Every finding on record at Sullivan Park Care Center

Based on observation, interview and record review, the facility failed to provide food at proper temperatures and palatable taste for 5 of 8 residents (Resident 4, 97, 92, 56 and 48) reviewed for food. This failure placed residents at risk for foodborne illness, decreased nutritional intake and weight loss. Findings included. Review of a policy titled, Food Safety, dated 02/2019, showed cold products will reach temperatures no greater than 41 degrees Fahrenheit (F-unit of measure). Review of a facility undated document titled Schedule of Mealtimes, showed Breakfast was served between 7:00 AM to 8:00AM, Lunch was served from 12:00 PM to 1:00PM and Dinner was served from 5:00 PM to 6:00 PM. Resident 4 During an interview on 06/22/2026 at 9:32 AM, Resident 4 stated the warm food they received was cold and the cold food was warm. Resident 97 During an interview on 06/21/2026 at 2:51 PM, Resident 97 stated the drinks they were provided were warm and not cold, and the ice cream was melted by the time they received their meals. During an observation on 06/23/2026 at 1:14 PM, Staff M, Dietary Manager, served a test tray to the surveyors and was checked for temperatures by Staff M, with the following results: Milk 48.9 F degrees Orange Juice 57.9 F degrees Strawberry Yogurt 44.2 F degrees Normal Range for cold food and drink is at or below 41 F degrees During a second test tray observation and concurrent interview on 06/24/2026 at 1:22 PM, Staff M served the test tray to the surveyors and checked the temperatures with the following results: Milk 52 F degrees Apple Juice 51.3 F degrees Peach Yogurt 60.4 F degrees Staff M stated the temperatures of the food and drink items were not within the required parameters for service and confirmed the cold food and drinks should be held at 41 F degrees or lower. Resident 92 During an interview on 06/21/2026 at 10:43 AM, Resident 92 stated they did not receive their breakfast until 9:45 AM that morning. Resident 92 stated their breakfast was cold and not hot or even warm. Resident 92 stated the food was lousy. Resident 92 stated the meat was very dry and difficult to eat. Resident 92 stated there was no organized system for food trays to be distributed timely. Resident 92 stated the staff would search through the food cart to get a resident's tray and then deliver to where there were, either the dining table or their rooms. An observation on 06/21/2026 at 12:50 PM showed the Hall 100 food cart delivered for lunch. During the lunch tray deliveries, the food cart door was left open for 14 minutes. During a follow-up interview on 06/25/2026 at 10:11 AM, Resident 92 stated their dinner the previous night was orange chicken that they could not cut it up as it was too tough, vegetables were mushy and the rice was terrible. Resident 92 stated they did not receive this morning's breakfast for 15 minutes after it was delivered to their area and their food was cold. Resident 56 During an interview on 06/21/2026 at 11:51 AM, Resident 56 stated the food was served cold when it should have been hot. Resident 56 stated the meat they would be served was very thin and overcooked and they did not like it. Resident 56 stated the meals were repetitive and lacked taste. Resident 48 During an interview on 06/21/2026 at 12:30 PM, Resident 48 stated the food tasted terrible. Resident 48 stated the food was cold, when it should be hot, and overcooked. Resident 48 stated the tuna fish and egg salad were horrible, and the tomato soup tasted like lukewarm tomato juice. An observation on 06/24/2026 at 1:03 PM showed the Hall 200 food cart delivered for lunch. During the lunch tray deliveries, the food cart door was left open for 13 minutes. During a follow-up interview on 06/25/2026 at 9:01 AM, Resident 48 stated the food was still lukewarm, never hot and tasted bad. Resident 48 stated their dinner the previous evening was mushy vegetables, chicken had soggy breading and tasted frozen. Resident 48 stated they could not tolerate the meal, and it was icky. Resident 48 stated they were aware of other options, however that would include tuna fish and egg salad which was horrible and not fresh tasting. Reference WAC: 388-97-1100(1)(2)(3)

Based on observation, interview, and record review, the facility failed to 1) ensure dry goods and refrigerated foods were properly stored, covered, and labeled with use-by dates for food safety tracking, and 2) maintain the kitchen, dishwashing area, entrance, and rear exit environments in a clean, sanitary, and repaired condition to prevent cross-contamination (harmful spread of diseases) for 1 of 1 kitchen reviewed. These failures placed residents at an increased risk for foodborne illnesses. Findings included.Review of the Washington State Retail Food Code [PHONE NUMBER]6(1)(2)(a)(b)(3)(4), dated March 1, 2022, showed ready-to-eat or refrigerated, time/temperature control for food safety must be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than twenty-four hours, to indicate the date or day by which the food must be consumed on the premises. Prepared foods must have the date or day of preparation, with a date to discard the food on or before the last date or day the food can be consumed on the premises. Review of the Washington State Retail Food Code [PHONE NUMBER]1(1)(a)(b)(c)(2)(3), dated March 1, 2022, showed food must be protected from contamination by storing the food in a clean, dry location at least six inches above the floor. Review of the Washington State Retail Food Code [PHONE NUMBER]0 and [PHONE NUMBER]0(3), dated March 1, 2022, showed physical plant structures and equipment must be maintained in good repair and kept clean and free of an accumulation of dust, dirt, food debris, grease, and grime. Review of facility's policy titled, Food Storage, dated 07/25/2024 showed foods shall be received and stored in a manner that complies with safe food handling practices. Staff were to label and date all foods when they were opened and the date when the food items must be used by. During the initial kitchen observation on 06/21/2026 at 8:36 AM showed the following: Dry storage: one case of milk used to prop open a door, one box containing five containers of salt, one container of Glucerna (brand of nutritional supplement drink), and one Ensure (brand of nutritional supplement drink) stored on the floor. Additionally, there were two cases of frozen chicken breasts stored on the freezer floor. Uncovered food: a cooling rack that held three trays of cookies, one tray of chocolate brownies, and five pieces of pecan pie were completely uncovered in a high-traffic area where staff traveled in and out of the kitchen. Food labeling: Multiple prepared foods and bulk storage items without appropriate or clear dates; Cookie bin: 22 bags of chocolate chip cookies with no dates,Refrigerator number one: 18 glasses of apple juice, 27 glasses of cranberry juice, 28 glasses of orange juice, 36 glasses of milk and seven glasses of thickened juice all without dates. Walk-in refrigerator showed a single date for: salad mix 06/06, tuna 06/15, applesauce 06/16, chocolate pudding 06/17, pan of white cake 06/17, egg salad 06/20 and two opened bags of lettuce. Kitchen bulk bins showed a single date for: flour 06/01 rice 06/02, and sugar 06/05.Dry storage bins showed a single date for: breadcrumbs 04/10, oats 06/02, brown sugar 06/16. During an interview on 06/21/2026 at 8:50 AM, Staff V, Cook, stated they thought the markings on the food items were made dates. Staff V stated there were no use by dates and they were unsure what the dates meant. During an interview on 06/21/2026 at 9:20 AM, Staff M, Dietary Manager, stated the facility does not place use by dates on food bins or prepared food. During a concurrent observation and interview on 06/22/2026 at 11:42 AM, Staff W, Cook, stated the single dates on the flour, sugar, oats and rice bulk bins were the dates the items were originally placed into the bins. Staff W stated they did not know when the bulk items should be used by. Staff W stated they assumed the standard was maybe three months. Staff W stated the food items in the walk-in refrigerator had a prepared dated and no use by date. Staff W stated the kitchen standard was to never use an item after it had been stored for more than three days. However, direct observation showed multiple food items exceeded this threshold. Staff W showed a container of applesauce dated 06/15 (six days old) and a container of white cheese dated 06/06 (15 days old), and stated these items were not good and should be thrown out. Environment Dishwashing drain: showed the food trap and drain underneath the dishwasher was filled to the top with food and debris.Wall maintenance: showed the entire length of the wall located directly behind the dishwasher was heavily coated in accumulated black dirt, grease and grime.Floor cleanliness: showed the entire floor surface underneath the dishwasher covered in garbage, black grease and grime.Walk-in cooler: showed the wall located to the left of the walk-in cooler had damage on the lower portion of the walk-in door. The metal wall covering was pulling away from the wall. A two-foot section at the bottom was completely open and detached and exposed the underlying wall, studs, accumulated dirt and black grime.Dish room door: showed the door that led into the dish room had deep scratches, exposed bare wood, with visible grease and grime that dripped down the door front Kitchen Entrance and Rear Exit An observation on 06/22/2026 at 3:04 PM showed:Entrance door: to the right side of the door a 9 inch (in- a unit of measure) by 5 in. section of missing paint alongside eight exposed drill holes. A utility access cover to a piping system failed to close that left interior pipes completely exposed and revealed a heavy rust accumulation along the bottom of the covering. Multiple quarter and dime sized areas had chipped paint visible throughout the entrance. The carpeted hallway that led to the back door was littered with scattered garbage that included a pile of mixed garbage in the corner to the right of the kitchen door. The back door was heavily coated in grease and grime with prominent black streaks and drippings. There was a four in. section of metal weather stripping at the bottom right of the back door that was bent and broken. During a concurrent observation and interview on 06/24/2026 at 10:22 AM, Staff M stated the expectation was for each shift to clean the kitchen, with sweeping and mopping completed each night. Staff M observed the area underneath the dishwasher, kitchen hallway and dishwasher walls and stated that the area had not been cleaned, and they expected the cleaning to be done daily, and it had not been completed. During a combined observation and interview on 06/24/2026 at 10:39 AM, Staff J, Maintenance Director and Staff A, Administrator, reviewed the kitchen environment. Staff J stated the kitchen definitely need to have more attention. Staff A stated the kitchen needed work and agreed the area was not clean. Reference WAC: 388-97-1100(3), 388-97-2980(3)

Based on observation, interview, and record review, the facility failed to ensure Enhanced Barrier Precautions (EBP- precautions to protect residents from multidrug-resistant organisms [MDRO-a germs that are resistant to medications that treat infections]) were identified for 1 of 3 residents (Resident 148) reviewed for infection control. Additionally, the facility failed to ensure EBP, and hand hygiene were implemented for 2 of 2 residents (Resident 6 and 139) as required during urinary catheterizations (a flexible tube inserted through the urethra [a small duct that carries urine from the bladder] into the bladder to drain urine). This failure placed the residents at risk for the spread of infections, illnesses and unnecessary health consequences. Findings included. Review of Centers for Disease Control and Prevention (CDC) guidance titled Enhanced Barrier Precautions in Nursing Homes, dated 06/2024, showed EBP's were an infection control intervention to reduce transmission of MDROs in nursing homes. EBPs required personal protective equipment (PPE-gloves, gown and face protection when performing an activity with risk of splash or spray) used during high-contact resident care activities, that include dressing, bathing, transferring, hygiene care, linen changes, changing briefs or toilet assistance, device care (urinary catheters) and wound care, for residents known to be colonized or infected with an MDRO and residents at increased risk of obtaining an MDRO. Resident 148 Review of Resident 148's medical record showed they were admitted to the facility with diagnoses which included dementia (a decline in mental function), Parkinson's disease (a progressive disease that destroys nerve cells) and history of bladder cancer with a urostomy (an opening in the abdomen which allows urine to drain into a collection bag). The comprehensive assessment dated [DATE] showed Resident 148 had an impaired cognition and required substantial assistance from staff members for activities of daily living (ADLs), including dressing, grooming, bathing and elimination needs. Review of Resident 148's admission nurse form, dated 06/13/2025, showed while in the hospital the resident was treated for MDROs in their urine with intravenous antibiotics (antibiotics delivered directly into the blood stream by a small needle inserted into a vein). The source of the infection was identified in the resident's urinary tract and required EBP upon admission to the facility to mitigate the risk of spreading the infection. During multiple observations of Resident 148's room showed on 06/21/2026 at 9:53 AM, 06/22/2026 at 10:22 AM, and 06/23/2026 at 10:26 AM, there was no EBP signage posted outside the resident's room to identify the staff requirement to follow EBP. During an observation and concurrent interview on 06/23/2026 at 11:30 AM, showed Staff U, Nursing Assistant (NA) and Staff Z, NA, assist Resident 148 to the restroom. Staff Z obtained a urinal and emptied Resident 148's urinary catheter bag wearing gloves only. Staff U assisted Resident 148 to change their clothes and wore only gloves. Staff U and Staff Z stated Resident 148 did not have an EBP sign posted to identify if they required EBP and there was not a supply of gowns or other PPE placed near Resident 148's room. During an interview on 06/24/2026 at 11:23 AM, Staff B, Director of Nursing, stated their expectation was residents that admitted with catheters were to be placed on EBPs and Resident 148 had been missed. Staff B stated staff were expected to wear correct PPE, including gown and gloves before providing care to the residents. Resident 6 Resident 6 was admitted to the facility with diagnoses including multiple sclerosis (a disease that damages communication between the brain and body, leading to muscle weakness, vision changes and memory issues), neuromuscular dysfunction of the bladder (nerve damage that interferes with normal control for bladder storage and emptying), and sepsis (a life-threatening body infection). The 06/06/2026 comprehensive assessment showed Resident 5 required the assistance of one staff member for ADLs and had an intact cognition. Review of the medical record showed Resident 139 was admitted to the facility on [DATE] with diagnoses including benign prostatic hyperplasia (BPH-a noncancerous enlargement of the prostate gland) with urinary retention (unable to empty all the urine from the bladder), recurrent urinary tract infections (infection in any part of the urinary system), and a left below the knee amputation. Review of Resident 139's nursing admission note, dated 06/19/2026 at 3:04 PM, showed they were alert and oriented, required the assistance of one staff member for transfers and care. An observation on 06/23/2026 at 3:04 PM, showed Staff Q, Licensed Practical Nurse, entered Resident 6's room that had an EBP sign on their door to perform a urinary catheterization (a procedure that requires a flexible tube be inserted through the urethra into the bladder to drain urine) for Resident 6. Staff Q performed hand hygiene and donned (put on) clean gloves and did not don a gown. Staff Q placed a urinary catheterization kit on Resident 6's bedside table and proceeded to obtain a cleaning wipe and wipe down the bedside table, then removed their gloves and placed them into the trash. In the same observation, Staff Q donned another pair of gloves, without performing hand hygiene, obtained two urinals from the restroom, opened the urinary catheterization kit, removed two protective drapes and placed one on the resident's bed and the other around Resident 6's genitalia. Staff Q removed the cleansing swabs from the kit and swabbed Resident 6's genitalia, removed gloves then removed sterile gloves from the kit and donned, without performing hand hygiene. Staff Q proceeded to prepare the urinary catheter as required and with their left hand, held Resident 6's genitalia and with their right hand, inserted the urinary catheter into the urethra until urine returned and flowed into a urinal. Upon completion of the urinary catheterization, Staff Q removed the catheter and placed it into the trash, removed their gloves, obtained another clean pair of gloves from the box and donned, then dumped the urine form the urinal into the toilet, and then rinsed the urinal in the resident's sink. Staff Q then returned to the bedside and collected all the used items and placed them into the trash and removed gloves and used hand sanitizer. Resident 139 Review of the medical record showed Resident 139 was admitted to the facility on [DATE] with diagnoses including benign prostatic hyperplasia (BPH-a noncancerous enlargement of the prostate gland) with urinary retention (unable to empty all the urine from the bladder), recurrent urinary tract infections (infection in any part of the urinary system), and a left below the knee amputation. Review of Resident 139's nursing admission note, dated 06/19/2026 at 3:04 PM, showed they were alert and oriented, required the assistance of one staff member for transfers and care. An observation on 06/23/2026 at 3:36 PM, showed Staff Q entered Resident 139's room that was identified as EBP by a posted sign on their door, without a gown as required. Staff Q donned gloves and placed the urinary catheterization kit onto the resident's bedside table. Staff Q removed Resident 139's pants and briefs, opened the kit, removed a drape and placed next to the resident on their bed and a second around the resident's genitalia. Staff Q removed their gloves and donned sterile gloves from the kit without hand hygiene. Staff Q removed the catheter and placed onto the sterile glove package, opened the lubricant and cleanser swab and with their left hand held the Resident 139's genitalia and used their right hand to cleanse the genitalia with the swab. Staff Q removed their left hand from Resident 139 once they completed the cleansing and obtained another cleansing swab from the package and did a secondary cleansing and then disposed into the trash. Staff Q proceeded to obtain the catheter and apply lubricant then inserted into Resident 139's urethra and placed a urinal between the resident's legs to collect the urine. When urine began to flow into the urinal, Staff Q took their right hand and rested on their lower back with soiled gloves on, then after a moment placed the same hand back on the catheter. When urine stopped flowing, Staff Q withdrew the catheter and removed the drapes and placed them into the trash. Staff Q took the urinal to the toilet and poured out the urine, rinsed the used urinal in the resident's sink, removed their gloves and donned new gloves without hand hygiene. Staff Q returned to Resident 139's bedside to pull up their brief and pants and assist with bed positioning. Staff Q removed their gloves and donned new gloves without hand hygiene, obtained peri-care wipes from Resident 139's cupboard and cleansed Resident 139's peri-area, when Staff Q completed the care, continued to pull up the resident's brief and pants. Staff Q gathered the used urinary catheter kit supplies and removed their gloves, placed them into the trash and with their bare hands, tied up the trash bag, grabbed a box of gloves, placed the resident's cell phone, water cup and miscellaneous papers and glasses back onto the bedside table. During an interview on 06/23/2026 at 3:52 PM, Staff Q stated they tried to maintain sterility with both resident's urinary catheterizations. Staff Q stated they did change their gloves many times as they were trying not to cross-contaminate. Staff Q stated they were supposed to use hand sanitizer each time they changed gloves or were contaminated, but they did not. Staff Q stated they did not want to bring and leave a sanitizer into the residents' rooms and did not want to use the wall mounted hand sanitizer in their rooms, as they did not want to keep going back and forth during the urinary catheterizations. Staff Q stated they were supposed to wear a gown for both residents as they were on EBP. Staff Q stated EBP was to protect the residents from any contamination, and they did not follow the EBP requirements. During an interview on 06/24/2026 at 4:57 PM, Staff A, Administrator, stated all staff should be using PPE and sanitizing hands when necessary and required. Staff A stated Staff Q should have worn EBP protections during the urinary catheterizations. Reference WAC: 388-97-1320(1)(a)(c)(5)(b)

Based on observation, interview, and record review, the facility failed to maintain a clean, safe, and homelike environment for 2 of 3 residents (Residents 13 and 6) and 4 of 6 shower rooms (Halls 100, 200, 500, and 600), reviewed for environment. This failure placed the residents at risk for potential accidents and not feeling safe/secure with their living conditions. Findings included . Review of the facility's policy titled, Maintenance Service, dated 12/2009, showed the maintenance director was responsible for developing and maintaining a schedule of maintenance service to ensure that the building, grounds, and equipment are maintained in a safe and operable manner. The maintenance director was also responsible for maintaining the building in good repair and free of hazards. Resident 56 Resident 56 was admitted to the facility with diagnoses including necrotizing fasciitis (an aggressive tissue bacterial infection), asthma (a condition that causes airways to swell, narrow and fill with mucous), and obesity. The 06/03/2026 comprehensive assessment showed Resident 56 required the assistance of one staff member for bathing and had an intact cognition. Resident 103 Resident 103 was admitted to the facility to the facility on [DATE] with diagnoses including lung and brain cancer, malnutrition, and anxiety. The 05/19/2026 comprehensive assessment showed Resident 103 was independent for activities of daily living (ADLs) and an intact cognition. Resident 9 Resident 9 was admitted to the facility with diagnoses including chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), diabetes (excess sugar in the blood), and depression. The 06/18/2026 comprehensive assessment showed Resident 9 required the assistance of one staff member for showering and set-up of assistance for ADLs. The assessment also showed Resident 9 had a moderate impaired cognition. Shower rooms An observation on 06/21/2026 at 10:30 AM, showed the shower room on the 500 Hall had a strong odor of mildew present inside the shower stall area. The interior left wall of the shower stall showed severe water damage, including deep gouges (deep groove, scratch on a surface) measuring 12 inches (in-a unit of measure) by five in, which exposed the underlying drywall (type of board used to create walls) and metal structural framing. The opposite side of this left wall showed peeling paint and multiple areas of missing paint, exposing the underlying drywall. Additionally, the right wall of the shower stall showed water damage with bubbling paint measuring five in by two in, exposing the underlying drywall and metal. The ledge situated to the right of the shower area had an unsealed, loose metal top piece measuring two feet (ft- a unit of measure) that was pulled upward, creating sharp, jagged metal edges. An observation on 06/21/2026 at 10:42 AM, showed the shower room on the 600 Hall shower stall edges were sealed with four ft of duct tape applied to the vertical edges on both sides. The top right edge of the stall was missing a six in section of tile, exposing sharp edges. The handwashing sink was pulling away from the structural wall, with chipped and missing paint that exposed the underlying drywall. Behind the toilet fixture, two baseball-sized unpainted circular areas with exposed screw holes were present on both the right and left sides of the wall. Lying loose across the wall within physical reach was a sharp-edged metal corner piece with jagged edges pointed upward. A black and brown substance was accumulated around the perimeter edges of the tile inside the shower stall. The front area of the shower stall exhibited a four in by two in section of cracked and missing tile, and the interior wall to the right of the entryway door showed multiple dime- to quarter- sized deep scratches that exposed the underlying drywall. During an interview on 06/21/2026 at 11:51 AM, Resident 56 stated the shower room on Hall 100, was moldy and had poor ventilation. Resident 56 stated they did not like to shower there and made it hard for them to breathe. An observation on 06/21/2026 at 1:49 PM, showed the 100 Hall shower room, had multiple broken floor tiles that were crushed and had blackish/brown debris in the grout lines within the shower stall area. The short wall that created the shower stall area had blackish/brown thick debris that connected the shower wall to the floor. On the right side of the shower area was a one ft by three ft area of brown/yellow film that covered the floor tiles. To the right of the shower stall area was a blue bin that overflowed with used white towels and a bag of dirty clothes. To the left of the shower stall area were 12 broken and crushed floor tiles with exposed concrete and blackish/brown debris in the grout lines. To the left of the shower area was a bedside table with white towels and a brown film on the exposed table area. There was a shower chair lying on its side, surrounded by a reddish/brown film on the floor. Along the back wall near the shower area and toilet was a five ft area of loose tile, with blackish/brown debris exposed and white caulking peeling from the wall. An observation on 06/21/2026 at 1:54 PM, showed the 200 Hall shower room had a four ft section of wall that was cracked and peeling paint. The floor in the shower stall area had a 10 in by eight in section of the linoleum peeled up and exposed concrete with stagnant water. The surrounding area of the peeling linoleum showed a six in by five in area of white/green cracked discoloration. The wall in the shower stall area had an eight inch by 10 in section in the center of the wall that had peeled paint that was white/green discolored and missing paint that exposed the underlayment and metal mesh. The shower room perimeter had a white powdery substance along the mopboard and floor joint. In the right corner of the shower room was a mounted metal cabinet with a brown, rusty orange color on the cabinet. On top of the metal cabinet was a pile of white bath towels, blue pants and an open package of incontinence briefs. During an interview on 06/24/2026 at 10:29 AM, Staff J, Maintenance Director, stated the staff communicated any issues or repairs needed through the TELS (an electronic computer system used to create work orders). Staff J stated they were not notified through the electronic system, so they did not receive a work order for the issue. Staff J stated they frequently identified issues through their own observations because staff frequently failed to use the TELS system. Staff J stated they did not conduct walking rounds of the facility on a consistent schedule and only performed room checks for repairs needed twice a year. Staff J stated their daily walking rounds were just to check for any obstructions and critical issues. Staff J further stated they were aware that the shower rooms in the facility needed a lot of work. During an interview on 06/24/2026 at 10:50 AM, Staff T, Nursing Assistant, stated they bathed residents in the shower rooms. Staff T stated they were aware of the condition of the shower rooms and have entered repair requests into TELS as required. Staff T stated the walls had peeling paint and room would become very hot and residents complained. Staff T stated there was a metal piece on the right shower stall ledge that had a metal piece that was lifted and was a safety concern, as a resident may harm themselves on it. During an interview on 06/24/2026 at 10:57 AM, Resident 103 stated they did not take showers at the facility because the shower room in their hall, (500 Hall), was in bad condition. Resident 103 stated they left the facility to shower at a friend's home. Resident 103 stated the shower room had holes in the walls, peeling paint and crumbling areas of the walls. During an interview on 06/24/2026 at 11:03 AM, Resident 9 stated the shower room on Hall 500 was terrible. Resident 9 stated it was moldy, with green and brown areas on the walls that were falling apart. Resident 9 stated one side of the shower stall ledge had a metal piece on the top that was lifted and sharp. Resident 9 stated to bathe in that shower room made them feel disgusting. During an interview on 06/24/2026 at 10:39 AM, Staff A, Administrator, stated they expected maintenance rounds to be completed monthly. Staff A stated they were aware of the physical deficiencies in the shower rooms. Staff A further stated walking rounds have not been completed and acknowledged the shower rooms needed attention. Resident Rooms Resident room [ROOM NUMBER]-A Resident 13 was admitted to the facility with diagnoses including Alzheimer's (a progressive disease that destroys memory and other important mental functions), sepsis, and hospice care (a type of care that focuses on comfort and quality of life for an individual who was terminally ill or near the end of their life). The 05/21/2026 comprehensive assessment showed Resident 13 was dependent on one to two staff members for ADLs and had a severe impaired cognition. An observation on 06/22/2026 at 10:23 AM, showed Resident 13's room had an exterior electrical outlet that was located near the floor on the wall. The area above the outlet had missing paint and exposed drywall and deep gouges. The electrical wire covering was not mounted on the wall evenly and showed unpainted areas, exposed drywall, white patches and scrapes. Resident room [ROOM NUMBER]-A Resident 6 was admitted to the facility with diagnoses including multiple sclerosis (a disease that damages communication between the brain and body, leading to muscle weakness, vision changes and memory issues), emphysema (a lung condition that makes it hard to breathe), and sepsis (a life-threatening body infection). The 06/06/2026 comprehensive assessment showed Resident 5 required the assistance of one staff member for ADLs and had an intact cognition. During a concurrent observation and interview on 06/23/2026 at 2:53 PM, showed Resident 6's bathroom had two holes in the wall across from the toilet that was covered with blue tape that was peeling. The wall next to the toilet had two areas behind the grab bar, three inches by three-inch round areas that were unpainted. The bathroom base trim was peeling from the wall on the left side of the room. The bathroom wood door had multiple long scratches across the front and back of the door that discolored the wood. The wall next to Resident 6's bed had deep gouges and scrapes four feet up their wall by their bed. Resident 6 stated the room looked like s**t, and their bathroom and room should be in a better condition. During an interview on 06/25/2026 at 8:52 AM, Staff A, Administrator, stated they would need to speak to maintenance and have these identified areas repaired. Reference: WAC 388-97-0880(1)(2)

Based on observation, interview and record review the facility failed to ensure a resident was free from physical restraints and had an evaluation and documented medical symptoms to validate the use of restraints for 1 of 2 residents (Resident 148) reviewed for restraints. Additionally, the resident's record did not show the least restrictive alternatives had been attempted prior to the restraint use or documentation of ongoing monitoring. This failure placed the residents at risk for injury, agitation and a decline in physical function. Findings included. Review of a facility policy titled Physical Restraints and Enabler Devices revised 07/2023 showed the definition of a restraint is as follows; A) Is attached or adjacent to the resident's body, B) Cannot be removed by the resident, C) Restricts the residents' freedom of movement. Resident 148 Review of Resident 148's medical record showed they were admitted to the facility with diagnoses which included dementia (a decline in mental ability) and Parkinson's disease (a progressive disease that destroys nerve function). Review of the resident's comprehensive assessment dated [DATE] showed the resident had cognitive impairment and required substantial assistance from staff for daily activities including dressing, grooming, bathing and mobility. During an observation on 06/21/2026 from 9:52 AM to 11:10 AM, showed Resident 148 in their room lying in bed. There were three pillows in the bed and a pillow on the floor. One side of the resident's bed was against the wall, and the other side was open to the room. The side open to the room had the sheet pulled up and a pillow wedged under the sheet creating a barrier to the edge of the bed. The resident attempted to roll to their right side, however had limited bed mobility related to the pillow that had been placed under the sheet. During an observation on 06/23/2026 from 10:11 AM to 11:30 AM, showed Resident 148 in the common area of the unit reclined in a lounge chair. The resident was not dressed and still in their night clothes with a blanket covering their lower body. The resident kicked their blanket off several times and attempted to get up, however was unable to related to the chair being in a reclined position which prevented them from rising. During an interview on 06/23/2026 at 11:09 AM, Staff U, Nursing Assistant, (NA), stated that Resident 148 had a rough night was agitated and had refused cares. Staff U stated the resident had been put in the lounge chair in the common area to provide enhanced supervision and the resident was unable to get out of the chair once placed in it. Additional medical record review showed Resident 148 had not been evaluated for medical symptoms to justify the use of a pillow under their sheet limiting bed mobility or for the lounge chair which prevented them from rising. The physician had not been notified for orders, or documentation of interventions to include least restrictive alternatives prior to the use of restrictive measures. During an interview on 06/24/2026 at 10:23 AM, Staff B, Director of Nursing, agreed that the pillow used to create a bed barrier and the lounge chair that prevented Resident 148 from rising would be considered restraints and required the appropriate assessments and follow up for use. Reference WAC 388-97-0620(1)

Based on interview and record review the facility failed to review and validate the Preadmission Screening and Resident Reviews ([PASARR], an assessment to ensure individuals with serious mental illness [SMI] or intellectual/developmental disabilities [ID/DD] were not inappropriately placed in nursing homes for long term care) had the required Level 2 referrals sent, or responded to in a timely manner by a licensed mental health professional when residents had a positive Level 1 PASARR for 2 of 5 residents (Resident 14, 97, ) reviewed for PASARR. This failure placed the residents at risk for not receiving the care and services appropriate for their needs. Findings included. Review of the facility policy titled, PASARR Process Revised 03/2019, showed when a Level 2 evaluation was indicated the Social Worker would ensure that a licensed mental health professional was scheduled to evaluate the resident. The Level 2 evaluator would determine if the residents' current care needs were able to be met at the facility and would provide recommendations to be incorporated into the current care plan. Resident 14 Review of Resident 14's medical record showed they admitted to the facility on [DATE] with diagnoses to include an anxiety disorder (a mental health condition characterized by intense, excessive, and persistent worry or fear about everyday situations), depression (a serious mood disorder that causes a persistent feeling of sadness, emptiness, and a loss of interest in activities), and a psychotic disorder with delusions (a mental health condition where a person experiences a persistent, unshakable belief in something that was completely untrue, even when presented with clear truth). Resident 14's comprehensive assessment dated [DATE], showed the resident's cognition was moderately impaired and required the assistance of one staff member for activities of daily living (ADLs). Review of Resident 14's PASARR dated 06/10/2026, showed under Section 1, SMI/ID the resident had two mental health diagnoses marked yes, specifically mood disorder, and an anxiety disorder. A referral for a Level 2 PASARR was required when any questions in Section 1A (1, 2, and/or 3) were marked yes. Review of Resident 14's medical records showed no referral had been sent for the Level 2 PASARR. Resident 97 Review of Resident 97's medical record showed they admitted to the facility on [DATE], with diagnoses including depression and Post Traumatic Stress Disorder ([PTSD], a mental health condition triggered by experiencing or witnessing a terrifying or life-threatening event). Resident 97's comprehensive assessment dated [DATE], showed the resident's cognition was moderately impaired and required supervision for ADLs. Review of Resident 97's PASARR dated 05/29/2026, showed under Section 1, SMI/ID the resident had two mental health diagnoses marked yes, specifically PTSD and other. A referral for a Level 2 PASARR was required if any questions in Section 1A (1, 2, and/or 3) were marked yes. Review of Resident 97's medical records showed no referral had been sent for the Level 2 PASARR. During an interview on 06/23/2026 at 10:08 AM, Staff G, Social Service Director, (SSD) stated they were responsible for ensuring Level 2 PASARR evaluations were completed. Staff B stated a Level 2 referral must be submitted whenever triggers appear on the Level 1 SMI section, and they routinely waited a month after admission to act. Staff B stated they had not sent referrals or follow up regarding Resident 14 and Resident 97 PASARR's. Staff B stated they only performed this task monthly and were trained that the initial determination served as an admission placeholder. Staff B further stated they had not been taught otherwise, and this was why referrals had not been sent out for Resident 14 and Resident 97. Staff B stated residents would then receive services when the Level 2 was completed when warranted. During an interview on 06/30/2026 at 2:40 PM, Staff G stated they had recompleted a lot of the older PASARR's in April and May of 2025 when they first became employed at the facility as many of the long-term care resident's PASARRs had previously been completed incorrectly and required updating. Staff G stated once the PASARR's had been completed correctly, they were then sent to the contracted agency, though often they did not get a timely response back from them, if at all. Staff G stated in conversations they had with the owner of the PASARR contracted agency, they were backlogged in getting the assessments completed. Staff G stated they had a list of residents that required an assessment for a Level 2 PASARR and the referrals were sent to the contracted agency. Staff G stated they realized some of the referrals for a NOD were a year or more out and still had not been completed and they needed to talk with the facility Administrator about setting up a system to get an answer back from the agency in a timely manner so the residents could get the resources they needed for their SMI or ID/DD diagnoses. Reference WAC: 388-97-1915 (1)(2)(a-c)

Based on observation, interview, and record review the facility failed to ensure a resident received treatment and services in accordance with professional standards of practice regarding implementation of resident directed care and treatment for a resident with a urostomy (a surgical opening in the abdomen that allows urine to exit through a stoma [an artificial opening] in a collection bag) for 1 of 2 residents (Resident 148) reviewed for quality of care. This failure placed residents at an increased risk for unidentified complications and a deterioration in their health status.Findings included . Review of an article in the American Journal of Nursing titled, Nursing Care for Patients after Urostomy Surgery, June 2024, volume 124, showed urostomy care included emptying the drainage bag daily or when full, every three to seven days, clean around the stoma, monitor and provide skin care and change the pouching system to avoid leakage and skin damage. Resident 148 Review of the Resident 148's medical record showed they were admitted with diagnoses which included history of bladder cancer with a urostomy, dementia (a decline in mental functioning) and Parkinson's disease (a progressive disease that damages nerve function). The comprehensive assessment dated [DATE] showed Resident 148 was cognitively impaired and required substantial assistance from staff for dressing, toileting activities, grooming and mobility. Review of Resident 148's history and physical dated 06/13/2025 showed the resident was admitted to the facility with a urostomy for urinary elimination needs. Review of the June 2026 physician orders showed no identification, or treatment interventions to ensure appropriate care was provided. Review of the progress notes from 06/13/2026 to 6/24/2026 showed no assessments or documentation that consistent licensed nursing care had been provided for 11 days since the resident's admission to the facility. During an interview on 06/23/2026 at 11:46 AM, Resident 148's representative stated they were required to provide urostomy care at least three times weekly when the resident had lived at home and they had been responsible for their care. During an interview on 06/24/2026 at 10:16 AM, Staff Y, admission Nurse, stated the resident was admitted on a weekend by a different nurse. Staff Y reviewed Resident 148's medical record and stated they could not find any physician or treatment orders to provide care for the resident's urostomy. Staff Y further stated their process for the use of any type of catheter was to obtain treatment orders for follow up care. During an interview on 06/24/2026 at 10;23 AM, Staff B, Director of Nursing, stated that the expectation on admission for a resident with a urostomy was to ensure the resident received appropriate treatment and had physician orders. Reference WAC 388-97-1060(1)(2)(3)

Based on observation, interview, and record review, the facility failed to ensure restorative (RNP-a specialized program to help long term care residents maintain or improve their maximum functional independence)nursing services programs were implemented for 1 of 4 residents (Resident 34), reviewed for restorative nursing and limited range of motion ( ROM-the extent the joint can move within the expected [normal] range of values). This failure placed the residents at risk for loss of ROM, deconditioning, pain, and contractures (a permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen). Findings included .Review of an undated facility policy titled, Restorative Nursing Program, showed residents would receive restorative nursing care to help promote optimal safety and independence. Residents may start on a RNP upon admission, during their stay, or when discharged from skilled therapy services. Restorative goals and objectives were to be individualized and placed in the resident's care plan. Resident 34Review of the medical record showed the resident admitted with diagnoses including chronic obstructive pulmonary disease (COPD- a long-term lung disease that made it hard to breathe) and congestive heart failure (CHF- a condition where the heart muscles become too weak or stiff to pump blood effectively). The 05/28/2026 comprehensive assessment showed Resident 34's cognition was intact and required the assistance of two staff members with activities of daily living and had an impairment to their lower extremities. The assessment further showed Resident 34 had no RNP in place. An observation and concurrent interview on 06/21/2026 at 11:12 PM, showed Resident 34 lying in bed with limited ROM to the left arm. Resident 34 stated they wanted exercises and felt forgotten and overlooked. Resident 34 stated they performed exercises as much as they could themselves and added that they would like to have someone lift their legs and bend their joints. An observation and concurrent interview on 06/23/2026 at 9:36 AM, showed Resident 34 lying in bed. Resident 34 stated they used to go to the gym but no longer received any exercise. Resident 34 stated, they would like to have ROM exercises done with their left arm. An observation and concurrent interview on 06/24/2026 at 4:06 PM, showed Resident 34 lying in bed. Resident 34 demonstrated how they tapped their legs to try and exercise and stated they used to have an exercise band but no longer knew where it was. An observation and concurrent interview on 06/25/2026 at 11:33 AM, showed Resident 34 lying in bed. Resident 34 could only actively lift their left arm midway; however, with assistance, the arm could be stretched further. Resident 34 stated they did not want to lose their mobility and wanted to be able to do their hair. Resident 34 demonstrated their range of motion by using their unaffected hand to assist their left arm to move further. The resident stated, My legs too, I need help because I can not keep my left leg bent without help, and I can not do good ROM by myself to strengthen them. Observation of the resident's lower extremities showed they were able to move both legs but could not maintain them in a fixed position without assistance. Review of Resident 34's care plan, dated 06/02/2026, showed there were no RNP's, floor maintenance program (FMP-a program for long term care residents that focuses on maintaining the resident's current level of functioning) or interventions in place. Review of Resident 34's task record from January 2026 to June 2026, showed no active RNP's, FMP's or individualized ROM interventions had been logged by nursing assistants. During an interview on 06/24/2026 at 3:37 PM, Staff P, Licensed Practical Nurse (LPN), stated that Resident 34 had not showed up on my radar for restorative services. Staff P stated that therapy typically referred residents to them. Staff P stated they did not know why Resident 34 was not on an FMP and directed the responsibility to Staff F, Resident Case Manager (RCM). Staff P stated that residents must show a decline to qualify for RNP's. During an interview on 06/24/2026 at 3:46 PM, Staff F, RCM stated they were unaware Resident 34 desired restorative services. Staff F stated the facility previously had the resident on an RNP, but it was discontinued by Staff P. Staff F stated they did not know why the program was discontinued, no transfer documentation was provided to explain why it was stopped. Staff F stated Resident 34 was in bed most of the time and would benefit from an FMP. During an interview on 06/24/2026 at 4:35 PM, Staff B, Director of Nursing, stated that RCMs were responsible for following up on the implementation of RNP's after therapy discharge. Staff B stated all residents were to be evaluated for restorative needs quarterly by the RCMs, and Resident 34 should have been assessed for an RNP or FMP during their quarterly assessment. Reference: WAC 338-97-1060 (1) (2)(b)(3)(d)

Based on interview and record review the facility failed to explain the arbitration agreement (a legal document that required the use of a third party to resolve a dispute) in its entirety, including the right to cancel the agreement within 30 calendar days, in a manner and language that the resident understood for 2 of 3 residents (Resident 138, and 2) reviewed for binding arbitration. This failure placed the residents at risk for losing legal protection, lack of understanding of the legal document, and the right to a jury or court hearing. Findings included. Review of a facility policy titled, Binding Arbitration Agreements, dated 11/2023, showed that in the event of a dispute the resident would waive their right to a jury by trial in the federal or state court system and that the resident or their representative acknowledged full understanding of the arbitration agreement. The facility would explain the agreement to the residents or representatives that ensured their understanding of the arbitration agreement, in a form and manner they understood with consideration of their language, literacy and preference for learning. Additionally, the residents or representatives were provided 30 days after signing the agreement to review and rescind the agreement. Resident 138 Review of the medical record showed Resident 138 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a brain condition that causes confusion and memory loss), sepsis (a severe infection that affects organs and tissues) and weakness. Review of a Social Services progress note, dated 06/19/2026, showed Resident 138 was not able to make their own decisions due to their cognitive impairment, and their family was involved for decision making. Review of Resident 138's arbitration document titled, Alternative Dispute Resolution Agreement Between Resident and Facility, dated 06/19/2026, the arbitration document was electronically signed by Resident 138 on 06/19/2026 and showed that no legal representative for the resident had signed the binding agreement. Additionally, Staff . Admissions Assistant, signed as the facility's authorized agent. During an interview on 06/21/2026 at 1:02 PM, Resident 138's Representative, (RR), stated they were the residents Power of Attorney (POA-legal representative to make decisions and sign documents for the resident's care) and were not aware of an arbitration agreement from the facility or that Resident 138 had signed an agreement. RR stated no staff members discussed the arbitration agreement with them, and they were unaware of what arbitration was or the ability to rescind an agreement. Resident 2 Review of the medical records showed Resident 2 was admitted to the facility on [DATE] with diagnoses including left leg and arm fractures, diabetes (excess sugar in the blood) and high blood pressure. The 05/05/2026 comprehensive assessment showed Resident 2 had an intact cognition. Review of Resident 2's arbitration document titled, Alternative Dispute Resolution Agreement Between Resident and Facility, dated 04/29/2026, showed the arbitration document was electronically signed by Resident 2 on 04/29/2026 and Staff . Admissions Assistant, signed as the facility's authorized agent. During an interview on 06/21/2026 at 3:57 PM, Resident 2 stated they did not know what arbitration was. Resident 2 stated they were also unaware they had signed an arbitration agreement or that they were able to rescind within 30 days. Resident 2 stated when they had admitted they were not thinking about documents they had signed. During an interview on 06/24/2026 at 3:32 PM, Staff R, Admissions Assistant, stated they were responsible for explaining arbitration agreements to residents. Staff R stated they told residents when or if they have a dispute that they could take the facility to court for, that arbitration was a faster process. Staff R stated they did not read the entire arbitration agreement to the residents and/or representative they only summarized. Staff R stated they had not read the arbitration agreement themselves and were not aware of the residents' right to rescind the agreement within 30 days after they signed. During a concurrent interview and record review on 06/24/2026 at 3:41 PM, Staff S, admission Director, stated they were responsible for overseeing the admissions and arbitration agreements. Staff S stated Staff R was responsible for reading and reviewing the arbitration agreements for residents and representatives to understand. Staff S accessed their computer screen to review an arbitration agreement, and stated residents had 30 days to rescind the agreement. During an interview on 06/24/2026 at 4:31 PM, Staff A, Administrator, stated arbitration was a way they helped disputes with residents/representatives be resolved outside a court process and could be rescinded within 30 days. Reference WAC: 388-97-1620(2)(b)(i)

Based on interview and record review, the facility failed to ensure residents had access to their personal trust fund money outside of normal business hours (Monday through Friday, 8:00 AM to 5:00 PM) and during weekends for 2 of 6 residents (Resident 4 and 76) reviewed for personal funds. This failure placed residents at risk for unmet financial needs and limited their right to self-determination. Findings included. During an interview on 06/22/2026 at 9:34 AM, Resident 4 stated they could not access their personal money after 5:00 PM during the week or on the weekends. During an interview on 06/23/2026 at 2:15 PM, Resident 76 stated they did not have access to their personal money on the weekends or after administration left during the week, further stating I don't even try because I know I cannot get it. During an interview on 06/23/2026 at 1:41 PM, Staff O, Registered Nurse, stated if the business office were open when the resident requested money, they would have business office staff talk with the resident. Staff O stated they were unsure of the process for accessing personal trust funds after hours or on weekends. During an interview on 06/23/2026 at 1:45 PM, Staff K, Business Office Manager (BOM), stated they had access to the resident's trust accounts, and the activities department got a list during the week of everyone who wanted to go shopping or who wanted money. When asked about weekend and after-hours access to personal trust funds, Staff K stated the facility had a weekend supervisor, Staff N, Licensed Practical Nurse (LPN), who had access to the cash box in the BOM's office. Staff K stated Staff N was the only person who had access besides the BOM. Staff K further stated that they were not sure of the process when Staff N was not available. During an interview on 06/23/2026 at 2:00 PM, Staff A, Administrator, stated that the facility had a weekend supervisor, Staff N, who was in the building on weekends until 10:00 PM to distribute funds. Staff A stated that no one else could distribute funds after hours on the weekends or during the week. Staff A stated that when a resident needed money after hours or after Staff N left the facility for the day, any staff member could call the BOM at home, and they could come to the facility to retrieve the money. Staff A further stated that staff could also call them directly and they would come to the facility to retrieve the money. Reference WAC: 388-97-0340(1)(2)(3)

Based on interview and record review, the facility failed to ensure pharmacy services were provided to meet the needs of 1 of 3 sampled residents (Resident 1) reviewed for medication management. The failure to ensure medications were acquired and administered as ordered placed residents at risk for adverse events related to missed medications. This constituted a Past Non-Compliance (the facility was not in compliance at the time the situation occurred; however, there was sufficient evidence that the facility corrected the non-compliance after it was identified). The facility educated staff, updated training methods, and monitored for additional missed medications, by 02/02/2026. The facility was notified of the past non-compliance on 06/18/2026.Findings included .Review of Resident 1's Skilled Nursing Facility Transfer Orders, dated 01/30/2026, showed the resident had diagnoses of diabetes (chronic condition that affects how the body uses blood sugar) and hypothyroidism (condition in which the thyroid gland does not produce enough thyroid hormone). Medication orders included the following:-daily levothyroxine (used to treat hypothyroidism) -daily liothyronine (used to treat hypothyroidism) -Novolog insulin (used to treat high blood sugar in diabetes) with meals and at bedtime-Gaviscon (used to relieve heartburn, acid indigestion, sour and upset stomach) after meals and at bedtime-methocarbamol (muscle relaxer) four times daily-daily losartan/hydrochlorothiazide (a combination medication that lowers blood pressure and prevents the body from absorbing too much salt)-daily fluoxetine (antidepressant)Review of the January 2026 Medication Administration Record showed on 01/30/2026 and 01/31/2026 Resident 1 did not receive all their ordered medications. Review of a facility investigation dated 02/02/2026 showed Resident 1 did not receive the following medications on the evening shift of 01/30/2026: Novolog, levothyroxine, methocarbamol, and Gaviscon. Additionally, the investigation showed medication errors on 01/31/2026 were noted. Follow up with the staff working on 01/31/2026 showed all ordered medications were given that day after they were received from the pharmacy.In a telephone interview on 05/26/2026 at 11:31 AM a representative for Resident 1 stated the resident discharged to the facility from a hospital on Friday evening, and nursing staff reported they did not have orders or medications for the resident. The representative stated they were especially concerned about the resident missing their insulin as their blood sugar was very high and required intervention during the first 48 hours they were at the facility. In an interview on 06/16/2026 at 12:36 PM Staff C, Licensed Practical Nurse, confirmed Resident 1 admitted to the facility on a Friday and when they worked with the resident on Saturday 01/31/2026 their medications had not yet arrived from the pharmacy. Staff C stated they called the pharmacy and had the medications delivered later that day, and administered ordered medications once they were available from the pharmacy. Staff C stated Resident 1 was a brittle diabetic (severe and unpredictable diabetes requiring frequent medical attention) and their blood sugar was elevated on 01/31/2026, requiring physician notification and additional doses of insulin.In an interview on 06/18/2026 at 9:57 AM Staff A, Director of Nursing, stated the facility followed up with Staff B, Registered Nurse, who did not acquire and administer Resident 1's medications on 01/30/2026. Per Staff A, medications such as insulin were available in the facility in their emergency medication supplies and the facility had a process in place to obtain medications timely from the pharmacy, but Staff B was unaware of these measures. Staff A stated additional training was provided for staff and the facility had systems in place to monitor for medication errors.This was a Past Non-Compliance, corrected on 02/02/2026, and is no longer outstanding.Reference: (WAC) 388-97-1300 (1)(a)(4)(e)

Based on interview and record review the facility failed to implement the facility's abuse prevention policy including identification of potential allegations, timely reporting allegations to the State Survey Agency as required, thoroughly investigating allegations, and monitoring residents for potential psychosocial harm after allegations were made for 6 of 10 sampled residents (Resident 42, 62, 63, 35, 311, and 20), reviewed for abuse. This failure placed residents at risk of potential abuse, neglect and/or misappropriation or their property and diminished quality of life. Findings included . Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised April 2021, documented the facility would develop and implement policies to prevent and identify abuse or mistreatment of residents; neglect of residents; and/or theft, exploitation or misappropriation of resident property. Staff would be provided orientation and training on abuse prevention, incident identification and reporting. The policy further showed all potential allegations of abuse, neglect, mistreatment, or misappropriation of resident property would be identified, reported within the required timeframes, investigated, and residents protected from potential harm during the investigation process. <Resident 20> The 01/10/2025 quarterly assessment documented Resident 20 was cognitively intact and made their needs known. In an interview on 02/24/2025 at 10:46 AM, Resident 20 stated there was a resident on the same hall that entered their room and yelled at them and wandered into their room often. Resident 20 stated three staff members removed the resident from their room. The incident for 02/05/2025 was written on a single piece of paper that stated Staff A, Administrator, spoke to Resident 20 regarding their interaction with Resident 89 on 02/05/2025 at 5:00 PM. Resident 20 stated Resident 89 was trying to enter their room, and Resident 20 blocked them from coming in with their wheelchair. Resident 20 stated Resident 89 placed their hand on their left arm to support themselves when they turned around. Staff A stated they had asked Resident 20 if Resident 89 had squeezed their arm, and Resident 20 said no. Resident 20 stated they told Resident 89 to leave their room, staff came and redirected the resident. Staff A stated Resident 20 reassured them several times that nothing happened, Resident 89 did not hit them, and they were not afraid of them. Review of the February 2025 incident log had no documentation that Resident 20 was involved in a resident-to-resident altercation and the State Survey Agency was not notified as required. In a follow-up interview on 02/28/2025 at 8:19 AM, Resident 20 stated Resident 89 had wheeled themselves into my room, they were angry and held my arm. Resident 20 stated they yelled at me, and this was the worst experience I had with them. Resident 20 stated you never knew how Resident 89 was going to act. The facility investigation did not include staff or other resident interviews. There was no progress note written on 02/05/2025 regarding the resident-to-resident altercation. A progress note on 02/06/2025 stated there was no evidence of latent injury to Resident 20's right arm and no psychosocial issues were noted. The investigation was reopened after concerns were shared with Staff A, Administrator. The investigation documented a stop sign was placed across Resident 20's door to their room, a behavioral health visit was requested for Resident 89, an activity referral was made, the interdisciplinary team discussed a memory care unit for the resident, and resident and staff interviews were completed. Staff A was provided re-education by the Regional Director of Clinical Services on Washington State reporting guidelines to prevent future similar incidents from going unreported. In an interview on 03/06/2025 at 11:18 AM, Staff B, Director of Nursing, stated it was important to do thorough investigations to prevent harm or re-occurrence and to identify triggers to prevent future occurrences. Staff B stated staff, and resident interviews should have been completed. 47328 <Resident 42> According to the 12/12/2024 annual assessment, Resident 42 had diagnoses including muscle weakness and pain. Resident 42 was cognitively intact and able to clearly verbalize their needs. In an interview on 02/24/2025 at 10:26 AM, Resident 42 stated the night prior (02/23/2025), they waited for an hour and 15 minutes for their call light to be answered. Resident 42 explained they had a clock in their room, turned their call light on at 9:45 PM to be changed after an incontinence episode but staff did not enter their room until 11:00 PM. Resident 42 further stated this had also occurred 4 other times. In an interview on 02/24/2025 at 2:02 PM, Staff A, Administrator, was notified of the allegation Resident 42 made earlier that morning. Staff A stated they were not aware of the allegation. Review of the 02/24/2025 facility incident investigation documented residents and staff were interviewed related to the allegation of delay in response to call lights the weekend on February 22 and 23, 2025. A 02/27/2025 statement by Staff I, Nursing Assistant (NA), documented Resident 42 was glad Staff I answered their call light because Resident 42 had waited for an hour to be changed. Staff I reported Resident 42's allegation of delayed call light response time to the nurse. The investigation further documented the allegation of abuse and/or neglect was not reported to the State Survey Agency until 02/24/2025 at 3:40 PM, after the allegation was brought up to administration by the surveyor. <Resident 62> According to the 01/14/2025 quarterly assessment, Resident 62 had diagnoses including anxiety and depression. In an interview on 02/24/2025 at 2:56 PM, Resident 62 stated approximately three months ago, a night shift staff knocked me on the head with a bottle of roll-on pain relief lotion that was on the bedside table. Resident 62 explained they had concerns with being hit in the head. Review of the facility 08/23/2024 facility incident investigation documented Resident 62 alleged they were hit in the head by the nurse around midnight when they had requested pain medications. The investigation further documented the allegation of abuse was not reported to the State Survey Agency until 08/23/2024 at 5:44 PM, over 24 hours after the allegation was made. Review of August 2024 nursing progress notes showed a 08/23/2024 note no behaviors noted. No further documentation was found until 08/27/2024, 4 days later, to monitor Resident 62 for potential psychosocial harm related to the allegation of abuse. <Resident 35> According to the 02/26/2025 annual assessment, Resident 35 was cognitively intact and able to clearly verbalize their needs. Review of the 10/31/2024 grievance form documented Resident 35 was missing $50 that was replaced by the facility when they were unable to locate the money. Review of the October 2024 through November 2024 incident log showed no entries for Resident 35's missing $50. <Resident 311> According to the 10/03/2024 discharge assessment, Resident 311 admitted to the facility on [DATE] and discharged on [DATE]. Resident 311 was cognitively intact. Review of the 10/02/2024 grievance form showed Resident 311 was missing $40 that was replaced by the facility when they were unable to locate the money. Review of the October 2024 incident log showed no entries for Resident 311's missing $40. <Resident 63> According to the 02/03/2025 quarterly assessment, Resident 63 had severe cognitive impairment with inattention and disorganized thinking. Resident 63 had worsening wandering that significantly intruded on the privacy or activities of others and placed Resident 63 at significant risk of getting into potentially dangerous places. Review of the September 2024 through November 2024 incident log showed Resident 63 was involved in resident-to-resident altercations on 10/30/2024, 11/10/2024 and 11/11/2024. Review of the facility incident investigations showed the following: -10/30/2024 at 1:45 PM: Staff witnessed Resident 63 open handedly slapped a peer on the back of their head. The incident was not reported to the State Survey Agency until 10/31/2024 at 1:00 PM, 23 hours after the physical aggression incident was witnessed by staff. -11/10/2024 at 11:45 AM: Resident 63 wandered onto 400 hall and had exhibited aggressive behaviors. Staff witnessed when Resident 63 pulled a peer's hair. The incident was not reported to the State Survey Agency until 11/11/2024 at 11:55 AM, 24 hours after the physical aggression incident was witnessed by staff and another resident-to-resident altercation occurred the following day. -11/11/2024 at 6:35 AM: Resident 63 wandered onto 500 hall and had exhibited aggressive behaviors. Staff found Resident 63 in a peer's room and they had hit them on the back of the head with a hairbrush. The incident was not reported to the State Survey Agency until 11/11/2024 at 11:40 AM. In an interview on 03/04/2025 at 5:15 AM, Staff K, NA, stated allegations of abuse needed to be reported to the State Survey Agency within two hours, the nurse should have been notified so the resident could have been monitored for potential psychosocial harm, and management notified so an investigation was completed. Staff K explained everyone was a mandated reporter and acknowledged allegations of waiting over an hour to have a call light answered, missing money, and resident-to resident verbal/physical aggression were all potential allegations of abuse and/or neglect that needed to be reported and thoroughly investigated. In an interview on 03/04/2025 at 9:42 AM, Staff H, Registered Nurse, stated when an allegation of abuse/neglect was made against a staff member, they needed to be immediately removed from providing direct resident care pending the results of the investigation. Staff H stated residents were placed on alert charting to monitor for potential psychosocial harm after an allegation was made. Staff H was unsure how abuse and/or neglect was ruled out. Staff H acknowledged allegations of waiting over an hour to have a call light answered, missing money, and resident-to resident verbal/physical aggression were all potential allegations of abuse and/or neglect that needed to be reported and thoroughly investigated. In an interview on 03/05/2025 at 12:03 PM, Staff E, Resident Care Manager, stated when an allegation of abuse was made resident safety was the first priority. Staff E explained if an allegation identified an individual staff, the staff needed to be immediately removed from direct resident care pending the results of the investigation. Staff E further stated all allegations needed to be reported to the State Survey Agency per the required timelines and thoroughly investigated by conducting resident and staff interviews. Staff E acknowledged allegations of waiting over an hour to have a call light answered, missing money, and resident-to resident verbal/physical aggression were all potential allegations of abuse and/or neglect that needed to be reported and thoroughly investigated. Staff E explained the facility would not wait until they suspected theft prior to reporting missing money because the facility might not suspect theft until instances of missing money were investigated. In an interview on 03/05/2025 at 3:44 PM, Staff B, Director of Nursing, stated allegations of abuse needed to be reported to the State Survey Agency within two hours, residents placed on alert to monitor for potential psychosocial harm after an allegation was made, abuse and/or neglect was ruled out through resident and staff interviews. Staff B was informed Staff I was informed of Resident 42's allegation of delayed call light response times when the incident occurred but it was not identified as a potential allegation or reported until the allegation was brought to administration by the surveyor. Staff B explained if an allegation identified an individual staff, ideally the staff was immediately removed from direct resident care pending the results of the investigation. Staff B was informed Resident 62's allegation of abuse occurred on night shift when only one nurse was working the South unit, but the identified nurse was not removed from direct resident care at that time and Resident 62 was not monitored for potential psychosocial harm following the allegation. Staff B further stated allegations of missing money was individualized depending on the amount of money missing and if it was found within 24 hours or not. Staff B was informed Resident 35 and 311's grievances of missing money were not identified as potential allegations, reported or investigated as such. In an interview on 03/06/2025 at 10:55 AM, Staff A, Administrator, stated allegations of abuse and/or neglect were reported to the State Survey Agency within two hours, thoroughly investigated, and residents monitored after allegations were made. Staff A explained if an allegation identified a staff, they would be removed from direct resident care as soon as the facility became aware of the allegation. Staff A stated they expected staff to report allegations within two hours. Staff A further stated instances of missing money were reported to the State Survey Agency on a case-by-case basis, if it was over $100 or if theft was suspected. Reference WAC 388-97-0640 (2) Refer to F725, F726, F600 and F689 for additional information.

Based on interview and record review, the facility failed to ensure 6 of 6 sampled residents (Resident 6, 23, 411, 416, 417, and 62) reviewed for trauma informed care, received culturally competent, trauma-informed care in accordance with professional standards of practice. The failure of the facility to adequately screen, assess, identify potential triggers (a psychological stimulus that prompts recall of a previous traumatic event), and develop and implement a Trauma Informed Care Plan to help limit the residents' exposure to potential trauma triggers, placed the residents at risk for re-traumatization and a diminished quality of life. Findings included . Review of the [DATE] facility policy titled, Trauma-Informed Care showed, the facility screened residents for indications of trauma for newly admitted residents and as part of the comprehensive care plan process, and developed appropriate interventions based upon the screening responses and resident observations. The facility interviewed the resident and/or their representative as part of the screening process and care plan development. <Resident 6> Review of a [DATE] admission assessment showed Resident 6 admitted to the facility on [DATE] with the diagnosis of Post Traumatic Stress Disorder (PTSD, a mental health condition that can develop after experiencing or witnessing a traumatic event). The staff assessed Resident 6 as cognitively intact. Review of a [DATE] hospital History and Physical document showed Resident 6 experienced sudden losses of relatives or spouse at a young age. Resident 6 also experienced gunshot wounds to the chest which left the resident unable to perform their job any longer. Review of a [DATE] facility Social History Assessment showed a questionnaire for Significant Life Events. The questionnaire asked about a number of difficult or stressful things that sometimes happen to people. All the events, to include, Assault with a weapon and Sudden, unexpected death of someone close to you were marked as Not sure. Review of the medical record showed four emergency contacts and relatives of Resident 6 listed. Progress notes review showed no indication the facility made additional efforts to collaborate with family members to determine the type of PTSD Resident 6 experienced and its possible triggers. Additionally, no care plan development for Trauma Informed Care was noted to help direct the staff on preventing re-traumatization of Resident 6. On [DATE] at 9:04 AM, Staff PP, Nursing Assistant (NA), stated that they were familiar with Resident 6, a resident on the 300 Hall. Staff PP stated that they knew if a resident was a trauma survivor by, I would hope that the nurses would articulate that to the aides to let us know because we do not have access to their personal record. Sometimes the admission person would let us know. On [DATE] at 9:24 AM, Staff QQ, Licensed Practical Nurse (LPN), stated that they were familiar with Resident 6 as they were a primary nurse assigned to the 300 Hall. Staff QQ stated that they did not know of any residents on the 300 Hall with the diagnosis of PTSD or were trauma-survivors. Staff QQ stated that they knew a resident was a trauma-survivor by, sometimes when they are admitted I will look at admission documents from hospital. Staff QQ stated that they knew what triggers to avoid to prevent re-trauma by asking the resident, reviewing the progress notes and, some of it is common sense thing. The above information was shared with Staff Q, Social Services Director, on [DATE] at 8:19 AM. Staff Q stated he was unaware of Resident 6's history of PTSD as stated in the hospital records of [DATE], It should be in the care plan but to be honest I don't think it got seen in those documents when [the resident] got here but that warrants a follow up. We would start with reaching out to a POA [Power of Attorney], always be our first step, spouse or child, any direct contacts. <Resident 23 and 417> Review of a Diagnosis Report showed Residents 23 and 417 resided on the 300 Hall and both carried the diagnosis of PTSD from admission. Record review showed Resident 23 admitted to the facility on [DATE] and Resident 417 on [DATE]. Neither resident's medical record showed the development of a Trauma Informed Care Plan to help direct the staff on recognizing triggers and preventing re-traumatization of the residents. Review of Resident 417's [DATE] and Resident 23's [DATE] Social History Assessments showed the answer of Not sure to all the Significant Life Events questionnaire. <Resident 411> Review of the medical record showed Resident 411 admitted to the facility on [DATE] with a diagnosis of PTSD. Review of an undated hospital admission referral showed, Pt [patient] requesting [their] door be left open and reports [their] father passed away while hospitalized . Review of a [DATE] Social History Assessment showed the answer of Not sure to all the Significant Life Events questionnaire. Resident 411 resided in the 200 Hall. <Resident 416> Review of the medical record showed Resident 416 admitted to the facility on [DATE] with a diagnosis of PTSD. Review of a [DATE] Social History Assessment showed the answer of Not sure to all the Significant Life Events questionnaire. Resident 416 resided in the 200 Hall. Neither Resident 411 or 416's medical record showed the development of a Trauma Informed Care Plan to help direct the staff on recognizing triggers and preventing re-traumatization of the residents. On [DATE] at 9:02 AM, Staff BB, Nursing Assistant stated that they were a primary aide on the 200 Hall. Staff BB stated that they became aware a resident was a trauma survivor by, It should come with their admission paperwork so we get that information in report. I don't remember if I've ever taken care of a resident with PTSD before. Staff BB stated that it was difficult for them to know what triggers to avoid for a resident with a history of trauma unless they know the type of trauma. Staff BB mentioned there might be a resident on the 200 Hall with PTSD because the resident, was telling me [they] had trauma. It just came in conversation. On [DATE] at 8:52 AM, Staff T, LPN, stated they were a 200 Hall primary nurse. Staff T stated that they knew a resident was a trauma survivor and what triggers to avoid through, report when they get here. Like in their History and Physical [from the hospital]. Find out from the family. Staff T was unaware of any residents on the 200 Hall with the diagnosis of PTSD. The above findings were shared with Staff Q on [DATE] at 9:01 AM. Staff Q stated that since nothing triggered secondary to the Not Sure answers throughout the Significant Life Events questionnaire, it did not trigger a Trauma informed Care Plan for the residents. 47328 <Resident 62> According to the [DATE] quarterly assessment, Resident 62 had diagnoses including anxiety and depression. The assessment further showed Resident 62 was able to clearly verbalize their needs. Review of the [DATE] behavior care plan showed Resident 62 rejected care, became mute, and made accusations. The care plan instructed staff to re-approach, create a calming environment, and inform social services of any new accusations. No documentation was found to show Resident 62 experienced trauma or any identified trauma triggers for staff to avoid. Review of the [DATE] trauma screen showed no documentation Resident 62 was asked if they had experienced any traumatic events. Review of the facility [DATE] facility incident investigation showed Resident 62 alleged being hit in the head by the nurse around midnight when they requested pain medications. In an interview on [DATE] at 2:56 PM, Resident 62 stated approximately three months ago, a night shift staff knocked me on the head with a bottle of roll-on pain relief lotion that was on the bedside table. Resident 62 explained they had concerns with being hit in the head because they previously lived in California, where the culture was different, and they were beat with a baseball bat. Resident 62 stated they were aware of the potential risk of death secondary to a head injury and explained they knew someone who died from a ruptured aneurysm (bulge or ballooning of a blood vessel) after they sustained a head injury. In an interview on [DATE] at 11:15 AM, Staff J, NA, was unsure if Resident 62 had experienced any traumatic events. In an interview on [DATE] at 12:19 PM, Staff E, Resident Care Manager, was unsure if Resident 62 had experienced any traumatic events. In an interview on [DATE] at 1:42 PM, Staff Q, Social Service Director, stated residents were screened for trauma upon admission but if they were not willing to talk about trauma experienced or if they state they did not experience trauma then the conversation stopped. Staff Q reviewed Resident 62's trauma screen. Staff Q acknowledged the trauma screen did not ask the resident if they had experienced any traumatic events, the screen only asked the resident if they wanted to talk about trauma experienced. Staff Q further acknowledged it would be better practice to ask the resident if they experienced trauma prior to asking them if they would like to talk about trauma because that way the facility could identify/be aware the resident experienced trauma so staff could be on the lookout for potential unidentified trauma triggers to avoid and/or verbalizations of trauma details. In an interview on [DATE] at 11:07 AM, Staff A, Administrator, stated they expected staff to appropriately screen residents for trauma to identify potential triggers to avoid. No associated WAC Refer to F607 for additional information.

Based on interview and record review the facility failed to ensure the facility had enough staff to provide care according to facility acuity (the level of severity of residents' illnesses, physical, mental, and cognitive limitations, and conditions) and/or care plans for 5 of 10 sampled resident's, (Resident 63, 62, 91, 89, and 42), reviewed for sufficient staffing. This failure placed all residents at risk for potentially avoidable accidents, unmet care needs, and diminished quality of life. Findings included . Review of the facility assessment reviewed January 2025, documented the facility's average daily census was 120. The facility admitted more acutely ill residents with multiple co-morbidities and provided care for an increased number of residents with drug abuse, cognitive impairment, behaviors and used a wander guard system (system consisting of a bracelet that would alarm when an exit door was approached) on the south side of the building (400, 500, and 600 halls) with secured doors leading onto the unit, for residents that wandered. The assessment further documented the interdisciplinary team met daily Monday through Friday to review resident acuity and staffing needs making staffing levels adjustments as needed. The facility utilized a staffing coordinator and staffed the facility based on [NAME] State's 'Per Patient Day' minimum staffing levels. Agency staff was used as needed to ensure proper staffing patters if in-house staff was not sufficient to meet resident needs. <Resident 63> According to the 02/03/2025 quarterly assessment, Resident 63 had severe cognitive impairment with inattention and disorganized thinking. Resident 63 had worsening wandering that significantly intruded on the privacy or activities of others and placed Resident 63 at significant risk of getting into potentially dangerous places. Review of the 11/01/2024 psychosocial behavioral care plan documented Resident 63 struck out, was combative, wandered, and exhibited verbal, physical and sexually inappropriate behaviors. The care plan instructed staff to administer medications as ordered, anticipate Resident 63's needs, provide supervision, offer distractions/activities as needed, provide simple, direct reminders, and observe whether behaviors endangered the resident and/or others and intervene if necessary. The 11/01/2024 elopement risk care plan documented Resident 63 wandered related to agitation and combative behaviors. The care plan instructed staff to administer medications as ordered, allow wandering in safe areas within the facility, check placement and function of the wandering bracelet/alarm system, address potential pain, encourage attendance and participation in activities. Review of August 2024 through November 2024 nursing progress notes documented Resident 63 spoke little English and had advanced cognitive impairment with hallucinations at times. Staff noted wandering in September 2024, and on 09/18/2024 Resident 63 was found in an opposite sex peer's bed, both sound asleep. On 10/01/2024 Resident 63 had increased confusion and wandered. On 10/15/2024 Resident 63 moved to the 400 hall. On 10/29/2024 Resident 63 demonstrated increased aggression over the last two days, entered other resident rooms with difficulty in redirection. On 10/30/2024 Resident 63 was involved in a resident-to-resident altercation where they open handedly slapped a peer on the back of their head. On 10/31/2024 Resident 63 refused medications, chased staff attempting to run them over, wandered through the lobby to the other side of the building, and a wanderguard was placed at that time. On 11/01/2024 Resident 63 wandered onto 400 hall and verbally harassed a peer while they swung a hairbrush. On 11/05/2024 Resident 63 wandered throughout the South side of the building. On 11/06/2024 verbal and physical aggression towards staff and they bit a staff member's arm. On 11/09/2024 at 2:30 AM, Resident 63 was found in a 400-hall peer's room and had rummaged through the bedside dresser, became agitated when redirected and threatened to throw objects at peers. On 11/10/2024 at 5:30 AM, Resident 63 undressed in the 400-hall, became violent and was combative by kicking, swinging arms and attempting to scratch staff with redirection. At 1:19 PM, Resident 63 yelled and cursed at peers, became aggressive with staff, and pulled a peer's hair on 400-hall. On 11/11/2024 at 6:30 AM, Resident 63 wandered into a peer's room on 500-hall and hit them in the head with a hairbrush. At 10:44 AM, medication changes were made, and staff were currently waiting to see if medication changes were effective. Review of the October 2024 through November 2024 incident log showed Resident 63 was involved in resident-to-resident altercations on 10/30/2024, 11/10/2024 and 11/11/2024. Review of the 11/10/2024 elopement assessment showed Resident 63 was cognitively impaired, wandered and significantly intruded on the privacy or activities of others and placed the resident at significant risk of getting to an unsafe place. The assessment identified Resident 63 as at risk to wander and/or elopement, a wanderguard was placed on the resident to enable maximal independence with mobility in facility while allowing safety. During observation on 02/24/2025 at 4:00 PM, Resident 63 was observed dressed, in their wheelchair, self-propelled and wandered down the South unit halls without staff supervision, picked up a peer's tumbler, and wheeled off with it as they drank the unknown contents. Similar unsupervised wandering observations were made on 02/26/2025 at 8:31 AM, 9:34 AM, and 1:04 PM, on 02/27/2025 at 2:38 PM, on 03/03/2025 at 9:29 AM, on 03/05/2025 at 11:21 AM, 11:54 AM, and 12:03 PM. In an interview on 02/25/2025 at 11:22 AM, Resident 63's family member acknowledged Resident 63 wandered often. In an interview on 02/26/2025 at 10:01 AM, Staff N, Nursing Assistant (NA), stated sometimes wandering interventions were in a resident's care plan. Staff N acknowledged Resident 63 wandered including entering into other resident's rooms. Staff N was asked what interventions Resident 63 had for wandering besides the use of a wanderguard. Staff N stated Resident 63 had a peer they were to avoid because of a previous resident-to-resident altercation, I guess, we just try to pay attention where [Resident 63] is at and staff on the South units halls attempted to redirect wandering residents. <Resident 62> According to the 01/14/2025 quarterly assessment, Resident 62 had diagnoses including anxiety and depression. Review of the facility 08/23/2024 facility incident investigation documented Resident 62 alleged being hit in the head by the nurse around midnight when they requested pain medications. Resident 62's care plan was updated to included two staff for all interactions including medication administration and conversations. Review of general information care plan documented Resident 62's care plan was updated on 09/04/2024 requiring two staff for all interactions. During an observation on 03/03/2025 at 1:14 PM, Staff J, Nursing Assistant, entered Resident 62's room alone to answer their call light. At 1:15 PM, Staff J informed the surveyor Resident 62 wanted to speak with them and the surveyor entered the room. Resident 62 stated they do not send two staff in here all the time. During an observation on 03/04/2025 at 10:59 AM, Staff J, again entered Resident 62's room alone to answer their call light. Staff J exited Resident 62's room at 11:01 AM. At 11:03 AM, Staff J returned to Resident 62's room with crackers as requested. At 11:06 AM, Staff J exited the room and informed Staff H, Registered Nurse (RN), Resident 62 was ready to take their pills. At 11:07 AM, Staff H entered Resident 62's room, alone, to administer medications. In an interview on 03/04/2025 at 11:16 AM, Staff J, stated Resident 62 had behaviors, yelled, cursed and was mean to staff. Staff J further stated Resident 62 was two person assist when care was provided but did not require two staff to answer the call light. Staff J reviewed Resident 62's record. Staff J acknowledged Resident 62 required two staff for all interactions and stated that would be hard to do. <Resident 89> According to the 01/30/2025 significant change in status assessment, Resident 89 had severe cognitive impairment. The assessment further documented Resident 89 had exhibited worsening wandering that significantly interfered with participation in activities and disrupted the living environment. Resident 89 was able to ambulate independently with staff supervision and exhibited verbal behaviors directed towards others. Review of the 08/14/2024 cognitive impairment care plan instructed staff to administer medications as ordered, cue, orient, and supervise as needed. Review of the 08/26/2024 behavior care plan showed Resident 89 wandered the halls, entered peer's rooms, and believed they were an employee. Behavioral interventions instructed staff to remind Resident 89 where they were, ensure their care needs were met, reduce stimulation in the environment, and redirect as needed. The 09/04/2024 elopement care plan showed Resident 89 exhibited exit seeking behaviors and wandered aimlessly with interventions to administer medications as ordered, allow for wandering in safe areas within the facility, approach in a calm manner, provide redirection as needed, check placement and function of the wanderguard system. Review of the August 2024 through January 2025 facility incident log documented Resident 89 eloped from the facility on 08/29/2024 and sustained falls on 10/15/2024, 10/24/2024, 12/09/2024, 12/28/2024, 01/11/2024, 01/26/2024, and 01/28/2024. During observation on 03/04/2025 at 4:08 AM, the secured South unit was entered, the double doors leading onto the South unit (400, 500, and 600 halls) were closed. Upon opening the doors, a strong pungent urine odor was smelled, and Resident 89 was observed sitting in the common area, shirtless. <Resident 91> According to the 02/24/2025 quarterly assessment, Resident 91 had severe cognitive impairment. The assessment further documented Resident 91 exhibited wandering that significantly interfered with their care, participation in activities, intruded on the privacy of others, and disrupted the living environment. Resident 91 was able to ambulate independently with staff supervision and exhibited verbal behaviors directed towards others. Review of the 09/24/2024 mobility care plan showed Resident 91 required distant supervision for transfers and used both a walker and wheelchair for mobility. The 10/08/2024 behavioral care plan showed Resident 91 often ambulated independently without an assistive device, followed staff as they performed their duties, entered peer's rooms, disrobed in public and wandered down other halls on the unit. Behavioral interventions instructed staff to distract Resident 91 with conversation of their favorite movies, remind resident sitting is safer, make family phone calls, offer television, and avoid overstimulation. The 12/16/2024 elopement care plan documented Resident 91 wandered related to cognitive impairment and instructed staff to allow for wandering in safe areas within the facility, approach in a calm manner, provide redirection as needed, check placement and function of the wanderguard system. Review of September 2024 through January 2025 facility incident log showed Resident 91 sustained falls on 9/25/2024, 9/27/2024, 10/13/2024, 10/29/2024, 12/06/2024, 12/24/2025, 12/25/2024, and 01/02/2025. Review of October 2024 through February 2025 nursing progress notes documented Resident 91 often ambulated independently on the unit, wandered into peer's rooms, rummaged through peer's belongings, was verbally and physically aggressive towards staff, took and wore peer's items and clothes. During observation on 03/04/2025 at 4:32 AM, Resident 91 stood in the doorway to their room, wandered down the hall, looked inside the ice chest, and stumbled to the common area on the South unit between 400, 500, and 600 halls. At 4:36 AM, Resident 91 wandered toward the nursing station and placed their hand in a bag with unknown contents. <Resident 42> According to the 12/12/2024 annual assessment, Resident 42 had diagnoses including muscle weakness and pain. Resident 42 was cognitively intact and able to clearly verbalize their needs. Review of a 10/15/2024 grievance form documented multiple residents had concerns about excessively long call light wait times and/or not having a call light within reach. In an interview on 02/24/2025 at 10:26 AM, Resident 42 stated the night prior (02/23/2025), they waited for an hour and 15 minutes for their call light to be answered. Resident 42 explained they had a clock in their room, turned their call light on at 9:45 PM to be changed after an incontinence episode but staff did not enter their room until 11:00 PM. Resident 42 further stated this had also occurred four other times. During observation on 02/27/2025 at 9:25 AM, the bathroom call light for room [ROOM NUMBER] came on. Staff answered the bathroom call light at 9:46 AM, 21 minutes later. During observation on 02/27/2025 at 9:28 AM, the call light for room [ROOM NUMBER] came on. Staff answered the call light at 9:54 AM, 26 minutes later. During observation on 02/27/2025 at 2:42 PM, the call light for room [ROOM NUMBER] came on while staff were observed at the nurse's station. At 2:47 PM, the resident in room [ROOM NUMBER] yelled out for assistance to get staff's attention. Staff then approached and the resident stated they needed oxygen. In an interview on 03/04/2025 at 4:19 AM, Staff KK, Nursing Assistant (NA), stated the facility did not have enough staff on night shift. Staff KK explained the South unit of the facility had a lot of residents that wandered, tried to elope, and exhibited behaviors. Staff KK further stated staff were unable to take lunch breaks most nights and had a hard time completing extra duties such as cleaning wheelchairs because they were too busy trying to manage resident care. Staff KK stated staffing an extra person on night shift would be very beneficial. In an interview on 03/04/2025 at 4:25 AM, Staff LL, Registered Nurse, stated the facility did not have enough staff. Staff LL explained the South unit had lots of behaviors, residents that wandered, and it was hard for the aides to keep up and get everything done. Staff LL further stated the South unit used to staff two nurses on night shift and it was rough with only one nurse. In a confidential interview on 03/04/2025 at 4:31 AM, Confidential Staff 1, stated the facility did not staff sufficient staff. Confidential Staff 1 explained the South unit had quite a few behaviors including residents that did not sleep, wandered, were aggressive, and high fall risks. Confidential Staff 1 further stated they were unable to check and change residents timely because of managing residents with behaviors and having an extra staff member would be helpful. In an interview on 03/04/2025 at 4:46 AM, Staff NN, Staffing Coordinator, stated they did not work night shift that night but was called in around 4:00 AM (the survey team entered the facility at 4:00 AM) to provide support. Staff NN stated the night shift on the South unit was typically staffed with only one nurse and one nursing assistant per each hall (400, 500, and 600). Staff NN further stated the South unit had gotten into a good routine and did not require more staff. Review of the 02/25/2025 secured South unit resident census showed the 400-hall had 22 residents, 500-hall had 18 residents, and 600-hall had 21 residents. 61 residents:1 night shift nurse and approximately 20 residents:1 NA. The secured South unit housed majority of the facility's cognitively impaired and behavioral residents. In an interview on 03/04/2025 at 4:59 AM, Staff K, Nursing Assistant, stated they worked day shift, which started at 6:00 AM, but often came in early at 5:00 AM to help clean, organize the unit, and prepare for the day. During a follow-up interview and record review on 03/06/2025 at 9:12 AM, Staff NN, stated the North unit was the more acute (intense) unit because that was where most of the new admissions were, and the South unit was more long-term care. Staff NN explained they used a spread sheet to determine staffing levels for day and evening shift. Night shift was always staffed with six nursing assistants, one per hall, two nurses on the North unit but only one nurse on the South unit. Review of the spread sheet provided documented three columns 1) resident census, 2) total day shift NAs, and 3) total evening shift NAs. Staff NN stated depending on the number of residents the next column showed how many NAs were needed. Staff NN further stated they had not heard night shift needed more staff to help manage residents that wandering and/or had behaviors. Staff NN stated Staff L, Maintenance Director, was responsible for staffing the laundry department, Staff NN only staffed laundry with nursing staff if they had a person with light duty restrictions. LAUNDRY STAFFING During an interview on 02/24/2025 at 3:03 PM, Resident 50 stated they had not sent their personal clothing to the laundry anymore, because it was not getting done. They further reported some laundry staff had quit and the facility was using maintenance staff now in that department. During an interview on 03/03/2025 at 12:56 PM, Resident 68 stated they requested to talk to the surveyor because some of their clothing (pants, shirts, underwear and socks) had not been returned from the laundry for about three weeks. During an interview on 03/03/2025 at 12: 59 PM, Staff W, NA, stated that resident laundry had been an issue for about three weeks and management was in the process of addressing it. Staff W further stated the priority was getting the linens and towels washed. Resident laundry was only delivered on Sunday or Monday and had not arrived yet. Additionally, if a resident was out of clothing, the aides had to go and dig through the bins, which were so high it was time-consuming to sort through them. The interview with Staff W was interrupted when Resident 33 was observed in their doorway, wearing only their footwear. Another staff went to the laundry to get some clothes for Resident 33, as they didn't have any in their room. During a tour of the laundry area on 03/05/2025 at 12:31 PM with Staff X, Laundry Aide/NA, a large rectangular rolling bin was observed in the soiled laundry area. This bin was approximately four feet wide, three feet deep and waist high. The bin was overflowing with resident clothing. During a concurrent interview, Staff X stated that they usually had 3 staff daily and just got approval to hire a fourth person for the laundry. Washing facility linens was currently prioritized over resident laundry, and nursing assistants brought the dirty linen from the resident care areas to the laundry, rather than having the laundry staff pick it up. Staff X further stated that if they had a sick call or not enough staff, a nursing assistant was pulled from resident care to help. Per Staff X, when fully staffed and resident clothing came into the laundry, it took 24 hours until it was returned to the resident. When asked how long it was currently taking to get resident clothing back to them, Staff X stated, honestly, about a week. In an interview on 03/06/2025 at 10:21 AM, Staff B, Director of Nursing, stated Staff A, Administrator, and Staff NN determined staffing levels based on census. Staff B explained night shift was staffed with two nurses on the North unit, one nurse on the South unit with one NA per each of the six halls. Staff B stated they had not heard residents and/or staff voice staffing concerns. In an interview on 03/06/2025 at 10:34 AM, Staff A, stated they expected sufficient staff to provide care to the facility residents and staffed the facility above the Washington State minimum requirements. Reference WAC 388-97-1080 (1), 1090 (1) Refer to F600, F656, F726, and WAC 388-97-1080 for additional information.

Based on observation, interview, and record review, the facility failed to provide appetizing and palatable food for 5 of 14 sampled residents (Residents 35, 46, 211, 20, and 17) reviewed for food. This failure placed the residents at risk for decreased nutritional intake, potential weight loss, and a diminished quality of life. Findings included . In a Resident Council (group of facility residents that regularly met to discuss care at the facility) Meeting on [DATE] at 10:37 AM, the Council stated the food was only good maybe two days a week. The Council explained the vegetables were overcooked, the menu lacked variety, and the weekend food was the worst. <Resident 35> The [DATE] comprehensive assessment documented Resident 35 had diagnoses which included diabetes and depression. Resident 35 was cognitively intact to make decisions regarding their care. In an observation and interview on [DATE] at 3:16 PM, Resident 35 was lying in bed and watching television. Resident 35 stated the quality and taste of the food had diminished over the past year. Resident 35 explained the meat (i.e., chicken, hamburger patties) was extremely overcooked and so tough they could not chew it, the vegetables were mushy, and desserts were even worse because there was often cake without icing. In an observation on [DATE] at 1:02 PM, Resident 35 was sitting up in their bed with their lunch tray on the table in front of them. The meal served was beef stroganoff with noodles, peas, a roll, cake and 1 cup of milk. The beef stroganoff looked like chunky gravy with barely any meat, all the peas were welted like raisins, and the cake looked dry with a thin layer of icing. Resident 35 only ate the noodles, half of the roll, cake, and drank half of their milk. In an observation and interview on [DATE] at 10:15 AM, Resident 35 was lying in bed making jewelry. Resident 35 stated last night's dinner was the worst meal they had been served. Resident 35 explained the chicken was so dry they could not swallow it, the vegetables were cooked to oblivion, the rice was undercooked, and the dessert was a version of a smashed flat chocolate peanut butter candy bar. Resident 35 stated that the meal was inedible and instead ate their left-over vegetable tray ordered from the local grocery store. 46033 <Resident 211> The [DATE] significant change assessment documented Resident 211 had diagnoses that included protein calorie malnutrition. Resident 211 was cognitively intact and required set-up assistance from staff to eat. During an interview on [DATE] at 4:10 PM, Resident 211 stated food was tough, overcooked and the hot food was not hot. On [DATE] at 2:56 PM, Resident 211 stated their lunch that day was not good. They stated the cheese ravioli had been cooked for so long that the sauce soaked completely into the pasta. They stated they picked off the pasta and were going to eat only the cheese insides, but that was rubbery and had no taste. They stated the pumpkin pie had a dark layer on top, beneath that was mushy and the pie had an off-putting smell. 46115 <Resident 20> The [DATE] quarterly assessment documented Resident 20 had diagnoses which included heart failure and diabetes. Resident 20 was cognitively intact and was independent with eating. During an interview on [DATE] at 10:31 AM, Resident 20 stated the food was terrible, overcooked and was served cold. On [DATE] at 12:27 PM, Resident 20 stated the chicken that was served was not good and they did not like it. In an interview on [DATE] at 12:27 PM, Resident 20 stated they did not like the beef stroganoff that was served so they requested an egg salad sandwich and said it was better than nothing. <Resident 71> The [DATE] quarterly assessment documented Resident 71 had diagnoses which included heart failure and diabetes. Resident 71 was cognitively intact and needed set up assistance for eating. In an interview on [DATE] at 2:43 PM, Resident 71 stated the food was not good, was not always served hot, the biscuits were hard, the food was flavorless, and the meat was tough and dry. During an interview on [DATE] at 12:30 PM, Resident 71 stated they were served tamales for dinner last night and it looked awful, and the beans were terrible. Resident 71 stated they had ordered food and ate that for dinner. 47328 <Resident 46> According to the [DATE] quarterly assessment, Resident 46 had diagnoses including malnutrition. The assessment further showed Resident 46 received a therapeutic diet, was cognitively intact and able to clearly verbalize their needs. In an interview on [DATE] at 2:19 PM, Resident 46 stated the food was terrible. Resident 46 explained there was an alternate menu, but they did not like that food either. <Test Tray> On [DATE] at 1:23 PM, a test tray of the lunch meal directly from the kitchen steam table was sampled by the survey team. The entree meal consisted of a lemon fish (cod) almondine, red bliss potatoes, candied carrots, and fruit parfait. The temperature of the food was lukewarm, and the appearance of the main entree was unappetizing with dull colors. The fish and potatoes tasted bland; the fish had no lemon or almond flavoring and the potatoes taste like plain salt free boiled potatoes, the textures were firm. The carrots were watery, mushy with minimal carrot flavor and not candied . An egg salad and bacon, lettuce, and tomato (BLT) sandwiches were also ordered from the alternate menu. The egg salad sandwich tasted like hard boiled eggs with no seasoning. The fruit parfait was diced soft peaches with cinnamon and tasted mediocre. The BLT sandwich was the only food item that was appetizing and tasted flavorful. In an interview on [DATE] at 3:31 PM, Staff Z, Dietary Manager, stated the cooks tasted the food during the cooking process. Staff Z further stated they themselves also tasted the food to check for proper seasonings to ensure the meal was palatable and tasty. Staff Z adjusted ingredients as needed and consumed each meal served while they were present. Staff Z stated sampling the food was important for resident satisfaction. In a follow-up interview on [DATE] at 10:52 AM, Staff Z stated they had also eaten the entree meal served for lunch on [DATE]. Staff Z acknowledged the lemon fish almondine had no lemon flavor and had to add seasoning to their meal. Reference WAC [DATE] (1), (2).

Based on interview and record review, the facility failed to ensure appropriate consents were obtained prior to the administration of psychoactive (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior and are typically used to treat mental health conditions) medications for 3 of 5 sampled residents (Residents 91, 102 and 411) reviewed for unnecessary medications. This failure precluded the residents or their representatives to participate in decisions regarding their care and treatment. Findings included . <Resident 411> A 10/2022 facility policy titled Psychoactive Medications showed, the staff obtained informed consent from the resident or their representative prior to the administration of any psychoactive medication. Informed consent included a review of the risks and benefits of the psychoactive medication. Review of a 02/21/2025 Social History Assessment showed Resident 411 admitted to the facility on [DATE] and the staff assessed the resident was, alert and oriented to time/date, able to make needs known. The assessment showed the resident was on several psychoactive medications, to include buspirone for anxiety, doxepin and duloxetine for depression, and aripiprazole for borderline personality disorder. Review of the February 2025 Medication Administration Record (MAR) on 02/27/2025, showed the staff administered the psychoactive medications since 02/20/2025. Review of the medical record showed no documentation the facility reviewed with Resident 411 the use the psychoactive agents, to include the risks and benefits. The above information was shared with Staff G, Resident Care Manager, on 03/04/2025 at 11:01 AM. Staff G stated that when a resident wass prescribed a psychoactive drug, the staff completed a consent evaluation before the first dose was given. Staff G acknowledged the medical record showed no consent evaluations and stated, I'm not seeing them in there. That should have been done on admission. 46033 <Resident 102> The 01/20/2025 five-day assessment documented Resident 102 had diagnoses that included delusional disorders (beliefs in things that could not possibly be true) and major depression. The resident was cognitively intact and took antipsychotic and antidepressant medications (collectively referred to psychotropic medications, used to treat delusions, hallucinations and depression) daily. On 01/14/2025, consents were obtained for Resident 102 to take citalopram daily for their depression, and risperidone twice daily for psychosis with behavioral disturbances, both ordered as part of the resident's transfer orders from the local hospital. The 02/23/2025 behavioral health provider progress note documented Resident 102 was seen for their initial evaluation. The resident appeared anxious and depressed and reported people in the facility were trying to poison them and had become increasingly depressed and suicidal related to their current situation. The provider recommended increasing the dose of the risperidone and stopping the citalopram. They also recommended starting escitalopram and increasing the dose after two days. The recommended changes were ordered on 02/25/2025. Further review of Resident 102's medical record failed to identify that consents had been obtained for the changes in the resident's psychotropic medications as required. During an interview with Staff F, Resident Care Manager (RCM) and Staff G, RCM on 03/05/2025 at 10:41 AM, Staff F stated the admission nurse was to obtain consents for antipsychotic medications on admission, and if medications changed, another consent was needed. Staff G stated new orders were discussed in the morning huddle and Resident 102 should have been discussed in their morning meetings but they could not remember doing so. Staff F and Staff G both stated when the escitalopram was ordered a new consent should have been obtained. 50027 <Resident 91> Per the 02/27/2025 comprehensive quarterly assessment, Resident 91 had diagnoses which included stroke, aphasia and dementia. The resident was severely cognitively impaired and unable to make decisions regarding their care. In addition, the assessment documented the resident had received psychotropic medications. Review of the Order Summary Report from September 2024 through February 2025 documented the resident was prescribed had been prescribed the following medications to treat their psychosis and insomnia: Trazodone on 09/25/2024, Seroquel on 9/20/2024 and Zyprexa on 11/25/2024 Review of Resident 91's record found an informed consent that explained the risks and benefits of taking psychotropic medications to treat psychosis and insomnia signed on 09/25/2024. However, this form was signed by Resident 91, whom had severe cognitive impairment. In an interview on 03/05/2025 at 3:30 PM, Staff B, Director of Nursing, acknowledged that the acknowledged the resident should not have signed the form. Reference WAC 388-97--0300(3)(a), -0260, -1020(4)(a-b).

Based on interview and record review, the facility failed to complete annual staff performance reviews yearly as required and provide education based on the outcome of these reviews for 4 of 6 sampled staff (Staff I, BB, N, and UU), reviewed for performance reviews. This failure placed residents at risk of receiving care from inadequately trained and/or underqualified care staff, and diminished quality of life. Findings included . <Staff N> Review of Staff N's, Nursing Assistant (NA), personnel file showed they were originally hired on 09/06/2016. No documentation of a performance evaluation was found. <Staff UU> Review of Staff UU's, NA, personnel file showed they were originally hired on 02/21/2018. No documentation of a performance evaluation was found. <Staff I> Review of Staff I's, NA, personnel file showed they were originally hired on 01/14/2022. No documentation of a performance evaluation was found. <Staff BB> Review of Staff BB's, NA, personnel file showed they were originally hired on 03/14/2022. No documentation of a performance evaluation was found. In an interview on 03/05/2025 at 2:42 PM, Staff AA, Human Resources, acknowledged Staff I, N, BB, and UU did not have a yearly performance evaluation on file, as required. In an interview on 03/06/2025 at 10:21 AM, Staff B, Director of Nursing, stated evaluations were completed yearly but when the recent facility change of ownership occurred, there was a gap in paperwork. Staff B acknowledged some staff did not have yearly performance evaluations on file, as required. In an interview on 03/06/2025 at 10:34 AM, Staff A, Administrator, stated they expected performance evaluations to be completed yearly, as required. Reference WAC 388-97-1680 (1), (2)(a-c) Refer to F600, F607, and F726 for additional information.

Based on observation, interview, and record review the facility failed to store, discard and distribute food, monitored temperatures of foods being served, ensure accuracy of preparation of thickened liquids, and maintain a cleaning schedule in accordance with professional standards for food safety for 1 of 1 facility kitchens, reviewed. This failure placed residents at risk for food borne illness and diminished quality of life. Findings included . Review of the U.S. Food and Drug Administration (FDA) Food Code 2022 revised [DATE], showed that food must be labeled with the date the food was prepared, the package opened, and the date the food must be discarded as directed by the food manufacturer's use-by-date. During a kitchen observation and interview on [DATE] at 09:02 AM, the reach-in refrigerator contained an unlabeled tossed salad covered with plastic wrap. Staff Z, Dietary Manager, acknowledged the salad should have been labeled with a date and quickly disposed of it. Staff Z stated that it was important for food to be discarded at the appropriate time to reduce potential for bacterial growth. During a kitchen observation and interview on [DATE] at 09:15 AM in the dry storage room, there were four opened bags of cereal with expired dates: Cornflakes expired on [DATE], Cheerios expired on [DATE], Raisin Bran expired on [DATE], and [NAME] Krispies expired on [DATE]. Further observation showed there was a 22-quart container of rice measured at 5 liters labeled with a use-by-date of [DATE]. During a kitchen observation on [DATE] at 09:22 AM, the walk-in refrigerator contained the following items opened and unlabeled with a date: precooked sausage patties (120 count), packages of sliced turkey meat, half a jar of dill pickles (,d+[DATE] count) size, 1 gallon of lemon juice with heavy sediment, 1 gallon of mayonnaise, 1 gallon of creamy Cesar salad dressing, 1 gallon of salsa. During a kitchen observation on [DATE] at 10:22 AM, the walk-in freezer contained the following items unlabeled with a date: frozen bunch of bananas blackened in a carboard box, 1 cup of bacon bits wrapped in plastic, 14 lemon cookies in a plastic bag, and a medium sized box of scones wrapped in an opened plastic bag. In an observation and interview on [DATE] at 09:45 AM, the north nourishment refrigerator was greatly overcrowded with resident commercial food and drink items. The refrigerator had the following resident food items opened and unlabeled with a date: overripen cut-up fruit in container, 3-inch block of cheese and a beef summer sausage in a plastic baggie, half of an egg salad sandwich in a baggie, two seafood salads in a bowl, dried up sliced raw vegetables in a container, medium sized bottle of V8 juice. Staff Z stated items in the refrigerator are rarely managed and the kitchen staff often inquired about unlabeled food. Staff Z stated the perishable food items should have been labeled with a date when opened and should have been discarded within 7 days due to bacterial contamination. Further inspection of the north nourishment refrigerator found 20 facility assembled cups of applesauce with lids unlabeled. Staff Z stated the facility used the FIFO method (first in and first out) to track when the applesauce was used. <Food Preparation and Service> Review of the facility policy titled, Food Temperatures, dated [DATE] (reviewed February 2019), showed the dietary department would check food temperatures on all items prepared by the dietary department, hot foods should be held at 135 degrees Fahrenheit (F), and potentially hazardous cold food kept at or below 41 degrees F. The policy instructed staff to measure and record food temperatures on a temperature log every meal. The Serving temperatures will be recorded by the cook or other designated personnel for all items served prior to serving on a temperature log. Review of the U.S. Food and Drug Administration (FDA) Food Code 2022 revised [DATE], showed that there is an increased risk of contamination when food is held, cooled and reheated at improper temperatures. Thus, temperatures of food must be taken and monitored. Records must be maintained to verify food temperatures are within the parameters required for food safety. During an observation of a tray line service held in the kitchen on [DATE] at 11:25 AM, the fruit cups being served for lunch were setting on resident trays stacked on the meal cart. At 11:48 AM, Staff ZZ, Dietary Cook, began to prep food items, such as chopped hamburger, fixings and place them in the steam table pans where the other entree items were already placed. At 11:53 AM, the dietary staff began coordinate and serve the lunch meal (lemon almondine fish, red bliss potatoes, steamed carrots, butter roll, fruit parfait, hamburger with fixings, BLT sandwich). Staff ZZ began to serve from the steam table. Staff ZZ placed the hamburger and fixings on a plate and began to add other food items to it. No staff checked the food temperatures of the food resting in the steam table. This surveyor prompted Staff ZZ to check the temperatures of all food items at the steam table. Staff ZZ stated they took the temperatures right before this surveyor entered the kitchen approximately 30 minutes ago. They replied with an undetermined explanation of their policy on checking food temperatures during tray line. At 11:56 AM, this surveyor informed Staff ZZ they needed to check the temperatures during the inspection visit and proceeded to check the temperatures. At 12:00 PM, the fruit parfait had a temperature of 46 F. Staff Z instructed the dietary staff to remove the fruit parfait from the meal cart and they placed them in the refrigerator. Staff Z stated the cold food temperature needed to be below 40 F due to prevention of bacterial growth. In an observation at 12:06 PM, staff ZZ still had not checked the temperature of the regular and chopped hamburger, and fixings (lettuce, tomato, cheese). In an observation and interview on [DATE] at 12:22 PM, Staff Z instructed the dietary staff to obtain the fruit parfait from the refridgerator. The staff began to add the fruit parfait to the meal trays. Staff ZZ stated the fruit parfait was below 70 F, but safe for consumption. In an interview on [DATE] at 12:39 PM, Staff Z stated the kitchen staff documented temperatures on a log daily. They stated holding temperatures were referenced to food items being held on the steam table. They stated that it was important to check food temperatures for prevention of bacteria, foodborne illness and ensure food palatability. Review of the kitchen temperature logs from [DATE] through [DATE] had missing final cooking and holding temperatures for the following dates: [DATE] to [DATE] and [DATE]-[DATE]. The log did not include temperature checks before tray line or mid service. <Thickened Liquids> Review of the facility policy titled, Thickened Liquids, dated [DATE], showed thickened liquids that not pre-thickened are prepared by the dietary department and thickened according to the mixing chart and provided for the requested meal or to nursing for hydration or medication pass, including oral liquids supplements. In an observation and interview during kitchen tray line on [DATE] at 12:10 PM, Staff AAA , Dietary Aide, pumped 3 full strokes of liquid thickener from a dispenser (Simply Thick Thickener) into an 8 ounce (oz) cup of lemonade, swished the cup around, placed a lid on the cup and set it on a tray in the resident meal cart. They stated the correct consistency for thickened liquids were 3 pumps for honey thick and 2 pumps for nectar thick liquids. They stated that if the liquid is too thin, then they added more thickener to thicken the drink. Staff Z stated the kitchen used the International Dysphagia Diet Standardization Initiative (IDDSI) Flow Test to measure the thickness of liquids with a syringe. In an interview on [DATE] at 12:15 PM, Staff Z stated that an 8 oz. cup of liquid required 4 pumped full strokes for honey thick and 3 pumped full strokes for nectar thick. Staff Z was informed of this surveyor's observations of Staff AAA. Staff Z acknowledged the dietary staff needed more education/training. Staff Z stated that this was important to ensure the accuracy of thickened liquids to decrease the risk of aspiration. In an interview on [DATE] at 3:31 PM, Staff Z stated the kitchen did not complete an IDDSI Flow Test every time thickened liquids were prepared. Staff Z stated they did not conduct training for all dietary staff but intended to do so. <Cleaning Schedule> In a kitchen observation and interview on [DATE] at 10:30 AM, there was no sanitizer bucket in the kitchen. Staff Z stated that the kitchen had a red sanitizer bucket that should have been in the designated area. Staff Z instructed Staff AAA to locate the sanitizer bucket. At 10:39 AM, Staff AAA found the bucket, filled it with cleaning solution and performed an Ecolab strip test (tool used to measure the concentration of various sanitizing and disinfecting solutions) which showed the correct strength. In an interview on [DATE] at 10:43 AM, Staff Z stated that they did not have a documented cleaning schedule for staff to follow. They stated they verbally instructed staff to complete cleaning tasks and they themselves inspected the results afterwards. They acknowledged there should have been a cleaning schedule log. They stated this was important to ensure proper sanitization, decrease bacteria and eliminate cross contamination within the kitchen was documented. Review of the latest cleaning schedule, Food Service Task Sheet, showed 3 weeks in the month of [DATE] (,d+[DATE]-,d+[DATE], ,d+[DATE]-,d+[DATE], & ,d+[DATE]-,d+[DATE]). The schedules had tasks that were not completed for the majority of the days. Reference: WAC [DATE](3)

Based on observation, interview, and record review, the facility failed to ensure infection control practices were followed during wound care to include removal of gloves and performing hand hygiene (HH) when indicated for 2 of 5 sampled residents (Residents 101 and 105), reviewed for pressure ulcers. Specifically, staff did not implement or follow Enhanced Barrier and Contact Precautions when indicated. Additionally, staff failed to notify the Infection Preventionist (IP) of a potential gastrointestinal (GI) outbreak in 1 of 4 units in the facility. These failures placed the residents at risk for the spread of infections, illnesses and unintended health consequences. Findings included . The Centers for disease Control (CDC) 2007 Guideline for Isolation Precautions: Preventing Transmission of infectious Agents in Healthcare Settings updated September 2004 retrieved from https://www.cdc.gov/infection-control/hcp/isolation-precautions/index.html documented Standard Precautions were recommended the use of gloves, disposable gowns, masks, or protective eyewear in any setting where there would be exposure to any body fluid. Contact precautions were recommended when the presence of excessive wound drainage, incontinence of stool or other discharges from the body created an increased potential for extensive environmental contamination. Implementation of Contact Precautions included donning a gown and gloves for all patient interactions upon room entry and discarding before exiting the room to help contain pathogens (viruses or bacteria that are highly contagious and cause illness) especially those transmitted through environmental spread including noroviruses and other intestinal pathogens. The CDC Implementation of Personal Protective Equipment (PPE, gloves, disposable gowns, eye protection or masks, for example) Use in Nursing Homes to prevent Spread of Multidrug-resistant Organisms updated July 12, 2002, retrieved from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/ppe.html recommended use of Enhanced Barrier Precautions (EBP) as an infection control intervention that employed targeted gown and glove use during high contact resident care activities when Contact Precautions do not apply for residents with wounds or indwelling medical devices such as feeding tubes or catheters. EBP directs staff to don gowns and gloves when dressing, bathing/showering, transferring, changing linens, providing hygiene, wound care and assisting with toileting. <Hand Hygiene> <Resident 101> During an observation of wound care on 02/27/2025 at 9:34 AM, Staff T, Licensed Practical Nurse (LPN), began a dressing change on Resident 101. Staff T donned gown and gloves before entering the resident's room. Resident 101 was assisted to their right side while in bed. Staff T removed two soiled dressings, one from each buttock. Staff T then removed their gloves, did not complete HH, donned new gloves, and cleansed the wounds to the buttocks. After cleansing the wounds, Staff T did not remove gloves and complete HH, proceeded to apply dressings to the wounds, and dated the dressings with a writing instrument taken out of their uniform pocket. Resident 101 then rolled to their back. With the same gloves on, Staff T reapplied the resident's incontinence brief. Staff T then proceeded to physically check Resident 101's gastrostomy tube (G-tube, a tube inserted through the belly that delivered nutrition directly to the stomach) site with the same gloves on, touched the dressing to the G-tube site, tossed the used wound supplies and wrappers, rubbed the resident's left shoulder, then removed the gloves and washed their hands. Staff T then donned a new pair of gloves, cleaned the G-tube site, then removed their gloves. Staff T completed no HH, then donned another pair of gloves, and applied a new dressing to the G-tube site. Staff T removed the glove to the right hand, obtained a piece of tape, put a glove back on the right hand, secured the G-tube site dressing with the piece of tape, and dated the dressing. Staff T completed HH. On 02/27/2025 at 9:58 AM, Staff T stated that HH during a dressing change should occur, before and upon glove switching. Staff T acknowledged the missed opportunities where hand hygiene should have occurred but did not. <No notice of potential outbreak and no implementation of contact precautions > <Resident 74> The 12/18/2024 quarterly assessment documented Resident 74 had diagnoses that included heart failure, high blood pressure, and anxiety. The resident was cognitively intact and made their needs known. During an interview on 03/03/2025 at 8:41 AM, Resident 74 stated they had the flu, in reference to having nausea, vomiting and diarrhea. On 03/03/2025 at 12:55 PM, there was no contact precaution sign on Resident 74's door. At 1:02 PM, Resident 74 was observed in bed and stated they did not feel good. <Resident 20> The 01/10/2025 quarterly assessment documented Resident 20 had diagnoses that included heart failure, high blood pressure and diabetes. The resident was cognitively intact and made their needs known. During an interview on 03/03/2025 at 8:42 AM, Resident 20 stated they were nauseated and had vomited. On 03/03/2025 at 12:56 PM, there was no contact precaution sign on Resident 20's door. In an interview on 03/03/2025 at 1:13 PM, Staff M, Registered Nurse, stated Resident 20 had vomiting and diarrhea on 03/02/2025 and Resident 74 had nausea and diarrhea that morning. During an interview on 03/03/2025 at 1:37 PM, Staff M, stated the residents probably needed contact precautions for nausea, vomiting and diarrhea. Staff M stated this was important to prevent the spread of germs to the other residents and themselves. Staff M added they needed to inform the infection preventionist when nausea, vomiting and diarrhea occurred but had not done so. <Enhanced Barrier Precautions Not Followed> <Resident 102> A review of the 01/20/2025 five-day assessment documented Resident 102 had diagnoses that included stroke and paralysis on one side of their body. Resident 102 had a stage 3 (involved all layers of skin loss that extended into the fat layer of tissue) and required substantial assistance from staff for their activities of daily living. On 03/03/2025 at 8:47 AM, the doorway to Resident 102's room was observed to have signage hanging that indicated EBP was to be used when care was provided for Resident 102. Upon entry, staff W, Nursing Assistant (NA), and Staff VV, NA, were observed standing next to resident 102's bed. They were moving a mechanical lift away from the bedside. Resident 102 was observed in bed. When asked if the resident required EBP, Staff W stated if they came in contact whit the resident's legs where there were wounds, they used EBP. Staff W stated they did not use EBP when they transferred the resident to bed or when they toileted the resident because they did not get near the legs. On 03/03/2025 at 11:48 AM, Resident 102's skin condition in their periarea (the groin, buttocks and lower back region) was observed. Staff W and Staff VV donned disposable gowns and gloves prior to entering the resident's room. When asked about the use of gown and gloves during this resident interaction, Staff W stated they planned on dressing Resident 102 in their pants after their skin was observed, so because they would be touching the resident's legs, they had to use EBP. <Resident 105> According to the 02/02/2025 admission assessment, Resident 105 had diagnoses that included malnutrition and muscle weakness. The assessment further showed Resident 105 had an indwelling urinary catheter (flexible tube inserted into the bladder to help drain urine) and required substantial staff assistance for most of their ADLs. Review of the 02/03/2025 bladder care plan showed Resident 105 used an indwelling urinary catheter and instructed staff to provide catheter care routinely and monitor for potential signs and/or symptoms of a bladder infection. The skin care plan implemented on 02/05/2025 showed Resident 105 had a deep tissue injury (DTI, intact or nonintact skin with localized area of persistent unchanging deep red, maroon, purple discoloration) to their buttock and bilateral heels blisters. The care plan did not include instructions for staff to use EBP. During an observation on 02/24/2025 at 10:21 AM, Resident 105's wound care was observed with Staff D, Infection Preventionist and a wound specialist staff. There was no enhanced barrier precaution signage posted outside of Resident 105's room and staff performing wound care did not don a disposable gown prior to providing the wound care. Resident 105 had an indwelling catheter present and a moist wound to their coccyx (tailbone) that was covered with dead tissue and required a dressing to contain drainage. In an interview on 03/04/2025 at 9:12 AM, Staff J, Nursing Assistant, explained enhanced barrier precautions was the use of gown and gloves during high contact care activities and were required when a resident had a catheter and/or a wound. Staff J stated staff should follow enhanced barrier precautions. In an interview on 03/05/2025 at 9:26 AM, Staff E, Resident Care Manager, explained enhanced barrier precautions included use of gloves and a gown during high contact care activities. Staff E further stated EBP should be implemented when a resident had a chronic wound such as a pressure injury to protect the resident. In an interview on 03/05/2025 at 11:48 AM, Staff D, Infection Preventionist, acknowledged they did not wear a gown on 02/24/2025 at 10:21 AM when completing Resident 105's wound care, and they should have. <Additional Observations> During an observation on 03/03/2025 at 1:23 PM, Staff GG, Nursing Assistant and Staff HH, Nursing Assistant, were in room [ROOM NUMBER] providing cares for a resident on EBP. Signage on the resident's doorway indicated EBP was to be used. Staff GG and HH were not wearing gowns as instructed. When interviewed at 1:31 PM, Staff HH stated they were not aware the resident was on EBP precautions because they did not see the sign. Staff HH stated they should have worn a gown, and this was important to protect the residents from the spread of germs. On 03/04/2025 at 10:01 AM, Staff II, housekeeper, was observed in Resident 74's room without a gown. At 10:02 AM, Staff II walked out of the room and was asked about contact precautions. Staff II looked at the contact precaution sign and stated they should have worn a gown. Staff II stated it was important to wear a gown to protect the residents and themselves from spreading germs. On 03/04/2025 at 7:51 AM, room [ROOM NUMBER] had a contact precaution sign posted outside the door that instructed staff to perform hand hygiene then put gloves and a gown on prior to entering. Staff JJ, Nursing Assistant (NA), entered room [ROOM NUMBER] without performing hand hygiene or putting gloves or a gown on. Staff JJ exited the room with a meal tray, placed it on the meal cart, then reentered the same room, again without performing hand hygiene, or putting on gloves and/or a gown. During observation and interview on 03/04/2025 at 9:27 AM, room [ROOM NUMBER] had a contact precaution sign posted outside the door that instructed staff to perform hand hygiene then put gloves and a gown on prior to entering. Staff H, Registered Nurse, entered room [ROOM NUMBER] without performing hand hygiene or putting gloves or a gown on. The sign was pointed out to Staff H. Staff H stated staff only had to put PPE on when they provided care, not when entering the room. On 03/04/2025 at 10:51 AM, Staff M was observed in room [ROOM NUMBER] applying a treatment to Resident 20's chest and did not wear a gown. At 10:53 AM, Staff M stated they should have worn a gown, and it was important to do so to prevent the spread of infections. On 03/04/2025 at 11:02 AM, Staff JJ, NA, brought a mechanical lift out of resident 71's room and wheeled it down the hall and parked it. Staff JJ did not clean the machine after using it. In an interview on 03/03/2025 at 1:51 PM, Staff D, Infection Prevention, stated they were unaware there were residents on the 400 hall with gastrointestinal issues. Staff D stated it was important to have contact precautions in place to ensure an infectious disease was not spread between residents. During an interview on 03/04/2025 at 11:46 AM, Staff B, Director of Nursing, stated mechanical lifts needed to be cleaned after each use for infection prevention. In an observation on 03/05/2025 at 9:21 AM, Staff M had assisted a resident on EBP and removed their PPE in the doorway. Staff M brought the soiled PPE down the hall and disposed of it in the soiled utility room. During an interview on 03/05/2025 at 9:28 AM, Staff D stated the PPE should have been placed in a bag and then disposed of to prevent exposure of germs. During an interview on 03/05/2025 at 3:42 PM, Staff B, Director of Nursing, stated they expected staff to implement and follow EBP when indicated. Staff B acknowledged Staff D should have worn a gown when providing wound care. During an interview on 03/06/25 at 10:47 AM, Staff D, Infection Prevention, stated staff education regarding the use of EBP occurred when they hung signage on a resident's doorway. It consisted of letting the staff on the unit at the time know the resident required EBP. Staff D stated the signage indicated what PPE was needed to be worn and when. Staff D stated there was no formal monitoring of staff compliance with EBP use. They expected the nurse on the unit to monitor the staff. Staff D stated they were comfortable having the nurses on the units determine when to implement EBP or contact precautions and then notifying them. Staff D stated they had not been notified of any residents on the 400's unit having diarrhea or vomiting and Staff D stated they should have been notified. Staff D stated most of the time, staff asked them when it was ok to take a resident off of isolation precautions. During an interview on 03/06/2025 at 10:52 AM, Staff A, Administrator, stated they expected staff to implement and follow EBP, as required. Reference: WAC 388-97-1320(1)(c)(2)(b) 46033 46115 47328

Based on observation, interview and record review the facility failed to ensure a resident was evaluated to self-administer their medications for 1 of 5 sampled residents (Resident 20), observed during medication administration. This failure placed residents at risk for missed medication doses or unintended health consequences. According to a 01/10/2025 comprehensive assessment, Resident 20 had diagnoses that included diabetes, heart failure and aphasia (a partial or total loss of the ability to articulate or comprehend language). Per the assessment, they could usually understand and made their needs known. Their Brief Interview for Mental Status (BIMS, a cognitive test) score was 00 (out of a maximum of 15), and all responses were either: no answer, missed, incorrect or could not recall. A review of Resident 20's care plan, initiated on 01/06/2022 and revised on 01/13/2025, showed a focus that the resident had episodes of refusing cares, and the goal was the resident would accept cares and have fewer episodes of refusals. An Interdisciplinary Team Conference Note, dated 01/10/2025, under Medication/Treatment compliance No was checked, and that the risk of refusal of medication/treatments/plan of care was explained to the resident and/or responsible party. No provider order or evaluation of the resident's ability to self-administer their medication was found in their medical record. On 02/25/2025 at 8:15 AM, Staff M, Registered Nurse, prepared medications for Resident 20, and placed them in a med cup. These included diabetic, blood pressure, heart failure, and blood thinner medications. Resident 20 was seated in a wheelchair in their room. Staff M told Resident 20 they had brought their morning medications and left the medication cup of pills on the table in front of the resident. Staff M had not asked the resident to take the pills at the time and left the room and passed medications to the next resident. On 02/25/2025 at 8:58 AM, observed that Resident 20's pills were no longer on their bedside table. The resident stated they had taken the medications. During an interview on 02/25/2025 at 1:13 PM, Staff M stated that Resident 20 was alert and took their medications without problems. They further stated that some residents were not responsible and nurses needed to make sure they took their pills. When asked if it was written anywhere if a resident could take their medication without supervision, Staff M looked in Resident 20's medical record and acknowledged they should have watched the resident take the pills, as there was nothing in their record that indicated the resident could take them independently. During an interview on 02/26/2025 at 1:55 PM, Staff B, Director of Nursing, stated that the expectation was for nurses to observe the residents take their medication, unless there was an evaluation/authorization that the medication could be left at the bedside. Staff B acknowleged that Resident 20 did not have the specific documentation that documented they could take their medication independently and should have been observed taking their pills. Reference: WAC 388-97-0440

Based on observation, interview, and record review, the facility failed to provide necessary pain management for 2 of 3 sampled residents (Resident 3 and 4), reviewed for pain. Resident 3 and 4 each experienced harm when the facility did not ensure they had the ordered pain medication, or another effective alternative, to treat the residents timely, which resulted in each resident requiring to transfer to the hospital to relieve their pain. This failure placed residents at risk of uncontrolled pain and diminished quality of life. Findings included . Review of the facility's policy titled, Controlled Substance Medication Orders, dated January 2023, showed a prescription required multiple components including a manual signature from the medical provider to be valid. <Resident 3> Review of the hospital discharge notes dated 07/26/2024 showed Resident 3 had pain to their right wrist, right groin, and right shoulder after a fall which resulted in fractures to the pelvis, rib and wrist. The resident was to discharge to a skilled nursing facility for physical and occupational therapy as they were not safe to discharge home. Per the 07/27/2024 hospital transition of care orders Resident 3 was ordered medications to treat pain: morphine instant release (IR) 15mg (milligrams) available every four hours as needed, and tramadol 50mg every six hours as needed. The hospital orders were electronically signed by the medical provider. Review of the July 2024 Medication Administration Record (MAR) showed neither of the medications listed above were administered to Resident 3. Review of the July 2024 progress notes showed Resident 3 admitted to the facility at 5:20 PM on 07/27/2024 and reported they had terrible pain that could become out of control quickly and was not relieved with tramadol. At 11:30 PM (six hours after the resident admitted to the facility) the resident called emergency medical services from their own cell phone to request transfer to the hospital for pain control. The notes showed the resident's documents listing the orders for pain medications were insufficient and most likely not sent to the pharmacy in time to allow for receipt from the automated medication dispensing system. In an interview on 08/09/2024 at 3:37 PM Resident 3 stated they admitted to the facility on a Saturday and were told that their medications would not be available from the pharmacy until the following Monday. The resident stated they reported pain to multiple staff and asked for their ordered pain medication at 8:00 PM and 10:30 PM, which they did not receive. Per Resident 3, when they notified staff they were calling emergency medical services for a transfer the staff offered a muscle relaxer, but it was not sufficient for pain control, and they had already been in pain for several hours. In an interview on 09/04/2024 at 10:15 AM Staff D, Resident Care Manager (RCM), stated the manager assigned on-call for the weekend was responsible for admission paperwork, including entering medication orders, but the orders could not be activated until the resident walked in the front door. Staff D stated on a weekday medication orders had to submitted to the pharmacy by 5:00 PM for timely processing, but they were not sure what times medications had to be submitted on a weekend. Staff D stated Resident 3 arrived late in the day on 07/27/2024 and the prescription for Resident 3's morphine was not valid. Staff D stated they were trying to work with the hospital on fixing the prescription, but in the meantime the facility's medical providers would not write an authorization for residents that they hadn't seen. Observation at 11:06 AM the same day with Staff E, RCM, showed the facility had morphine IR 15mg available in the automated medication dispensing system. Staff E stated the morphine was stocked along with other commonly prescribed medications, but narcotic pain medication required pharmacy authorization to access. In an interview on 09/04/2024 at 11:20 AM Staff B, Director of Nursing, stated if there was a problem with the prescription from the hospital, the facility's medical provider was not comfortable writing a prescription, so the only option was to send the resident back to the hospital. <Resident 4> Review of the hospital discharge summary dated 07/05/2024 showed Resident 4 had multiple abdominal surgeries and discharged with two surgical drains (to remove fluid from a wound) to the abdomen. The resident was to discharge to a skilled nursing facility as they were not safe to return home. Per the 07/07/2024 skilled nursing facility transfer orders Resident 4 was ordered oxycodone 5mg one or two tablets every four hours as needed for pain and acetaminophen 650mg four times daily. Review of the July 2024 Medication Administration Record (MAR) showed the order for acetaminophen was not entered. Additional review showed no administration of the oxycodone. Review of the July 2024 progress notes showed Resident 4 admitted to the facility at 4:31 PM on 07/07/2024. No pain assessment on admission was documented. Per the notes, at 8:30 PM (four hours after admission) two facility nurses disagreed about the validity of the resident's oxycodone prescription as well as procedures to administer the oxycodone. The notes documented that the resident should be sent to the hospital for further care until their supplies and medications had been received or ordered. In an interview on 08/09/2024 at 4:06 PM Collateral Contact (CC) 4 stated nothing was done about Resident 4's pain until approximately 10:00 PM the night they admitted . Per CC4, Staff I, Registered Nurse, got permission from [the] supervisor to get one pain medication from the kiosk. CC4 stated about 10 minutes later Staff H, Licensed Practical Nurse, told them the facility was discharging the resident back to the hospital because the facility did not receive records related to the resident's condition, and the facility could not provide pain control and necessary wound care. In an interview on 08/09/2024 at 4:13 PM Resident 4 stated the staff at the facility had a nonchalant attitude about their pain. Resident 4 stated they reported pain to staff multiple times and were told the nurse would be right in but then they did not see a nurse until 10:00PM. In an interview on 08/19/2024 at 2:32 PM Staff H stated the pharmacy told them they would send Resident 4's medications, but the medications would not arrive until after 10:00 PM. Staff H stated Resident 4 did not complain of pain to them but they were told by Staff B, Director of Nursing, that other staff reported they had allowed the resident to suffer for six hours. Observation at 11:06 AM on 09/04/2024 with Staff E, RCM, showed the facility had oxycodone 5mg available in the automated medication dispensing system. Staff E stated the oxycodone was stocked along with other commonly prescribed medications, but narcotic pain medication required pharmacy authorization to access. In an interview on 09/04/2024 at 11:20 AM Staff B stated pain had been an issue for Resident 4 and Staff H reported that pain medication was not available due to an insurance issue with the pharmacy. Staff B stated upon investigation after the resident's discharge it was found that there were no issues with the pharmacy and pain medication was available in the facility, but Staff H did not have access to the automated medication dispensing system. See F-684 Quality of Care for additional information. Reference: WAC 388-97-1060(1)

Based on observation, interview, and record review, the facility failed to provide the identified transfer assistance required to prevent injury for 1 of 3 sampled residents (Resident 1), reviewed for accidents and supervision. This failure resulted in actual harm to Resident 1, who sustained a fracture and pain during a transfer without utilization of a two-person assist and appropriate equipment, as required. Findings included . Review of the 01/02/2024 annual assessment showed Resident 1 was dependent on staff for transfers, had impaired mobility to one upper and one lower extremity, and had no falls since the previous assessment. Per the mobility care plan initiated 01/08/2021, Resident 1 was to use a sit-to-stand lift (a mechanical lift used to transfer residents who could bear some weight) for transfers. The care plan included the instruction: this needs to be done with two people. Additionally, the care plan stated if the resident was drowsy, having increased weakness, or decreased ability to bear weight, staff were to use the Hoyer lift (full body mechanical lift used to transfer residents with increased assistance needs due to mobility challenges and weakness) with two people. Review of an 01/19/2024 facility investigation report showed Staff G, Nursing Assistant (NA), used a sit-to-stand lift to transfer Resident 1 from their wheelchair into their bed around 6:50 PM that day, without the assistance of a second staff member. Per the report, after seating the resident on the edge of the bed, Staff G moved the lift away and attempted to move the resident's legs up into the bed and the resident fell to the floor and landed on their right side. During interview with the facility investigator Staff G stated they had been trained that they could use the sit-to-stand lift by themself (see F-726 Staff Competency for more information). The investigation report showed the resident complained of pain to their right arm several hours later and was found to have a mid to distal humeral shaft fracture with malalignment (fracture to the upper arm where the bones do not align properly). Review of the orthopedic consultation notes dated 01/29/2024 showed the fracture to Resident 1's right arm was placed in a brace and surgical repair was not recommended due to the resident's other health conditions. A follow-up orthopedic consultation note dated 02/26/2024 showed no significant bone healing was noted on X-ray of Resident 1's right arm that day. Observation on 02/16/2024 at 2:51 PM showed Resident 1 was sleeping in bed with their right arm in a brace. The right arm was swollen despite elevation with pillows. The resident did not wake up when spoken to. In an interview at 2:54 PM the same day, Staff E, Licensed Practical Nurse, stated Resident 1 wore a brace to their arm continuously, except for showers. Per Staff E, the resident had pain to their arm initially after the incident, for which they received pain-relieving medication, but had not had recent complaints of pain. Staff E stated the resident used to be up in their wheelchair more frequently before the incident, and two staff members would assist with transfers via the sit-to-stand lift, but now the resident was in bed more frequently and utilized the Hoyer lift for all transfers. In an interview on 02/29/2024 at 2:41 PM Staff G stated Resident 1 had not shown any signs of increased drowsiness or weakness before the incident on 01/19/2024, so they used the sit-to-stand lift to transfer the resident by themself, as they had on previous occasions. Staff G stated they thought Resident 1's care plan said one or two people could transfer the resident prior to the incident but they were not sure. In an interview at 3:09 PM the same day, Staff C, Resident Care Manager, confirmed Resident 1's care plan stated they were to have the assistance of two staff members for transfers with the sit-to-stand lift prior to the incident on 01/19/2024 and did not know why Staff G transferred the resident by themself. Staff C stated Staff G should have been educated on reading resident care plans during their orientation period and should have known to use two staff members during Resident 1's transfer. In an interview at 4:32 PM on 02/16/2024, Staff A, Director of Nursing, confirmed the facility's investigation found the root cause of Resident 1's injury to be a transfer that was not done according to the resident's identified care needs. Reference (WAC) 388-97-1060(3)(g)

Based on observation, interview, and record review, the facility failed to provide adequate supervision for staff and residents to mitigate a hazardous environment and avoid accidents and incidents, for 1 of 3 sample residents (Resident 2) resulting in harm to the resident, when the resident fell asleep with hot coffee and subsequently spilled the coffee, sustaining second degree [CONDITION(S)]. In addition, the facility failed to evaluate and analyze the incident, to find root cause analysis to identify hazards and risks, and reduce the potential for similar accidents to protect residents. Findings included . Review of the 12/21/2020 admission assessment showed Resident 2 had diagnoses including impaired cognition, and required extensive assistance with activities of daily living including dressing, bathing, and toileting. The 02/06/2021 facility investigation showed Resident 2 had sustained a burn to the right upper leg, when falling asleep while holding a cup of hot coffee, spilling the contents on her lap. Staff F, Nursing Assistant Student, allegedly reheated the coffee in the microwave, but denied doing so in a written statement. A written statement from Staff H, Nursing Assistant, reported when they arrived on shift, the resident stated she had burned her leg with coffee. Staff H asked the resident how it happened, and Resident 2 stated a boy heated up her coffee at lunch time, and she fell asleep holding it. Staff H stated it looked like a burn from hot liquid with a flat looking blister. The statement further showed that Staff H had immediately notified Staff J, Registered Nurse, who reportedly looked at the burn and provided the resident with an instant ice pack in a pillow-case to hold on the leg. A written statement from Staff J showed she did not recall Staff H reporting the incident to her. Per the investigation, the incident occurred on 01/29/2021, and was not reported or investigated until 02/06/2021, eight days later. Review of the nursing progress notes showed the first mention of the injury on 02/06/2021 at 9:11 AM, when Staff G, Nursing Assistant, asked Staff I, Licensed Nurse, to assess the area during the resident's scheduled shower. In an interview on 03/22/2021 at 12:00 PM, Staff C, Resident Care Manager (RCM), stated full skin assessments were completed weekly by the nurse on the resident's scheduled shower days. She further stated if a new skin issue was identified, it was the licensed nurse's responsibility to report it, complete an incident report, and make the appropriate notifications. In an interview on 04/01/2021 at 2:25 PM, Staff H, Nursing Assistant, stated she had reported the incident when it happened, because the resident had a blister. When asked if she had reported it to anyone else, she said no. She further stated it wasn't her job to tell the nurse to do their job stating she was upset because when the director of nursing had asked about the reporting of the incident and injury, Staff J denied the whole thing, because it had been a week and she hadn't done anything about it. On 04/01/2021 at 2:35 PM, an attempt was made to interview Resident 2, who was very hard of hearing; a dry erase board was used. The resident communicated that the burn was all healed up now, stating she spilled coffee. When asked if the burn was painful, she stated, not anymore. In an interview on 04/01/2021 at 4:45 PM, Staff O, Charge Nurse, stated the incident report had been filled out late because it had been reported late. Staff O further stated Staff P, Resident Care Manager, completed the assessment (no assessment was found in the electronic record). 04/06/2021 at 1:15 PM, an observation was made of Staff G heating coffee in the microwave. When asked if it was normal practice to reheat coffee for residents, he stated yes, and also stated the temperature was checked. The temperature was checked at the time, and was 151.8 degrees. When asked what a safe temperature was, Staff G stated 155 degrees. In an interview on 04/06/2021 at 1:20 PM, Staff E, Nursing Assistant, when asked about reheating coffee in the microwave, stated it should not be done. When asked about Resident 2, Staff E stated the resident now received coffee in an insulated cup with a lid since the burn incident. In an interview on 04/08/2021 at 2:05 PM, Staff Q, Nursing Assistant, when asked if they ever reheated coffee in the microwave, stated they were not supposed to heat liquids in the microwave, but sometimes did so, stating they had a thermometer and a temperature guide in the nourishment room. Review of the facility policy titled Microwave Reheating, revised 05/2019, addressed reheating of food products, and did not address reheating liquids such as coffee. The policy stated It is the policy of this facility that ALL foods, as needed, will be reheated in the microwave to the proper temperature to avoid bacteria growth. Food will sit uncovered at least two minutes before serving to resident. Reference WAC 388-97-1060(3)(g)

Based on observation, interview, and record review, the facility failed to ensure one of four sample residents (#1), reviewed for medication errors, was free from a significant medication error. Failure to ensure medications were administered to the right resident, resulted in harm to Resident #1, who required transportation to the emergency room to receive medical intervention. Findings included . According to the facility's policy on medication administration (dated (MONTH) (YEAR)), the five rights are: the right resident, the right drug, the right dose, the right route, and the right times for each medication being administered. The policy also showed residents were identified using two methods of identification: checking the photograph attached to the medical record, calling resident by name (except residents with cognitive impairments), having the resident verify his/her last name, or if necessary, verifying the resident with another facility staff member. Per the 05/07/19 care plan, Resident #1 became confused at times, had memory deficits, and impaired decision-making abilities. Per the record, Resident #1 scored 16/30 on a clinician administered examination, used to identify persons who have dementia, dated 05/02/19. A score of 16 indicated Resident #1 had dementia. According to the facility incident report dated 06/06/19, Staff B, Licensed Practical Nurse (LPN), administered Resident #2's ordered medication to Resident #1 that evening, without correctly identifying the right resident. Included in the medications were [MEDICATION NAME] (an antipsychotic medication used to treat [MEDICAL CONDITION] - a severe mental disorder) which Resident #1 did not have. Resident #1 also received [MEDICATION NAME] - a laxative medication used to treat liver disease, and an additional laxative. Staff B discovered the error when another resident questioned why Resident #1 was in the area (and not where his room was located). Review of the record dated 06/06/19 revealed after the incident, Resident #1 was taken back to his room, where he became unresponsive in his wheelchair shortly thereafter. The ambulance was called at 4:15 PM, and Resident #1 was transported to the hospital. According to the 06/06/19 hospital records, Resident #1 was diagnosed with [REDACTED]. During the hospitalization , Resident #1 required a pharyngeal airway (a medical device used to assist in maintaining an open airway) to assist with breathing, due to his excessive sleepiness. During an observation on 06/27/19 at 12:20 PM, Resident #1 was seated in his wheelchair in the hallway near his room. He said hello, but was unable to state his first and last name. In an interview on 06/27/19 at 2:30 PM, Staff A, Director of Nursing, confirmed Staff B, LPN, had not identified the correct resident prior to providing the medication, resulting in a medication error. Reference: (WAC) 388-97-1060(3)(k)(iii)

Based on interview and record review, the facility failed to ensure timely physician notification of critical laboratory values, for one of three sample residents (#1), reviewed for notification of laboratory results. Failure to notify the physician in a timely manner of critical laboratory values, delayed treatment, which resulted in harm to Resident #1, who required hospitalization with medical interventions. Findings included: Per the State Operations Manual, (MONTH) (YEAR) (Appendix P, Severity Level 3) shows noncompliance resulting in actual harm, can include but may not be limited to clinical compromise, decline, or the resident's inability to maintain and/or reach his/her highest practicable well-being. According to the facility record, Resident #1 admitted to the facility on [DATE], from an acute care hospital, with [DIAGNOSES REDACTED]. Per hospital record review, Resident #1's kidney labs were assessed, prior to discharge from the hospital, and showed creatinine (a blood test that measures kidney function) of 3.1 and sodium (a blood test that measures kidney function, and level of hydration) of 145. Normal function, found on the hospital lab report, showed creatinine should be between 0.7-1.3, and sodium between 136-145. Per record review, the physician assessed Resident #1 on 07/08/18, and ordered staff to monitor the resident's kidney function. Record review of a progress note dated 07/18/18 at 2:37 p.m. showed Staff D, Licensed Practical Nurse, received an order from the nurse practitioner to obtain a renal panel (kidney blood test), on 07/19/18. According to the record, on 07/19/18 at 3:49 p.m., the lab called the facility and reported critical results for Resident #1, to Staff E, Registered Nurse. Critical results on 07/19/18 were as follows: Creatinine 3.48 (it had previously been 3.1 on 07/07/18, upon admission to the facility) Sodium 162 (it had previously been 145 on 07/07/18, upon admission to the facility) Review of the facility's completed investigation, dated 07/24/18, revealed the critical lab results were not called to the physician until 07/23/18 - five days after they were reported to facility staff. The investigation showed as a result of the delay, a substantial injury to Resident #1 was sustained (see below). On 07/23/18 at 1:35 p.m., progress notes showed Staff D contacted the nurse practitioner with the critical lab results from 07/19/18. The nurse practitioner gave orders to transfer Resident #1 to the hospital. According to hospital records, Resident #1 arrived at the hospital on [DATE] at 3:07 p.m. He received an admitting [DIAGNOSES REDACTED]. Creatinine 6.2 (increased from 3.48 on 07/19/18) Sodium 158 (above the reference range of 136-145) Further review of hospital records showed Resident #1 required anesthesia for a cystoscopy (a diagnostic procedure to determine [DIAGNOSES REDACTED]. In an interview on 08/02/18 at 10:50 a.m. with Staff C, Resident Care Manager, licensed nurses were expected to call critical labs to the physician immediately upon knowledge of the values. On 08/02/18 at 11:15 a.m., Staff B, Director of Nursing, confirmed the physician was not notified of Resident #1's critical labs, according to facility practice and professional standards. Resident #1 was not available for interview as he was hosptalized on [DATE], when the critical lab results were identified, and emergent intervention occurred. Refer to F658 for additional findings. Reference: (WAC) 388-97-1620 (6)(b)(i)

Based on observation, interview, and record review, the facility failed to ensure the care plan was followed for two of two sample residents (#83, 105), reviewed for accidents. Failure to follow Resident #105's care plan for fall inteventions, placed the resident at increased risk for falls and injury. The facility's failure to follow the care plan for transferring Resident #83 resulted in actual harm, as a result of an injury which required sutures. Findings included: 1. Per the admission assessment dated [DATE], Resident #83 had [DIAGNOSES REDACTED]. The assessment indicated the resident was moderately cognitively impaired, had unsteady balance, and needed extensive assistance of two or more staff for bed mobility and transfers. A review of the care plan dated 12/18/17, and last updated 01/26/18, revealed Resident #83 required total assistance from two or more staff and a Hoyer lift (a type of mechanical device), for transfers. A review of a facility investigation dated 12/29/17 revealed Staff O, Nursing Assistant, had transferred Resident #83 from her bed to a wheelchair, by himself, rather than utilizing an additional staff person and Hoyer lift. After placing the resident in her wheelchair, Staff O, noticed her left leg was bleeding and notified Staff P, Registered Nurse. Upon assessment by Staff P, the resident's left shin was found to have four triangular shaped lacerations, each approximately 3.0 x 3.0 inches in size. Staff P then applied pressure dressings, and the resident was sent to the hospital for sutures. In an interview on 02/06/18 at 9:51 a.m., Staff S, Resident Care Manager, was asked about the incident on 12/29/17, and if Resident #83's care plan was followed. Staff S stated the resident was not transferred according to her care plan, and as a result, received a laceration to her left leg, which required her to be sent to the hospital for sutures. 2. Per record review, Resident #105 had a fracture from a fall, prior to admission. The 01/11/18 admission assessment showed the resident required extensive assistance from staff with mobility, and transferring from one surface to another. The assessment also showed the resident had two additional falls since admission. The resident's 01/18/18 care plan for fall prevention instructed nursing staff to use a pressure alarm (a device that would sound an alarm, if pressure was not directly applied by the resident's body weight) while in bed, when up in a wheelchair, and in a recliner chair. Staff were directed to inform nursing staff of unsafe movements, as the resident rarely notified staff of the need for assistance. On 02/02/18, from 6:26 - 7:40 a.m., it was observed the resident's pressure alarm device was not properly set up. During that time, staff were coming in and out of resident rooms, and not in direct line of sight of Resident #105, as they were assisting other residents. At 7:40 a.m., Staff AA, Nursing Assistant, was told by the surveyor the pressure pad was not attached to the alarm box. Staff AA confirmed that it should be, and reconnected it. On 02/05/18 at 9:56 a.m., the resident was observed asleep, sitting in a brown recliner with his legs elevated. The pressure alarm was not in place, as directed on the care plan. Upon further review, the alarm was found sitting on the wheelchair in the resident's room. Later that day at 10:08 a.m., Staff M, Registered Nurse, stated the resident was sitting in the recliner for approximately one to one and a half hours, before staff assisted him back into the wheelchair. Staff M confirmed staff did not ensure the pressure alarm was placed on the recliner, at the time the resident was transferred into it. On 02/07/18 at 11:25 a.m., Staff J, Unit Manager, confirmed the resident's current plan of care for fall prevention included using the pressure alarm at all times, with the exception of when he was being assisted with cares. Reference WAC 388-97-1060 (3)(g)

Based on observation, interview and record review, it was determined the facility failed to ensure safety interventions and adequate supervision was implemented for 1 of 4 residents (#1) related to transfers that involved the use of a mechanical lift. . Resident #1 experienced actual harm as of result of a fall when care plan interventions were not followed. In addition, after the fall, the facility failed to reevaluate and develop targeted interventions for Resident #1 to ensure proper supervision, technique, and safety precautions were thoroughly understood and implemented by staff who transferred the resident. This failure allowed the resident to be at continued risk of fall and injury during transfers. This was determined to be an Immediate Jeopardy on 8/12/14. Findings include: Resident #1 had [DIAGNOSES REDACTED]. Per record review, Resident #1 was alert and oriented and able to make her needs known. She required extensive assist with transfers. The resident's care plan identified the resident was at risk for falls related to total body flaccidity, and impaired vision. The care plan directed staff to use a Hoyer ( a mechanical lift) with 2 person assist when transferring. A mechanical lift is used by placing the resident in a sling which is then lifted in the air by hydraulic power. This allows the resident to be transferred between areas like a bed to a chair. There was no safety assessment found for the use of the mechanical lift to be used for this resident with muscle spasms. In addition the care plan identified the resident's need for an upper body harness and seatbelt while in wheelchair to maintain position and safety related to inability to control body movements. According to the resident's record, on 7/24/14 while suspended in the Hoyer lift, the resident fell forward, face first and hit her forehead on the floor. There was only one staff member completing the transfer at the time of the fall. The resident was sent to the hospital for required medical treatment of [REDACTED]. Per review of the facility investigation, the facility provided a "mini" inservice to staff dated 7/25/14. The inservice stated that "all Hoyer transfers were to be done with 2 person total assist and while transferring with a Hoyer both staff members were to ensure the sling was placed correctly, surrounding areas are clear and the bed, wheelchair etc. are ready". Despite the knowledge of the resident's previous fall, no education specific to Resident #1 and risk of her falling forward was given to staff. The "mini" inservice was signed by only 6 staff members. No changes were made to Resident#1's care plan at that time. The safety of the Hoyer lift was still not evaluated. These failures placed the resident at risk for another significant injury. During an interview on 8/11/14 at 1:00 p.m., Resident # 1 was able to recall the fall, she pointed to her forehead where a scar was visible. She stated prior to her fall she had been transferred with only one staff member using the Hoyer lift. On 8/11/14 at 1:15 p.m., an observation was made of Resident #1 being transferred from her wheelchair to the toilet. Resident #1 was in her wheelchair seated in an upright position and her seat belt and safety harness were removed by staff. The resident was left slumped in her wheelchair with no safety devices in place, while both staff proceeded to gather supplies in the resident's room and bathroom. Neither staff were facing the resident, nor were they in arms length of resident. Leaving the resident unattended after removing her safety harness and seatbelt placed the resident at risk to fall out of her wheelchair. Resident #1 was then placed in the Hoyer sling, and taken to bathroom. During that time Staff #A was controlling the Hoyer's lift mechanism and Staff# B was behind the resident and intermittently placed her hands on the resident's back. Neither staff members were positioned in front of the resident to prevent her from falling forward as she had in the fall less than a month prior. Upon return from the bathroom the resident experienced a muscle spasm causing her to jerk her body forward, at that time she was suspended over her bed still in the Hoyer sling. Staff #B who was observed by surveyor transferring the resident was not listed as receiving the inservice dated 7/24/14. In an interview following the transfer Staff #A stated staff use different slings. There were no specific instructions on which sling should be used for this resident. The slings observed were different sizes and would suspend the resident at different angles. No evaluation was completed to determine which sling was safest for this resident who was at high risk to fall forward. Resident #2 was observed being transferred using a Hoyer by 2 staff members from her bed to her wheelchair on 8/11/14 at 10:00 am. While in the Hoyer Resident #2 was suspended in the air and swinging back and forth and the fabric strap was hitting the resident's face. Staff #C commented to the resident about the strap hitting her, but made no attempts to keep it away from her face. Staff #C operated the Hoyer lift controls (elevation and decent) and Staff #D prepared and positioned the wheelchair, neither staff had their hands on the resident until she was lowered into the wheelchair. Per interview after the transfer was complete, Staff #C stated it was a normal transfer and the job of the second person during the transfer was to spot and help position the resident. In a follow up interview 8/11/14 at 5:07p.m., Staff #C stated Staff #D "should have been spotting the resident and could have stopped her from swinging by grabbing the sling". Neither Staff #C or #D were listed as receiving the inservice given on Hoyer transfers after the fall involving Resident #1. On 8/11/14 the facility was informed of the observations and the concern for resident safety related to transfers using the Hoyer. Staff# E, the Director of Nursing immediately provided re-education to current staff on duty which included to read the care plan in the resident's closet that provided direction on how to transfer the resident to ensure safety. Per review of the care plan, the last update/revision was dated 6/4/13. No updates were made to the resident's care plan related to Hoyer transfers or to be aware of her risk to fall forward. The inservice directed the staff to follow the resident's care plan but the facility failed to update the resident's care plan. This again placed the resident at risk for significant injury. Per interview with physical therapy department on 8/12/14 Staff #F stated they perform safety assessments on residents if they were notified to do so. Per Staff #G, Director of Rehabilitation, the last assessment completed on Resident #1 was dated April 2014 and was related to a wheelchair assessment. On 8/12/14 Staff #H stated he had reviewed the mini inservice with staff that morning and was planning to watch them complete a transfer later that morning. Staff were allowed to continue transfers with the resident before being evaluated on their transfer methods despite prior knowledge unsafe transfers had occurred with Resident #1 the day before. The lack of supervision of staff performing transfers again placed Resident #1 at risk for another injury. The facility failed to ensure safety interventions and adequate supervision was implemented and despite a resident experiencing a fall with a head injury requiring medical treatment no thorough reevaluation of safety was completed. No targeted interventions to ensure proper supervision, technique, and safety precautions were developed to ensure safe transfers for the resident. These failures resulted in continued risk of significant injury to Resident #1 and others residents using a Hoyer lift.