that behavior monitors were used to monitor the frequency of target behaviors, which helped the facility assess the effectiveness of the medication. When asked how someone could determine the effectiveness of a medication based on the frequency target behaviors were demonstrated, if the behaviors a medication was initiated to target were never identified, Staff B provided no response. Review of Resident 6's as needed alprazolam order history showed the resident had an active order for alprazolam every eight hours as needed, for the following time periods:a) 01/19/2026 - 02/05/2026 (15 days). b) 02/10/2026 - 02/24/2026 (15 days); the electronic health record (EHR) showed there was no provider documented clinical rationale for the extension of the as needed alprazolam.c) 02/26/2026- 03/09/2026 (14 days); the EHR) showed there was no provider documented clinical rationale for the extension of the as needed alprazolam.d) On 03/10/2026 Resident 6's as needed alprazolam order was extended for an additional 120 days. A pharmacy recommendation, dated 03/06/2026, documented Resident 6 had been receiving as needed alprazolam since 01/23/2026 and instructed if the provider wanted to extend the prescription, they must document a clinical rationale for the extension and indicate a specific duration in days for the extension. Further review showed the provider checked the box for extending the as needed alprazolam for 120 days and documented panic disorder as the clinical rationale for the extension. On 03/27/2026 at 2:29 PM, Staff B, DNS, was asked for a copy of the provider documented rationales for each time Resident 6's as needed alprazolam was extended beyond 14 days. No further documentation was provided. Review of the February 2026 MAR showed there were no non-pharmacological interventions identified for nurses to attempt prior to administering Resident 6's as needed alprazolam, which was administered 23 times during the month. On 03/27/2026 at 2:29 PM, documentation of the non-pharmacological interventions facility nurses attempted prior to administering the as needed alprazolam was requested. On 03/30/2026 at 1:58 PM, Staff B responded in an email that she was unable to find that any non-pharmacological interventions were attempted prior to administration of Resident 6's as needed alprazolam. Resident 50Resident 50 was admitted to the facility on [DATE]. Review of the admission MDS, dated [DATE], showed the resident was cognitively impaired, had diagnoses of depressive disorder (a serious, common mood disorder causing persistent sadness, loss of interest, and low energy that interferes with daily life), psychotic disorder (a mental health condition characterized by a loss of contact with reality, where individuals struggle to distinguish what is real from what is not) and received antipsychotic and antidepressant medication during the assessment period. Review of Resident 50's electronic health record (EHR) showed orders for the following psychotropic medications (rugs that affect the mind, emotions, and behavior by altering chemical levels in the brain):a) Aripiprazole (an antipsychotic) once a day for psychosis, dated 03/05/2026.b) Escitalopram (an antidepressant) once a day for depression. Review of the 02/10/2026 Psychoactive Drug Consent for aripiprazole showed verbal consent was obtained from Resident 50's representative for the treatment of unspecified psychosis. Further review of the document showed the sections for non-pharmacological interventions in use prior to start of medication, benefits of medication use, and indication for use (target behaviors) were all left blank. An impaired psychosocial well-being related to depression and psychosis care plan, initiated 02/10/2026, documented the resident was on behavior monitoring for 30 days to establish target behaviors, triggers and interventions. Staff were instructed to monitor for refusals and self-isolation, as well as for adverse side effects associated with antidepressant and antipsychotic medications. The care plan did not identify what medications Resident 50 was receiving or the target behaviors they were initiated to treat. Review of the EHR showed no documentation that staff asked/discussed what associated behaviors Resident 50 had demonstrated related to their diagnosed psychotic disorder and depressive disorder. The March 2026 MAR showed there were no target behaviors identified or being monitored. Review of Resident 50's Point of Care behavior monitor showed it was the same prefabricated behavior monitor as Resident 6 had. The behavior monitor did not identify which behaviors were targeted by which medication. On 03/26/2026 at 12:31 PM, Staff C, Resident Care Manager, explained during the facility's psychotropic meetings, behavior monitors to were used to assess the effectiveness of psychotropic medications. When asked what specific behaviors were targeted by the aripiprazole versus the behaviors that were targeted by the escitalopram Staff C, said, We are monitoring for behaviors, but again I cannot see a differentiation (of which behavior(s) were targeted by what medication). Resident 9 Resident 9 was admitted to the facility on [DATE] with diagnoses of depressive disorder (mental health condition characterized by persistent feeling of sadness or loss of interest) and post-traumatic stress disorder (mental health condition that can develop after a person experiences or witnesses a traumatic event). According to the Quarterly MDS, dated [DATE], Resident 9 was moderately cognitively impaired. Resident 9 had a provider order, dated 03/17/2026, for Seroquel (antipsychotic medication that affects brain chemicals and may stabilize mood, thinking and behavior) to be given daily for post-traumatic stress disorder. Resident 9 had another provider order, dated 02/24/2026, for venlafaxine, (an antidepressant medication), to be given daily for major depressive disorder. Further review of Resident 9's orders showed there were no behavior monitors ordered for the licensed nursing staff to document behaviors related to the antipsychotic or the antidepressant. Resident 9's Behavior Monitoring & Interventions task documentation (where Certified Nursing Assistants were to document observed behaviors) reviewed from 03/01/2026 through 03/30/2026, showed an area to document sad/tearful, but did not indicate which medication or diagnosis this behavior was being monitored for. On 03/26/2026 at 12:22 PM Staff C, Resident Care Manager, Registered Nurse, said his expectation was for Resident 9's antidepressant and antipsychotic medications to have target behavior monitoring in place. When asked if the antipsychotic medication target behaviors were being monitored, Staff C said they had monitors in place. When asked if there were specific monitors, Staff C said sad and tearful was on the care plan. When asked if Resident 9 was taking both the antipsychotic and the antidepressant for sad and tearful, Staff C said they could not answer without reading more in the chart. Resident 45 Resident 45 was admitted to the facility on [DATE] with diagnoses of anxiety, depression, and restlessness and agitation. The admission MDS, dated [DATE], showed Resident 45 was cognitively intact and taking an antipsychotic and an antidepressant. Review of Resident 45's current orders, showed they were taking an antidepressant, trazodone, ordered on 03/18/2026, and they were no longer taking an antipsychotic. Further review of Resident 45's orders, showed there was no behavior monitor ordered for the licensed nursing staff to document behaviors related to the antidepressant. Review of Resident 45's psychoactive drug consent, dated 12/29/2025, indicated they were taking the antidepressant for the following behaviors/actions/thoughts: feeling sad, little interest or pleasure in doing things, low motivation, loss of interest in food, and sleeplessness. The indication for Resident 45 using an antipsychotic medication at this time, was for agitation, elevated mood, and poor emotional control. Resident 45's psychoactive drug consent, dated 03/23/2026, indicated Resident 45 was taking the antidepressant for the following behaviors/actions/thoughts: sleeplessness. Review of Resident 45's psychosocial well-being care plan, last revised on 01/28/2026, showed Resident 45 had anxiety disorder and depression with target behaviors listed as agitation, anger, cursing, grabbing, hitting, kicking, screaming, yelling, throwing fecal matter at staff, racist slurs, non-complaint with cares, and accusing of others. This care plan listed Resident 45 as taking an antipsychotic medication and an antidepressant/anxiolytic (anti-anxiety). There was no clear distinction of which target behaviors were being treated by which psychotropic medication, nor was there a distinction between observed behaviors not being treated by medication and target behaviors being treated by the psychotropic medication. During an interview on 03/26/2026 at 10:42 AM, Staff C, Resident Care Manager/ Registered Nurse, said that psychoactive drugs require a monitor for behaviors and adverse side effects. For Resident 45, Staff C said their care plan had their behavior monitors listed. When asked how the facility knew which behaviors were being treated/monitored for each class of psychotropic medication listed on the care plan, Staff C said they did not know if they were differentiated on Resident 45's care plan. Staff C acknowledged Resident 45's antidepressant would not be used for treating racists slurs. Staff C showed the facility had a generalized behavior monitor, recorded by the Certified Nursing Assistants (CNAs). When asked if Resident 45 had a antidepressant specific behavior monitor in place, with staff tracking if the behaviors did or did not happen related to this antidepressant, Staff C said they could not say the behavior monitor was specific to the antidepressant. During an interview on 03/26/2026 at 1:16 PM, Staff B, Director of Nursing Services, said their expectation for behavior monitors related to psychotropic medications, was for there to be open ended behavior monitoring on admission, they should be on an alert for medications, and then after a month or so the facility could narrow down (behaviors) and update/adjust the care plan. Staff B said they expected staff to chart under the task (this was the CNAs' charting) and nursing charting. When asked about Resident 45 and how staff would know how to consistently document racial slurs under their generic behavior monitor (for the CNAs), Staff B said social work was supposed to go back and follow up and tweak the care plan. When asked if they had behavior monitors for each psychotropic drug, Staff B said yes, it was under the tasks and nursing charting. Resident 7 Resident 7 was admitted to the facility on [DATE] with a diagnosis of major depressive disorder. Resident 7's Quarterly MDS, dated [DATE], documented the resident was moderately cognitively impaired and required partial to moderate assistance with activities of daily living. The MDS documented Resident 7 was on an antipsychotic and an antidepressant . Review of the EHR showed Resident 7 had orders for scheduled psychotropic and antidepressant medications: -Aripiprazole one time a day related to Major Depressive Disorder, order dated 04/28/2025 -Venlafaxine one time a day for depression, order dated 08/07/2025 -Venlafaxine one time a day related to Major Depressive Disorder, order dated 12/17/2025 On 03/26/2026 at 12:31 PM, Staff C, Resident Care Manager/Registered Nurse, said Resident 7 had behaviors such as being tearful, sad, and really liked their Pepsi. Staff C said they try to console Resident 7 and redirect them when they have these behaviors. Staff C said the behaviors and interventions being documented by the CNAs were similar to other residents who were on an antidepressant and antipsychotic and not specific to Resident 7. They were the same monitors and interventions in place similar to the other residents. On 03/27/2026 at 8:16 AM, Staff K, Registered Nurse Med Nurse, was asked where they would document if Resident 7 was having behaviors and Staff K responded by saying I would have to put in a progress note. Staff K was asked if they documented Resident 7's behaviors every shift and they said only if it was noteworthy or Resident 7 was on alert. On 03/27/2026 at 8:22 AM, Staff J, Licensed Practical Nurse, said they could chart Resident 7's behaviors everyday but did not unless it was something new. Staff J said they would write a progress note. Reference WAC 388-97-0620 (1)(a)

Based on observation, interview and record review the facility failed to assess food preferences and provide food that met preferences for 3 of 7 residents (Residents 75, 76, and 11) reviewed for food. These failures placed residents at risk for hunger, nutrient deficiency and diminished quality of life.Findings included.Resident 75 & 76 On 03/24/2026 at 8:36 AM, Resident 75 said they had recently been admitted to the facility, no one had talked to them about their food preferences yet (neither the Dietary Manager or the Registered Dietitian) and they had not been able to eat most of the food because they were supposed to be a on a diabetic diet. Observation of Resident 75's meal ticket documented CCHO [consistent carbohydrate diet], diet is eating the same amount of carbohydrates every day. This helps keep your blood sugar, or glucose, levels stable], NAS [no added salt] thin liquids. Observation of Residents 75's breakfast meal tray showed, Resident 75 was served pancakes with packaged syrup, sausage and packaged brown sugar. Resident 75 ate one pancake with no syrup (packages still closed), half of the sausage and did not open the brown sugar. Resident 75 said they did not like pancakes or sausage, but they had to eat something. Resident 75 said they asked for sugar free syrup and was told by staff the facility did not carry that. Resident 75 said they never opened the brown sugar because they do not eat brown sugar. On 03/24/2026 at 9:13 AM, Resident 76 said they had recently been admitted to the facility and already had concerns with the food. Resident 76 said the food was always cold and half the time they did not eat the food because they did not know what it was and no alternatives had been provided. On 03/25/2026 at 8:17 AM, Resident 75 said Staff E, the Dietary Manager, finally came to interview them and their roommate the previous night about food preferences and had documented their likes and dislikes. Resident 75 said Staff E had told them about an alternative menu and was supposed to bring them a copy of the alternative menu, but Staff E had never returned last night. Observation of Resident 75's meal ticket documented Regular CCHO, NAS, thin liquids; Dislikes milk, pancakes, French toast, pork, eggs, canned fruit, hot cereal and cold cereal. Observation of Resident 75's meal tray included one English muffin (cut in half) with two sugar based jellies (one grape and one orange), no other foods or condiments were on the plate (to include butter). Resident 75 said they needed some type of protein like a piece of cheese or cottage cheese to have the strength to complete physical therapy today, this was all carbs and sugar and they could not go without eating. On 03/25/2026 at 8:23 AM, Resident 76 said Staff E came in the previous night and spoke with them about the likes and dislikes. Observation of Resident 76's meal ticket documented Regular diet, regular texture, thin liquids; Dislikes: eggs, milk, yogurt, pancakes, French toast, hot cereal. Resident 76 said they did like eggs but not every day and sometimes not in the AM. Observation of Resident 76's meal tray included one English muffin (cut in half) and one piece of bacon; no other foods or condiments were on the plate (including butter or jellies). Resident 76 said they had eaten one piece of bacon. On 03/25/2026 at 8:29 AM, Staff L, Certified Nursing Assistant (CNA), was asked to make an observation of the meal trays delivered this morning. Staff L confirmed they had delivered breakfast meal trays this morning. Staff L said when they delivered meal trays, they would take the tops off the plates, offer assistance with set up and help reposition residents who needed it. When asked what was offered to residents, Staff L [NAME] they would offer drinks and condiments like mayo, mustard, ketchup, salt, pepper, jelly, syrup. When asked specifically about butter, Staff L said yes, they offered butter, for like pancakes, toast or rolls. Staff L was shown both Resident 75' and Resident 76's meal tray. Staff L confirmed neither resident had butter on their plates and said it should have been offered. Staff L then exited the room. On 03/25/2026 at 8:45 AM, Resident 75 said they could no longer wait for staff to return with butter, then took three bites of what they described as a cold, dry English muffin. Resident 75 said they were not going to eat the rest. Resident 76 said they were not going to eat their cold dry English muffin. Staff L never returned or offered an alternative or condiments. On 03/25/2026 at 12:44 PM, observation of Resident 75's lunch meal with pasta taking up 50% of plate, 25% of plate a breadstick, and less than 25% of plate cauliflower (a small helping) and a banana on the side of tray. Resident 75 said they did not eat bananas and it was too many carbohydrates for them. Resident 75 said they needed some protein, they would have preferred the alternative but were never asked. At 2:05 PM, observation of the banana, bread stick and a large pile of pasta remained on Resident 75's plate, only the cauliflower had been consumed. On 03/25/2026 at 10:51 AM, Staff E said when staff deliver meal trays, they should ask the residents what they want to drink and offer condiments, like salt or pepper to go with their meals. Staff E said the facility offered different types of condiments, like if the resident wanted jelly or syrup for their pancakes or ketchup for other meals. When asked if floor staff delivered those items, Staff E said no, kitchen staff would primarily plate those items when tray line was completed, but residents could ask floor staff for more or if it was missing. When asked about diabetic options for residents, Staff E said the facility carried sugar free jellies, for residents who were diabetic. Staff E said those options were also put on the delivery cart with the drinks, so staff did not have to run back and forth to the kitchen, but if they were out of that item on the carts, then staff could come back to the kitchen to get more. Staff E pointed and showed a box of sugar free jellies sitting on the drink cart. The observation of the English muffins were explained, Staff E said the expectation was the residents should have had butter on their plates for the English muffins. When it was explained that both residents waited 15 minutes for the staff (after the interview) to bring them butter and then finally decided not to eat, because it was cold and dry, Staff E apologized and said that was not acceptable. On 03/25/2026 at 1:21 PM, Staff F, Registered Dietitian (RD), said when a new resident was admitted to the facility, they have 14 days to complete the assessments regarding the residents' diet/nutritional requirements. When asked about residents who were diabetic and meeting their nutritional requirements when admitted (during the assessment period), Staff F said if there were concerns regarding a resident's diet, staff would notify the RD and the provider. When asked if a resident was not eating due to being served too many carbohydrates, or items outside of a diabetic diet, Staff F stated, diabetics need a certain amount of sugar in their diet. When the observation of the English muffin was explained for two different residents and asked if that was acceptable, Staff F did not answer. When asked if the resident should have been offered an alternative meal when not eating the pasta, Staff F did not answer. When asked how the facility was meeting the residents' nutrition needs and preferences, Staff F said we need to do a food preference evaluation with the residents. Resident 11 Resident 11 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with a diagnosis of chronic kidney disease. According to the Discharge Return Anticipated Minimum Data Set (MDS, and assessment tool), dated 02/19/2026, Resident 11 was independently able to make decisions regarding tasks of daily life. On 03/23/2026 at 12:13 PM, Resident 11 said they had issues with food due to their kidney disease which changed the food flavors and consistency, food would taste like mud. Resident 11 said they could have soft food but the facility was pureeing their food, they did not recognize the food served and they did not want to eat it. On 03/23/2026 at 12:27 PM, Resident 11 received their lunch and told staff they disliked pureed food and nobody had asked them if they wanted pureed food. Review of Resident 11's food meal ticket showed they were to have soft and bite sized food. Observation of Resident 11's meal showed some diced potatoes, with the rest of the food present being pureed. On 03/24/2026 at 12:41 PM, Resident 11 had a lunch meal that had mashed potatoes, beef that had some texture to it and the rest of the food on the plate was pureed. Resident 11 said the food had just showed up pureed one day and they hated pureed food. Resident 11 said they had told staff from day one that they were not going to eat pureed food and they did not know where the orders for pureed food came from, the changes were made without their knowledge, and it was annoying. Resident 11 had an order, dated 03/13/2026, for CCHO (consistent carbohydrate), Renal diet (therapeutic diet designed for individuals with kidney disease), soft and bite sized texture, and thin liquid consistency. Review of the electronic health record showed the last food preference evaluation for Resident 11 was dated 12/01/2025, during a previous stay at the facility. On 03/25/2026 at 1:51 PM, Staff E said options for soft bite sized food included meat cut up, mashed vegetables, mashed potatoes, cottage cheese, diced fruit and other soft types of foods. Staff E said residents with soft and bite sized diet orders would also get pureed items depending on the type of food it was, giving the example of green beans saying they were stringy and it could get lodged in the throat and a resident could choke on it. When asked if substituting a different soft vegetable for the day rather than pureeing the vegetable was possible, Staff E said yes, and residents could also have a vegetable juice if they preferred. During this interview, regarding Resident 11, Staff E said their diet was soft and bite size. When asked if Resident 11 required pureed food, Staff E said, it would depend and gave the example of bread saying it was a choking hazard. Staff E said she had talked to Resident 11 quite a few times as they had been in and out of the facility, but this was the first time they had a soft and bite sized diet. When asked if there was a reason Resident 11 was getting pureed food instead of soft and bite sized as ordered Staff E said it depended on the vegetable some could not be mashed. Regarding Resident 11 having a diet for soft and bite sized and receiving pureed foods, Staff E said a lot of times if the food for that day was too crunchy, they would have to give it to the residents pureed. On 03/25/2026 at 1:58 PM, Staff F, Registered Dietician, when asked if there was any reason Resident 11 would be served pureed food rather than their ordered diet of soft and bite sized, said they did not know. Staff F said pureed food was a downgraded diet texture from soft/bite sized diet, and the two textures were different. Staff F said that Resident 11 was supposed to receive a soft and bite sized meal from the kitchen vs a pureed meal, but she was not sure if Resident 11 could tell the difference. When asked when Resident 11 had a diet order for soft and bite sized diet should they be receiving pureed food, Staff F said, no and if the resident could tell the difference between soft and bite sized and pureed, they should have received what was ordered. Staff F said Resident 11's food preferences should have been updated, it was last done on their previous admission on [DATE], and food preferences should have been obtained on admission. Reference WAC 388-97-1120 (2)(a), -1100(1), -1140 (6)

Based on interview and record review, the facility failed to implement a system that ensured a copy of a residents advanced directives (AD, written instruction for the provision of health care when the individual is incapacitated, such as a living will or durable power of attorney for health care) were requested/obtained upon admission and residents without ADs were provided written information about and informed of their right to formulate one, for 2 of 4 residents (Resident 11 & 8) reviewed for ADs. This failure placed residents at risk of not having their health care goals and treatment choices honored in the event they were incapacitated.Findings included . Resident 11Resident 11 was admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS, an assessment tool), dated 03/18/2026, showed the resident was cognitively intact. Review of the electronic health record (EHR) showed a document titled Advanced Directive was scanned into the miscellaneous section. Review of the document showed it was a Portable Order for Life-Sustaining Treatment (POLST) form, not an advanced directive for healthcare. A Care Conference note, dated 12/24/2025, showed under paperwork reviewed staff placed a checkmark next to Advance Directive. Further review showed staff failed to document whether Resident 11 had an AD for health care or not, or if Resident 11 was informed and provided written information about their right to formulate one.Resident 8Resident 8 was admitted to the facility on [DATE]. Review of the Significant Change MDS, dated [DATE], showed the resident was cognitively impaired. Review of the EHR showed a document titled Advanced Directive was scanned into the miscellaneous section. Review of the document showed it was a Portable Order for Life-Sustaining Treatment (POLST) form, not an advanced directive for healthcare. A Care Conference note, dated 12/08/2025 (greater than 10 months after admission), showed under paperwork reviewed staff placed a checkmark next to advanced directive. Further review of the Care Conference note showed staff documented Power of Attorney (POA) paperwork was discussed with the daughter who indicated her sister previously started the POA for healthcare process and may have the paperwork.Review of the EHR showed no documented attempts to contact the other daughter to determine if POA for healthcare paperwork had been completed and/or to request a copy of the document.On 03/23/2026 at 10:44 AM, Staff H, Social Services Director, said it appeared some staff were not aware of the difference between a POLST form and an AD for healthcare, noting that both above referenced residents had their POLST forms scanned into the EHR and labeled as ADs. Staff H also said when staff check that ADs were reviewed on the care conference form, their documentation should identify if the resident had one, if so, whether a copy was provided/requested, and if not, whether the resident was informed of their right to formulate one. Reference WAC 388-97-0300 (1)(b), (3) (a-c).

Based on interview and record review, the facility failed to designate a member of their inter-disciplinary team (IDT) who would be responsible for working with the hospice representatives to ensure effective coordination of care between the facility and hospice staff and to have documentation in residents' Electronic Health Records (EHR) that showed when hospice disciplines (e.g. registered nurse, chaplain, certified nursing assistant, massage therapist) participated with care and what care was provided for 1 of 1 sampled resident (Resident 3) reviewed for hospice services. These failures detracted from staffs' ability to effectively collaborate, communicate and coordinate care with the hospice provider and placed residents at risk for not receiving necessary care and services and/or unmet care needs. Findings included .Resident 3 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set, (MDS, an assessment tool), dated 02/23/2026, documented Resident 3 was severely cognitively impaired and was receiving hospice services. A [name of hospice provider] Home Coordinated Task Plan of Care, dated 01/13/2026, documented Resident 3 was to have a hospice nurse visit two times a week (Tuesdays and Fridays), a hospice aide visit two times a week (Tuesdays and Fridays), a social worker visit and Chaplin visit per resident preference and wound care each visit, all starting 12/26/2025. Resident 3's EHR documented no hospice nurse, hospice aide, social worker or Chaplin visit notes or updates. On 03/26/2026 at 8:38 AM, Staff N, Licensed Practical Nurse (LPN), was asked where the hospice binders were located. Staff N said hospice binders were located at the nurses' station based on what hall the resident resided on. Staff N looked for Hospice binder for Resident 3 but was unable to locate the binder at nurses' station across from Sunshine/dining room. When asked where they would find hospice information about a resident, Staff N said in the EHR. On 03/26/2026 at 8:46 AM, Staff D, Registered Nurse (RN), was asked to located Resident 3's hospice binder. Staff D said the binder would be located at the nurse's station by the dining room. When it was explained the hospice binder was not there, Staff D looked at main nurses' station and was unable to locate Resident 3's hospice binder. When asked if there was any other locations hospice information could be, Staff D said that one of the Resident Care Managers (RCM) may have the binder. Staff D said they did not know where to locate hospice information in the EHR. On 03/26/2026 at 8:50 AM, Staff B, Director of Nursing Services, Staff O, LPN, and Staff C, RN/RCM, were asked about Resident 3's hospice binder. All three staff said the hospice agency did not have binders. When asked where to find Resident 3's hospice information, including nurses' and aides' notes Staff B said they would get the information. On 03/26/2026 at 10:08 AM, Collateral Contact 3 (CC3), Hospice Aide, said they come to the facility twice a week to provide shower and care to Resident 3. CC3 said today Resident 3 had a rough morning, but were about to change the residents' sheets, did pericare, gave Resident 3 a quick bed bath and changed them. CC3 said whenever they complete any type of care, they document it on shower sheet and place it in the binder located at the nurse's station. CC3 was asked to show the binder located at the nurses' station. CC3 walked to nurses' station (across from Sunshine/dining room) and pulled the shower binder. CC3 showed the shower sheet dated 03/26/2026. The shower binder was reviewed for further documentation of Resident 3's previous hospice nurse and aide visits. No other documentation was found. CC3 said they had always placed the showers sheet in the binder but did not know what the facility does with the shower sheets. When asked about hospice nursing notes, CC3 said they did not know what the process was for nurses' notes. On 03/26/2026 at 11:08 AM, when asked about the updated hospice paperwork, Staff C, RN/RCM, stated I just got off the phone with the hospice agency. They are sending the paperwork. On 03/26/2026 at 11:57 AM, Staff B, DNS, confirmed the facility did not have the hospice documentation and Staff C had contacted the facility to obtain the updated information/documentation. When asked how staff would know about hospice changes for Resident 3, Staff B said the hospice staff would check in with the floor nurses and provide any necessary information when needed. When asked who was the facility's point of contact for the hospice agency (s), who should have requested this information, Staff B said no one was currently assigned, but it used to be Staff O, LPN. No associated WAC.

Based on observation, interview, and record review the facility failed to ensure potential restraints were assessed for safety, risks versus benefits associated with the device were discussed with the resident and/or representative and consent was obtained prior to device implementation for 1 of 2 residents (Resident 6) reviewed for physical restraints. This failure placed residents at risk for feelings of powerlessness, restrained or inhibited movement, physical injury, psychosocial harm and diminished quality of life. Findings included .Review of the facility's Physical Restraint and Enablers/Devices policy, updated January 2025, showed a restraint was defined as any manual method, physical or mechanical device, equipment or material attached or adjacent to the resident's body that meets all of the following: is attached to or adjacent to the resident's body; cannot be removed easily by the resident; restricts the resident's freedom of movement or normal access to his or her body. Prior to implementation of a physical or mechanical device a device evaluation would be completed and the risks and benefits of the restraint or enabler device would be discussed with the resident and/or the resident's representative and consent obtained. If the device was assessed to be a restraint the provider would be contacted to obtain an order for the specific device, and the reason and duration of use. If not considered a restraint a physician order was not required. Resident 6Resident 6 was admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS, an assessment tool), dated 02/09/2026, showed the resident was cognitively impaired, had a diagnosis of multiple sclerosis (MS, a chronic, often disabling autoimmune disease of the central nervous system where the immune system attacks the myelin sheath protecting nerve fibers ), required partial/moderate assistance to roll left and right in bed, and to move from lying to sitting on the edge of the bed. On 03/23/2026 at 9:29 AM, Resident 6 reported that recently, while she was out of her room, staff removed the mattress on her bed and replaced it with a new one without discussing it with her or obtaining her consent. Observation of Resident 6's mattress showed it was a perimeter mattress (a mattress with firm elevated foam bolsters around the edges that encourage centered positioning and designed to prevent falls). Resident 6 explained with the standard mattress, she was able to roll to the edge of the bed and reach items on the dresser that she needed. Resident 6 said since the perimeter mattress was placed, she could no longer reach those items and had to call staff whenever she wanted to grab an item or put one back. Resident 6 reported the perimeter mattress made her feel like she was stuck in a hole in the middle of the bed and insisted that it be removed. Review of the electronic health record showed facility staff did not complete a device evaluation, explain the risks and benefits of perimeter mattress use to the resident or obtain their consent for its use prior to implementation. On 03/26/2026 at 3:30 PM, Staff B, Director of Nursing Services, said facility staff should have completed a device evaluation to determine if it restrained Resident 6's movement, explained the risks and benefits of perimeter mattress use and obtained the resident's consent prior to implementation. When asked if there was documentation to show staff completed any of those Staff B stated, No. Reference WAC 388-97-0620(1).

Based on interview and record review, the facility failed to ensure residents were free from unnecessary medication related to excessive duration for 1 of 6 residents (Resident 19) reviewed for medications. This failure placed residents at risk of medication complications and a diminished quality of life.Findings included.Resident 19 was admitted to the facility on [DATE]. The admission Minimum Data Set assessment, dated 03/05/2026, showed Resident 19 was cognitively moderately impaired.Resident 19 had a current order for a lidocaine patch (topical numbing medication), ordered on 03/05/2026. Starting on 03/08/2026, the order was to remove the patch at 8:59 AM and to apply at 9:00 AM. The lidocaine patch was applied from 03/08/2026 to 03/21/2026 (13 total administrations of 24 hours of duration) with the patch applied and removed the following day before a new application. During an interview on 03/23/2026 at 2:36 PM, Resident 19 said that staff put their lidocaine patch on for 24 hours at a time, and would take it off and put one right back on. Resident 19 said that is not how it should be done. During an interview on 03/23/2026 at 10:28 AM, Staff D, Registered Nurse (RN), said lidocaine patches should only be on for about 12 hours at a time, and normally would not be worn for 24 hours at a time. During an interview on 03/26/2026 at 10:32 AM, Staff C, Resident Care Manager/ RN, said lidocaine patches should be worn for 12 hours and then off for 12 hours. Staff C said Resident 19's lidocaine order was transcribed incorrectly by nursing and should have been on in the morning and off in the evening per the provider's notes. During an interview on 03/27/2026 at 10:43 AM, Staff B, Director of Nursing Services, said the standard amount of time lidocaine patches should be worn continuously for was 12 hours, and acknowledged the provider's intent was for only 12 hours of use. Reference WAC 388-97-1060 (3)(k)(i)

Based on observation, interview, and record review, the facility failed to provide adequate staff supervision to ensure fall prevention interventions were adequate, effective, and/or implemented for residents assessed at high fall risk for 3 of 4 residents (Resident 1, 2 and 4) reviewed for falls. Resident 1, who had eight unwitnessed falls from their bed, experienced harm when two of the unwitnessed falls resulted in injury that required transportation to the hospital for treatment. Resident 1 sustained a fracture of the lumbar (lower back) spine during one of the falls and sustained facial fractures in a separate fall occurrence. These failures placed residents at risk for further falls, injury, and decreased quality of life. Findings include:Review of the facility policy, titled Fall Management and Neurological Check, updated 01/2025, showed .the LN [Licensed Nurse] updates care plans reflecting individualized intervention in an attempt to reduce or prevent falls.The resident care plan is reviewed quarterly and after a fall to determine effectiveness of current interventions.A new intervention is not required with each new fall, as not all falls require an intervention nor a change in intervention. A systematic review of current interventions is completed post fall and root cause is identified.Should a new intervention be implemented, previous interventions are reviewed for discontinuation to determine if they are ineffective.Resident 1Resident 1 was admitted to the facility on [DATE] with diagnoses including dementia (loss of memory, language and problem solving), seizures and atrial fibrillation (irregular and often rapid heart rhythm). The resident's Minimum Data Set (MDS) assessment, dated 10/09/2025, showed the resident had cognitive impairment, had verbal behaviors, used a wheelchair (w/c), required assistance for sit to lie positioning, chair to bed transfers and toilet transfers, was occasionally incontinent of bladder, always incontinent of bowel and had two or more falls since admission.Review of Resident 1's fall risk assessment, dated 01/21/2025, showed a score of 105. A score greater (>) than 45 indicates a high falls risk.Fall 1Review of a facility documentation for Resident 1's fall, dated 10/26/2025, showed the resident had an unwitnessed fall and sustained a bruise to the forehead. An intervention to place a fall mat was implemented.Fall 2Review of a facility documentation for Resident 1's fall, dated 11/27/2025, showed the resident had an unwitnessed fall without injury. An intervention for lab testing and a urinalysis was implemented.Fall 3Review of facility documentation for Resident 1's fall, dated 11/30/2025, showed the resident had an unwitnessed fall in their room and did not sustain an injury. The facility documented an intervention to monitor latent injuries. No intervention was implemented to prevent further falls.Review of a Computed Tomography (CT) (medical imaging technique) report, dated 12/03/2025, showed .Acute to subacute superior end plate fracture [broken bone] at the L2 [lower back] vertebral body.Review of a progress note, dated 12/03/2025 at 7:50 PM, showed the resident returned from the hospital and a CT scan showed a wedge compression fracture of the 2nd vertebrae.Review of a Nurse Practitioner note, dated 12/03/2025, showed the resident was found on the floor and had a fall on 11/30/2025 and .she reports severe back pain that is described as sharp, stabbing.Xray of lumbar [lower back] and thoracic [midsection] spine showed multilevel compression fx [fracture].Called 911 for transportation to ER for further imaging and acuity staging.Fall 4Review of Resident 1's progress note, dated 12/12/2025 at 02:29 AM, showed the resident had an unwitnessed fall .was bleeding from her right nostril and right side of her mouth. Crying.Resident stated.got out of bed to potty, but fell.C/o [complains of] headache and back pain.EMTs arrived at facility.Resident was transported by ambulance to.hospital.Review of Resident 1's hospital emergency department note, dated 12/12/2025, showed [Resident] presents to Emergency Department with a fall and facial injury today.c/o headache and has swelling to right periorbital [area around the eye] region and right cheek.Fall was unwitnessed.Review of Resident 1's hospital documentation, dated 12/12/2025, showed a CT with acute maxillofacial (upper jaw and face) fractures involving the right orbital lateral wall and floor (part of the eye socket), the right maxillary sinus anterior (cheek area) and lateral walls (nasal area). Findings included subcutaneous edema (swelling) and hematoma (localized swelling of blood that is caused by a vessel rupture) at right side of face.Review of Resident 1's care plan, revised 12/12/2025, showed an intervention for a fall mat to the right side of the bed was implemented.Fall 5Review of facility documentation for Resident 1's fall, dated 12/12/2025 at 3:00 PM (2nd fall on 12/12/2025), showed Resident 1 had an unwitnessed fall in their room. Resident 1 struck their face and had blood in their nostrils. An intervention for a pharmacy review and a bedside commode was implemented.Fall 6Review of a progress note for Resident 1, dated 12/25/2025 at 9:30 AM, showed the resident had an unwitnessed fall in their room without injury.Education given to resident of importance to wait for assistance for safety.verbalized understanding.assisted to recliner in room, with call light. (Resident with cognitive impairment).Review of Resident 1's care plan, revised 12/26/2025, showed no new intervention implemented to supervise the resident.Fall 7Review of facility documentation for Resident 1's fall, dated 12/26/2025, showed the resident had an unwitnessed fall in their room and sustained a bruise to the left knee.Review of Resident 1's care plan ,revised 12/29/2025, showed they would add a soft touch call light for easier use.Fall 8Review of facility documentation for Resident 1's fall, dated 01/06/2026, showed the resident had an unwitnessed fall in their room. The resident sustained a laceration to the right eyebrow and was transferred to the hospital and returned to the facility. The facility changed the resident's room to increase supervision on 01/06/2026.Review of Resident 1's provider note, dated 01/07/2026, showed .The patient was seen for a re-admission after having a fall and hitting her right side of her face and requiring CT scans, and sutures above right eye.Observation of Resident 1 on 01/14/2026 at 2:00 PM, showed the resident resting in bed with a regular call bell in the resident's hand.Observation of Resident 1 on 01/15/2026 at 12:25 PM, with Staff C, Licensed Practical Nurse, showed the resident seated in a w/c in their room with a regular call bell in the resident's hand. Staff C acknowledged the resident did not have a soft call light as indicated on the care plan.Resident 2Resident 2 was admitted to the facility on [DATE] with diagnoses including prostate cancer with metastasis, diabetes and bipolar disorder. The resident's MDS assessment, dated 11/27/2025, showed the resident had cognitive impairment, had no behaviors, used a w/c, required staff assistance for sit to lie positioning, chair to bed transfers, was frequently incontinent of bladder and bowel, and had two or more falls since admission.Review of facility documentation showed Resident 2 had 11 falls without injury from 11/22/2025 - 01/14/2026.Review of a falls risk assessment, dated 11/21/2025, showed a score of 65. Score greater than 45 indicates resident is at high risk for falls.Review of facility documentation for Resident 2's fall, dated 11/25/2025, showed the resident had an unwitnessed fall. The intervention implemented was to monitor for latent injuries.Review of facility documentation for Resident 2's fall, dated 11/28/2025 at 12:30 PM, showed the resident had an unwitnessed fall outside the dining room. The resident was placed outside the dining room after eating the lunch meal by staff. The intervention implemented was to provide training to the resident to stay in the dining room. (Resident with severe cognitive impairment)Review of facility documentation for Resident 2's fall, dated 11/28/2025 at 9:20 PM, showed the resident had an unwitnessed fall from his bed. No intervention was implemented to prevent further falls.Review of facility documentation for Resident 2's fall, dated 12/19/2025, showed the resident had an unwitnessed fall near the nursing station. During an interview on 01/14/2026 at 2:30 PM, Staff B, Director of Nursing Services and Registered Nurse said the intervention had been to place the resident on 1:1 supervision with a staff member.Review of facility documentation for Resident 2's fall, dated 12/20/2025 at 3:50 AM, showed the resident was observed crawling out of bed by a staff member. (Resident was on 1:1 staff supervision)During an interview on 01/14/2026 at 2:30 PM, the DNS acknowledged Resident 2 had 12 falls from 11/22/2025 - 1/14/2026 and was placed on 1:1 staff supervision from 12/19/2025 - 01/01/2026. The DNS acknowledged Resident 2 had cognitive impairment and educating the resident was not an appropriate intervention to prevent further falls.Resident 4Resident 4 was admitted to the facility on [DATE] with diagnoses including hemiplegia (paralysis affecting one side of the body), hemiparesis (weakness on one side of the body), epilepsy and vascular dementia (decline in thinking skills caused by damaged blood vessels in the brain). The resident's quarterly MDS assessment, dated 12/09/2025, showed the resident had cognitive impairment, had no behaviors, used a w/c and walker, required staff assistance for sit to lie positioning, chair to bed transfers, was frequently incontinent of bladder and bowel, and had two or more falls since admission.Review of facility documentation showed Resident 4 had five falls without injury from 10/30/2025 - 01/14/2026.Review of a falls risk assessment, dated 09/15/2025, showed a score of 55. Score greater than 45 indicates resident is at high risk for falls.Review of facility documentation for Resident 4's fall, dated 12/30/2025, showed the resident had an unwitnessed fall in the resident's room. An intervention of a bedside commode was implemented.Review of facility documentation for Resident 4's fall, dated 01/12/2026, showed the resident had an unwitnessed fall in the resident's room. No intervention was implemented after the fall to prevent further falls. Documentation showed a fall mat was placed at the bedside.Review of facility documentation for Resident 4's fall, dated 01/14/2026, showed the resident had an unwitnessed fall in the resident's room. No intervention was implemented after the fall to prevent further falls. Documentation showed .already on fall monitoring.Observation on 01/16/2026 at 1:00 PM, with Staff D, Licensed Practical Nurse showed Resident 4 resting in bed in his room. There was no fall mat or bedside commode in the resident's room. Staff D acknowledged the fall mat and bedside commode were not in Resident 4's room.During an interview with Staff A, Administrator and Staff B, DNS acknowledged Resident 1 had a fall on 11/27/2025 and 12/12/2025 and sustained a lumbar and facial fractures and interventions were not implemented to prevent further falls. They stated the facility policy indicated that every fall does not require a new intervention but does need to be reviewed. They acknowledged new fall interventions were not implemented after falls for Residents 1, 2 and 3.Reference WAC 388-97-1060 (3)(g)

Based on interview and record review, the facility failed to ensure sufficient staffing levels were met to follow the plan of care and services for 5 of 10 residents (1, 2, 4, 5 & 6) reviewed for staffing. This failure placed residents at risk for unmet physical, mental and psychosocial needs, a decline in health status and a diminished quality of life.Findings included.Resident interviews, observations & record review1) Resident 1 was admitted to the facility on [DATE] with diagnoses of dementia, post-traumatic stress syndrome (a mental health condition that's caused by an extremely stressful or terrifying event), and diabetes mellitus. The quarterly minimum data set (MDS), an assessment tool, dated 06/30/2025, documented Resident 1 had moderate cognitive impairment and required supervision with bathing.Record review of the care plan, dated 02/26/2025, showed Resident 1 will have a shower on Sunday and Wednesday.On 08/18/2025 at 2:08 pm, Resident 1 said the facility had staffing problems. Resident 1 said medications were late, there were long waits to answer the call light, and staff rush when assisting the resident. The resident said staff did not spend time with the residents. Resident 1 said showers did not always happen or did not happen on their preferred day. Resident 1 said they preferred to shower on Sundays, so they were clean for church. The resident said it was annoying when they did not get their shower when they preferred.Record Review of bathing documentation, dated 08/13/20025 to 09/12/2025, showed Resident 1 received 3 of 8 bathing opportunities. One shower was not given on the planned day.2) Resident 2 was admitted to the facility on [DATE] with diagnoses of asthma, and chronic pain syndrome. The quarterly MDS, dated [DATE], documented Resident 2 had no cognitive impairment and was dependent on staff with many activities of daily living (ADLs).Record review of the care plan, dated 10/08/2024, showed Resident 2 will have baths on Tuesdays and Saturdays.On 09/18/2025, at 12:22 pm, Resident 2 said the facility had staffing issues. Resident 2 said baths were not consistently getting done. The resident said the facility pulled the bath aides (BA) to the floor when they must cover a shift or someone calls in sick. Then, it was the nursing assistants (NA) responsibility to get the baths while being responsible for all their other duties. So, baths did not always happen. The facility would make temporary fixes to the staffing issues, but nothing would stick and eventually, it goes back to how it was.Record review of bathing documentation, dated 08/13/20025 to 09/12/2025, showed Resident 2 received 3 of 8 bathing opportunities.3) Resident 3 was admitted to the facility on [DATE] with diagnoses of major depressive syndrome and spinal stenosis (narrowing of the spine, which puts pressure on the spinal cord and nerves causing pain). The quarterly MDS, dated [DATE], documented Resident 3 had moderate cognitive impairment and required substantial assistance with ADLs.On 09/12/2025 at 2:19 pm, Resident 3 said there was a problem with staffing. Resident 3 said there were not enough staff to answer the call light promptly. Often, the resident waited for 20 minutes or longer to have the call light answered. Resident 3 said they were often waiting to use the bathroom and the resident needed two people to assist them. Resident 3 said weekends and lunch time were the worst times.4) Resident 4 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (lung and airway diseases that restrict your breathing) and a cerebral vascular accident (a stroke). The admission MDS, dated [DATE], documented Resident 4 had no cognitive impairment and required moderate assistance with ADLs.Record review of the care plan, dated 05/23/2025, showed Resident 4 required an assist of one staff, using a slide board, to use the bath.On 07/22/2025 2:04 pm, Resident 4 appeared disheveled and in a gown. Resident 4 had many sores and scabs visible along their arms and legs.Record review of bathing documentation, dated 08/13/20025 to 09/12/2025, showed Resident 4 would receive showers every Monday, Thursday, and Saturday at noon. Resident 4 received 8 of 12 bathing opportunities.5) Resident 5 was admitted to the facility on [DATE] with diagnoses of dementia and major depressive disorder. The quarterly MDS, dated [DATE], documented Resident 5 had severe cognitive impairment and required moderate assistance with ADLs.Record review of the care plan, dated 04/25/2025, documented Resident 5 would receive showers every Tuesday and Friday.Record review of bathing documentation, dated 08/13/20025 to 09/12/2025, showed Resident 5 received 4 of 8 bathing opportunities.6) Resident 6 was admitted to the facility on [DATE] with diagnoses of left tibia fracture (lower leg break) and pressure ulcer (injuries to the skin and the tissue below the skin that are due to pressure on the skin for a long time) of the right foot. The quarterly MDS, dated [DATE], documented Resident 6 had severe cognitive impairment and was dependent on staff with bathing.Record review of the care plan, dated 05/23/2025, documented Resident 6 will receive a bed bath every Sunday and Wednesday.On 09/18/2025 at 1:15 pm, Resident 6 said staff gave them a bath recently but they had gone awhile without one. Resident 6 said it felt so good to get cleaned up.Record review of bathing documentation, dated 08/18/20025 to 09/17/2025, showed Resident 5 had five refusals of baths and 1 of 8 bathing opportunities. The medical record did not show staff reattempting to give the resident a bath after the refusal.Nursing schedulesA review of the nursing schedules from 06/24/2025 to 07/06/2025 showed:On 06/24/2025 a BA was removed from the shift.On 06/26/2025 a BA was removed from the shift.On 07/02/2025 a BA was removed from the am and pm shifts.On 07/06/2025 a BA was removed from the shift. A review of the schedule from 08/31/2025 to 09/11/2025 showed:On 09/02/2025 a BA was removed from the shift.On 09/03/2025 a BA was removed from the am and pm shifts.On 09/04/2025 a BA was removed from the shift.On 09/06/2025 a BA was removed from the shift.On 09/07/2025 a BA was removed from the shift.On 09/08/2025 a BA was removed from the shift.On 09/09/2025 a BA was removed from the shift.On 09/011/2025 a BA was removed from the am and pm shifts.Resident CouncilReview of Resident Council Minutes, dated 04/16/2025, showed concerns with short staffing and call light response. Residents never know who's working. Medications were expiring without notifying residents who were required to order more.Review of Resident Council Minutes, dated 05/1642025, showed concerns with inconsistency in the amount of nursing assistants scheduled. One day we will have 8 aides and the next 3. Residents report difficulty with agency staff.Review of Resident Council Minutes, dated 07/09/2025, showed nurses were let go and agency staff were filling in until there were replacements. More residents needed to move into the building to get more staffing.Review of Resident Council Minutes, dated 08/20/2025, showed concerns showers were not getting done on scheduled days. Low census of staff means no BA. A resident reported two missed showers.GrievancesReview of Grievance Form, dated 08/15/2025, showed during resident council, residents reported they were not getting showers, or the shower aide was unavailable on multiple occasions. The investigation/findings noted audits would be done daily. A list would be put out for nurses to follow daily. The schedule had been modified to reduce the workload of the staff.Review of Grievance Form, dated 09/05/2025, showed Resident 10 had not received a shower despite being told they would. The resident appeared in poor condition and has had visitors report the same concerns. The investigation/findings noted Resident 10 did not receive a shower as scheduled. Documentation of of showers was found to be inconsistent. Staff were not performing showers or making up showers despite daily audit or make up list. Schedule was adjusted and resident placed on makeup shower list.Staff interviewsOn 09/12/2025 at 1:19 pm, Staff H, NA, said some days were harder than others related to staffing. Showers were the biggest issue especially when there was no BA. If staff called out, the BA was the first to be pulled. Then, the staff on the floor must cover the showers. Residents who take long showers or who were hard to get done were the most difficult to complete. Staff H stated there was not much that happened when they went to leadership with their concerns.On 09/12/2025 at 2:29 pm, Staff G, NA, said it could be a challenge to get showers done when they were short staffed.On 09/12/2025 at 2:33 pm, Staff C, licensed practical nurse (LPN), said staffing was an issue with the facility. Sometimes the nurses had up to 30 residents to care for. They get late with passing medication. Showers do not get done. Staff C says they feel bad for the residents as it's their basic human need and right; Staff D, LPN, said there were 27 showers to do this day. There were, at times, not enough NAs and all that could be done was providing for basic needs. Staff feel overwhelmed and stressed.On 09/12/2025 at 2:52 pm, Staff F, BA and NA, said they had 4 to 8 baths scheduled unless they were removed from working on the floor. This happens pretty often. The amounts of baths [NAME] when the BA is pulled to the floor. They can have 20 or more showers to do in a day in this situation. This is a challenge to get done. Sometime baths or refusals are not documented due to time constraints. Voicing concerns to leadership regarding staffing was ineffective.On 09/12/2025 at 3:38 pm, Staff E, registered nurse (RN), said she was an agency nurse and was new to the facility. Staff E said the facility had residents who were high acuity and have a lot of needs. The facility was experiencing a COVID outbreak, has staffing issues, and printers and fax machines were not working, making staffing even more challenging. Due to all the issues, they could not get things like daily orders or treatments done resulting in a delay in care. Staff E said there was not enough support.On 09/18/2025 at 2:15 pm, Staff B, RN and Director of Nursing Services, said they started having a BA to help address missed showers. When people called off, they would pull the BA to the floor. They do have agency staff they use to try and cover shifts. Staff B acknowledged concerns have been reported in both Resident Council and through the grievances process related to showers and staffing concerns. Staff B said showers are an issue. Staff B said the facility has residents who have complex needs. Staff B said they had been trying to do things like consolidating medications to reduce the medication pass.On 09/18/2025 at 2:52 pm, Staff A, Administrator, acknowledged they had issues with bathing and staffing. Staff A said they have done many things such as job fairs and bonuses to increase staffing levels. They use agency staff but, at times, when they are scheduled to work they do not show up. Leadership is expected, and does, cover shifts and help on the floor.Reference: (WAC) 388-97-1080 (1)

Based on interview and record review, the facility failed to ensure physician ordered laboratory values were obtained for 1 of 3 residents (Resident 14) who was declining, found unresponsive and had to be hospitalized , and failed to ensure the bowel protocol was followed for 2 of 7 residents (Residents 13 & 49) reviewed for bowel protocol. Resident 14 experienced actual harm when the facility failed to follow physician orders, failed to provide adequate hydration and failed to consistently monitor and document resident's change in condition and the resident developed altered mental status and sepsis (infection of the blood) and urinary tract infection (infection in the urine) and required intensive care level hospitalization . This failure placed residents at risk for unidentified and untreated sepsis, dehydration, constipation, decline, and a diminished quality of life. Findings included . <hospitalization > Resident 14 was admitted to the facility on [DATE] with diagnoses including epilepsy (seizure disorder) and surgical aftercare following surgery on the genitourinary system. The Significant Change, Minimum Data Set Assessment (MDS, an assessment tool), dated 01/07/2025, showed Resident 14 was severely cognitively impaired and dependent on staff for cares. Review of the Electronic Health Record (EHR) showed Resident 14 was hospitalized from 10/12/2024 to 10/18/2024 to have bilateral urethral stents placed (a thin tube was placed in each ureter to keep them open, to allow movement of urine from the kidneys to the bladder). Resident 14 was re-hospitalized from 10/19/2024 to 10/29/2024 for acute encephalopathy (when the brain does not function as well), obstructive hydronephrosis (issue with urine draining out of kidney) status post bilateral urethral stent, complicated urinary tract infection, acute kidney injury, and possible recurrent seizure. A progress note, dated 11/09/2024, showed Resident 14 was diagnosed with hemorrhagic cystitis (inflammation of the bladder lining that causes bleeding and pain with urination). Resident 14 was placed on a 10-day course of an antibiotic. During the antibiotic period of 10 days, on 11/14/2024 a progress note reported Resident 14 required intravenous (IV) fluids for electrolyte imbalance. Review of the November 2024 MAR showed that Resident 14 on 11/12/2024 had received IV fluids for dehydration (dehydration can cause elevated sodium levels). Review of the 11/12/2025 laboratory results from 8:59 AM collection time, showed Resident 14 had an elevated sodium level of 149 (normal range listed as 135-146). Review of the 11/14/2025 laboratory result from 8:50 AM collection time, showed Resident 14 had an elevated sodium level of 154 (normal range listed as 135-146). Review of the EHR showed Resident 14 completed their 10-day course of an antibiotic on 11/19/2024. After the antibiotic had completed on 11/20/2024, a progress note showed Resident 14 was placed on an 1800 milliliter (ml) fluid restriction per day and a no added salt diet. Review of the Medication Administration Record (MAR) by the licensed nurses (LNs) and the Point of Care Fluids by the Certified Nursing Assistants (CNAs) showed the following amount of fluid consumed recorded: 11/20/2024: order started at 2:00 PM, 1,330 ml (milliliters)(400 ml recorded by LN, 93 ml by CNA) 11/21/2024: 1,480 ml (1000 ml by LN, 480 ml by CNA) 11/22/2024: 1,060 ml (700 ml by LN, 360 ml by CNA) 11/23/2024: 1,600 ml (1,000 ml by LN, 600 ml by CNA) 11/24/2024: 540 ml (300 ml by LN, 240 ml by CNA) 11/25/2024: 640 ml (240 ml by LN, 400 ml by CNA) 11/26/2024: 780 (560 ml by LN, 220 ml by CNA) 11/27/2024: 1,340 ml (980 ml by LN, 360 ml by CNA) 11/28/2024: 1,960 ml (1,000 ml by LN, 960 ml by CNA) 11/29/2024: 944 ml (200 ml by LN, 744 ml by CNA) 11/30/2024: 960 ml (600 ml by LN, 360 ml by CNA) Review of the 11/05/2024 nutritional evaluation form, completed by the Registered Dietician, documented Resident 14's hydration needs as 1500 ml of fluid. The documented fluid amounts during 11/21/2024-11/30/2024 showed that Resident 14 was not meeting their daily hydration needs for 8 of 10 days reviewed. Review of a 11/21/2024 progress note showed Resident 14 had a decline in condition and needed increased assistance. Review of a 11/22/2024 progress note showed the provider had requested a nephrology (doctor whom specializes in kidney disease) referral, a urinalysis (UA, analyzes the urine) with culture and sensitivity (if an organism was present would show which one, and allow better selection of what antibiotic to use), a complete blood count (CBC, can detect infection or low red blood cells or platelets), and an abdominal x-ray. The progress note said the resident was on alert for decline and labs. A review of the 11/23/2024 progress note showed Resident 14 continued to have decline and weakness, with hematuria (blood in the urine). EHR showed the next progress note was seven days later on 12/01/2024 which documented Resident 14 was found unresponsive and unable to arouse with the following abnormal vital signs: Temperature 102.5 (fever is anything over 100.4) Heart rate 132 (60-100 generally considered normal for an adult) Blood pressure 89/59 (normal adult blood pressure typically considered 120/80) Resident 14 was then sent to the hospital. Review of the hospital update documentation showed Resident 14 arrived to the hospital with altered mental status, a fever, was hypotensive (low blood pressure) and required fluid boluses and IV Levophed (vasopressor used for treating severely low blood pressure) for pressure support. Review of the hospital discharge summary, dated showed Resident 14 was diagnosed with a urinary tract infection and sepsis. Review of the EHR showed neither the UA or the CBC (from the 11/22/2024 progress note) were obtained/completed. One administration note for the UA and CBC showed Unable to obtain at this time will try again on 11/23/2024. No additional documentation was found. On 03/17/2025 a request was made for the facility policy on vitals. On 03/17/2025 at 10:32 AM, Staff B, Director of Nursing Services (DNS) documented via email that there was no vital signs policy. During an interview on 03/17/2025 at 12:47 PM, Staff D, Resident Care Manager (RCM), when asked what services were provided by the facility to prevent the hospitalization on [DATE], said it looked like Resident 14 was placed on a fluid restriction and an abdominal x-ray was obtained. Staff D said they looked in the chart and called the hospital but there was no record of the UA or the CBC being obtained, and their expectation was it would have been drawn and collected, and acknowledged neither was done. When asked about the alert charting for decline and how long the resident should have charting done for, Staff D said they did not know and they did not have a policy specific to this area of concern. Regarding Resident 14, Staff D said they could see a lot of charting was not completed while they were on alert and they continued to decline, and their expectation was for staff to have charted on them every shift. When asked if there was documentation of Resident 14's clinical status during that time, Staff D said no. Staff D confirmed there were no vitals taken for Resident 14 between 11/23/2024 and 12/01/2024. During an interview on 03/18/2025 at 2:24 PM, Staff B, Director of Nursing Services (DNS), when asked how the facility prevented the hospitalization , stated they did not prevent it when they did not get the laboratory tests, and they could have potentially prevented the hospitalization by getting the UA. <Bowel Protocol> Review of the facility's policy titled, Bowel Protocol, dated with a revision date of 03/2018, showed that if the resident did not have a bowel movement for three days, then the nurse was to administer the physician ordered bowel program. The bowel protocol showed the residents were supposed to receive the following medications to stimulate a bowel movement: a) Milk of Magnesia, if no bowel movement for three days, administer on day four. b) If no result from Milk of Magnesia, then Bisacodyl suppository (small bullet sized medication inserted via rectum) on the next shift during waking hours c) If no result from suppository, then an Enema (liquid inserted via rectum) on the next shift, during waking hours If after the enema there was no bowel movement, then the facility was to notify the provider. <Resident 13> Resident 13 was admitted to the facility on [DATE]. Review of the Significant Change MDS, dated [DATE], showed Resident 13 was severely cognitively impaired and was dependent on staff for cares. Review of the past 30-day bowel monitor showed Resident 13 did not have a bowel movement from 02/09/2025 to 02/18/2025 (10 days). Review of the MAR showed Resident 13 had as needed bowel medications ordered, the same as from the bowel protocol and in the same order. The February 2025 MAR showed a fleet enema was given on 02/14/2025 but did not indicate whether or not there were results Review of the nursing progress notes, from 02/10/2025 to 02/18/2025, showed no alert charting for Resident 13 regarding and the intervention of the enema, lack of bowel movement, or alert charting. Review of the EHR showed no explanation of why the fleet enema was given out of order from the bowel protocol/instructions in the provider order. During an interview on 03/17/2025 at 12:35 PM, Staff D, RCM, when asked about this period without a bowel movement, looked in the EHR and said they were given an enema on 02/14/2025 and this did not follow the orders or the bowel protocol. Staff D was unable to find any documentation of refusals of less invasive routes per the bowel protocol for this time period. Staff D said their expectation once a resident was on the no bowel movement list, that staff would place on alert charting and documenting about the lack of bowel movement and treatments. During an interview on 03/17/2025 at 4:44 PM, Staff B, DNS, said their expectation for the bowel protocol was that on day four it would be started. Staff B said Resident 13's records did not meet expectations, as staff needed to follow physician orders. 37044 <Resident 49> Resident 49 admitted to the facility on [DATE] with the following bowel care orders: a) Milk of Magnesia, if no bowel movement for three days, administer on day four. b) If no result from Milk of Magnesia, then Bisacodyl suppository on the next shift during waking hours c) If no result from suppository, then an Enema on the next shift, during waking hours If after the enema there was no bowel movement, then the facility was to notify the provider. The February 2025 bowel record showed Resident 49 had no bowel movement from 02/16/2025 - 02/19/2025 (four days). Review of the February 2025 MAR showed Resident 49 was not administered Milk of Magnesia on the fourth day without a bowel movement as ordered. On 03/18/2025 at 8:33 AM, Staff B, DNS, said the nurse should have administered Resident 49's Milk of Magnesia on 02/19/2025 as ordered, but failed to do so. Reference WAC 388-97-1060 (1)

Based on observation, interview and record review, the facility failed to ensure resident meal intake was accurately recorded, nutritional supplements were provided as ordered, weights were timely obtained and evaluated, significant weight loss was identified, and nutritional interventions were implemented and evaluated for effectiveness for 3 of 5 sampled residents (Residents 14, 49, & 29) reviewed for nutrition. Resident 14 experienced harm when they had a severe weight loss of 14.89% over six months. Resident 49 experienced harm when they had a 11.09% weight loss in 34 days before it was identified by staff. This failure placed all residents at risk of malnourishment, weakness, unidentified care needs, and a diminished quality of life. Findings included . Review of the facility's policy, titled Nutrition Hydration Skin Committee, updated 11/2012, showed the facility held the committee for evaluating residents with declining nutrition, hydration, and skin status. Residents to be reviewed could include residents with significant decline or improvement in condition, trending or significant weight change, changes in meal intake, requiring thickened liquids, having a decline in diet food texture, or due to intake and output. The committee was to meet routinely to address identified issues and track residents being monitored. For residents being reviewed, the committee was to review and revise the care plan with measurable goals and appropriate interventions. For any medically unavoidable weight loss or gain, the committee was to place a referral to the physician for request of documentation on unavoidable weight change. Review of the facility's policy, titled Weights, last revised 07/20/2024, showed new admission residents were to have weekly weights for one month. If stable, then the resident could have monthly weights. The policy provided guidelines for residents that may need weekly weights, with wording saying it was not all inclusive, for residents that had the following: a) Food intake declined and persisted b) Slow trending of weight loss or gain c) Significant weight loss or gain d) Significant change in condition If a resident had a 5-pound variance between weights, a re-weigh would be required. If the significant weight loss was still present after the re-weigh, the nurse was to document in the medical record/progress note, revise the care plan, refer to the Nutrition Hydration Committee, and to notify the provider and the resident/resident representative. Progress notes by the nurse were to include any responses by the provider. Review of the facility's policy, titled Preparation and Serving of Nutritionally Enhanced Meals (NEM), updated 11/2018, showed the facility was to add NEM designation to the resident's tray ticket, each tray would have 8 ounces (oz) of whole milk, and dietary would provide enriched cereal topping to the breakfast and extra margarine to breads, potatoes, pasta, rice, vegetables or other appropriate foods. Resident meal trays could also have extra high calorie and high protein foods to further enhance nutrition, such as yogurt, ice cream, pudding, extra egg at breakfast, and/or peanut butter. <Resident 14> Resident 14 was admitted to the facility on [DATE] and had diagnoses of weakness, major depressive disorder (depression), and dehydration. The Significant Change Minimum Data Set Assessment (MDS/an assessment tool), dated 01/07/2025, showed Resident 14 was severely cognitively impaired, dependent on staff for cares, and during the assessment period had required supervision or touch assistance for eating. Review of the weights showed: 1 month: On 02/02/2025, the resident weighed 110.8 lbs. On 03/02/2025, the resident weighed 104 pounds which is a -6.14 % Loss. 3 months: On 12/07/2024, the resident weighed 119.6 lbs. On 03/02/2025, the resident weighed 104 pounds which is a -13.04 % Loss. 6 months: On 09/01/2024, the resident weighed 122.2 lbs. On 03/02/2025, the resident weighed 104 pounds which is a -14.89 % Loss. Review of progress notes showed: On 08/12/2024, Resident 14 had a 5.4% weight loss in 30 days, that the resident was declining to eat in the dining room, and there were no new orders. On 10/30/2024, Resident 14 was reviewed by the nutrition committee related to the weight loss of 5.10% over 28 days, it was acknowledged that the resident may have lost weight due to hospitalization and illness, and a house supplement was added one time daily (it was discontinued on 12/07/2024). Between 12/07/2024 and 03/10/2025 Resident 14 was not on a calorie dense supplement/house supplement. On 03/10/2025, Resident 14 was noted to have 5.8% weight loss over 30 days. Interventions at that time included encouraging to go to dining room, offering snacks, and adding back/administering Cal dense (nutritional supplement) 60 milliliters with medication pass two times a day. On 01/06/2025, Resident 14 was reviewed by the nutrition committee for weight loss of 10.7% in less than two months. It was identified Resident 14 had poor oral intake and would at times refuse food/fluids/medications. On 01/13/2025, Resident 14 was noted to have a 15.8% weight loss in the previous three months. Provider was notified and NEM was added to diet on 01/06/2025. During an observation on 03/12/2025 at 9:42 AM, Resident 14 was seen with two drinks in front of them, a water and a thin dark brown drink, presumably coffee. No milk was seen (the facilities identified NEM intervention) At 12:56 PM, Resident 14 was seen eating lunch, without milk (the facilities identified NEM intervention) On 03/13/2025 at 12:58 PM, Resident 14 was seen eating lunch, without milk (the facilities identified NEM intervention). Resident 14's tray slip said soft bite sized regular, NEM, thin liquids. The slip had standing orders of 8 oz juice and 8 oz of beverage of choice. Dislikes did not include milk. Resident 14 was observed to have the head of their bed at 30 degrees, was leaning over their left side, and was seen to drop a small amount of food on themselves and their bed. Staff N, Certified Nursing Assistant (CNA) entered and exited Resident 14's room, said it was not good for Resident 14 to have been eating in that position but did not provide assistance. Resident 14 did not eat all of their meal. On 03/14/2025 at 8:34 AM, Resident 14 was seen with a neck pillow around their neck, ate from a red bowl, did not eat anything off their plate, and did not have milk (the facilities identified NEM intervention) with their breakfast. At 8:40 AM, Resident 14 closed their eyes and stopped attempting to eat. At 9:25 AM, a CNA entered the room, attempted to wake Resident 14 up, said they were going to take their tray, and left the cup with juice. On 03/17/2025 at 1:15 PM, Resident 14 was seen with their tray slip saying NEM, with it listing juice and beverage of choice. No milk was observed (the facilities identified NEM intervention). Resident 14 did not eat their chopped-up meat or side of beans. The record showed that Resident 14 did not have weekly weights obtained; despite having the following guidelines identified in the facilities policy as indicators a resident may need weekly weights: a) Food intake declined and persisted b) Trend of weight loss c) Significant weight loss d) Significant change in condition During a phone interview on 03/13/2025 at 2:33 PM, Staff G, Registered Dietician (RD), said Resident 14 had a significant weight loss over 30 days. Staff G said their expectation was for staff to follow the diet order with NEM, to provide Cal Dense two times a day, and that they would recommend weekly weights to catch weight loss sooner than a month away. When asked about the intervention of snacks between meals, Staff G said this was a standard for every person in the building, and under the tab to document snacks (excluding PM snack) there was no documentation. During an interview on 03/14/2025 at 9:30 AM, Staff H, CNA, said they had been working with Resident 14 since October, and that Resident 14 was not great at eating their meals, and did not eat a whole lot. Staff H, when asked about Resident 14's breakfast, said they had only eaten 0-25% of their meal, and they were unsure if Resident 14 needed an alternative as they tried to wake them, but they were hard to wake up. When asked what helps Resident 14 eat more, Staff H said sitting them up, making sure they were awake helps. When asked when Resident 14 was offered snacks, Staff H responded at around 8:00 PM. Staff H reported Resident 14 liked the chocolate flavor. At 10:59 AM, Staff I, Licensed Practical Nurse (LPN), said Resident 14 hated the Calorie Dense, and it was a vanilla flavor. Staff I went into the room to see if Resident 14 would take the Calorie Dense, Resident 14 was heard saying It's crap. Staff I asked if Resident 14 liked vanilla and was told no. Resident 14 reported they liked chocolate. At 11:16 AM, when asked about what triggered the significant change MDS assessment, Staff D, Resident Care Manager (RCM), said Resident 14 had gone to the hospital, had urinary stent (thin tube to allow flow of urine) placements, blood in the urine, significant decline requiring two person assistance, slumping over during meals, refusing to go to the dining room most of the time, and a decrease in activities of daily living. When asked how the facility was reassessing interventions for effectiveness, Staff D said, resident weights. Staff D said Resident 14 should have had weekly weights and did not. When asked about the house supplement being discontinued on 12/07/2024, if there was an intervention in place at that time, Staff D said no. Regarding the NEM diet added on 01/06/2025, when asked how the facility assessed it was effective, Staff D said if there was continued weight loss, it had failed, and they needed to come up with something else. Staff D said anytime Resident 14 came up for significant weight loss, it should have been reviewed for effectiveness. Staff D said Resident 14 had not been willing to eat a whole meal but did drink fluids well with a two-handed cup. Staff D checked with dining on if milk was on Resident 14's dislikes, and said it was not on their dislikes, and they should receive whole milk due to the NEM diet. When asked about the slip mentioning NEM but not anything about whole milk, Staff D said the CNAs usually encourage milk but the resident had the right to refuse. When asked if the facility had attempted an alternative to white milk (the resident stated they liked chocolate milk), Staff D said, not to my knowledge. Staff D said the CNAs provided Resident 14 with what they liked to drink if they would not answer. When asked if there had been a discussion of an appetite stimulant for Resident 14, Staff D said no. At 12:03 PM, when asked about NEM on the resident's tray slip, Staff J, CNA, said they did not know what it meant when the slip said NEM. When asked what they do for drinks, Staff J said they did not know and asked if that was protein shakes. At 12:08 PM, when asked about NEM, Staff H, CNA, said they were not sure what it meant. When asked about what they do for drinks, Staff H said they did not know. At 12:09 PM, Staff K, CNA, when asked about NEM, said they did not know what it was and did not know what it meant for drinks. At 12:18 PM, Staff M, Registered Nurse (RN), said they had not received training on what NEM diets were or if there were specific beverages the resident should or should not receive. At 1:16 PM, Staff L, Advance Registered Nurse Practitioner, said they had been working with Resident 14 for six months. When asked about the significant weight loss, Staff L said that most recently the facility had provided them with a fax communication of a certain percentage of weight loss and that they had added a supplement to the meal, with only the previous 30 days of weight loss discussed. After being told about the past one month, three months, and six months of weight loss numbers, Staff L said they were not aware of the prolonged weight loss. Staff L said they were not aware of any attempt to add an appetite stimulant, and they might need to look into implementing something to stimulate appetite. Staff L said their expectation was that the facility provided everything Resident 14 needed to maintain a healthy weight for life purposes, the diet promoted decreased skin breakdown, and the facility provided the nutrients needed for their diet. During an interview on 03/18/2025 at 2:04 PM, Staff B, Director of Nursing Services (DNS), said their expectation for residents with significant weight loss was that the nutrition hydration committee followed them, and the provider and registered dietician would be notified. Regarding significant weight loss, Staff B said weights should be done weekly times 4, and for Resident 14 they should have been changed back to weekly and were not. When asked about the role CNAs have with NEM diets, Staff B said the meal try slip should direct the aids to serve whole milk, which would allow them to participate in NEM without knowing what it was. When told about the observations of Resident 14 without whole milk and no mention of whole milk on the meal tray slips, Staff B said their expectation was that the meal tray slip would have said milk on it. When asked about snacks between meals and how the facility evaluated it for effectiveness, Staff B said the only documentation they could find was the bedtime snack, and Resident 14 was only receiving a bedtime snack since 11/05/2024. When asked how the facility was evaluating the effectiveness of the NEM diet added on 01/06/2025, Staff B said NEM was not happening as they were not giving the whole diet (not giving whole milk). 37044 <Resident 49> Resident 49 admitted to the facility on [DATE]. Review of the Admission MDS, dated [DATE], showed the resident had moderate cognitive impairment, diagnoses of non-Alzheimer's dementia and unspecified nausea and vomiting, required setup assistance with meals and had no known significant weight loss in the previous six months. A Nutrition/Hydration care plan, revised 02/17/2025, directed staff to encourage Resident 49 to eat 50% or more of their meal; if meal intake was 50% or less, to offer a substitute meal or supplement; and to provide diet as ordered. Hospital transfer orders, dated 02/04/2025, showed Resident 49 weighed 192 lbs., was on a regular, low sodium diet, and had an orders for Ensure Plus (a liquid nutritional supplement that provides concentrated calories and protein to help gain or maintain a weight for patients with malnutrition or otherwise at nutritional risk) two times a day. One carton was to be provided with breakfast and the other with dinner. Resident 49's weight record showed the following: 02/04/2025- 193 lbs. 02/09/2025- 189 lbs. 02/10/2025- 188 lbs.; - 5 lbs. in six days. A Nutrition Evaluation Form, dated 02/10/2025, documented Resident 49 weighed 188 lbs., was on a regular, no added salt diet, and was independent with meals after setup. Staff G, RD, identified the residents who took diuretic medication (medication to draw fluid from body) as having the potential to cause fluctuations in weight, but documented the resident had no edema at that time. Resident 49's average meal intake was estimated to be 80% of breakfast, and 75% of the lunch and dinner. Staff G, RD, concluded that Resident 49's overall nutrition status was stable and adequate. Review of the evaluation form showed Resident 49's 02/10/2025 weight of 188 lbs. was used as the resident's baseline weight. Under Additional Weight History staff documented not applicable. The facility's 02/04/2025 admission weight of 193 lbs., which was consistent with the hospitals 02/04/2025 discharge weight of 192, was not acknowledged nor was the 5 lbs. weight loss the resident in the six days since admission. There was no information provided to indicate if the facility had provided the supplement or whether the resident had been drinking it. Review of Resident 49's Electronic Health Record (EHR) and physicians' orders showed the Ensure Plus order had not been transcribed and/or implemented. A progress note, dated 02/11/2025, documented Resident 49 reported being nauseas and vomiting twice. Review of the February and March 2025 MARs revealed a 02/04/2025 order for Ondansetron (anti-nausea medication) and showed it had been requested and administered on the following dates: 02/11/2025 at 3:48 PM 02/12/2025 at 8:02 AM 02/18/2025 at 3:40 PM 02/19/2025 at 9:48 AM 02/22/2025 at 11:55 AM 02/26/2025 at 11:27 AM 03/07/2025 at 10:17 AM On 03/02/2025 at 11:02 AM, Resident 49's weight was 177.8 lbs. A reweigh was obtained at 2:02 PM, and was 178 lbs. This showed a significant weight loss of 7.8% in 28 days. Review of the EHR showed Resident 49 was not reviewed in the facility's 03/04/2025 weekly nutrition meeting. No documentation was present in the record to indicate facility staff had identified the significant weight loss, notified the physician or developed and implemented any nutritional interventions to address it. On 03/09/2025 at 11:04 AM, Resident 49's weight was 172 lbs. A reweigh was obtained at 2:04 PM and was 171.6 lbs. This confirmed the resident's consistent and unplanned significant weight loss, which was now at -11.09% in 34 days without identification by facility staff, or the development and implementation of nutritional interventions. A 03/10/2025 Nutrition Hydration Skin Committee Review Form, identified the reason for review as significant weight loss of greater than 5%. The sections for weight loss of 7.5% and 10% respectively, remained unchecked. The review identified the resident had consumed 51-100% of most meals over the previous seven days, and did not receive any nutritional supplements. The Interdisciplinary Team (IDT) determined the resident's current meal and fluid intake were adequate to meet the resident's needs but recommended adding NEM to Resident 49's diet. There was no evaluation of the conditions impacting the resident's intake or effectiveness of current interventions. On 03/14/2025 at 1:07 PM, Resident 49 was observed sitting up in bed, their lunch tray was on the bedside table, which was pushed away from the edge of the bed. Observation of the tray showed the pork patty, mixed vegetables, dinner roll with packet of butter, and cake were untouched. The silverware was clean and unused. There was one cup on the tray that had a few drops of red liquid remaining in it. When asked why he had not eaten anything, Resident 49 stated, I drank the juice, but I just don't have an appetite. The resident reported it was not due to the quality of the food and reiterated I just don't have an appetite. Resident 49's tray showed a NEM diet was not provided (No whole milk was on the tray, they had drank their juice and may have drank the milk) and they ate 0% of the meal. Review of the March 2025 meal monitor showed staff documented on 03/14/2025 at 12:00 PM that Resident 49 ate 51- 75% of lunch and drank 480 milliliters (ml) of fluid, despite lunch meal service for Hall 2 being at 12:30 PM, the resident only being provided one 240 ml cup of juice on their tray and not eating any of the meal. On 03/18/2025 at 7:59 AM, Staff B confirmed there was no documentation to show the facility provided the resident Ensure Plus (or a therapeutic interchange) twice a day as ordered. When asked why Resident 49 was not reviewed for significant weight loss during the facility's 03/04/2025 weekly nutrition meeting, given on 03/02/2025 the resident showed a significant weight loss of 7.8% in 28 days, Staff B, DNS, said they did not have a nutrition meeting that week because the RD was out of town, but acknowledged Resident 49 should have still been reviewed and assessed by the rest of the nutrition IDT, but was not. Staff B shared that Resident 49 was reviewed the following week by the nutrition IDT and NEM was added to their diet. On 03/18/2025 at 8:08 AM, when informed that observation of Resident 49's meal trays showed they were not provided NEM, and interviews showed facility staff did not know what NEM on a resident's tray car meant, or what action, if any, it called for them to do. Staff B, DNS, indicated there was a need for education and acknowledged someone from the IDT should be following up on nutritional recommendations to ensure they were fully implemented, and to assess the effectiveness. When asked if that occurred for Resident 49's nutritional interventions Staff B, DNS, said no. Surveyor: [NAME], Tnesa E. <Resident 29> Resident 29 was admitted to the facility on [DATE]. The Annual MDS dated [DATE], documented Resident 29 was severely cognitive impaired. The EHR documented Resident 29 weighed 91.6 pounds on 10/01/2024. On 02/02/2025 Resident 29 weighted 87.0 pounds and on 03/02/2025 weighed 82.2 pounds. This resulted in a -5.75 % loss in 30 days and a -10.48 % loss in six months. The EHR documented Resident 29 was prescribed a therapeutic diet on 02/14/2024 to include a regular diet, regular texture with thin liquids with NEM. Resident 29 was also prescribed a calorie dense supplement three times a day and to be offered again when Resident 29 ate less than 50% of their meal. A Nutrition Assessment, dated 02/05/2025, documented Resident 29 was maintaining weight, was to continue a regular diet, regular texture with thin liquids with NEM and had no concerns at the time of the assessment. On 03/13/2025 at 12:07 PM, observations of Resident 29's meal card documented resident was on a regular diet with think liquids and beverage of choice was whole milk and resident did not have any dislike. Meal ticket did not document NEM diet. At 12:25 PM, Resident 29 was observed wheeling themselves away from the table and out of the dining room. No staff approached Resident 29 or offered an alternative meal or supplement. Resident had only eaten a few bites of beef tips (more than 75 % still on plate), 2-3 spiral noodles were eaten (more than 75% still on plate), all the vegetables were still on the plate, the dinner roll had been eaten and all the juice in the cup had been drank. No milk was on the table. No NEM diet was provided or documented on meal card. At 12:26 PM, when asked what should happen when a resident ate less than 50% of their meal, Staff P, CNA, said they should be offering the resident an alternative meal or supplements. Staff P said per Resident 29's Power of Attorney, they had been directed not to offer Resident 29 an alternative or supplement meal. They had provided Resident 29 with two peach yogurts prior to lunch. On 03/14/2025 at 11:00 AM, Collateral contact 1, Resident 29's POA, was sitting in the lobby with Resident 29. Collateral contact 1 said a while back Resident 29 was having difficulty eating and the facility was in the process of conducting a nutritional assessment with Resident 29. Collateral contact 1 said they told the facility not to offer Resident 29 extra food during the assessment period because they wanted a accurate assessment on Resident 29's ability to swallow. Collateral contact 1 said they wanted Resident 29 to be offered alternative food, if Resident 29 was eating less than 50% of the meal. Collateral contact 1 said she would expect the staff to help Resident 29 choose food that was soft and easy for Resident 29 to chew, due to swallowing difficulties. Collaterals contact 1 said they facility should be cutting up large portions foods too. When observations of Resident 29's meal for March 13 and 17 were explained, including no NEM, Collateral contact 1 said they did not know Resident 29 was on an NEM diet. Collateral contact 1 asked how much Resident 29 weighed. When February and March's weights were provided, Collateral contact 1 said no one had notified them that Resident 29 had lost weight. On 03/17/2025 at 12:13 PM, observations of Resident 29's meal card documented resident was on a regular diet with think liquids and beverage of choice was whole milk and resident did not have any dislike. At 12;19 PM, Resident 29 was observed wheeling themselves away from the table and out of the dining room. No staff approached Resident 29 or offered an alternative meal or supplement. Resident had only eaten half the bowl of soup with crackers, 1/4 of the ham and cheese sandwich, two bites of dessert and 90% of her juice. Left on the plate included 3/4 of the sandwich, half cup or sop with crackers, a full unopened bag of chips and a full salad cup. No NEM diet was provided or documented on meal card. A Nutrition-Meal Monitor Follow Up Question Report, dated 03/01/2025-03/17/2025, documented on 03/13/2025 at 1:04 PM, Resident 29 ate between 0-25% of the meal, no alternative meal/supplement was provided. On 03/17/2025 at 1:37 PM, documented Response Not Required. Documentation showed no alternatives meals were offered for March 13th and 17th. A phone interview was completed on 03/13/2025 at 2:33 PM, with Staff G, RD. When asked about Resident 29's diet, Staff G said Resident 29's weight had been in the 80-90's for the last year and Resident 29 had just recently triggered for weight loss and they did not know if it had been struck out (meaning determined to be a false weight). Staff G said Resident 29 was on a regular, regular diet with thin liquids and NEM. Resident 29 was also receiving a calorie supplement. When observation of no NEM diet was reported and no documentation on the meal card of NEM diet, Staff G said Resident 29 should have received the NEM diet and the meal card should reflect the correct diet type to include NEM. On 03/17/2025 at 2:38 PM, Staff D, RCM, with Staff C, RCM, present, said the process for when a resident has been identified as losing weight included bringing the concerns to the weekly nutrition meeting. Staff, including the Registered Dietitain, would make recommendations, review current interventions and complete a new assessment for the resident. Staff C said it also included notifying the family and provider of the resident's weight loss. When asked about Resident 29's weight loss, Staff D said Resident 29 was not triggered for weight loss. Staff D was shown Resident 29's weight loss calculations, Staff D said they were not aware Resident 29 had lost weight. Staff D confirmed there were no progress notes or current evaluations completed for Resident 29's weight loss. Staff D said Resident 29 was on regular diet with thin liquids with NEM. Staff D said staff should be offering Resident 29 an alternative meal or supplements if the resident ate less than 50% of the meal. Staff D said it was the responsibility of the RCMs to ensure residents received the correct diet that matched the meal card. March 13th and 17th observations were explained about no NEM diet on meal card and no staff had offered Resident 29 an alternative meal. Staff D said it was the expectation that residents received the correct diet, and staff would offer an alternative meal. On 03/18/2025 at 12:53 PM, when asked about Resident 29's weight loss, Staff B, DNS, with Staff E, Divisional Director/Regional RN present, said they were aware Resident 29 had lost some weight over the past year and had been trending down recently. Staff B said Resident 29 was on a regular, regular diet with thin liquids and NEM. Staff B said the NEM diet should have been documented on the meal card. Staff B said they provided documentation of Resident 29 being offered alternative meal, the Nutrition-Meal Monitor Follow Up Question Report. When asked about the observations that no staff had offered an alternative meal to Resident 29, Staff B said an alternative meal was offered, surveyor just didn't observe it. Reference WAC 388-97 -1060 (3)(h) 46793

Based on interview and record review the facility failed to ensure staff performed complete Cardio-Pulmonary Resuscitation (CPR/an emergency procedure consisting of chest compressions combined with giving breaths of air) and failed to assure required staff had unexpired CPR certifications for 1 of 1 resident (Resident 2) who was found unresponsive and had a physician's order for CPR. The failure of facility staff to initiate respirations during CPR placed all residents who chose to have CPR initiated at risk for serious injury, harm, impairment or death and represented an Immediate Jeopardy (IJ) situation. On [DATE] at 4:25 PM, the facility was notified of an IJ at CFR 483.24 (a)(3), F678 CPR, the IJ was determined to have begun on [DATE] when the facility failed to perform complete CPR with respirations. The facility's failure placed residents at risk for serious injury, harm, impairment or death. The facility removed the immediacy on [DATE] with an onsite verification by the investigator by review of staff education, verification staff obtained active CPR certifications, observation of facility emergency equipment, conducting staff interviews related to staff re-education regarding CPR policies and procedures which ensured an effective system was in place to safeguard, protect and prevent residents who require CPR. Findings included . Review of Lippincott Manual of Nursing Practice, Eleventh Edition, dated 2019, showed the following steps for performing CPR included .3. Deliver 30 compressions at a rate of at least 100 compressions a minute. Always allow for complete chest recoil after each compression without taking your hands off of the chest between compressions. 4. Taking no more than 10 seconds, open the airway and deliver 2 breaths. 5. Continue resuscitation at a rate of 30:2 with one or two rescuers . Review of the facility policy titled Cardiopulmonary Resuscitation (CPR), revised ,d+[DATE], showed 1 .Licensed nurses (LN) employed by the Center are required to have current CPR certification .7 .CPR is initiated for those residents who .a. Have requested, through advanced directive or POLST/POST (Physicians Order for Life Sustaining Treatment), to have CPR initiated when cardiac or respiratory arrest occurs .b. Have not formulated an advanced directive nor have a POLST in their medical record .c. Do not have a valid DNR (Do Not Resuscitate/a medical order that instructs healthcare providers not to perform CPR if a patient's heart stops beating or breathing stops) . Resident 2 was admitted to the facility on [DATE] with diagnoses including fracture of the left femur (thigh bone), Chronic Obstructive Pulmonary Disease (restricted airway) and Hypertension (high blood pressure). The admission Minimum Data Set (MDS), an assessment tool, dated [DATE], showed Resident 2 was alert and oriented and required staff assistance for activities of daily living. Resident 2's POLST form, dated [DATE], showed to attempt resuscitation/CPR, full treatment, use intubation, advanced airway interventions, mechanical ventilation, cardioversion (medical procedure used to restore a normal heart rhythm by delivering electrical shock) as indicated, transfer to hospital if indicated, including intensive care treatment. Resident 2's nurse's note, dated [DATE] at 8:03 AM, showed while serving Resident 2 breakfast staff reported the resident was not breathing. The nurse's note showed Staff D, Licensed Practical Nurse (LPN), assessed Resident 2 and found no respiratory rate or heart rate, initiated CPR and called 911. Resident 2's nurse's note, dated [DATE] at 8:12 AM, showed .911 arriving in facility, taking over CPR on resident . Resident 2's nurse's note, dated [DATE] at 8:36 AM, showed paramedics pronouncing Resident 2's death at 8:26 AM. Review of the facility's investigation, dated [DATE], showed a statement by Staff D .this nurse was called to the residents room by the CNA [Staff C, certified nursing assistant] stating that the resident was not breathing at 0745. Resident was observed lying on her back sideways in the bed .resident was not breathing and did not have a pulse. Resident was Cyanotic (bluish or gray color of skin) but warm to touch. This nurse and RN [Staff E, Registered Nurse] started CPR, CNA [Staff C] brought the crash cart and helped with CPR .911 was called and CPR continued by this nurse, [Staff E] and [Staff C] until paramedics arrived . Review of staff CPR certification showed the following: Staff C CPR certification expired [DATE]. Staff D CPR certification expired [DATE]. Staff E CPR certification expired [DATE]. In an interview on [DATE] at 10:11 AM, Staff C, Certified Nursing Assistant (CNA), said she delivered the breakfast tray to Resident 2 on [DATE] and found the resident to be lying in bed unresponsive. Staff C said she went to the hallway and yelled for help. Staff C said nurses responded and Staff C went to the nurse's station to find the Resident 2's code status, retrieved the emergency cart and returned to Resident 2's room. Staff C said Staff E called 911 and Staff D and Staff C did chest compressions. Staff C acknowledged staff did not administer respirations (breaths) during CPR. Staff C said the cart was missing stuff .like the breathing tube . In an interview on [DATE] at 10:19 AM, Staff D said she was passing medications on [DATE] and a CNA reported Resident 2 was not breathing. Staff D said she went to Resident 2's room and found Resident 2 unresponsive. Staff D acknowledged they initiated chest compressions but did not administer respirations because the ambu bag [bag valve mask/handheld device used to deliver ventilation to patients who are breathing inadequately or not at all] was not on the cart. Staff D acknowledged the paramedics arrived on scene and took over CPR. Staff D acknowledged the resident expired at the facility. In an interview on [DATE] at 3:50 PM, Staff A, Administrator, and Staff B, Director of Nursing, acknowledged the facility had several staff changes and they became aware numerous staff had expired CPR certification. Staff B acknowledged Staff C, Staff D and Staff E had expired CPR certification. Staff A and B acknowledged CPR consists of rescue breathing and chest compressions and is provided to all residents' dependent on their POLST form and advanced directives. Staff B acknowledged staff are expected to provide respirations if resident is not breathing using an Ambu (bag/valve mask), barrier mouthpiece or mouth to mouth if no other equipment is available. Staff A and Staff B acknowledged Resident 2 expired at the facility. Reference WAC [DATE] (1)

Based on interview and record review, the facility failed to ensure a physician ordered foot care referral for a podiatrist, and a physician ordered wound care referral were followed and not delayed, for one of three sampled residents (#1) reviewed for foot wound care. This failure placed residents at risk for unmet care needs, serious injuries and a diminished quality of life. This caused harm to Resident #1 when the wound worsened due to not receiving the required medical care and treatment by the qualified professional as ordered. Findings included . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set, an assessment tool, dated 12/02/2020, documented the resident was cognitively intact; was at risk for pressure injuries; and had no ulcers, wounds or skin problems. A physician's orders [REDACTED]. A nursing progress note, dated 12/16/2020, documented, Resident with skin breakdown to his right great toe and 2nd metatarsal (toe joint) . LN (licensed nurse) cleansed foot and initiated treatment. Provider was notified . Care plan updated, Braden (skin) and Pain evaluations completed. Placed resident on alert to monitor for signs and symptoms of infection. A physician's orders [REDACTED]. Resident #1's medical record, dated 12/16/2020 to 01/10/2021, showed the podiatry referral was not attempted or completed as ordered on [DATE] (25 days after ordered). The record showed the wound care referral and evaluation for the resident's toes were not completed as ordered on [DATE] (36 days after ordered). A nursing progress note, dated 01/11/2021, documented, Resident with sig (significant) change in right foot 2nd toe wound. Resident second toe with approximately 0.4 cm (centimeter) exposed metatarsal bone, with tip of toe appearing to be connected with soft tissue only . request facility reach out to orthopedic services to facilitate transfer to hospital. Resident without existing orthopedic care in relation to wound. A nursing progress note, dated 01/11/2021, documented, Orthopedic clinic called facility . believes (physician) in podiatry is best suited to address the foot wound at this time . recommendation is for patient to be sent to (local hospital emergency room ) for direct consult (consultation) and admit per (physician) . he may need possible vascular consult and likely surgical amputation of toe. The resident's medical record showed the resident was transferred to the local hospital on [DATE]. On 01/26/2021 at 1:50 PM, Staff B, Registered Nurse and Director of Nursing Services, said the wounds to the resident's toes were first discovered on 12/16/2020. Staff B said she did not think the podiatry referral was completed. Staff B said in the end, the facility was able to get a podiatrist to come to the local hospital emergency roiagnom on [DATE] to evaluate the toes. On 01/28/2021 at 10:44 AM, Staff B said the wound care clinic was following Resident #1 for other wounds, but not the wounds on the resident's toes. Staff B said Resident #1 started seeing the wound care clinic on 12/15/2020. Staff B said the wound care clinic should have seen the toes on the next visit, but there were no wound care notes on the toes. Staff B said it looked like the toe injury was not referred to the wound care clinic, and it should have been referred to them. Reference WAC 388-97 -1060 (3)(j)(viii)

Based on interview and record review, the facility failed to ensure residents were free from neglect for 1 of 13 sampled residents (#1) reviewed for neglect. This failure placed residents at risk for physical harm, pain, and a diminished quality of life. This failure caused harm to Resident #1 when she experience pain, incontinence, and emotional distress after not receiving care. Findings included . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), a comprehensive assessment tool, dated 09/30/19, documented Resident #1 had no cognitive impairment and required extensive assistance with activities of daily living. The plan of care, dated 09/27/19, documented the resident was incontinent of urine and would be monitored for an appropriate bowel and bladder training program. The progress notes, dated 11/06/19, documented Resident #1 was diagnosed with [REDACTED]. On 11/07/19 at 2:00 PM, Resident #1 said two to three days ago, she had not received assistance with incontinence care or bedtime cares on the evening shift. Resident #1 said the morning shift had assisted her prior to the end of the shift. The resident said around 3:30 PM, she put on her call light for assistance with incontinence care. Resident #1 said no staff came to answer her light or assist her until her dinner tray was delivered. At that time, the staff member told Resident #1 they could not assist her because they were passing dinner trays. As the evening progressed, Resident #1 became cold due to a combination of a breeze in the room and a soaked incontinent brief. Resident #1 said she was also experiencing pain because she had recently been struggling with a urinary tract infection [MEDICAL CONDITION]. The resident said she had a friend come and help her to bed and did not see the staff member caring for her until the night shift started. At that time, staff gave her an ice pack to help with her urinary pain she experienced due to the UTI. Resident #1 said another time she was left with no covers and no call light for 45 minutes while her primary nursing assistant when to get second CNA (Certified Nursing Assistant) to come and help her primary staff member lift her up in bed. Resident #1 said she had to start banging on her garbage can to get the staff's attention. While Resident #1 was talking about this, she was observed with tears in her eyes. Resident #1 talked repeatedly about being cold and in pain, saying it was an awful experience. Resident #1 said she reported the allegation to the therapist and other staff had been in to ask her about the incident. On 11/08/19 at 12:00 PM, Staff B, Director of Nursing Services (DNS) and Registered Nurse, said she had no investigations or reports to the state agency Hotline for Resident #1. At 2:50 PM, Staff F, Physical Therapist, said the allegation of neglect was reported to her by Staff G earlier in the week. Staff F said she asked Staff G to report the allegation to the appropriate staff members. At 3:00 PM, Staff G, Occupational Therapy, said Resident #1 reported the allegation of neglect of care to her around 11/06/19. Staff G said she reported the allegation to the DNS. On 11/19/19, at 4:00 PM, Staff A, Administrator, said the allegation was not reported to the state agency Hotline or investigated until 11/09/19. Staff A said upon completing the investigation, the facility substantiated Resident #1's allegation of neglect of care and the certified nursing assistant assigned to Resident #1 no longer worked at the facility. Reference WAC 388-97-0640(1)

Based on interview and record review, the facility failed to ensure residents 1 of 13 sampled residents (#4) reviewed received care and treatment in accordance with professional standards of practice and received the necessary care and services to attain or maintain their highest practicable level of well-being. These failures placed the residents at risk for unmet care needs, discomfort, and diminished quality of life. This caused harm to Resident #4 when the resident developed pneumonia and septic shock resulting in death. Findings included . Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), a comprehensive assessment tool, dated 08/07/19, documented Resident #4 had moderate cognitive impairment and required supervision with activities of daily living. Record review of the resident's medical record showed lack of documentation on the resident from 09/19/19 to 09/30/19. No vital signs and respiratory status were documented from 09/11/19 to 09/30/19. Progress notes, dated 09/30/19, documented Resident #4 was in the dining room and was observed having trouble eating. A certified nursing assistant (CNA) brought the resident out to the hallway. The resident was observed to be pale, have an abnormal breathing patterns and breathe sounds, and had oxygen saturations of 74%. Resident #4 was sent to the hospital via ambulance. Hospital History and Physical notes, dated 09/30/19, documented Resident #4's FM reported to the facility nurse she was concerned about the resident's breathing the day prior. The notes documented while at dinner, Resident #4 had a sudden onset of shortness of breathe and low oxygen saturation . Resident #4 was transported to the hospital and was diagnosed with [REDACTED]. The notes documented it was unclear if the resident had aspirated recently. Resident #4 passed away from his illness on 10/01/19. Hospital Chest Radiography (X-ray) report, dated 09/30/19 at 7:06 PM, documented right lower lobe consolidation (lung filled with fluid instead of air) may be due to pneumonia or aspiration. On 11/07/19 at 12:55 PM, Resident #4's family representative (FM) said she was visiting Resident #4 on 09/29/19 and noted something was not quite right with him. Resident #4's FM said she went and told staff at 1:33 PM that she was concerned Resident #4 was coming down with something and asked staff to check on him. Resident #4's FM said she did not hear anything from staff until the next day when Resident #4 was admitted to the hospital. Resident #4's FM said the hospital provider told her Resident #4 possibly aspirated (inhaling food/fluids into lungs) on food and had a [MEDICAL CONDITION]. The FM said Resident #4 passed away shortly after. On 11/19/19 at 3:30 PM, Staff I, CNA, said she had worked with Resident #4 the weekend before his hospitalization and had not noted anything abnormal. Staff I said it was reported to her Resident #4 had eaten 12 cans of little sausages in addition to an additional meal on Saturday, 09/28/19. Staff I said Resident #4 later had episodes of vomiting. Staff I said on 09/30/19, while at dinner, Resident #4 reported to her he was feeling short of breath, which was abnormal for him. Staff I said she told Staff E, Licensed Practical Nurse (LPN), of these concerns. Staff I said Staff [NAME] did not go to the dining room and assess the resident's respiratory status. Staff I said at this time, Resident #4's oxygen saturation was 95%. Staff I said she reported his oxygen saturation to Staff [NAME] who said that is adequate oxygenation. Staff I said she went back to Resident #4 and encouraged him to eat. Resident #4 took only one bite. Staff I said she noted the resident appeared pale, sweaty, and his hands were ice cold and turning purple. Staff I said she decided to bring Resident #4 to Staff [NAME] in the hallway since she did not come to assess the resident. Staff [NAME] then rechecked the resident's oxygen again and found the saturations were in the 70's. Staff I said Resident #4 was transported to the hospital at this time. At 3:41 PM, Staff [NAME] said she had not worked with Resident #4 in about a week and did not recall anything abnormal with the resident. Staff [NAME] said during supper, staff had reported concerns to her about Resident #4's status, and brought the resident to her medication cart. Staff [NAME] said initially, Resident #4's oxygen saturation was 94% then as she assessed the resident, she noted Resident #4 was having serious respiratory issues. 911 was called and the resident was transported to the hospital. At 4:30 PM, Staff A, Administrator, said staff should be documenting changes in condition and monitoring in the resident's medical records. On 11/20/19 at 4:35 PM, Staff R, Licensed Practical Nurse, said she was working the weekend before the resident was sent to the hospital. Staff R said she recalled hearing Resident #4 was vomiting during the weekend. Staff R said she did not recall Resident #4's FM reporting concerns about the resident on 09/29/19. Reference WAC 388-97-1060 (1)

Based on interview and record review, the facility failed to ensure timely assessment, treatment, and monitoring to prevent the development and worsening of pressure ulcers for 3 of 4 sampled residents (#1, 2, & 3) reviewed for pressure ulcers. This failure placed residents at risk for worsening skin impairment, a change in health status, pain and a diminished quality of life. This caused harm to Resident #1 and Resident #2 when they each developed pressure ulcers in the facility. Findings included . The facility's policy Skin Integrity, dated (MONTH) 2019, documented staff will complete a Braden Scale (a tool determining risk of skin breakdown) upon admission, then weekly for 3 weeks, annually, and with a significant change in condition. Ongoing skin evaluations would continue weekly. Any skin impairment would be measured for size, color, odor, exudate (drainage), and pain, and documented in the nursing notes and weekly wound evaluation. The policy documented staff would establish a plan of care based on risk factors and include interventions to prevent or limit pressure ulcers (PU). The policy documented if a resident refused treatment, education on risk would be provided to the resident, documented in the medical record, and documented in the care plan. 1). Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), a comprehensive assessment tool, dated 04/23/19, documented Resident #1 had moderate cognitive impairment and required extensive assistance with activities of daily living (ADLs). The MDS documented Resident #1 was at risk for skin breakdown and had no skin impairment. The Braden Scale, dated 11/30/18, documented Resident #1 was at risk for skin breakdown due to inadequate nutritional intake and minimum assistance with repositioning and mobility. No additional Braden Scales were completed. The care plan, dated 03/26/19, documented to encourage off-loading of heels as resident allowed. The care plan, updated 04/15/19, documented Resident #1 required incontinence care, repositioning every two hours and a pressure reducing mattress. A Hospice note, dated 04/18/19, documented Resident #1 developed a PU to the sacrum and left lateral foot. Resident #1's medical record was reviewed (progress notes, skin assessments, care plans) and showed from 11/30/18 to 06/25/19 the resident did not have a Braden Scale, wound evaluation or monitoring, or care plan completed related to pressure ulcers. The physician orders, dated 04/27/19, documented staff to apply foam dressing to bilateral heels related to PU and change dressing every other day. The hospice orders, dated 05/03/19, documented Resident #1 had bilateral PU to her heels, 1 cm in diameter. An order was obtained the same day for dressing changes every 3 to 5 days. A hospice note, dated 05/15/19, documented Resident #1 continued to have PU to the heels. The note documented Resident #1 did not have a protective dressing on and her heels were not floated, and now had a 3 centimeter (cm) x 3 cm fluid filled blister to her left heel. The note did not address the sacrum. A hospice note, dated 06/24/19, documented the heel wound as a stage 2 PU, measuring 2.1 cm x 1.5 cm. On 07/10/19 at 1:25 PM, Staff G, Nursing Assistant (NA), said Resident #1 required repositioning every few hours and her heels being floated. Staff G said Resident #1 would often refuse repositioning. At 2:30 PM, Resident #1 was observed with heel protectors and a dressing to her left foot. The resident said she was not having pain. On 07/12/19 at 11:45 AM, Staff B, Director of Nursing Services (DNS) and Registered Nurse (RN), said no Braden or wound monitoring were performed for Resident #1. Staff B said the facility did not start weekly monitoring for Resident #1's PU until 06/25/19. On 07/16/19 at 6:15 AM, Resident #1 was observed in bed and her heel protectors were on her chair in the room. Resident #1's heels were observed directly on the bed with no pressure relief. A dressing change for her PU was observed and a foam dressing was removed from the left heel. The left heel wound measured 1.0 cm x 0.8 cm. The wound was observed to have slough (yellow, stringy tissue) adhered to the wound. Staff B said she would classify this wound as a Stage 3 (full-thickness loss of skin with slough present), and said the wound was improving. Staff B said Resident #1 should have her heels protected. At 7:15 AM, Staff B said Resident #1 often refused heel protectors. Staff B said no comprehensive skin assessment was completed for Resident #1 to determine appropriate interventions and alternative interventions due to the resident's refusal of heel protectors. Staff B said she would expect an air mattress to be in place for Resident #1 because she was on hospice, but said Resident #1 did not have an air mattress in place. At 7:25 AM, Staff C, Staff Development and Licensed Practical Nurse (LPN), said the facility was not documenting refusals of heel protectors. Staff C said Resident #1 did have an air mattress at one time, but she fell out of it so they removed it. Staff C said she could not find any documentation to support they performed an assessment of risk for PU when removing the air mattress. Staff B said these concerns with the air mattress and refusal of heel protectors should be documented in the medical record. 2) Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS, dated [DATE], documented Resident #1 had moderate impairment and required extensive assistance with ADLs, was at risk for skin impairment and had no pressure ulcers. Progress note, dated 04/20/19, documented Resident #2 had redness/breakdown to the left ear. Zinc (used to treat wounds) was ordered to apply to Resident #2's ear twice daily. No Braden Scale, wound evaluation, or care plan interventions were documented in the medical record at this time. The Wound Clinic progress notes, dated 05/28/19, documented Resident #2 had a PU to her left ear due to sleeping on her left side. Measurements documented the wound was a Stage 1 (skin intact with persistent redness) measuring 1.0 cm length x 0.5 cm width x 0.1 cm depth. The wound care provider recommended repositioning every 2-3 hours for pressure relief. The progress notes, dated 05/29/19, documented Resident #2 developed a PU to her left ear, measuring 1.0 cm length x 0.5 cm width x 0.1 cm depth, due to a pillow that came from home. The pillow was replaced with a new pillow. The Weekly Skin Evaluation, dated 06/04/19, documented Resident #2's Stage 1 PU to the left ear, measuring 0.4 cm length x 0.1 cm width x 0.1 cm depth. The Progress notes, dated 06/05/19, documented Resident #2's PU was now a Stage 2 (shallow, open ulcer) due to a small open area. The Wound Clinic progress notes, dated 06/11/19, documented Resident #2 PU was healed. The progress notes, dated 06/23/19, documented Resident #2 was found with open areas to her feet: -Left inner foot: measuring 2.0 cm x 2.5 cm width with non-blanchable redness (redness indicating pressure injury to skin). -Middle left inner foot: measuring 1.0 cm x 1.0 cm with non-blanchable redness. -Inner aspect of left heel: measuring 3.0 cm x 3.0 cm with non-blanchable redness with a blister in the center measuring 2.5 cm x 1.5 cm. -Right distal aspect of the foot: measuring 1.0 cm x 1.0 cm with dark purple/red deep tissue injury (DTI) (purple discoloration indicating underlying skin damage). The wound was boggy with surrounding area of 2.0 cm x 1.5 cm of non blanchable redness. -Right distal, lower aspect of the foot: measuring 1.5 cm x 2.5 cm intact blister with a 0.5 cm surrounding non blanchable redness. -Right ankle: measuring 1.5 cm x 1.0 cm dark purple/red deep tissue injury (DTI) (purple discoloration indicating underlying skin damage). The wound was boggy with surrounding area of 5.0 cm x 4.2 cm of non blanchable redness. The Braden Scale, dated 06/24/19, documented Resident #2 was at high risk for skin breakdown due to poor nutrition intake, maximum assistance with mobility and limited ability to walk. Weekly Skin Evaluations were completed 06/26/19, 07/02/19, and 07/09/19 with improvements noted in the wounds. The care plan, dated 06/27/19, documented Resident #2 had potential for skin breakdown due to fragile skin, impaired sensation, poor safety awareness and poor nutritional intake. The care plan documented staff would float Resident #2's heels while in bed and position off of bony prominences. On 07/10/19 at 1:00 PM, Resident #2 was observed in bed with her eyes closed. The resident's legs and heels were elevated with a bolster to reduce pressure on the heels. No other issues with Resident #2's skin were observed. At 1:20 PM, Staff E, Certified Nursing Assistant (CNA), said Resident #2 was turned every two hours. Staff [NAME] said Resident #2's heels are floated with a wedge and pillows for positioning. On 07/12/19 at 11:10 AM, Staff B, said Resident #2 was found to have a pressure ulcer to her ear due to a foam pillow which was really hard. This pillow was replaced. Staff B said there was no Braden/skin assessment completed prior to or at the time she discovered the ear PU. Staff B said she was unsure if the ear was a PU when it was discovered in (MONTH) 2019 because no assessment was completed at that time. Staff B said Resident #2 then developed PUs to her feet and a skin assessment and weekly monitoring was implemented. Staff B said Resident #2's PUs improved. Staff B said the care plan did not reflect all the interventions implemented including use of a neck pillow and a turning and repositioning schedule. 3) Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission baseline care plan documented Resident #3 was forgetful and was dependent on staff with ADLs. The emergency room notes, dated 07/02/19, documented Resident #3's skin was dry and intact. The Braden Scale, dated 07/02/19, documented the resident was at high risk for skin breakdown. The progress notes, dated 07/02/19, documented Resident #3's buttock, coccyx, and sacral area was red and purple in color, non blanchable, open area noted, only surface area of the skin. Protective skin cream was ordered. No evaluation of the open area was completed at this time. The Care Plan, dated 07/03/19, documented Resident #3 had potential or actual skin impairment due to decreased mobility, poor nutrition intake and assistance with mobility. The care plan documented the resident should be positioned off of bony prominences and staff would use barrier cream with incontinent episodes. The Admission Nursing Evaluation, dated 07/05/19, documented Resident #3's skin was pink and dry; and currently had a pressure ulcer, skin tear, abrasion, burns, or other skin issue. The evaluation did not document what type of skin issue(s) the resident exhibited. The Weekly Skin Evaluation, dated 07/09/19, documented Resident #3 had a Stage 2 PU to the coccyx measuring 2.5 cm x 1.0 cm. On 07/12/19 at 11:40 AM, Staff B said there was no documentation evaluating Resident #3's pressure ulcer when the wound was initially discovered on 07/02/19. Reference WAC 388-97-1060(3)(b)

Based on observation, interview and record review, the facility failed to provide necessary care, services, treatment and assessment, in accordance with professional standards of practice, for 2 of 8 sampled residents (#24 & 18) reviewed for falls, behaviors and bowel management. This failure placed residents at risk for medical complications, injury, and a diminished quality of life. This caused harm to Resident #24 when the resident was moved after a fall before being adequately assessed. Findings included . 1) Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool, dated 03/15/19, documented the resident required one person assistance for ambulation. On 05/04/19 at 10:40 AM, Resident #24 was observed lying on the floor just inside the doorway to her room, yelling for help. The resident was lying on her left side, with her head and back against the wall near the sink, opposite from the bathroom. There was a brief with bloody stool in the doorway of the room, and bloody stool and pink tinged urine on the floor near and under the resident. The call light was not on and the resident was yelling, Please help me. Please help me. When staff, Staff P, Licensed Practical Nurse (LPN) and Staff Q, Nurse Assistant (CNA), arrived to the room, Staff P glanced at the resident head to toe and asked what happened. Resident #24 told Staff P she did not know and kept repeating, It hurts. It hurts. Staff P asked where it hurt and the resident pointed to her left hip, and stated, My hip. Staff P assisted the resident to a sitting position from the floor and the resident said loudly, It hurts so bad, Ow, Ow, Ow. Staff P told Staff Q, We need to get her off the floor. Staff Q put a gait belt (device used to aide in transfers) around the resident's waist. Staff P and Staff Q assisted the resident to a standing position and placed her in a wheelchair (w/c) while the resident continued to yell out loud. Staff P stated to Staff Q, We need to get her into the bed. At 10:45 AM, Staff R, Regional Director of Operations, entered the room. Resident #24 continued to say her hip hurt. Staff R identified himself as a nurse and told the staff not to move the resident further. Staff R asked if vital signs (VS) had been done or the medics called. Staff P said they had not. Staff R told staff to get the resident's VS and call the medics now. At 10:50 AM, Staff Q said he had last checked on the resident one half hour before being called to the room for the fall. At 11:00 AM, the medics arrived at the facility. The four medics were observed to transfer the resident into a gurney while the resident continued to yell. One medic stated, Looks as if her left leg is rotated out, she'll need orthopedics. At 1:14 PM, when asked why she moved the resident when the resident was crying out, Staff P said she did not see any obvious injury. Staff P said the resident was lying on a cold floor in urine and stool, so she thought it would be better to get her up. Staff P said she could assess her more once she was up. Staff P stated, In retrospect, I guess, I should have just left her lying there and called 911. At 6:54 PM, Staff J, LPN, said the resident had been admitted to the hospital for a [MEDICAL CONDITION] and a [MEDICAL CONDITION]. On 05/09/19 at 3:49 PM, Staff B, Registered Nurse (RN) and Director of Nursing Services (DNS), stated, If a resident has a fall, an assessment should be done where they lay, and if they are having any pain they should not be moved. 2) Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The bowel movement (BM) monitor, dated 04/06/19 through 05/05/19, showed the following: -From 04/06/19 to 04/12/19, a total of seven days/21 shifts, there was no documentation to show the resident had a BM. -From 04/16/19 to 04/18/19, a total of three days/nine shifts, there was no documentation to show the resident had a BM. -From 04/30/19 to 05/02/19, a total of three days/nine shifts, there was no documentation to show the resident had a BM. The (MONTH) 2019 and (MONTH) 2019 Medication Administration Record [REDACTED]. On 05/09/19 at 2:30 PM, Staff C, LPN, said the bowel protocol was if a resident had not had a BM in three days staff should start the bowel management protocol. Staff C said the resident care managers used to run a report daily of residents who had not had a BM and gave it to the nurses for follow up. Staff C said that had not been happening recently. At 2:33 PM, Staff L, LPN, stated, We can see a BM list on our dashboard on the computer for the past 72 hours. I pull my own report sheet every day. The interim DNS used to bring us a list, but no one has done that in a long time. Each nurse should be responsible to run their own report. At 3:36 PM, Staff B said the nurses have the ability to see BM monitoring for the last 72 hours on their computer dashboard and should be monitoring them. After reviewing the BM monitoring for Resident #18, Staff B said there should have been an intervention done. Reference WAC 388-97-1060 (1)

Based on observation, interview, and record review, the facility failed to ensure residents were safe when smoking and failed to ensure residents were free of falls for 2 of 6 sampled residents (#2 & 3) reviewed for accident hazards. This failure placed residents at risk for falls, injuries and a diminished quality of life. This caused harm to Resident #3 when he burned himself while smoking. Findings included . 1) The facility's policy, Resident Smoking Safety, updated (MONTH) (YEAR), noted all residents may only smoke with supervision while on the facility's grounds and must store tobacco products and fire materials at the nursing station. Resident # 3 was admitted to the facility 03/08/19 with [DIAGNOSES REDACTED]. The MDS, dated [DATE], indicated the resident was cognitively intact and required extensive assistance with activities of daily living. Resident #3's care plan, dated 02/05/19, showed he had a history of [REDACTED]. An intervention showed Resident #3 was allowed to keep his lighter at his bedside (not following the smoking policy). Nursing notes, dated 04/01/19, documented the resident had one fresh and two [MEDICAL CONDITION] his index finger from unsafe smoking. Nursing notes, dated 04/08/19, showed Resident #3 was observed throwing a lit cigarette into a garbage can. Nursing notes, dated 04/09/19, noted Resident #3 was found with cigarettes and a lighter in his clothing. On 04/16/19 at 2:15 PM, Resident #3 was observed with a blister on his left index finger. The resident said he burned his finger while smoking because he wasn't paying attention and the cigarette burned down too close to his finger. Resident #3 said there was a staff person present, and was smoking with residents when he burned himself. At 3:37 PM, when asked about a staff person who was supervising smoking when Resident #3 burned himself, Staff B said the staff member was not interviewed about the incident. Staff B said Resident #3 had a history of [REDACTED]. 2) The Facility Policy, Fall Evaluation (Morse Scale) and Management, dated (MONTH) (YEAR), directed staff to complete a Morse Scale (to measure risk for falling) upon admission to the facility and incorporate findings into a care plan to reflect appropriate fall prevention interventions. The policy noted the Morse Scale should be completed and the fall prevention care plan be revised after each new fall. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS, dated [DATE], documented Resident #2 had moderate cognitive impairment, required extensive assistance with activities of daily living, and had a history of [REDACTED]. The care plan, dated 01/31/19, documented Resident #2 required two staff members to transfer his position. The care plan, dated 02/04/19, documented Resident #2's bed should be up against the wall, in the lowest position when staff were not assisting the resident, and a fall mat on the floor in the front of the bed. The falls risk assessment, dated 03/20/19, identified Resident #2 had a high risk for falls related to a history of falling (overestimated and forgot limitation, and impaired walking). The falls assessment, dated 03/27/19, documented Resident #2 was found on the floor by the staff. The assessment's documentation did not show the resident's activity at the time of the fall and specific interventions to prevent the fall from recurring. The falls assessment, dated 03/29/19, documented Resident #2 was found on the floor in his room behind his door by the staff. The assessment documentation did not show the resident's activity at the time of the fall and specific interventions to prevent the fall from recurring. Progress notes, dated 04/05/19, documented at 1:30 AM Resident #2 was found with his high/low bed (a bed that adjusted different heights) in the highest position. When Staff attempted to lower the bed to a regular height, the resident was startled awake and started hitting staff. The note documented to put bed down to a safer level due to poor safety awareness and history of self-transfers. Progress notes, dated 04/10/19, documented Resident #2 was found with his bed in the highest position, keeping the bed controller down the front of his shirt. Resident #2's clinical record documentation did not show a safety assessment for continued use of the high/low bed. On 04/16/19 at 4:40 PM, Resident #2 was observed in his wheelchair in his room. Resident #2 pointed to the mat on the floor near his bed and said it was there to soften the blow when he fell . The care plan, revised 04/17/19, documented Resident #2 used his bed controller to put his bed in the highest position, which placed him at risk for injury and directed staff to encourage the resident to keep the bed in the lowest position. On 04/23/19 at 12:35 PM, Resident #2 was observed in his bed in the lowest position, with his leg crossed, off the side of the bed. The fall mat was observed between the closet and the night stand, not next to the bed. At 12:40, Staff C, a Certified Nursing Assistant (NAC), said housekeepers should have placed the mat back on the floor when they were finished mopping. On 04/24/19 at 10:45 AM, Resident #2 said he is able to raise his bed up and down on his own. At 3:10 PM, after observing Resident #2's bed, Staff A, Administrator, said the resident did have a high/low bed. At 3:15 PM, Staff B said Resident #2's falls were not comprehensively assessed to determine appropriate intervention to prevent further falls. Staff B indicated it was her expectation the facility policy regarding fall prevention and safety would be followed. Reference WAC 388-97-1060(3)(g)

Based on observation, interview, and record review, the facility failed to evaluate root causes, provide adequate supervision and revise and implement fall prevention interventions specific to resident needs for 1 of 4 sampled residents (#1) reviewed for accidents. This failure placed residents at risk for falls, injuries and a diminished quality of life. This caused harm to Resident #1. Findings include . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool, dated 11/01/18, documented Resident #1 was severely impaired with daily decision making skills, required extensive assistance from staff with activities of daily living and had not had a fall since the last MDS. Resident #1 Care Plan, dated 09/13/18, directed staff to encourage resident out of room when in wheelchair for safety and bring to populated area. On 01/04/19 at 9:30 AM, Resident #1 was observed sitting in her wheelchair in the hallway. The resident was observed to have extensive bruising around both eyes and forehead. At 11:30 AM, resident's room was observed with Resident #1 roommate's fall mat was on the floor in front of the roommate's bed. The fall assessment, dated 11/21/18, documented while in the dining room Resident #1 was observed to fall forward out of the wheelchair, onto to her right shoulder then hitting her right elbow on the floor resulting in bruising to her right eyebrow. Staff believed resident was attempting to pick up papers, which were scattered throughout the dining room. The fall assessment checklist was blank without documentation regarding determination of pain, mental status, and predisposing environmental factors, psychological factors, and situational factors. The assessment showed Resident #1's wheelchair seat was not lowered and staff would be educated to lower the seat when the resident was not eating. A physical therapy referral was documented as an intervention. The Care Plan, dated 11/21/18, documented therapy consult for strength and mobility and wheelchair as a fall intervention. The wheelchair seat was not documented. The fall assessment dated [DATE], documented while in the dining room, Resident #1 was observed to lean forward and fell out of her wheelchair hitting her arm and head resulting in bruising to her right knee and an abrasion to her forehead. Staff believed the resident was picking up paper from the floor. Resident #1 wheelchair seat was found in the leaned back position. The resident was noted to be weaker due to recent pneumonia and a referral for therapy was appropriate. No additional interventions were recommended. The care plan, dated 11/24/18, documented refer to therapy for weakness/trunk control and reacher/grabber evaluation and to anticipate resident's needs. The Interdisciplinary Therapy Screen, dated 11/24/18, documented therapy services were not appropriate at this time. The fall assessment, dated 12/10/18, documented Resident #1 was found in her room on the floor with facial swelling and bruising. Resident #1 was found caught up on her roommates fall mat and her legs tangled in her wheelchair. Staff felt the resident was trying to get by the fall mat or pick the fall mat up. The resident was sent to the emergency room for evaluation and found to have a right elbow fracture. Interventions included moving Resident #1 roommate's bed, to remain in sight line of staff, and referral to therapy. The fall assessment documentation did not show the use of the wheelchair drop seat or therapy service status. The Interdisciplinary Therapy Screen, dated 12/11/18, documented therapy services were not appropriate at this time. The care plan, dated 12/13/18, documented therapy to consult for strength and mobility and wheelchair, therapy to assess for Bentley wheelchair, move roommates bed against wall to allow for more space for the resident to wheel around room, and ensure drop seat wheelchair was lowered/dropped when the resident was not eating. The fall assessment, dated 12/30/18, documented Resident #1 was heard yelling help in the dining room and was found lying on the floor with blood pooling on the floor. Resident #1 had hit her nose and had a purple goose egg to the center of her forehead. An x-ray showed no fractures. The fall assessment did not document the use of the wheelchair drop seat or witness statements. Interventions included a therapy referral. The care plan, dated 12/30/18, noted for therapy to evaluate the resident's wheelchair. An evaluation and treat for therapy was ordered on [DATE]. No documentation was found showing the evaluation was completed. On 01/04/19, at 12:10 PM, Staff E, Director of Therapy Services, said Resident #1 was screened but was not appropriate for any services so no interventions were implemented. Staff E said while Resident #1 has had falls, she was not appropriate for therapy services. Staff E said therapy had now received an order for [REDACTED]. At 1:20 PM, Staff G, Certified Nursing Assistant (CNA), said Resident #1's falls were related to picking up items off the floor. Staff G said he was not aware of how much supervision the resident needed. At 1:35 PM, Staff F, licensed practical nurse (LPN), said staff attempt to keep a close eye on the resident to prevent falls. Staff F said dropping the wheelchair seat would not prevent the resident from falling out of her wheelchair, but it is used for comfort and positioning. At 1:50 PM, Staff C, Resident Care Manager (RCM), said Resident #1 was very busy and difficult to monitor. Staff C said there is little else the facility can do to prevent falls other than one to one supervision. Staff C staff attempted to position the resident in locations that are in the site line of the staff. At 4:05 PM, Staff B, Director of Nursing Services (DNS), Registered Nurse, said the facility lacks comprehensive fall assessments to determine appropriate interventions to prevent further falls for Resident #1. Staff B said Resident #1's roommate fall mat should not be on the floor when the roommate is not in her bed. At 4:05 PM, Staff A, Administrator, said Resident #1's falls assessments are not comprehensive. Reference WAC 388-97-1060(3)(g)

Based on interview and record review, the facility failed to provide basic life support services in a timely manner when staff were unable to locate a working suction machine to remove secretions for 1 of 3 sampled residents (#2) reviewed for quality of life. Failure to respond in a timely manner with a functioning suction machine resulted in Resident #2 not getting the airway support needed, and constituted a Past Non-Compliance Immediate Jeopardy. The facility was notified on [DATE]. Findings include . Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set, a comprehensive assessment tool, dated [DATE], documented Resident #2 was alert and oriented, made his own care decisions, and required extensive assistance with activities of daily living. Resident #2's Physician order [REDACTED]. A physician order, dated [DATE], documented Resident #2 could receive oral suctioning on an as-needed basis, and the resident could perform independently. The order stated staff were to check contents of suction container each shift and clean, per protocol, every shift. A nursing note, dated [DATE] at 11:09 AM, documented, LN (licensed nurse) notified by patient's wife that patient was choking around 10:25 (AM). LN immediately went to patient and sat patient up as far as possible. At this time patient was not breathing and was cyanotic (bluish discoloration of the skin related to lack of oxygenation). LN swiped patient's mouth out and was able to get patient to breathe some. Approx 6 respirations/min. LN had aides grab a new suction machine because the other was not working . (Resident #2) then quite breathing completely, had no pulse, or heartbeat at 10:50 (AM). The facility's investigation statement of conclusion, dated [DATE], documented Resident #2's family member stated that she felt the nurse at that time did not know what she was doing and appeared frantic and stressed, 'running for different tubings and machines.' The statement of conclusion documented the facility apologized for the traumatic experience and expressed condolences. In a witness statement, dated [DATE], Staff A documented, I witnessed (Resident #2's) family member come down the hallway saying that (Resident #2) was choking and his suction was not working. (The nurse) and I quickly went to (Resident #2's) bedside and tried to get the suction to work. In the meantime we asked (NA A) to go and get another suction machine out of the oxygen room. I would say it took approximately ,[DATE] min for (NA A) to return to the room. While (NA A) was working on putting together the new suction, (NA B) was working on dumping the old suction in the toilet. Approximately ,[DATE] min later (NA A) was unable to get the lid on the second suction machine to stay on so then I went and got the crash cart. The crash cart suction was fully functioning for (the nurse) until (Resident #2) passed away. The nurse asked (NA A) to go get .the RN on shift to call time of death. On [DATE] at 3:45 PM, a family member of Resident #2 said she went to the nurses station to get help from staff because Resident #2 was choking. The family member said Resident #2 had an extractor (suction machine) but it wasn't working. I don't know if it was full, it wasn't working. The family member ran down the hall to let the nurse know that Resident #2 was choking. The family member said, A nurse and an aide came to the room. The aide could not get the suction machine to work, she left the room about four times, bringing new parts of machines and new machines, and nothing was working. Finally, (Staff A) said, there is one on the crash cart. They looked at each other and then went running down the hall. It took quite awhile and in the meantime, (Resident #2) died . The total time was probably about 25 minutes. They're just up the road from the hospital. They could have had 911 there easily. They could have done a lot of things easily. Whether they would have saved his life, I don't know. On [DATE] at 11:00 am, when asked about the incident, Staff A stated, (LN B) tried using the suction he had, but it was clogged. I tried to change the suction but couldn't get the top to go on. A CNA went to find a different type of suction. Then (NA B) tried to dump it out but couldn't get the lid off. I tried to change the tubing. An aide went and got the crash cart and the nurse tried to suction him out, the suction worked then. On [DATE] at 11:20 AM, when asked about the incident, NA A stated, The resident had a hard time breathing. His wife was there. The suction wasn't working so we tried to change it. The suction cup that we had didn't fit. The new ones didn't fit. So I said why don't we just dump it out and clean it? On [DATE] at 11:30 AM, when asked about the incident, NA B stated, The suction in Resident #2's room wasn't working. LN B kept trying to use it. We rushed to go find another machine or other parts but didn't know how to put it together. We had to search for the supplies, one came from Central Supply, one was in his bathroom. (LN B) put it together. The darker blue (lid) wasn't the right one. The bottle and the lid did not go correctly, we couldn't close the lid. We had to go get the crash cart, that one was all together. On [DATE] at 4:40 PM, LN C (a registered nurse and staff educator) said nursing staff had undergone training recently on use of suction machines. LN C said the education included checking for supplies, cleaning, resupplying and set-up of the suction for immediate use. When asked if the education included how to troubleshoot difficulties with set-up, LN C, said, It will now. On [DATE] at 1:50 PM, LN A was observed changing the suction canisters on each of the facility's 3 suction machines. The suction machines were observed set-up with either a light blue top or a dark blue top, and matching canisters, each slightly different from each other. Two different manufacturers of suction supplies were observed in the supply room which were not interchangeable. LN A was observed to have difficulty fitting a dark blue plastic top onto a canister and was not able to fit the two pieces together. LN A asked the supply aide for assistance locating additional supplies. The supply aide was not able to locate additional supplies that fit the dark blue top. On [DATE] at 4:10 PM, the Administrator stated the Staff Development Coordinator told her some suction pieces did not fit with other equipment, and he was looking into it. The suction supplies were observed in the office. Between [DATE] and [DATE], the facility had trained the nursing staff on the use of suction machines including checking for supplies, cleaning, resupplying, and set-up for immediate use. The facility provided monitoring for the suctions machines and continued ongoing training to facility staff. This was a Past Non-Compliance Immediate Jeopardy situation and is no longer outstanding. Reference WAC [DATE](1)

Based on interview and record review, the facility failed to ensure residents were free from abuse for 1 of 3 sampled residents (#1) reviewed for abuse. This failure placed residents at risk for inappropriate sexual contact by a licensed nurse, and resulted in continued abuse to the resident. This caused harm to Resident #1. Findings include . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/08/18 at 1:00 PM, the Executive Director (ED) stated they did not view an allegation reported to them as a sexual abuse allegation so they did not report it to the state. Because they did not view this statement as a sexual abuse allegation, they did not question any other residents or staff or conduct any further investigation. The ED said LN A was not suspended from the building at the time and was permitted to continue to provide care for residents. The ED said he had recently discovered that Resident #1 was supposed to have only female caregivers since (MONTH) (YEAR), but that it was never implemented into the care plan. Resident #1 had both male and female caregivers during this time. On 2/08/18 at 1:20 PM, Nursing Assistant Certified (NAC) A stated in mid-January (YEAR) he was walking into Resident #1's room to provide assistance for her roommate (Resident #2). When he entered the room, he saw that Licensed Nurse (LN) A was transferring Resident #1 to bed, and saw that Resident #1's briefs were around her knees. LN A told NAC A that he was transfering Resident #1 to bed. At 1:40 PM, NAC C stated LN A did skin checks on Resident #1 even though he worked on a differnt wing and Resident #1 was not one of his assigned residents. NAC C said she had heard LN A make inappropreate jokes regarding Resident #1 such as, takes it anyway she can get it. At 2:00 PM, NAC B stated in (MONTH) (YEAR) she entered Resident #1's room to provide assistance for Resident #2 when she saw LN A in the room with Resident #1. Resident #1 was naked from the waist down and sideways on the bed. LN A stated that he was providing incontient care. NAC B said that she reported concerns of sexual abuse to the Director of Nursing (DON) and Executive Director (ED). The local police incident report documented, on 2/14/18, LN A stated he had been aware of past allegations of inappropriate behavior between Resident #1 and himself, but he did not change the way he provided care to Resident #1. LN A said he actually began spending more time with Resident #1. LN A stated he gave more care to Resident #1 because he liked her personaltiy. LN A stated he knew Resident #1 was highly sexual, and he had touched Resident #1's vagina about five times for non-medical purposes. Reference WAC 388-97-0180-0640 (1)

Based on interview and record review, the facility failed to report to the state survey agency allegations of sexual abuse of a resident for 1 of 3 sampled residents (#1) reviewed for abuse. This failure placed residents at risk of undiscovered and potentially, continued abuse. This failure caused harm to Resident #1. Findings include . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. In a facility statement, dated 11/10/17, Nursing Assistant Certified (NAC) B documented an allegation of sexual abuse. The facility was unable to provide an investigation for this allegation and the allegation was not reported to the state survey agency. On 2/08/18 at 1:00 PM, the Executive Director (ED) stated they did not view the statement as a sexual abuse allegation so they did not report it to the state. Because they did not view this statement as a sexual abuse allegation, they did not question any other residents or staff or conduct any further investigation. At 2:00 PM, NAC B said she reported concerns of sexual abuse to the current Director of Nursing (DON) and ED in (MONTH) (YEAR), and was unaware she was required to notify the state hotline. On 3/15/18 at 12:00 PM, the Interim Director of Nursing stated what should have occurred with an abuse allegation was the incident should have been reported to the state hotline. Refer to F-600 Reference WAC 388-97-0180-0640 (6)(c)

Based on interview and record review, the facility failed to thoroughly investigate allegations of sexual abuse to rule out abuse and neglect and protect residents and prevent further incidents of abuse for 1 of 3 sampled residents (#1) reviewed for abuse. This failure placed residents at risk for abuse and neglect due to lack of thorough investigations. This caused harm to Resident #1. Findings include . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/05/18 at 6:00 PM, when asked about a sexual abuse allegation reported on 02/04/18, the Director of Nursing (DON) stated an investigation had been done in (MONTH) (YEAR) and they had ruled out sexual abuse. The DON stated she believed the allegation made on 02/04/18 to the state hotline was referring to that previous allegation. In a facility statement, dated 11/10/17, Nursing Assistant Certified (NAC) B documented allegations of sexual abuse. On 2/08/18 at 1:00 PM, the Executive Director (ED) stated they did not view this (the above mentioned allegation) as a sexual abuse allegation, they did not question any other residents or staff or conduct any further investigation. The ED said LN A was not suspended from the building at the time. The police incident report, dated 02/18/18, documented, on 02/14/18, LN A indicated he had sexual contact with Resident #1 about five times. On 3/15/18, at 12:00 PM, the Interim Director of Nursing stated what should have occurred with an abuse allegation was that LN A should have been removed from the building pending the results of a facility investigation. Refer to F-600 Reference WAC 388-97-0180-0640 (6)(a)(b)

Based on interview and record review, the facility failed to prevent the development of pressure ulcers/pressure injuries for 1 of 3 sampled residents (#1) reviewed for pressure ulcers. This failure placed residents at risk for the development of pressure ulcers and a diminished quality of life. This caused harm to Resident #1. Findings include . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set, a comprehensive assessment tool, dated 12/23/17, documented Resident #1 had moderately impaired cognition, required supervision or limited assistance with activities of daily living, required supervision and set-up help to ambulate in his room and in the corridor, and did not have an unhealed pressure ulcers. Nursing progress notes documented Resident #1 had an unwitnessed fall on 02/08/18 and sustained substantial injuries resulting in three (3) neck fractures and two (2) [MEDICAL CONDITION]. A nursing note, dated 02/09/18 at 12:10 PM, noted Resident #1 was to return to the facility from the hospital with no changes to his order exception of a C-collar (cervical collar for stabilization). A nurse practitioner note, dated 02/15/18 at 3:38 PM, documented, Patient seen in room. Seen post fall with cervical 1-3 fracture with collar - he took off and I encouraged him and he allowed replacement (of collar). A nursing progress note, dated 02/16/18 at 8:59 PM, documented, Res continues to get up on his own, and remove neck collar. A nursing progress note, dated 02/18/18 at 7:05 PM, documented, Resident took off his Aspin neck collar. Collar is poor fitting and appears too big for resident. When collar removed an abscess to mid upper chest was observed, it began to drain and a large amount of thick white/yellow pus drained. Surrounding area is red. Also resident's collar bones were found to have pressure areas on them from the neck brace. MD notified and new orders received including pad around neck brace and call to find a way to get it refitted or replaced with brace that fits (multiple calls made without progress). A care plan, dated 02/19/18, documented, Actual infection AEB (as evidenced by) infection at neck abscess. The goal was for [MEDICAL CONDITION] will resolve with current TX (treatment). Interventions included to monitor for and notify MD of any ASE (adverse side effects) to ABO (antibiotic); monitor neck abscess for increased warmth, pain, drainage, or other s/sx of increased infection and notify MD; and provide TX as ordered. A nursing progress note, dated 02/19/18 at 7:12 PM, documented, .(Physician) assessed neck collar and ordered resident to have an urgent referral to get collar that fits. Resident has an appointment this Thursday, 02/22/18. In the meantime, abscess on mid chest is covered with foam dressing and bilat (both) clavicles are covered with padding to prevent further skin injury from pressure. A Weekly Skin Evaluation, dated 02/20/18 at 08:00 AM, documented Resident #1 had a pressure ulcer wound on the left clavicle, pressure from cervical collar. Appointment made with trauma surgery follow-up .for refitting of collar. A neurologist consultation, dated 02/22/18, the physician documented Resident #1 presents to neurosurgery clinic for .further recommendations for his care and seeks clarification on duration of wearing hard collar. Under plan, the physician documented, Follow-up advised in 1 month. Patient must wear hard collar without fail for full 6 weeks. Resident #1's (MONTH) (YEAR) Treatment Administration Record (TAR) noted a weekly skin audit to be done on day shift every Tuesday. A plus (sign) indicated new skin impairment, and a minus (sign) indicated no new impairment. On 02/06/18 no new skin issues was documented. On 02/13/18 and 02/20/18, a plus sign was documented indicating new skin impairment. On 03/02/18 at 3:28 PM, when asked whether the expectation was to remove the cervical collar and inspect Resident #1's skin for breakdown during the weekly skin assessments, Licensed Nurse (LN) A said, The nurses didn't want to take it off if they didn't have to. LN A said nursing staff normally assesses skin for breakdown when other medical devices such as leg braces are used. When asked whether nursing should have clarified with the physician orders [REDACTED].#1's skin under the cervical collar, LN A said, Yes, I think that should have been done. I wouldn't have wanted to take it off without an order just because of the risk to the resident. On 03/02/18 at 4:52 PM, when asked whether the pressure ulcers Resident #1 acquired on his chest and collarbone were something expected to develop, LN A, said, No. LN A said it should not have happened. Reference WAC 388-97-1060(3)(b)

Based on observation, interview and record review, the facility failed to implement necessary interventions, consistent with the resident needs, to prevent development of a pressure ulcer for 1 of 2 sampled residents (#56) reviewed for pressure ulcers. This failure caused harm to Resident #56 when the resident developed a facility acquired pressure ulcer. Findings include: Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set, an assessment tool, dated 6/6/17, documented the resident had minimal cognitive impairment and needed extensive assistance of 1-2 person for transferring, toileting and hygiene needs. Resident #56 was frequently incontinent of bowel and bladder and was not on a toileting program. Pressure ulcers were documented as none. Impaired skin integrity care plan was reviewed, and documented excoriated area to buttocks, healed, goal date 7/31/17. On 6/21/17 at 9:02 a.m., Resident #56 was asked, Are you having any pain, heaviness, burning or hurting with no relief? The resident stated, Yes, I have an open sore on my backside. I got it here. At 10:39 a.m., Licensed Nurse (LN) A stated the resident had a Stage III ulcer(defined by National Pressure Ulcer Advisory Panel as full thickness loss of skin) to the right buttocks. On 6/23/17 at 10:43 a.m., LN B showed the resident's diabetic ulcer on the bottom of her left foot when asked about Resident #56's wounds. LN B did not mention a wound to buttocks. At 9:50 a.m., NA B showed the kiosk area where the NAs can reference the care delivery guide for each resident. Resident #56's guide instructed NA staff, to please let nurse know when changing briefs to observe. At 9:55 a.m., the resident's buttocks was observed with an open area in the middle of the right buttock, approximately the size of a dime, with no drainage. About an inch below that area was another open area the size and shape of a kidney bean, open without drainage. Bilateral buttocks were red and the resident stated they were tender. A wound assessment, dated 6/20/17, documented the resident had a Stage III pressure ulcer to the buttocks. On 6/27/17 at 9:12 a.m., LN A stated the Stage III ulcer on the right buttocks was discovered on 6/20/17 during wound rounds. The resident was being seen by the wound team for her foot ulcer at that time. LN A stated, If a resident complained of anything else that hurt or was bothering them we generally check it out while we are doing our rounds. LN A stated the recommendation from the wound team was to use Zinc at that time. LN A stated he could not find documentation in the nursing notes concerning the newly discovered pressure ulcer to the buttocks. The facility failed to monitor resident skin, resulted in a Stage III pressure ulcer to Resident #56. WAC 388-97-1060 (3)(b)

Based on interview and record review, the facility failed to identify weight loss and implement interventions for 1 of 3 sampled residents (#57) reviewed for weight loss. This failure placed the resident at risk for unplanned decline in weight. This resulted in an 8.8% weight loss and harm to Resident #57. Findings include: Resident #57 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the weight record for Resident #57 showed a significant weight loss of 14 pounds during his 3 week stay at the facility. The admission weight on 1/23/17 was 159 pounds. On 1/30/17 the resident refused to be weighed. On 2/6/17 his weight was 147 pounds and on 2/13/17 his weight was 145 pounds. This was an 8.8% weight loss in 14 days. A progress note dated 1/25/17 documented the resident's usual weight was 165 pounds and he stated he lost weight due to having pneumonia. The note referred to the RD assessment completed 1/25/17. Review of a nutrition assessment, dated 1/25/17, showed the resident required 2165 calories and was consuming 1100 calories making the resident at nutritional risk. No interventions were listed to prevent further weight loss. No other nutritional assessments were noted to be made by the RD. Progress notes from 1/23/17 through 2/16/17 showed there was no documentation the weight loss had been identified, the physician or family had been notified, the RD was notified and interventions were made to prevent further weight loss. Review of the February 2017 RD referral book did not include Resident #57. On 6/23/17 at 2:56 p.m., the Registered Dietician (RD) stated the weight loss should have been identified and the interdisciplinary team (IDT) would have followed the resident weekly. On 6/26/17 at 11:49 a.m., the Director of Nursing Service stated if a resident was identified to have lost weight the expectation was that the physician and family would be notified, the RD would be notified and the IDT would follow. WAC 388-97-1060 (3)(h)

Based on interview and record review, the facility failed to prevent the development of an avoidable pressure ulcer for 1 of 9 residents (#3) reviewed for skin issues. This failure caused harm to Resident #3 who developed a pressure ulcer on her heel as a result of interventions applied after an injury which occurred at the facility. Findings include: Resident #3 was admitted to the facility on [DATE] with multiple diagnoses, including dementia, arthritis and [MEDICAL CONDITION]. The Minimum Data Set (MDS), an assessment tool, dated 12/8/16, documented Resident #3 was moderately cognitively impaired and required extensive assistance with activities of daily living. On 2/21/17 at 12:15 p.m., LN A stated on 1/15/17 Resident #3's daughter told her the resident's foot looked swollen and asked LN A to look at Resident #3's foot. LN A stated Resident #3 told her when someone was pushing her in her wheelchair, the resident's foot got caught up in the chair. LN A stated Resident #3's foot looked swollen, she put it on cluster call (a scheduled daily call to the physician), and elevated the resident's foot. LN A said Resident #3 got a sore on the back of her right heel about a week after. A nursing note, dated 1/27/17 at 3:36 p.m., documented the presence of a blister to Resident #3's right heel. The heel was treated with an antiseptic swab and a dressing placed on it. Orders entered in Resident #3's Treatment Administration Record (TAR), dated 1/27/17, called for Resident #3's heels to be floated (elevated on pillows) when in bed. A wound/skin evaluation form, dated 2/21/17, documented Resident #3's right heel blister was identified and measured 4 cm by 6.2 cm (approximately 1.5 by 2.5 inches) on 1/27/17. A nursing note, dated 1/30/17 at 12:53 p.m., documented open area to right heel healing well. Dressing changed per order, no sign of infection noted. A physical therapy clinical note, dated 1/30/17 at 7:50 p.m., documented, Per orders physical therapy to find a soft boot to protect the right heel ulcer. A clinical note, dated 2/15/17 at 9:55 p.m., documented, Resident with new (deep tissue injury) to right heel which may have occurred (related to) wheel chair foot pedal pressure. The facility investigation, dated 2/3/17 at 1:16 p.m., noted it was observed the positioning of Resident #3's foot on the foot pedal of the wheelchair was applying pressure, and therapy placed a brace on the resident's foot to keep all pressure off Resident #3's heel until the wound has resolved. Refer to F-323

Based on interview and record review, the facility failed to prevent injury to 1 of 9 residents (#3) reviewed for accidents when Resident #3's lower leg became trapped under her wheelchair when she was being pushed by a staff member. This failure caused harm to the resident, resulting in pain and delayed treatment. Findings include: Resident #3 was admitted to the facility on [DATE] with multiple diagnoses, including dementia, arthritis and osteoporosis.The Minimum Data Set (MDS), an assessment tool, dated 12/8/16, documented Resident #3 was moderately cognitively impaired and required extensive assistance with activities of daily living, including transfers. The MDS documented the resident could move around the facility independently while in a wheelchair. On 2/14/17 at 2:40 p.m., Resident #3 was observed sitting in a wheelchair wearing a soft boot on her right lower leg. When asked what happened to her leg, Resident #3 stated when she was being pushed in her wheelchair by a staff person, her foot had gotten stuck under the front wheel and it had gotten hurt. On 2/21/17 at 1:04 p.m., NA A stated when she was pushing Resident #3 in her wheelchair to the dining room for lunch, she heard the resident yell out. NA A stated she stopped briefly in the hallway and continued on to the dining room. NA A stated she looked at Resident #3's foot where the resident had complained of pain and didn't really see anything. In a statement dated 1/31/17, NA A documented Resident #3's foot was caught under the wheelchair on 1/13/17. When asked if anyone was told about Resident #3's foot being caught in the wheelchair, NA A said, No. Normally I let the nurse know right away and I didn't that day. I don't know why. NA A said the next time she worked with Resident #3, the resident's foot was wrapped and she had a boot on. NA A stated now she knows to use the foot pedals (foot rests) on the resident's wheelchair. On 2/21/17 at 12:15 p.m., LN A stated Resident #3 had stayed in bed on 1/15/17 and did not feel like getting up. Later that day, Resident #3's daughter told her the resident's foot looked swollen and asked LN A to look at Resident #3's foot. LN A stated Resident #3 told her when someone was pushing her in her wheelchair, the resident's foot got caught up in the chair. LN A stated Resident #3's foot looked swollen, she put it on cluster call (a scheduled daily call to the physician), and elevated the resident's foot. In a nursing note, dated 1/15/17 at 3:49 p.m., LN A documented Resident #3 c/o (complained of) right foot pain. Right ankle swollen. Resident stated her foot got caught up under her wheelchair yesterday while heading to dining room . The facility's investigation, dated 1/29/17, noted LN A stated on 1/15/17 Resident #3 stayed in bed all day. Resident #3's daughter stated her mother's foot appeared to be red and requested that LN A look at it. LN A stated when she asked the resident if she hurt her foot, Resident #3 stated it got caught under her wheelchair on her way to lunch. The resident stated her pain was a 9/10. The resident could not specify what day. LN A said she put the previous day's date because the resident had remained in bed all shift that day (1/15/17). In a statement, dated 1/31/17, NA A documented when she escorted Resident #3 in her wheelchair to the dining room on 1/13/17, her foot dropped and went under - she replied Oh that hurt. I examined ankle and foot - they seemed ok. I took her to the dining room. She seemed ok the rest of the day. The xray results documented Resident #3 sustained a small avulsion (detachment of a bone fragment that results from the pulling away of a ligament or tendon from its point of attachment on a bone) and soft tissue swelling at the front of her lower leg. After consultation with an orthopedist (bone specialist), orders were received on 1/17/17 for Resident #3 to work with physical therapy, and to continue ace wrap, ice and pain medication as needed. On 2/21/17 at 1:48 p.m., the Administrator said NA A was an experienced aide and was surprised she did not tell anyone about the incident when it occurred.

Based on observation, interview and record review the facility failed to ensure timely assessment, consistent monitoring and reporting to the physician in a timely manner for 2 of 3 sampled residents (#'s1, 2) reviewed for care and services. These failures resulted in delayed treatment for [REDACTED]. Findings include: All interviews took place on 1/09/13 unless otherwise specified. Observations were made of the general environment and staff to resident interactions. <Resident #1> Resident #1 had [DIAGNOSES REDACTED]. Resident #1 had been placed on anticoagulation medication in November 2012 when she was discharged from the hospital to the facility. Document review noted Resident #1 was sent to the hospital on [DATE] (time unknown). A hospital report dated 1/05/13, noted Resident #1 was admitted with 3+ [MEDICAL CONDITION] (swelling) up to her knees, she had significant [MEDICAL CONDITION] disease symptoms and she was in heart failure. The report documented the facility had noted increased shortness of breath over the course of 2-3 days prior to her admission to the hospital. Resident #1 passed away in the hospital on [DATE] and was not interviewed. On 1/09/13, the Director of Nursing Services (DNS) said she had completed a medication error report for Resident #1 on 12/27/12. The report documented Resident #1 was to receive a blood thinning medication twice a day to prevent stroke and blood clot formation related to her A-fib diagnosis. The DNS discovered Resident #1 had not received any of the medication for 28 days from 11/29/12 to 12/27/12. The report documented there was no negative outcome to the resident. The DNS stated facility staff did not place Resident #1 on alert monitoring after she did not receive 28 days of medication for her chronic heart condition. There were no chart notes documenting the resident's condition after the medication omission was found on 12/27/12. The DNS acknowledged the resident was not monitored for the medication omission error. On 1/03/13 chart notes documented at 2:00 p.m., Resident #1 complained of being "so tired", her blood pressure was elevated to 190/120 at 8:00 a.m. and then down to 118/56 at 11:00 a.m. No contact was made to the physician. A chart note, dated and timed 1/03/13 at 11:15 p.m., reported the resident should have her blood pressure checked 30-40 minutes after she had her medications. There was no further assessment of the resident until 1/04/13 at 2:00 p.m. On 1/04/13 a chart note documented at 2:00 p.m., Resident #1 was on oxygen (O2) at 3 liters and her oxygen saturation levels were down to 88% (normal ranges would be in the upper 90% range on room air). No contact was made to the physician. There was no further assessment of the resident's condition by any nurse on the following shifts until 2:00 p.m. on 1/05/13. On 1/05/13 a chart note documented at 2:00 p.m., (24 hours later) Resident #1 was "Exhausted, lethargic, somnolent, pale, using accessary neck muscles and pursed lips for breathing. Will send to ER (emergency room ) via ambulance." Licensed Nurse A (LN A) had documented all three notes over the three day period. A facility "Physician Communication and Progress Note " (no date) documented Resident #1 had a problem with inspiratory/expiratory crackles in her lungs that started "possibly yesterday 1-4-13." On 1/09/13, the facility physician acknowledged Resident #1 had not received her blood thinning medication for 28 days so she had to reinstate the medication on 12/27/12. The physician felt the missed medication had no relationship to her condition on 1/05/13. However, the physician stated she was not aware of the change of condition for Resident #1 on 1/04/13, otherwise she would have sent the resident to the emergency room for evaluation. On 1/10/13, the DNS reported LN A had not felt Resident #1 was having a change in condition on 1/04/13 even though she had very low O2 levels as well as the previous high blood pressure reading (a risk factor for stroke). LN A reported the physical therapist had noted the low O2 levels and asked LN A to increase her oxygen (increasing the flow of O2 in a patient with [MEDICAL CONDITION] can cause serious complications and a physician would need to be consulted before increasing levels). On 1/10/13 LN A said on 1/05/13 Resident #1 had been able to complete physical therapy after the O2 was increased. LN A documented she increased the O2 at the instruction of the physical therapist with no consultation to the physician. The DNS acknowledged LN A should have reported the resident's condition to the physician as well as obtaining an order for [REDACTED]. Record review found no follow-up monitoring for missed heart treatment medication. There was no indication the resident was assessed for her condition change for over a 24 hour period until she was in extreme heart failure and sent to the hospital. The facility failed to adequately monitor Resident #1 after she missed medication for almost one month, when she reported feeling weak and tired, experienced low oxygen saturation levels for 2 days and had an abnormally high blood pressure 3 days before she was hospitalized . <Resident #2> Resident #2 had [DIAGNOSES REDACTED]. He was on chronic anticoagulation therapy and was taking significant daily doses of a blood thinning medication that required regular blood test monitoring to prevent the resident from complications of excessive bleeding. Review of a facility policy documented, "Residents receiving anticoagulation medications are monitored for side effects and have [MEDICATION NAME] studies and the International Normalization Ratio (INR) regularly to determine therapeutic dosing ...Ensure all lab results and current orders are updated on [MEDICATION NAME] (blood thinning medication) on flow sheet. Flow sheet and lab results to be faxed (to the physician) for every INR. Do not continue to give [MEDICATION NAME] until new orders are received." Document review noted Resident #2 was sent to the hospital on [DATE] in a "hypo cogulative state" (his blood clotting abilities were low and he was anemic). Tests performed at the hospital noted his blood level ratio testing was extremely high at an INR of 13.1 and hematocrit extremely low at 21 (normal INR levels are 2-3 and hematocrit should be at 42 or higher). Resident #2 had to have the effects of his blood thinning medication reversed and he received 4 units of blood. Resident #2 remained in the hospital and was not interviewed. On 1/09/13 the Director of Nursing Services (DNS) said the policy for monitoring residents on blood thinning medication included regular blood draws to determine the INR and report to the physician with each test. One of her nurses had recently found an issue with nursing staff not monitoring blood thinning medication levels. Review of Resident #2's chart flow sheets for September and October documented Resident #2 had his INR tested on average every 3-7 days and the physician was notified at each blood test. The flow sheets indicated his INR levels ranged from 2 to 3.8 with a high of 5 on 9/20/12. The DNS could not locate any flow sheets for November 2012. By 12/22/12 his INR was dangerously high at 13.1 and he was hospitalized . The DNS thought the November flow sheet may have been sent to the hospital with Resident #2 by mistake. A flow sheet for December was found in the chart dated 12/28/12. On 1/10/12 the DNS reported she had called the lab on 1/10/13 and located an INR completed on 11/05/12 that was not in the resident's record. The DNS noted Resident #2 had refused to have the blood test done on 11/04, 11/20, 11/23 and 12/14/12. The refusals were not documented in the resident's chart. There were no assessments of the resident regarding his refusals or attempts to develop a plan to address monitoring the medication blood levels. Resident #2 had a test done on 11/05/12 and then went for 45 days without having his INR tested . The DNS acknowledged her staff had not informed her or the physician when Resident #2 had multiple refusals to have his blood checked. The DNS said had she known she would have the physician assess Resident #2 and counsel him on the importance of having his blood levels checked to prevent complications from bleeding. .

Based on observation, interview and record review the facility failed to ensure 1 of 2 current sampled residents (#77) reviewed for pressure ulcers. This failure caused the resident to develop a pressure ulcer in the facility,and placed the resident at risk for pain, discomfort, and infection. This caused physical harm to Resident #77. Findings include: Resident #77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Minimum Data Set (MDS), an assessment tool, dated 8/14/11,11/2/11 and 1/22/12, documented the resident was at risk for developing pressure ulcers. On 12/28/11, an entry in the resident's medical record, and written by a wound nurse, documented a "dusky blister type area " on the resident's remaining heel of his right foot, the skin was intact. It documented " found a piece of adhesive fabric/tape in the heel of shoe, and the seam on it matches where the blister is. This was removed from his shoe." The area was covered with a dressing. The plan written by the wound nurse for the facility to follow was " Please increase foot checks for pressure areas and perhaps have shoe insole/insides of the shoes for causes of pressure." There was no documentation the shoe was changed at the wound clinic. A facility Pressure Ulcer Investigation Form, dated 12/29/11, documented the cause of the right heel pressure ulcer was the resident's shoe. It documented the intervention was "shoe was padded by hospital wound clinic, will see a podiatrist to have shoe evaluated for pressure areas," and the treatment for [REDACTED]. A facility Care Conference Meeting, dated 1/11/12, documented the resident agreed to go to the podiatrist for a shoe and foot evaluation. The resident's MDS, dated [DATE], documented the resident had an unstageable pressure wound that was not present on admit. On 2/1/12 the facility Nutritional Note Progress Notes documented by the DNS stated the resident had not gone to the podiatrist for a foot and shoe evaluation, and that the wound was 0.6 x 0.4 centimeters. The facility Pressure Ulcer care plan documented 3/19/12 the resident's pressure ulcer to his heel that was identified 12/28/11. It documented the goal was for the pressure ulcer to "exhibit signs of healing,evidenced by decrease in size, improved appearance,and be free from signs and symptoms of infection" with a target date documented as 5/20/12. On 3/26/12, a patient note from a hospital in the resident's medical record, by the same wound nurse indicated, "the gentleman is here today for wound care to his right heel pressure ulcer. This lesion started some time ago with a piece of tape in his shoe. I have instructed the patent in previous visits for a different wound to have his shoes checked and possibly the insert re-fitted. He states this will be done on Thursday." The note documented that the skin was open, and "presents with a dusky base, and about 30% slough. The periwound is macerated and peeling." The plan by the wound nurse was to put a specialized medical grade honey to the area with slough and cover with a foam dressing. On 4/3/12, at 4:33 p.m., the Director of Nursing (DNS) stated the resident's right heel pressure ulcer, had started (was acquired) in the facility. She stated the resident had been told to not stay in his wheelchair for extended periods of time, but there wasn't other inventions tried to decrease the pressure to that area. She indicated the resident had not seen the podiatrist as of yet to have his foot and/or shoe evaluated. The facility identified the resident was at high risk for developing pressure ulcers in the Braden Skin Assessment, MDS and Pressure Ulcer care plan. There was no documentation in the resident's medical record of the facility providing interventions to remove the source identified as the causal factor of the ulcer (the resident's shoe), decrease the pressure to the area, or reassess the current interventions on the care plan. At 4:52 p.m., the wound and dressing change was observed with Resident Care Managers (RCM) A and B. The wound was measured by RCM A as 2.5 x 4.5 x 0.2 centimeters. The wound was red, and peeling around the perimeter of the wound, and the center was macerated (soggy, wrinkling) and white. RCM A was stopped prior to using contaminated gloves on the open wound bed. RCM B was observed not wearing gloves while touching the resident's heel while the contaminated old dressing was removed. At 6:42 p.m., the DNS stated she knew the RCMs had not done the dressing change correctly, the wound went from being intact to open, but felt the medical grade honey had improved the wound, and that it would continue to improve. .