Every finding on record at Washington State Walla Walla Veterans Home

Based on interview and record review, the facility failed to ensure adequate supervision was consistently implemented to prevent resident-to-resident altercations with Resident 1 for 1 of 4 residents (Resident 2) reviewed for avoidable accidents. This failure placed the residents at risk for additional physical altercations, serious injury, and emotional distress.Findings included. Review of a policy titled, Safety and Supervision of Residents, revised 07/2017, showed the interdisciplinary care team (a group of healthcare professionals from different disciplines to help people receive the care they need) would analyze information obtained from assessments and observations to identify specific accident hazards or risks for individual residents. The care team would target interventions to reduce individual risks, including adequate supervision. Resident supervision was a core component of the system approach to safety. Resident 1Review of the medical record showed Resident 1 was admitted to the facility with diagnoses including dementia with behavioral disturbance (a progressive disease that destroys memory and other important mental functions, with agitation, physical aggression, wandering, and hoarding), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and an irregular heart rhythm. The 03/21/2026 comprehensive assessment showed Resident 1 required moderate/maximum assistance of one staff member for activities of daily living [(ADLs) activities related to personal care]. The assessment also showed Resident 1 had a severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and senses). Resident 2Review of the medical record showed Resident 2 was admitted to the facility with diagnoses including neurocognitive disorder with Lewy bodies (a progressive brain disorder that causes changes in thinking, movement, and behaviors), bipolar disorder (a mental health condition that causes extreme shifts in mood, energy, and activity levels), and heart failure. The 04/01/2026 comprehensive assessment showed Resident 2 required assistance of one staff member for ADLs. The assessment also showed Resident 2 had a severely impaired cognition. Resident 3Review of the medical record showed Resident 3 was admitted to the facility with diagnoses including Alzheimer's disease, bipolar disorder, and dementia with agitation (a behavioral and psychological symptoms that cause sudden, persistent, and unprovoked restlessness, emotional distress, or irritability). The 04/29/2026 comprehensive assessment showed Resident 3 required assistance of one staff member for ADLs. The assessment also showed Resident 3 had a severely impaired cognition. Record review of Resident 1's care plan dated 05/05/2026, showed Resident 1 was not to be seated next to any male resident during meals or activities. Offer to seat them at a different table, the kitchen counter, or move the male resident away from Resident 1 as needed to maintain a safe distance. The care plan also showed Resident 1 should be positioned in ways that staff could quickly intervene when necessary and moving other residents may be necessary. Staff should intervene as necessary to protect the rights and safety of others. Record review of a facility investigation dated 05/25/2026 at 2:30 PM, Staff C, Nursing Assistant (NA), was in the kitchen area while Resident 1 and Resident 2 were sitting next to each other at the kitchen counter and Resident 3 was standing at the entrance gate to the kitchen. Resident 3 was giving Resident 1's colored pencils to Resident 2. Resident 1 became angry and yelled at Resident 2 to give their colored pencils back, while stabbing Resident 2's left arm with a colored pencil, then hitting their left arm with an open hand. Record review of a witness statement dated 05/25/2026, showed Staff C documented they were in the kitchen getting water pitchers to pass out. The kitchen gate was closed, and Resident 3 was standing in front of the gate. Resident 1 and Resident 2 were at the kitchen counter together. Resident 3 gave Resident 1's colored pencils to Resident 2, which made Resident 1 angry. Staff C asked Resident 2 to give the pencils back and they refused. Resident 1 began hitting Resident 2 with a pencil. During an interview on 06/04/2026 at 12:46 PM, Staff D, Registered Nurse/Resident Care Manager, stated Resident 1 was not supposed to sit next to anyone. They stated staff had been educated that Resident 1 was not to come within arms reach of any other resident. They stated Resident 1 did not have adequate supervision that day; the NA had turned their back on the resident. They stated the NA should have had their eyes on Resident 1 at all times and should not have let Resident 1 get within arms reach of the other residents. During an interview on 06/04/2026 at 2:09 PM, Staff B, Director of Nursing, stated the staff had their back to the residents when the incident occurred. The staff should have been watching Resident 1. When another resident was in Resident 1's space, the staff should have removed them for safety. During an interview on 06/04/2026 at 2:25 PM, Staff A, Administrator, stated Resident 1 needed to have supervision to prevent incidents. They stated Resident 1 should not have been allowed to be that close to another resident. This is a recurring deficiency previously cited in the Statement of Deficiencies dated 04/14/2026. Reference: WAC 388-97-1060(3)(g)

Based on interview and record review, the facility failed to provide adequate supervision and update care plan interventions to prevent resident-to-resident altercations with Resident 2 for 1 of 3 residents (Resident 1) reviewed for accidents. This failure placed the residents at risk for potential verbal and physical abuse, serious pain and injury, and emotional distress.Findings included. Review of a policy titled, Safety and Supervision of Residents, revised 07/2017, showed the interdisciplinary care team (a group of healthcare professionals from different disciplines to help people receive the care they need) would analyze information obtained from assessments and observations to identify specific accident hazards or risks for individual residents. The care team would target interventions to reduce individual risks, including adequate supervision. Resident supervision was a core component of the system approach to safety. The type and frequency of resident supervision may vary over time for the same resident. Resident 1Review of the medical record showed Resident 1 was admitted to the facility with diagnoses including age-related cognitive decline (a natural slowing of processing speed, reduced working memory, and occasional word-finding difficulties, but generally does not impair daily functioning), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and anxiety disorder. The 02/07/2026 comprehensive assessment showed Resident 1 required maximum assistance/dependence on one to two staff members for activities of daily living [(ADLs) activities related to personal care)]. The assessment also showed Resident 1 had a severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). Resident 2Review of the medical record showed Resident 2 was admitted to the facility with diagnoses including dementia with behavioral disturbance (a progressive disease that destroys memory and other important mental functions, with agitation, physical aggression, wandering, and hoarding), Alzheimer's disease, and an irregular heart rhythm. The 03/21/2026 comprehensive assessment showed Resident 2 required moderate/maximum assistance of one staff member for ADLs. The assessment also showed Resident 2 had a severely impaired cognition. Review of Resident 2's care plan dated 04/08/2026, showed identified interventions for episodes of verbally and physically abusive behavior that included avoid seating Resident 2 near (identified residents) for meals.whenever possible. Encourage Resident 2 to sit at another table for activities.Resident 2 generally prefers to sit with Resident 1 and if Resident 1 is sitting at another table that may persuade Resident 2 to sit in a different location than (identified residents). Additional interventions included Resident 2 having a quiet moment in their room, on the patio, and going for a walk. Position Resident 2 and staff in ways to enable quick intervention when necessary. Intervene as necessary to protect the rights and safety of others. Remove from the situation and take to alternate location as needed. Record review of a facility investigation dated 02/05/2026, showed on 02/02/2026 at 5:15 PM, Resident 2 was irritable and having difficulty getting along with other residents. Resident 1 had received their plate of food for dinner and Resident 2 accused Resident 1 of taking their dinner plate. Resident 2 became angry and hit Resident 1 on their left arm. Record review a facility investigation dated 04/04/2026, showed on 04/03/2026 at 6:00 PM, Resident 2 became agitated with Staff B, Registered Nurse (RN), during their medication administration. Resident 2 became verbally aggressive with Staff B and was redirected to their room to calm down. Resident 2 did not remain in their room and wheeled themselves in their wheelchair to sit next to Resident 1. Resident 2 stated to Resident 1 you are not helping me and hit Resident 1 twice in the left arm. During an interview on 04/14/2026 at 3:07 PM, Staff D, RN, stated when Resident 2 had behaviors the staff tried to intervene and redirect them. They stated Resident 2 connected with Resident 1 and considered them a surrogate (substitute) spouse. Staff D stated Resident 1 used to call staff over to sit and talk with them; now Resident 2 sat and talked with them so staff did not have to. Over the last month, Resident 1 had become more agitated and more difficult to redirect. Staff D stated Resident 2 was more agitated with Resident 1, angry with them, and cursed at them. They stated Resident 1 was not offended when Resident 2 swats at them. Staff D stated the care plan interventions were appropriate in the past but with the new abuse allegations, they should have been updated. Staff D stated they were responsible for updating the care plan interventions but had not done so for Resident 2, despite the resident-to-resident altercations. During an interview on 04/14/2026 at 3:27 PM, Staff A reviewed the facility policy related to safety and supervision of residents and stated the facility did not follow the policy. Cross reference to F600 for further information. Reference: WAC 388-97-1060(3)(g)

Based on interview and record review, the facility failed to implement their abuse prevention policy in the areas of prevention and protection for 1 of 3 residents (Resident 1) reviewed for abuse. This failure placed the residents at risk for continued unidentified abuse, fear, and dissatisfaction with their living situation.Findings included. Review of a policy titled, Resident Abuse Prevention, dated 12/18/2024, showed prevention of abuse included identifying, correcting, and intervening in situation in which abuse, neglect, and/or misappropriation of resident property was likely to occur. The facility would provide sufficient staff to meet the needs of the residents and ensure the staff assigned had knowledge of the individual resident's care need. Assessments, care planning, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors. Review of a policy titled, Abuse and Neglect, dated 12/18/2024, showed upon receiving notice of allegations of resident abuse, the Administrator, or designee, shall undertake reasonable and prudent actions to ensure the safety and protection of the rights of the alleged victim and other residents of the facility. Resident 1Review of the medical record showed Resident 1 was admitted to the facility with diagnoses including age-related cognitive decline (a natural slowing of processing speed, reduced working memory, and occasional word-finding difficulties, but generally does not impair daily functioning), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and anxiety disorder. The 02/07/2026 comprehensive assessment showed Resident 1 required maximum assistance/dependence of one to two staff members for activities of daily living [(ADLs) activities related to personal care)]. The assessment also showed Resident 1 had a severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). Resident 2Review of the medical record showed Resident 2 was admitted to the facility with diagnoses including dementia with behavioral disturbance (a progressive disease that destroys memory and other important mental functions, with agitation, physical aggression, wandering, and hoarding), Alzheimer's disease, and an irregular heart rhythm. The 03/21/2026 comprehensive assessment showed Resident 2 required moderate/maximum assistance of one staff member for ADLs. The assessment also showed Resident 2 had a severely impaired cognition. Review of a nursing progress note (PN) dated 02/02/2026 at 6:51 PM, showed Resident 2's irritability was increasing throughout the afternoon with behaviors including yelling at others and calling staff b*****s. Resident 2 believed Resident 1 was eating from their dinner plate and they hit Resident 1. Review of a PN dated 04/03/2026, showed Resident 2 had an altercation with Staff B, Registered Nurse (RN), related to their medication administration. Resident 2 was placed in their room due to their escalating behaviors of hitting, kicking, and cursing at Staff B. Resident 2 came back out of their room in their wheelchair, wheeled over to Resident 1, stated to them you are not helping me, and punched them twice on their left arm. During an interview on 04/14/2026 at 3:07 PM, Staff D, RN, stated Resident 2 had increased behaviors over the last month. They stated when the resident had increased behaviors, staff tried to redirect them. Staff D stated Resident 2 had connected with Resident 1 after Resident 2's spouse passed away and thought it was good that Resident 1 had a companion, someone to sit with, and someone to talk to, despite Resident 2 being an aggressor, getting angry with, and cursing at Resident 1. During an interview on 04/14/2026 at 3:27 PM, Staff A, Director of Nursing Services, stated once abuse was identified, the residents would be separated to protect the alleged victim. Staff A stated they did not know why the residents were encouraged to sit together and not separated after the first incident. They stated the facility policy was not followed. Cross reference F600 for further information.Reference: WAC 388-97-0640(1)(2)(a)(b)(5)(a)(a)(b)(c)

Based on interview and record review, the facility failed to protect the resident's right to be free from physical and verbal abuse by Resident 2 for 1 of 3 residents (Resident 1) reviewed for abuse. This failure placed the residents at risk for continued abuse, injury, and emotional distress. Findings included. Review of a policy titled, Abuse and Neglect, dated 12/18/2024, showed physical abuse was the willful action of inflicting bodily injury or physical mistreatment that included striking with or without an object, slapping, pinching, choking, kicking, shoving, or prodding. Mental abuse was a willful verbal or nonverbal action that threatens, humiliates, harasses, coerces, intimidates, isolates, or punishes a vulnerable adult (a person [AGE] years of age or older who has the functional, mental, or physical inability to care for themselves) that may include ridiculing, yelling, or swearing. Resident 1Review of the medical record showed Resident 1 was admitted to the facility with diagnoses including age-related cognitive decline (a natural slowing of processing speed, reduced working memory, and occasional word-finding difficulties, but generally does not impair daily functioning), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and anxiety disorder. The 02/07/2026 comprehensive assessment showed Resident 1 required maximum assistance/dependence of one to two staff members for activities of daily living [(ADLs) activities related to personal care)]. The assessment also showed Resident 1 had a severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). Resident 2Review of the medical record showed Resident 2 was admitted to the facility with diagnoses including dementia with behavioral disturbance (a progressive disease that destroys memory and other important mental functions, with agitation, physical aggression, wandering, and hoarding), Alzheimer's disease, and an irregular heart rhythm. The 03/21/2026 comprehensive assessment showed Resident 2 required moderate/maximum assistance of one staff member for ADLs. The assessment also showed Resident 2 had a severely impaired cognition. Record review of Resident 2's care plan dated 04/08/2026, showed Resident 2 had episodes of verbally and physically abusive behavior. An intervention for the behavior showed to avoid sitting Resident 2 near specific residents at meals whenever possible; Resident 2 preferred to sit with Resident 1. If Resident 1 was sitting at another table, that may persuade Resident 2 to sit away from the other residents. Record review of a facility investigation dated 02/05/2026, showed on 02/02/2026 at 5:15 PM, Resident 2 was irritable and having difficulty getting along with other residents. Resident 1 had received their plate of food for dinner and Resident 2 accused Resident 1 of taking their dinner plate. Resident 2 became angry and hit Resident 1 on their left arm. Record review a facility investigation dated 04/04/2026, showed on 04/03/2026 at 6:00 PM, Resident 2 became agitated with Staff B, Registered Nurse, during their medication administration and accused Staff B of stealing their inhaler (a handheld device that delivers medication directly to the lungs). Resident 2 became verbally aggressive with Staff B and was redirected to their room to calm down. Resident 2 did not remain in their room and wheeled themselves in their wheelchair to sit next to Resident 1. Resident 2 stated to Resident 1 you are not helping me and hit Resident 1 twice on the left arm. During an interview on 04/14/2026 at 2:22 PM, Staff C, Nursing Assistant, stated Resident 2 had random outbursts that was normal behavior for them. They stated Resident 2 was mean to Resident 1. Staff C stated there was an incident when Resident 2 yelled at Resident 1 over dinner then hit Resident 1. Staff C stated Resident 2 was frequently upset with the staff when they tried to take Resident 1 to their room for personal cares. Staff C stated Resident 1 did not realize what was happening and could not advocate for themselves. During an interview on 04/14/2026 at 2:53 PM, Staff B stated they recalled the second incident between Resident 1 and Resident 2. They stated Resident 2 became angry with them during their medication administration. Staff B stated Resident 2 continued to escalate and punched and kicked at them. They stated they took Resident 2 back to their room because there were other residents in the dining area. Staff B stated Resident 2 came back out of their room. They recognized that they were causing Resident 2's behaviors to escalate and stepped back to allow a different staff member to attend to Resident 2 and continued to monitor them from a distance. Resident 2 became angry with that staff member, went to Resident 1 and punched them in the arm twice. Staff B stated they had seen Resident 2 hit other residents in the past. They stated Resident 2 had altercations with whoever gets in their way but goes towards (Resident 1). During an interview on 04/14/2026 at 3:27 PM, Staff A, Director of Nursing Services, stated they did not look at abuse as a resident-to-resident issue, but as a staff to resident issue. They stated they now understood the definition of abuse and agreed that Resident 1 was abused by Resident 2. Reference: WAC 388-97-0640(1)

Based on observation, interview, and record review the facility failed to identify hazards and risks to ensure the resident's environment remained free of accident hazards for 1 of 3 residents (Resident 80) reviewed for hospitalization. The failure to consistently complete a thorough safety assessment of Resident 80's environment with the use of their powered wheelchair (w/c) caused Resident 80 to experience harm when they drove their powered w/c off a curb and sustained an injury that required hospital and surgical intervention. Findings included . Resident 80 Review of the resident's medical records showed they admitted with diagnoses to include bladder cancer (the uncontrolled growth of abnormal cells in the body), wet macular degeneration (an eye condition that causes blurred or reduced central vision, and can cause distortions, such as straight lines that appear to be bent), and myopia (an eye condition that leads to vision loss) of an unidentified eye/eyes. The 11/22/2025 comprehensive assessment showed Resident 80's cognition was intact, had impaired vision, and wore eyeglasses. The assessment showed the resident required one to two staff assistance with activities of daily living and used a motorized (powered) w/c for mobility. Review of a 12/28/2025 incident investigation report at 10:08 AM, showed a call came over the communication radio from the activities department that there was a resident observed outside, in the parking lot, and they had fallen out of their w/c and onto the pavement. The staff found Resident 80 had driven off the end of the sidewalk/curb, causing them to fall out of their w/c. The report showed Resident 80's body was twisted and appeared to be resting on the top of the left leg, and the left leg appeared to be deformed (distorted from the usual shape or form) and could not move on their own. Additionally, Resident 80 received cuts and scrapes on their left knee, hands, fingers and toes. The report showed the resident thought there was a ramp at the end of the sidewalk that that went down into the parking lot, and it was too late to stop when they realized there was not a ramp. Paramedics were called and Resident 80 was sent to the hospital. The report showed the investigation concluded on 01/03/2026 (six days after the incident, and not within the required five days to rule out abuse and neglect) with no updates to the care plan in regard to the fall and the safety awareness of the powered w/c (there was no care plan for the powered w/c prior to or after concluding the incident). The report showed there were no witness statements obtained from the activities staff that observed the fall and called out on the radio, or from the second Nursing Assistant (NA) and Licensed Nurse that were first to find the resident, education provided, or in-services regarding w/c safety and following resident care plans. Review of the 12/28/2025 hospital records showed Resident 80 was admitted to the hospital for surgical repair of a comminuted (a bone that was broken or shattered in three or more pieces), angulated (the bone was slightly bent or angled), and displaced (the bone fragments were moved out of alignment) fracture to their upper left leg. Review of a 01/04/2025 Power-Mobility Indoor Driving Assessment showed the environment Resident 80 was assessed in was SNF [Skilled Nursing Facility] indoor and the resident had five years' experience with the current, personally owned, powered w/c and could not transfer in and out of the w/c without the assistance of two staff and a mechanical lift (a mechanical device used to transfer a person with limited mobility from one surface to the other). The assessment showed Resident 80 requested to use the w/c for appointments only. The assessment showed the resident was unable to open the automatic or regular doors on their own, refused to complete parallel parking or parking under a table, and required staff assistance or supervision going up and down a ramp, going backwards, and with maneuvering unexpected obstacles. The assessment showed the resident was assessed to be hesitant, required several tries, required speed restrictions, and/or bumps walls and objects lightly for manipulating a congested area and maneuverability. The result of the assessment showed, in the opinion of the assessor, Resident 80 was able to drive independently with no restrictions (indoors). Review of Resident 80's 12/11/2025 care plan showed a care plan for Resident 80's impaired visual function with interventions dated 12/23/2024 to remind and ensure resident was wearing their eyeglasses when up and a magnifying glass was used to read fine print. The care plan showed no care plan had been developed for the use and safety of the powered w/c. During an interview on 02/26/2026 at 3:52 PM, Staff M, Director of Rehabilitation Services, stated normal processes were to assess residents in their powered w/c in their indoor and outdoor environments for safety. Staff M stated Resident 80 refused to be assessed outdoors because they had no plans to use the w/c outside independently. Staff M stated Resident 80 was not assessed again after the 01/04/2025 (11 months and 24 days prior to the incident) assessment because they did not get out of bed for what seemed like a year. Staff M stated the resident received a new powered w/c around the middle of summer and the vendor showed the resident how to use the functions on the wheelchair and how to load and offload from the bus for appointments but that was the extent of the assessment. Staff M stated the therapy assessment was not the final decision for the use of the w/c, it was the decision of the Interdisciplinary Team as a whole. Staff M stated they would have expected the same staff supervision and assistance to be provided, per the assessment, whether Resident 80 was inside or outside. During an interview on 02/26/2026 at 4:02 PM, Staff H, Registered Nurse, stated they had given Resident 80 their medication around 8:00 AM to 8:30 AM on the morning of 12/28/2025, and at that time educated the resident how important it was for them to get up and out of bed. Staff H stated it was a constant battle of encouraging the resident to get up and rarely ever did. Staff H stated when they heard the call over the radio that a resident had fallen out of their w/c outside, they were shocked to see that it was Resident 80. Staff H stated they asked the resident what they were doing and the resident told them they had gone outside for some fresh air and didn't realize there was a curb at the end of the sidewalk. Staff H stated Resident 80's eyesight was really bad, and they did not have their eyeglasses on. Staff H stated Resident 80 was not known to get out of bed let alone go outside on their own. During an interview on 02/27/2026 at 10:02 AM, Staff G, Registered Nurse/Resident Care Manager, stated it was a huge challenge to get Resident 80 out of bed and into their powered w/c and that they preferred to stay in bed all the time. Staff G stated Resident 80 had a history of refusing to follow their plan of care (obtaining weights, blood pressures, fluid retention interventions, and getting up for mobility). Staff G stated the only time Resident 80 was up in their powered w/c was for an appointment and they would sit by the front door and wait for the bus to arrive and either a staff member or the bus driver would take them to the bus. Staff G stated a staff member was required to escort the resident to their appointments because the resident was unable to maneuver the w/c by themselves while holding onto appointment packets/paperwork. Staff G stated Resident 80 was not known to be outdoors without someone with them and it was unknown if the resident could open the doors on their own, but if not, staff would have to have opened the door for them if they could not. Staff G stated Resident 80 received a new powered w/c and was very large and top heavy and because the resident was taller, their longer legs unbalanced the w/c, and the w/c had to be tilted in a backward seat position to maneuver the little lip of the ramp on the bus. Staff G stated Resident 80 did have vision issues and was to wear glasses when up but often refused them. Staff G stated they would often see Resident 80 reading, large print, without their glasses. Staff G stated they should have developed a care plan for Resident 80's powered w/c but since the resident never used the w/c, it was missed. Staff G stated Resident 80's recent visit to the hospital for heart failure (12/08/2025), refusals of care, treatments/medication, refusals to wear their eyeglasses, and to get up and out of bed, and changes in their powered w/c with minimal use and knowledge of it, were not indicative of notifying therapy for a new safety assessment. Staff G stated normal process was to assess use of equipment quarterly and with any change of condition but did not feel there had been any change in the resident since they were alert and oriented and were able to communicate that. During an interview on 02/27/2026 at 11:29 AM, Staff B, Director of Nursing Services, stated there were no other witness statements for Resident 80's incident on 12/28/2025. Staff B stated the process was that every resident with a powered w/c was assessed for safety. Staff B stated they did not know what the assessments entailed or how they were completed because they were completed by therapy. Staff B stated they would have expected the assessments to be completed in any environment that the resident was going to be using the w/c in and then reassessed quarterly and for any changes. Staff B stated they would have expected the powered w/c to be care planned with interventions and realized during the investigation that had not been done. During an interview on 02/27/2026 at 11:43 AM, Staff A, Administrator, stated they did not know whether residents were assessed with the use of their powered w/c inside and outside and did not feel that it would make much of a safety difference if only one or the other environment was assessed. Staff A stated the residents were free to come and go as they please and they could not keep them from doing what they wanted to do even if they were assessed to be unsafe. During an interview on 02/27/2026 at 12:23 PM, Staff U, Activities Assistant, stated on the morning of 12/28/2025, they exited out of the facility door at one end of the building when they observed Resident 80 exiting out the door at the other end of the building. Staff U stated they had to look twice because they could not believe they were seeing Resident 80 out of their bed, in their w/c and outside. Staff U stated Resident 80 continued down the long sidewalk towards the curb to the parking lot, then right before reaching the curb, where the sidewalk ends and splits to the right or the left, the resident slowed down as if they were assessing the area, and then all of a sudden, sped up faster and went straight, off the curb, causing their w/c to flip over forward. Staff U stated they immediately called for assistance on the radio and by the time they reached the resident, other NAs had already come out, and they all met up at the same time. Staff U stated Resident 80 was not wearing glasses at the time and was awake. Staff U stated they thought they completed a witness statement but then again, could not remember if they had or had not. During a telephone interview on 03/04/2026 at 4:00 PM, Staff A, along with Staff B, stated when residents refused a complete and thorough evaluation for safety in their powered w/c then the resident would not have been able to use the equipment or they would have obtained a signed risk and benefit detailing the importance of the assessment and the risks if the resident chose not to follow them. Staff B stated that was not done with Resident 80. Staff B stated their expectation of assessments would be to obtain a new assessment when a new w/c was received or with a change in their condition. Staff A stated in the middle of 2025 (exact date could not be provided), Resident 80 received a new manual w/c because they did not like their powered w/c and the powered w/c was only to be used for appointments. Staff A stated there were no other w/c safety assessments completed for Resident 80 other than the initial w/c assessment dated [DATE], right after admission. Staff A stated the LN staff would have had to request a safety evaluation for the new w/c and that had not been done. Staff B stated direct care nursing staff would have known which w/c to use by following the Kardex (information used by direct care staff when providing the resident with their care needs), but since there was no w/c care plan, they would not have known to transfer the resident to their manual w/c rather than to the powered w/c. Reference: WAC 388-97-1060 (3)(g)

Based on interview, and record review, the facility failed to ensure a Preadmission Screening and Resident Review [(PASARR) a process to determine if a potential nursing home resident had mental health/intellectual disability needs which required further assessment/treatment] accurately reflected residents' mental health conditions for 4 of 8 residents (Resident 5, 12, 13, and 7) reviewed for unnecessary medications. This failure placed the residents at risk for inappropriate nursing home placement and/or not receiving timely and necessary services to meet their mental health needs.Findings included.Resident 5 Review of the medical record showed Resident 5 was admitted to the facility on [DATE] with diagnoses including Post Traumatic Stress Disorder [(PTSD) a mental health condition triggered by witnessing or experiencing terrifying events, such as violence, accidents, or disasters], depression, anxiety, and dementia (a progressive syndrome characterized by severe cognitive decline that interferes with daily life). The 02/09/2026 comprehensive assessment showed Resident 5 was independent with activities of daily living [ADLs) activities related to personal care] and moderate assistance of one staff member for showers. The assessment also showed Resident 5 had an intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and senses). Record review of a PASARR Level I form updated 05/06/2025, showed Resident 5 did not have a diagnosis of dementia, despite the diagnosis listed in their medical record. Resident 12 Review of the medical record showed Resident 12 was admitted to the facility on [DATE] with diagnoses including dementia, depression, anxiety, and PTSD. The 01/17/2026 comprehensive assessment showed Resident 12 required substantial/maximum assistance of one staff member for ADLs. The assessment also showed Resident 12 had a severely impaired cognition. Review of a PASARR Level I form dated 10/28/2025, showed no diagnosis of anxiety listed as a serious mental health indicator and showed they did not have a diagnosis of dementia. The form showed the resident was admitted with an exempted hospital discharge (requiring fewer than 30 days of nursing facility services). There was no updated PASARR Level 1 form in the medical record, despite staying past the 30-day exempted stay. Resident 13 Review of the medical record showed Resident 13 was admitted to the facility on [DATE] with diagnoses including PTSD and depression. The 01/09/2026 comprehensive assessment showed Resident 13 required setup/clean up assistance of one staff member for activities of daily living [(ADLs) activities related to personal care] and was independent with ambulation and transfers. The assessment also showed Resident 13 had no memory issues and was able to make independent decisions regarding daily life. Review of a PASARR Level I form dated 10/01/2025, showed Resident 13 had a serious mental illness indicator of a mood disorder. There was no documentation of the resident's diagnosis of PTSD. Resident 7Review of the medical record showed they were admitted to the facility on [DATE] with diagnoses including a system wide infection, Post-Traumatic Stress Disorder (PTSD, a mental health condition that's caused by an extremely stressful or terrifying event), insomnia (difficulty falling or staying or returning back to sleep), Bipolar disorder (a mental illness that causes extreme shifts in an individual's mood, energy, and activity levels), anxiety and substance abuse. The 02/03/2026 comprehensive assessment showed the resident was cognitively intact and able to make their needs known. Review of Resident 7's Level I PASARR form, dated 01/13/2026 showed SMI of PTSD and anxiety were marked down. The SMI did not include the resident diagnosis of bipolar disorder or substance abuse and the resident did not have a Level II referral sent due to being assessed as an exempt hospital discharge (meeting the criteria of the individual likely requiring fewer than 30 days in the facility and a Level II would be completed if not discharged with the 30 days). During an interview on 02/26/2026 at 12:48 PM, Staff C, Social Worker, stated the process for ensuring PASARR's were complete and accurate included screening the referral on admission and assessing for a Level II evaluation (an in-depth, person-centered evaluation triggered by a positive Level 1 screen to determine if an individual required specialized services) if needed. If the resident had a mental health diagnosis, a Level II evaluation would be required prior to admission. If the resident arrived at the facility and there were diagnoses not listed or identified on the admission packet, the facility would complete an accurate Level I PASARR and a Level II evaluation if indicated. When a resident has an exempted hospital discharge status, the facility would need to screen for a referral if they were in the facility longer than the 30 days. Staff C stated they did not have a tracking process for residents that admitted to the facility with the exempted hospital status. Staff C stated they completed an audit of all PASARR's on 02/23/2026 and had identified several inaccurate PASARRs. Staff C stated they did not catch those inaccuracies upon admission. During a continued interview on 02/26/2026 at 1:13 PM, Staff C stated that Resident 7 was an exempted hospital discharge and should have had a Level II referral sent on 02/14/2026 and the resident was currently 12 days over that. Staff C stated the correct process for the facility's PASARR referrals was not being completed. Reference: WAC 388-97-1915(1)(2)(a)(b)(c)

Based on observation, interview, and record review, the facility failed to discard expired foods and complete daily cleaning tasks for 6 of 8 kitchens ([NAME], Umatilla, Palouse, [NAME], [NAME], and [NAME]) and 1 of 1 dry storage area, and the facility failed to consistently monitor cooked food temperatures prior to serving regular and pureed food for 1 of 3 staff (Staff W) observed for safe and sanitary kitchen. This failed practice placed residents at risk for Food borne illness (caused by consuming foods that are contaminated with harmful pathogens [bacteria that reproduce rapidly once entered in the body and can damage tissues and cause illness]). Findings included.Kitchens [NAME] An observation and concurrent interview on 02/25/2026 at 12:07 PM, showed. Three 13.5-ounce (oz., a unit of measure) containers of Strawberry Jello, expired 02/21/2026 one six oz. container of cottage cheese with blueberries, expired 01/26/2026 16 round individual cream cheese, dated 12/19/2025 with no use by date Three 25 oz cartons of concentrated orange juice, expired 02/13/2026 One clear gallon sized baggie with frozen hashbrowns or white cheese, unlabeled and no use by or opened date One clear gallon sized baggie, one quarter full (a unit of measure), of frozen pepperoni slices, unlabeled, dated 11/05/2025, with no use by date. One-clear gallon sized baggie, one quarter full, of frozen beef meat balls, dated 10/29/2025 with no use by date One package of frozen rice, dated 12/23 with no use by date One clear gallon sized baggie of frozen white/tan food with no label or open or used by dates The ice machine was observed to have a vent to the left side that had dried on splatters of food and dust particles and dried brown and white food on the refrigerator doors and handles. Staff AA stated the cooks were to monitor the refrigerators and freezers for expired or old food and discard them. Staff AA stated food is to be labeled and the open/prepared date and the use by date should be on all food. Staff AA stated they did not know how often frozen foods should be kept once opened. Umatilla During an observation and concurrent interview of the on 02/25/2026 at 12:46 PM showed. Two 25 oz cartons of concentrated orange juice, expired 02/13/2026 One square, clear carton of mixed berries, store bought, expired 02/17/2026 (belonged to resident or staff) Three 13.5 oz cartons of Strawberry Jello, expired 01/24/2026 One eight oz bag of soy protein powder, half used, with no dates One 32 oz bag of slithered almonds, three quarters full-no dates One gallon size clear baggie of walnuts, half full, no dates or label One five-pound (lb., a unit of measure) turkey meat, thawing, with no dates One bag of open and frozen, half used cheese ravioli, not labeled or dated One container of Oikos vanilla yogurt, expired 01/19/2026 One 11 oz can of strawberry milkshake (belonged to resident or staff) unlabeled or dated One clear baggie with 12 oatmeal/chocolate chip cookies, with no label or dates One blue baggie with 12 sausage dogs, no label or dates One gallon size clear baggie, half full, with tater tots, no labels or dates The ice machine was observed to have a vent to the left side that had dried on splatters of food and dust particles. Staff BB stated they were an on-call cook that had been working full-time for the past two months. Staff BB stated they last checked for expired or old food last week. Staff BB stated the fruit and the strawberry milkshake were not products the facility used and should not have been in the refrigerator. Staff BB stated they did not know how long frozen foods should be kept for once they were opened but that all foods should have been dated and labeled. An additional observation and concurrent interview on 02/27/2026 at 9:11 AM, Staff FF, removed the cover to the left side of the ice machine, exposing the coils (condenser). The coils had a thick layer of gray, fuzzy dust. Staff FF stated they had a cleaning cycle with cleaning solutions, they could use a cleaning. Staff FF stated the ice machines were cleaned semi-annually. Palouse During an observation on 02/25/2026 at 1:11 PM showed. A clear bag, one fourth full of raw, fresh mushrooms with no dates One clear bag of shredded cheese, no use by date One clear bag of parmesan cheese, shredded, no use by date One three lb. tub of whipped cream cheese spread with no use by date or expiration date Four 25 oz cartons of orange juice that expired on 02/13/2026 Two eight oz packages of frozen grilled chicken, both opened, with no use by dates One five lb. bag of breaded food with no label or no use by or opened date 16 packages of eight waffles each package, frozen, with no labels, use by date, or date opened One green, one lb. bag, with veggie sausage and a use by date of 09/23. An additional observation and concurrent interview on 02/27/2026 at 9:11 AM, Staff FF removed the vent cover and exposed the coils with a thick layer of gray dust on them. Staff FF stated it was time for them to be cleaned. [NAME] During an observation and concurrent interview on 02/26/2026 at 10:41 AM showed. One two-gallon baggie with whitish colored grainy powder, one fourth full, not labeled or a use by date One bag of egg noodles, opened, one fourth full, no dates One clear baggie of fresh potatoes with a date of 01/14/20266 and no use by date One plastic grocery bag, with 12 0.98 oz packages of instant oatmeal, with no dates on the bag or expiration dates on the individual packages One opened, five lb. box of buttermilk biscuit mix, dated 12/27/2025 with no expiration date on the box itself or a use by date. One opened five lb. box of Spice cake mix, dated 12/31/2025, with no expiration date on the box itself of a use by date. One clear gallon size baggie with two clear bags inside, one labeled half batch of coffee cake mix, dated 09/27/2025 and the second bag labeled coffee cake streusel dated 09/27/2025. Neither bag had an expiration date or a use by date One opened clear bag with six frozen pre-made egg omelets, dated 12/31/2025, no use by date One opened bag of impossible burger patties unlabeled or undated, half full One bag, half full of pepperoni slices dated 09/17 with a use by date of 10/20/2025 One clear bag of a brownish rectangle meat product, dated 02/19 and no use by date One baggie with ten hot dogs, dated 01/07 with no use by date One plastic container, opened, uncovered because the top did not seal, of two lb. Provolone cheese slices, half full. Three 25 oz cartons of concentrated orange juice, expired 02/13/2026 Seven 13.5 oz containers of strawberry Jello, expired 02/21/2026 The ice machine was observed to have a vent to the left side that had built up dust particles and dried food splatters throughout the vent. Also, the left side of the ice machine had a broken, plastic piece, leaving a hole and sharp edges, the size of a 50-cent piece. The refrigerator and freezer doors had dirty fingerprint smears across the doors and in the handles, there was a shallow area that was filled with dirt and food crumbs. The cupboards in the kitchen, below the sink, were warped and missing the outside laminate covering, exposing the surface of the wood or particle board. Inside of the ovens, one on top of the other, there were dust particles hanging down out of the vents, and the areas beside the oven doors, where they close, were built up dust particles. Staff W stated they did not have a process for checking for expired and old foods, it has been a while.hasn't been done this year yet. Staff W stated maintenance was responsible for cleaning the ice machine vents and the cooks were responsible for nightly cleaning. Staff W stated it was not their process to document nightly cleaning. [NAME] An observation on 02/26/2026 at 1:30 PM showed. Two 25 oz cartons of concentrated orange juice, one expired on 02/13/2026 and the second one expired on 01/15/2026 One opened 12 oz bag of brown gravy mix, no dates Two opened 20 oz bag of country gravy mix, no dates One baggie with different colored cookie decorations, dated 8/17/2025, no use by date One opened 24 oz bag of lime gelatin mix, three quarters full, dated 09/04/2025, no other dates One square, clear, container, filled with a white cream, dated 02/04/2026, unlabeled and no use by date One 32 oz package of roasted turkey sandwich meat, full, undated 12 hardboiled eggs in a clear bag, undated Greater than 25 small round white patties in a clear bag, dated 02/01/2026, unlabeled Nine four oz cartons of prune juice, expired 09/14/2025 One 16 oz container of whipped cream topping, thawed, undated A bag of cheese slices, yellow, greater than 25 slices, no dates on the bag or the package One plastic backage of reddish/brown circles, unlabeled and undated The ice machine vent had built up dust particles on the outside and some dried food. The glass stove top had broken, jagged, edges of the glass missing on both sides and a crack in the glass across the bottom about one quarter of the way from the left to the right. [NAME] During an on observation and concurrent interview on 02/23/2026 at 12:29 PM, showed the laminate covering in front of the dishwashing sink had been ripped off and was being held together by clamps. Staff (Amber [NAME], Cook) stated the chemical company accidentally pulled that off when their jacket got caught on it the other day, and the clamps were placed there until it gets fixed. The ice machine vent had dust particles in the vents and splatters of dried food. During an observation on 02/26/2026 at 12:08 PM showed. One 12 oz package gravy mix, one fourth full, opened, not sealed, and no dates One 14 oz package of poultry gravy mix, one fourth full, opened, and no dates. One gallon size clear baggie, one fourth full of parmesan shredded cheese, dated 01/11/2026, and no use by date. One package of mixed shredded cheese, half full, opened, not sealed or in a bag, dated 2/22/2025, and no use by date One 12 oz package, with a yellow substance in it, unlabeled, dated Five lbs. of raw bacon in a box, not sealed, with no use by date One 48 oz container of whipped cream cheese spread, opened, with no date. One gallon of balsamic vinegarette dressing, three fourths full, with no use by date. 22 breakfast wraps 2.50 oz. los Cabos [brand name] in a large clear bag, dated opened 08/01/2025 and a use by date of 12/01/2025. The wraps had egg, cheese, potato, and cooked sausage in them. Dry Storage 12 Containers of Orange Juice Concentrate-25 oz., expired 02/13/2026 One 28 oz. box-Gluten Free Cream of [NAME] Hot Cereal, expired 09/17/2023 During an interview on 02/27/2026 at 9:30 AM, Staff V, Dietary Manager, stated the food should be labeled with the name, date the food was made or opened, and the date the food was to be used by. Staff V stated the cooks had been given new food labels to use and had been educated on them, but it's a work in progress. Staff V stated their expectation of the cooks was to clean things as they cooked and then to clean daily and as needed. Staff V stated they had floats [additional staff] that came in to clean and organize for a more deep cleaning. Staff V stated they did not document cleaning to keep track of when it had been completed and to track who had completed the cleaning. Staff V stated they used the floats to complete cleaning audits and identify areas that needed worked on. Staff V stated they did not monitor the float/auditor staff or the cooks, to ensure the audits were being done or to ensure the identified areas were being cleaned daily. Staff V stated they had recently put into place a system with a sign that showed how long certain foods should have been kept once opened or used, but the signs were not observed in the kitchens and when asked, the cooks went by how long they thought something should be kept before discarding it. They could not identify a thorough process for discarding foods. Staff V stated they did not know how the cooks would know when individual bulk packages expired because the cooks shared out of a box and they would assume the date would have been on the box. During an interview on 02/27/2026 at 12:16 PM, Staff B, Director of Nursing Services, stated the process for cleaning and maintenance of the ice machines should have been completed according to the schedule and the manufacturer's instructions. Temperatures An observation and concurrent interview on 02/26/2026 11:08 AM, Staff W, Cook, was preparing for lunch in the [NAME] kitchen. The food warmer cart was set to 150 degrees Fahrenheit (F, a unit of temperature) and on the top of the cart were two bowls of fresh pears, two bowls of chocolate pudding, and six cups of freshly baked brownies. The top of the warmer was warm to the touch. At 11:22, Staff W started to prepare pureed textured food and removed cauliflower out of the oven, without checking the temperature, and placed it into the blender. Staff W then added warm water to the blender, blended cauliflower, and then a piece of fish (no temperature check upon removing from the oven), and then added the blended food to the plate and still did not check the temperatures once completed. At 11:36 AM, Staff W began to serve out lunch, Tilapia (a type of fish), potato wedges, cauliflower, chocolate pudding, and brownies. In the bottom of the oven, that was set at 170 F, was holding two baked potatoes, a small pot of mashed potatoes, and the plate of pureed food. Staff W began putting food onto the plates, when the Surveyor stopped them to ask them if they were going to check the temperatures of the food they just cooked. Staff W stated, yes, I can do that, opened the drawer to obtain the thermometer and stated, I need to go get one, mine must have been taken. The temperatures showed. Tilapia, 170.6 F Potato Wedges, 167.5 F Cauliflower 165.2 Chocolate pudding (sitting on the top of the warmer), 63.5 (was to be a cold food) Mashed potatoes, 150 F Pureed plate of food, 193 F Staff W discarded the pudding and the pears and served a different dessert to replace the warm pudding. Staff W stated the pears were to be a cold dessert as well and they knew they would be warm and discarded them. Staff W placed a metal sheet pan of white rolls onto a three-tiered rolling cart that had food crumbs on all three tiers and was soiled with dried on food. During a follow-up interview at 3:42 PM, Staff W stated they documented food temperatures on a food temperature log. Review of the food temperature log for the lunch meal showed the three temperatures that were logged for the main courses, the fish, cauliflower, and potato wedges, were 160 F, 161 F, and 160 F, none of those were temperatures observed when the food was done cooking. Staff W stated they checked food temperatures once a meal, at the time they started to prepare the pureed food. Staff W stated they did not check the temperatures of the pureed food after it was prepared. During an interview on 02/27/2026 at 9:30 AM, Staff V stated the cooks should have checked temperatures of the food when the food was done cooking and then again before the food was served out but I would need to check the policy to make sure that's correct. During an interview on 02/27/2026 at 12:10 PM, Staff A, Administrator, stated they would have expected Staff V to be monitoring their kitchens for cleanliness, completeness of tasks, and broken equipment or items that needed to be repaired. Staff A stated they were not aware of the cracked ice machine, the broken glass top on the stove, or the missing laminate on the cupboards that exposed non-cleanable surfaces. Reference: WAC 388-97-1100 (2)(3)

Based on interview and record review, the facility failed to ensure, 1) residents on as needed (PRN) psychotropic medications (drugs that affect brain activities associated with mental processes, emotions and behavior) were limited to 14-days or had a documented rationale for the extended use of the PRN psychotropic and, 2) that non-pharmacological interventions (alternative treatment of a resident's symptoms that are directed toward understanding, preventing and relieving a resident's distress or loss of abilities and do not involve the use of medications) were consistently attempted to reflect an adequate need of the medication for 2 of 5 residents (Residents 7 and 35) reviewed for unnecessary medications. This failure placed residents at an increased risk for experiencing medication-related adverse side effects, and unmet care needs. Findings included . Review of the facility's policy titled, Psychotropic Medication Use, dated February 2025, showed that PRN psychotropic medications were limed to 14-days unless the facility's provider documented a clinical rationale for extending the use of the psychotropic medication beyond 14-days. The policy showed that PRN antipsychotic (a type of psychotropic drug used to manage symptoms like hallucinations [a false perception of objects or events involving your senses that seem real, but are not], delusions [a false belief or judgement about external reality, held despite evidence contradicting it]and disordered thoughts) medication could not be renewed unless the provider evaluated the resident and documented the appropriateness of the medication for that resident. The policy showed that residents on psychotropic medications were to be monitored for behavioral and non-pharmacological interventions .to minimize or eradicate (to put an end to) the need for medications, permit the lowest possible dose if indicated, and support efforts at gradual dose reduction (a steady calculated decrease in dosage to determine if symptoms or conditions can be managed with a lower dose or discontinuation of the medication) which would be documented in the residents medical record. Resident 7Review of the medical record showed they were admitted to the facility on [DATE] with diagnoses including a system wide infection, Post-Traumatic Stress Disorder (PTSD, a mental health condition that's caused by an extremely stressful or terrifying event), insomnia (difficulty falling or staying or returning back to sleep), Bipolar disorder (a mental illness that causes extreme shifts in an individual's mood, energy, and activity levels), anxiety and substance abuse. The medical record showed they returned to the hospital on [DATE] and re-admitted on [DATE] with a diagnosis of an infection within the abdomen. The 02/03/2026 comprehensive assessment showed the resident was cognitively intact, able to make their needs known, and was currently taking an antipsychotic medication. Review of Resident 7's physician orders for medication showed: On 01/28/2026 Prochlorperazine (a specific type of antipsychotic medication, that can also be used for controlling severe nausea and vomiting) was ordered to be administered PRN every six hours for nausea and vomiting. Additionally, the Prochlorperazine order showed indefinite (lasting for an unknown or unstated length of time). On 02/03/2026 monitoring/non-pharmacological interventions were ordered for Resident 7's episodes of nausea/vomiting along with use of the PRN antipsychotic (six days after the PRN antipsychotic Prochlorperazines was ordered). Additionally, the documentation of the non- pharmacological interventions were to include effectiveness, complaints of gas pain/nausea/vomiting, number of episodes occurring each shift and attempts of; offering carbonated soft drinks, encouraging deep breathing, small sips of water and offering a salty snack. Review of Resident 7's medication/treatment administration record (MAR) for January 2026 through February 2026, showed the resident was given the Prochlorperazine medication 10 times from 02/06/2026 to 02/25/2026. Additionally, the MAR showed no documentation of non-pharmacological attempts made for the resident regarding the antipsychotic medication Prochlorperazine. During an interview on 02/26/2026 at 10:23 AM, Staff EE, Registered Nurse/Resident Care Manager, stated that PRN antipsychotic medication were limited to 14-days, could not be renewed unless the provider evaluated/documented the appropriateness of the medication for that resident, and if used beyond the 14-days the provider would document a rationale for extending the use of the medication. Additionally, for PRN psychotropic medications, the non-pharmacological interventions would be implemented and documented in the resident's medical records. During an interview on 02/26/2026 at 1:08 PM, Staff C, Social Services, stated that Resident 7's Prochlorperazine was ordered after the resident had readmitted on [DATE] for nausea/vomiting and should have been limited to 14-days due to the medication being a PRN psychotropic medication or have a documented rationale for the extended use. Staff C stated the Prochlorperazine should have non-pharmacological interventions implemented/attempted regarding Resident 7's PRN psychotropic. After reviewing Resident 7's medical records, Staff C stated, I don't see the extended use justification and it should have been completed 14-days after the order was started. Additionally, Staff C stated they were unable to find non-pharmacological interventions were being attempted and the correct process for Resident 7's 14-day PRN/non-pharmacological interventions was not being completed. During an interview on 02/27/2026 at 10:46 AM, Staff B, Director of Nursing Services, stated that Resident 7's PRN psychotropic medication should have had the required documented rationale for the extended use of the Prochlorperazine and non-pharmacological interventions were being attempted/offered to the resident. Staff B stated the process for Resident 7's PRN Prochlorperazine and non-pharmacological interventions was not completed correctly. Resident 35Review of the medical record showed they were admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), insomnia (a sleep disorder that may include trouble falling asleep and/or staying asleep) and anxiety (feeling of worry, nervousness or unease). The 12/12/2025 comprehensive assessment showed Resident 35 required substantial/dependent assistance of one to two staff members for activities for daily living and had severe impaired cognition. Review of Resident 35's November 2025, December 2025, January 2026 and February 2026 Medication Administration Record (MAR), showed a, 10/21/2025 physician order for Ativan (anti-anxiety medication) 1 milligram (mg-unit of measure), for end-of-life care (the comprehensive support that focuses on physical, emotional, social, and spiritual needs to manage symptoms of the dying process), agitation, seizure (a loss of consciousness and violent muscle contractions) or intractable (difficult to control) nausea and vomiting to be given by mouth every six hours as needed (PRN) with no end date. Further review of the November 2025 through February 2026 MARs, showed Resident 35 had a total of 10 administrations of Ativan. During an interview on 02/25/2026 at 9:13 AM, Staff D, Registered Nurse (RN), stated Resident 35 was ordered Ativan for air hunger (difficulty in breathing and/or breathing sufficiently) and end-of-life stuff, comfort care only. Staff D stated Resident 35 rarely was provided Ativan. Staff D stated they did not know how long PRN orders were to be prescribed for. During an interview on 02/25/2026 at 9:47 AM, Staff E, Resident Care Manager, stated Resident 35 could be combative and hysterical at times. Staff E stated Resident 35's condition was unique as they would be in bed for a few days, then stay up for three days. Staff E stated the goal was to keep them comfortable and the Ativan was used for sleep. During an interview on 02/27/2026 at 9:13 AM, Staff F, RN, stated Resident 35's Ativan did not work for them. Staff F stated Resident 35 was provided Ativan when they became aggressive with care, including punching, biting, hitting and paranoia with staff. Staff F stated the Ativan was used as a last resort to help decrease the behaviors and the medication hardly worked and would take hours to be effective. During an interview on 02/27/2026 at 10:28 AM, Staff B, Director of Nursing Services, stated Resident 35 did not have a diagnosis for end of life. Staff B stated the Ativan was for end of life as a PRN medication order. Staff B stated to use a PRN medication for over 14 days, there needed to be a justification to use beyond the 14 days. Staff B stated Resident 35 did not have Staff B stated they believed Resident 35 did not need the order for Ativan as they were not end of life. Reference: WAC 388-97-1060(3)(k)(i)

Based on observation, interview, and record review, the facility failed to recognize a change in condition for 1 of 3 residents (Resident 13) reviewed for hospitalization and follow physician orders as written for 3 of 4 residents (Resident 8, 6, and 80) reviewed accuracy of physician orders related to fluid restrictions and hospitalization. This failure placed all residents at risk for delay in treatment, medical complications, and negative health outcomes. Findings included. Review of a policy titled, Change in a Resident's Condition or Status, revised 12/2016, showed the facility would promptly notify the resident, their attending physician, and representative of changes in the resident's medical/mental condition and/or status. The nurse would notify the resident's attending physician or physician on call when there had been a significant change in the resident's physical/emotional/mental condition. A significant change of condition is a major decline in the resident's status that would not normally resolve itself without intervention by staff or implementing standard disease-related clinical interventions. Review of a policy titled, Encouraging and Restricting Fluids, dated 10/2010, showed the general guidelines included following specific instructions concerning fluid intake or restrictions, accuracy when recording fluid intake, and encouraging the resident's family and visitors to stay within the limits of their intake. Staff should remove the water pitcher and cup from the resident room. If the resident refuses to have the water pitcher removed, the resident's physician would be notified. Change In Condition Resident 13 Review of the medical record showed Resident 13 was admitted to the facility with diagnoses including iron deficiency anemia (a common condition where blood lacks healthy red blood cells due to insufficient iron), heart failure, and kidney disease. The 01/09/2026 comprehensive assessment showed Resident 13 required setup/clean up assistance of one staff member for activities of daily living [(ADLs) activities related to personal care] and was independent with ambulation and transfers. The assessment also showed Resident 13 had no memory issues and was able to make independent decisions regarding daily life. Review of Staff G's, Registered Nurse (RN), nursing progress note (PN) dated 11/21/2025 at 1:33 PM, showed Resident 13 was not eating that day and had stated they were too shaky and refused to work with therapy as they were too short of breath when not using their continuous positive airway pressure [(CPAP) a machine that blows a continuous, steady stream of air through a tube and mask to prevent the airway from collapsing while sleeping]. Review of Staff C's, Social Worker, social services PN dated 11/21/2025 at 5:20 PM, showed Resident 13 had increased anxiety and refused to participate in therapy. The resident was noted to be pale in appearance, lying in bed covered with a blanket with CPAP in place while awake. Resident 13 reported they had no appetite, decreased their therapy participation due to difficulty breathing when not utilizing their CPAP, and were having increased tremors that had worsened. Resident 13 reported they felt they were physically unable to participate at that time and were concerned about their health. The PN showed nursing and primary care provider were notified of Resident 13's concerns. Review of Staff H's, RN, nursing PN dated 11/23/2025 at 1:21 PM, showed Resident 13 was lying in bed with both hands up in the air attempting to catch something. When asked if they were feeling well, Resident 13 stated they were seeing speckles and dots and was trying to catch them. The note showed Resident 13 did not appear at baseline, was oriented only to self, and thought they were at their brother's house. They did not recall what the year, time, or date was. Resident 13 had mild, slurred speech and their blood pressure was 91/53 mmHg (millimeters of mercury – the standard unit of measurement for blood pressure, with normal readings typically measuring 120/80 mmHg). Resident 13's primary care provider was notified and recommended transfer to the local emergency room for evaluation. Review of Staff I's, RN, nursing PN dated 11/24/2025 at 12:10 AM, showed they had contacted the local emergency room for a status update on Resident 13. Staff I was informed that the resident was not returning to the facility and had been transferred to a regional medical center for further treatment. Review of Staff J's, RN, nursing PN dated 11/24/2025 at 4:24 AM, showed Resident 13 was admitted to the regional medical center and had received a blood transfusion of two units of packed red blood cells (200-300 milliliters of concentrated red blood cells per unit) and a bolus (a rapid infusion of a large volume of intravenous fluid – 500 milliliters or more - to quickly restore blood volume and increase blood pressure) to stabilize the resident's condition. Resident 13 also received a medication to lower their potassium level of 7.0 mmol/L (millimoles per liter – a unit of measurement, with the normal levels between 3.5 – 5.2 mmol/L, levels above 5.2 can cause muscle twitching, shaking, and cramping, along with fatigue and breathing difficulties). During an interview on 02/26/2026 at 8:42 AM, Staff G stated Resident 13 had started to develop a tremor and was not as active as they normally were. They stated they remembered a nurse reporting something didn't look right in regard to the resident's condition. They stated Resident 13 was short of breath and needed to use their CPAP. Staff G stated when they spoke with Resident 13 on 11/21/2025, they were pale and had been in bed a lot and were complaining of being shaky. Staff G stated Resident 13 had a history of frequent health concerns and did not recall them looking as bad as what was noted. Staff G stated if the provider had been contacted regarding the resident's condition, there should have a been a nursing progress note in the record. During an interview on 02/26/2026 at 3:57 PM, Staff C stated when they visited Resident 13 on 11/21/2025, they were gray in color, which was not normal for them. Resident 13 complained of being fatigued and were not feeling well. Staff C stated the resident kept their CPAP on during the entire interaction. They stated they reported Resident 13's condition to the nurse on duty and the resident's primary care physician. During an interview on 02/26/2026 at 3:18 PM, Staff K, RN, stated they worked on 11/21/2026 and did not recall any reports of Resident 13's condition. They stated when they received a concern regarding a resident's condition, their process included completing a full resident assessment and reporting any acute findings (sudden, severe, or rapidly developing symptoms) to the primary care provider, depending on the severity of the symptoms. Staff K stated they did not recall Staff C reporting any concerns regarding Resident 13's condition. During an interview on 02/27/2026 at 8:32 AM, Staff L, Medical Director, stated they were informed of the resident's change in condition (on 11/23/2025) and had informed the nurse at that time, that they would not be able to assess the resident due to time constraints and recommended sending Resident 13 to the emergency room. Staff L stated if the social worker had alerted the nurse to a change in Resident 13's condition on 11/21/2026, the nurse should have done an evaluation of the resident's condition and notified them of any acute changes at that time. During an interview on 02/27/2026 at 8:46 AM, Staff M, Director of Rehabilitation Services, stated Resident 13 had been participating in therapy services regularly and had progressively complained of a lot of fatigue. They stated Resident 13 was motivated to do therapy but was not doing well health wise and had refused their scheduled sessions on 11/20/2025 and 11/22/2025, the two sessions prior to their transfer to the hospital. During an interview on 02/27/2026 at 9:00 AM, Staff B, Director of Nursing Services, stated the process for addressing and monitoring a resident's change in condition included the licensed nurse completing a thorough assessment, notifying the provider, and placing the resident on alert charting for monitoring. Staff B stated they would have expected the nurse to follow that process once they were notified by Staff C. Fluid Restriction Resident 8 Review of the medical record showed Resident 8 was admitted to the facility with diagnoses including kidney failure, high blood pressure, and heart failure. The 01/08/2026 comprehensive assessment showed Resident 8 required substantial/maximum assistance of one staff member for ADLs. The assessment also showed Resident 8 had a severely impaired cognition. Review of physician orders dated 12/03/2025, showed fluid restriction: 1500mL (milliliter – a unit of measurement)/day (700 day, 700 eve, 100 noc (night). Review of the medical record showed total fluid intake from the licensed nurses and nursing assistants (NA) as follows: 02/14/2026 total: 2580 mL, 1080 mL over the fluid intake allotment (the amount of something given to a person). 02/15/2026 total: 2480 mL, 980 mL over the fluid intake allotment. 02/16/2026 total: 2580 mL, 1080 mL over the fluid intake allotment. 02/17/2026 total: 2460 mL, 960 mL over the fluid intake allotment. 02/18/2026 total: 2520 mL, 1020 mL over the fluid intake allotment. 02/19/2026 total: 2460 mL, 960 mL over the fluid intake allotment. 02/20/2026 total: 2540 mL, 1040 mL over the fluid intake allotment. During a concurrent observation and interview on 02/25/2026 at 8:43 AM, Resident 8 was at the entrance of their room. There was a water tumbler on their beside table that was half full and an empty coffee cup. Resident 8 stated when I see water I drink as much as I want. They stated the staff gave them juice or water whenever they asked for it. Resident 8 stated they did not know that they were on a fluid restriction. During an interview on 02/25/2026 at 8:30 AM, N, NA, stated they tried to limit the fluids that Resident 8 consumed. They stated the resident had a water tumbler in their room that staff refilled at 6:00 AM and 2:30 PM every day. Staff N stated the water tumbler held 720 mL of fluid. They stated Resident 8 had an extra cup of coffee in their room that morning that added an extra 240 mL to their intake, but they did not include that in their charting. Staff N stated they did not report the total resident fluid intake to the nurse but charted it in the medical record. They stated Resident 8 asked for extra fluids all the time and the nurses were aware of it. During an interview on 02/25/2026 at 8:49 AM, Staff O, RN, stated they did not know exactly how much fluid Resident 8 was consuming, that it was more of an estimate. They stated Resident 8 went to the multipurpose room during the day and they were unsure of how much fluid was consumed there. Staff O stated the fluid restriction was mostly an encouragement and the probability of exceeding the daily limit was likely. Staff O stated it was assumed that Resident 8 consumed what the kitchen served, the NA's kept track of that, and the licensed nurses kept track of what they gave. Staff O stated there was a good process in place to monitor fluid intake, and they felt, with their current process, they could get very close to an accurate number. During an interview on 02/25/2026 at 9:13 AM, Staff B, Director of Nursing Services, stated the NA's documented what they gave the resident and the licensed nurses documented what they gave, and they total that intake for the day. During a follow up interview at 11:25 AM, Staff B stated the facility had a process in place for monitoring fluid restrictions, but the staff were not following it. Staff B stated the facility needed to ensure residents were willing to follow a fluid restriction, and if not, they should be completing risks and benefits, notify the provider, and possibly discontinue the order. Resident 6 Review of Resident 6's medical record showed diagnoses including End Stage Renal Disease (a condition in which the kidneys lose the ability to remove waste and balance fluids), dependance on dialysis (a procedure to remove waste products and excess fluid from the blood), diabetes (excess sugar in the blood) and heart failure. Review of the 01/15/2026 comprehensive assessment showed Resident 6 was independent with ADLs and had an intact cognition. Review of Resident 6's medication administration record (MAR) for February 2026 showed physician orders for an 1800 ml fluid restriction for kidney failure. The order was written as 240 ml with breakfast, lunch and dinner, other fluids to be divided as 480 ml on day shift, 480 ml on evening shift, and 120 ml of night shift. Document ml consumed on each shift outside of meals and medication pass. A second physician order showed to administer 120 ml of fluid with each medication pass four times a day. The February 2026 MAR showed a third order for Nepro (a high therapeutic nutritional liquid supplement for people on dialysis) one time a day and to document the ml consumed. Review of the February MAR showed from 02/01/2026 through 02/27/2026, 240 ml was consumed every morning. During an observation and concurrent interview on 02/25/2026 at 12:01 PM, showed a 22-ounce water jug on Resident 6's bedside table. Resident 6 stated they monitored their fluid intake themselves and filled the jug with ice three times a day chewed on the ice and drank the melted ice. Resident 6 stated they kept other drinks in their personal refrigerator, and they had not been asked by staff how much they consumed in a day. Resident 6 stated they were unaware of how much fluid they were allowed to have in a day. During an interview on 02/26/2026 at 9:07 AM, Staff N, NA, stated Resident 6 was provided with an ice pitcher in the morning and chewed on the ice. Staff N stated it was hard to say the definite amount Resident 6 consumed. During an interview on 02/26/2026 at 9:19 AM, Staff P, RN, stated Resident 6 had an 1800 ml fluid restriction. Staff P stated the nurses were to document the fluid intake with their medication administration, the fluid intake for breakfast, lunch and dinner and the nursing assistants were to document how much Resident 6 took with their meals. During an interview on 02/26/2026 at 2:35 PM, Staff T, Licensed Practical Nurse, stated they were unaware if Resident 6 was on a fluid restriction. Staff T stated if they were they would ask the NA's how much fluid was consumed. During an interview on 02/26/2026 at 2:38 PM, Staff Q, RN, stated Resident 6 was on an 1800 ml fluid restriction. Staff Q stated it was hard to know exactly how much fluid Resident 6 consumed, and they just documented what amount of fluid the order showed. During an interview on 02/27/2026 at 10:35 AM, Staff B stated the fluid restriction process needed to be a combined intake of fluids from the nurses, NA's and a discussion with the residents on how much was consumed. Staff B stated the current process for fluid intake needed to be reevaluated and the current process was not working. Accuracy of Physician Orders Resident 80 Review of the resident's medical record showed they admitted with diagnoses to include congestive heart failure (CHF, a condition where the heart cannot pump blood efficiently, which leads to fluid buildup in the body, and respiratory failure (when your lungs cannot get enough oxygen into the blood). The 11/22/2025 comprehensive assessment showed Resident 80's cognition was intact and required one to two staff assistance with ADLs. Review of Resident 80's 12/08/2025 hospital discharge notes showed the resident was admitted to the hospital for fluid retention (when the body accumulates too much fluid in the tissues). The notes showed Resident 80 required 17 pounds (lbs., a unit of measure) of fluid to be removed. Review of the notes showed one new order for Metolazone (a medication used to remove fluid from the body) five milligrams (mg, a unit of measure) to be given every 72 hours as needed for a weight gain of three lbs. or more for two or more days in a row. The notes showed changes to the medication Resident 80 had previously taken, Bumetanide (a medication that helps reduce fluid build-up) one mg twice a day and one additional tablet to be taken for a weight gain of three lbs. or more in a 24-hour period or five lbs. or more in any seven-day period. The baseline weight was to be obtained by the facility upon readmission. Both medications were used for Resident 80's CHF. The notes additionally showed detailed notes of how these two medications should be administered as follows. Weight goes up three lbs. in a 24-hour period from baseline, take the additional bumetanide The next day, if the weight is back to baseline, continue as normal, but if weight has gone up three or more pounds from baseline, give additional dose of Bumetanide and the dose of Metolazone. The following day, if weight has returned to baseline, continue as normal, but if the weight has continued to climb after the doses of Bumetanide and Metolazone, then it's time to return to the hospital. Review of Resident 80's weights showed no weight had been obtained on readmission until 12/11/2025 (three days after readmission) at 3:19 PM of 255 lbs., which would be used as the baseline weight. Review of Resident 80's December 2025 Medication Administration Records (MAR), showed an order dated 12/08/2025 for Metolazone as written in the discharge notes on 12/08/2025 and an order dated 11/14/2025 for Bumetanide, one mg twice daily for edema (swelling caused by fluid build-up in the body) with no other details to show there are additional directions or orders for increased weight gain. There is a second 11/14/2025 order that showed Bumetanide one mg every 24 hours as needed for fluid retention, and can give an extra one mg for fluid retention once a day. The orders showed no other orders for the changes of weight parameters ordered on 12/08/2025. There was an order dated 12/12/2025 (four days after readmission) to obtain daily weights. Additionally, the MAR showed. 12/12/2025, weight was 255 lbs., no weights on 12/13/2025 and 12/14/2025 (refused). 12/15/2025, weight was 258 lbs. (three pounds over baseline), dose of Bumetanide should have been given, but was not. 12/16/2025, weight was 261lbs. (six pounds over baseline), dose of Bumetanide should have been given, along with the dose of Metolazone, but only the Metolazone was given. 12/17/2025, weight was still 261 lbs. (six pounds over baseline), no additional doses of medications were given. 12/18/2025, weight was back to baseline, 255lbs. 12/19/2025, weight was 265 lbs. (ten pounds over baseline), no additional medications were given. No weight was obtained on 12/20/2025 (refused). 12/21/2025 and 12/22/2025, weight was four lbs. greater than baseline, 12/23/2025, weight was 11.5 lbs. greater than baseline, 12/25/2025 weight was six lbs. greater than baseline, and no additional medications were given. 12/27/2025, weight was eight lbs. over baseline, Bumetanide was not given, but Metolazone was, and 12/28/2025 weight was seven pounds over baseline, and no additional medications were given. During an interview on 02/27/2026 at 10:19 AM, Staff G, Registered Nurse, stated they were unaware Resident 80 returned with changed orders to their Bumetanide. Staff G reviewed the 12/08/2025 discharge hospital orders and stated it looked as if the old order was brought forward and the changes were not made as ordered. Staff G stated two nurses reviewed discharge orders on return and they both must have missed the new order. During an interview on 02/27/2026 at 11:29 AM, Staff B, Director of Nursing Services, stated their expectation was for one Licensed Nurse (LN) to enter the hospital discharge orders on readmission, and then a second LN would verify the orders entered were correct. Staff B stated for Resident 80, that process was not followed correctly, and the Bumetanide order did not get updated. Reference WAC: 388-97-1060(1)(3)(k)

Based on interview and record review, the facility failed to ensure residents who were trauma survivors received culturally competent, trauma informed care (TIC), complete with identified experiences and preferences regarding potential triggers (a stimulus that could prompt a recall of a previous traumatic event even if the stimulus itself is not traumatic or frightening) that may cause re-traumatization (occurs when a current situation triggers the emotional and physical responses of past trauma, making it feel as if the original traumatic event was happening again) for 1 of 4 residents (Resident 7) reviewed for TIC. This failure placed the resident at risk for unidentified triggers and re-traumatization.Findings included .Review of the policy titled, Trauma Informed Care and Culturally Competent Care, dated August 2022, showed that TIC was an approach to care delivery that recognized the widespread impact and signs/symptoms of trauma within the facility's residents and incorporating the knowledge of a resident trauma into the care plan to minimize triggers and/or re-traumatization. The policy showed the resident would be screened to identify possible exposure to traumatic events such as trauma history, trauma related symptoms, interpersonal or developmental concerns, history of mental health diagnosis and substance abuse. The policy showed that an in-depth assessment was completed to identify potential triggers and then develop an individualized care plan with modifications to resident care approaches and strategies in order to minimize or decrease a resident's exposure to triggers that may cause re-traumatization.Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnoses including a system wide infection, Post-Traumatic Stress Disorder (PTSD, a mental health condition that's caused by an extremely stressful or terrifying event), insomnia (difficulty falling or staying or returning back to sleep), Bipolar disorder (a mental illness that causes extreme shifts in an individual's mood, energy, and activity levels), anxiety and substance abuse. The medical record showed the resident had a previous stay with the facility from 03/04/2025 to 07/04/2025. The 02/03/2026 comprehensive assessment showed the resident was cognitively intact and able to make their needs known. During an interview on 02/24/2026 at 11:18 AM, Resident 7 stated they had discussions about their past traumatic experiences/events with the facility staff before, the connections to the PTSD diagnosis and possible triggers. Resident 7 stated they were trigger when someone did not hear the resident when they were talking or when the resident was not getting the whole story from another individual or another person not showing Resident 7 that the resident was being understood in a conversation.Review of Resident 7's medical record showed no TIC screening or assessment had been completed for the resident.Record review of Resident 7's care plan, dated 01/14/2026 through 02/23/2026, showed no documentation of an individualized TIC focus or intervention plan regarding the resident's history of trauma, potential triggers nor modifications of resident care approaches identified to decrease Resident 7's exposure to triggers that may cause re-traumatization.Review of a progress note dated 05/24/2025, showed that social services noted Resident 7's history of trauma from their childhood, time spent in the military, substance abuse, PTSD and night terrors (a sleep disorder characterized by repeated intense nightmares that mostly center on threats to physical safety and security).During an interview on 02/26/2026 at 10:23 AM, Staff EE, Registered Nurse/Resident Care Manager, stated Social Services was charged with screening/assessments of TIC and developing an individualized care plan for trauma history and a resident's PTSD diagnosis.During an interview on 02/26/2026 at 1:08 PM, Staff C, Social Services, stated their process was to complete a TIC screening/assessment on all the facility's residents when admitted to the facility to identify potential triggers from traumatic events. Staff C stated that a lot of residents denied trauma/triggers due to the population of residents being prior military. Staff C stated that even if a resident denied a history of trauma and had a diagnosis of PTSD, an individualized care plan would have been developed, along with collection of records from the Veteran Affairs regarding the residents PTSD diagnosis. Staff C stated that Resident 7 had a history of trauma, and they had just spoken to the resident the other day about how changes and not feeling heard triggered the resident and they would become anxious. After reviewing Resident 7's medical record, Staff C stated that a TIC assessment had not been completed on either of the residents stays at the facility nor had the historical records of Resident 7's diagnosis PTSD been collected. Staff C stated that an individualized care plan regarding the resident trauma history, diagnosis of PTSD or potential triggers was not developed. Staff C stated the correct process for TIC was not completed for Resident 7.During an interview on 02/27/2026 at 10:46 AM, Staff B, Director of Nursing Services, stated that Resident 7 should have been assessed for traumatic experiences, potential triggers that could have caused re-traumatization and had an individualized care plan development regarding the TIC assessment/PTSD diagnosis. Staff B stated the correct process for TIC was not followed. Reference: WAC 388-97-1620(2)(b)(i)(ii)

Based on interview and record review, the facility failed to maintain a Quality Assurance Performance Improvement (QAPI) program that, 1) included the thorough collection of data/feedback and systematic investigations and/or analysis regarding adverse events (an unexpected, undesirable and usually unanticipated event that causes death or serious injury to a resident) within the facility and, 2) showed actions taken towards development of activities regarding, recent adverse events within the facility, problem prone areas, and contributing factors that could impact quality of care, quality of life, and/or resident safety for 1 of 1 QAPI program, reviewed for quality assessment and assurance. This failure placed residents at an increased risk for unidentified complications, prompted corrective action regarding adverse events and unmet care needs.Findings included .Review of the facility's policy titled, Quality Assurance Performance Improvement (QAPI) Plan, dated 05/15/2025 showed, the facility's QAA/QAPI committee members included the Administrator, Director of Nursing Services (DNS), Infection Preventionist (IP)/QAPI coordinator, Medical Director and other management staff. The policy showed the IP/QAPI coordinator and committee staff were responsible/accountable for developing, leading and monitoring the QAPI program. The policy showed that data/feedback monitored through QAPI included adverse events, which were collected from incident reports and clinical review meetings. The policy showed the IP/QAPI staff member attended clinical review meeting and would be informed of adverse events, patterns/trends identified. The policy showed the committee would prioritize/identify .areas of improvement and rank them by factors such as prevalence, risk, cost, relevance, responsiveness, feasibility (have the ability or being capable of completing the task), and continuity. Performance Improvement Projects (PIP's, a concentrated effort on a particular problem and involves gathering information systematically to clarify issues or problems and intervening for improvements) will be determined from this list. Additionally, the policy showed the QAPI program took systematic action/analysis by utilizing processes to identify PIP opportunities such as; plan, do, study, act (PDSA) and a root cause analysis (RCA).Review of the facility incident log for December 2025, showed on 12/28/2025 Resident 80 had a fall outside of the facility, which they obtained substantial fractures from and were sent to the hospital. Record review of the facility's documents for the quarterly QAA/QAPI meeting conducted on 01/15/2026 showed that Staff GG, IP/QAPI, Staff A, Administrator, Staff B, DNS, and the Medical Director attended the meeting. The documents of the meeting showed, .painted curbs for potential safety concern, and no documentation of the data/feedback collection, systematic investigation and/or analysis regarding the adverse event that had taken place on 12/28/2025. Additionally, no documentation showed that a PDSA nor RCA had been completed towards development of activities regarding recent adverse events within the facility, problem prone areas, and possible contributing factors from the adverse event that could impact quality of care, quality of life, and/or resident safety.During an interview on 02/23/2026 at 12:26 PM, Staff A, Administrator and Staff B, DNS, stated that Staff GG was the IP/QAPI coordinator and both the QAA/QAPI committee were in the same meeting. During an interview on 02/27/2026 at 11:51 PM, Staff GG stated they oversaw the QAA/QAPI committee meetings, arranged the quarterly meetings and had the records of the QAPI meeting information/documents. Staff GG stated the QAA/QAPI committee identified/prioritized the patterns and trends for PIP implementation from the facility's quality measures (statistical analysis of facility's resident information, that can show patterns or trends that can result in an actual or potential undesirable resident outcomes) and did not include adverse events or resident safety concerns. After reviewing QAA/QAPI documents from 01/15/2026, Staff GG stated they did not review Resident 80s adverse event in the meeting nor did they complete a PDSA or RCA, because the fall was not a pattern. Staff GG stated that adverse events and/or abuse would be investigated through the specific incident and not brought/reviewed in the QAA/QAPI meetings. Staff GG stated that adverse events like Resident 80's fall with major injury would be noted on the incident log and the DNS would bring that into QAPI, but that was not being done. During an interview on 02/27/2026 at 12:57 PM, Staff B stated they were involved in QAA/QAPI, and they brought data/information from the clinical nursing aspect of the facility into the QAA/QAPI meetings. Staff B stated the committee identified/prioritized information from the quality measure to decide what PIP to start. Staff B stated they did not bring in adverse events or potential abuse concerns, which would be identified on the facility's incident logs, into QAPI. Staff B stated they would have expected that Resident 80's adverse event to be reviewed during the QAPI meeting, due to the potential impact on resident safety, but it was not. Staff B stated they did not review the resident incident log for patterns/trends within QAPI. Staff B stated they should be collecting/analyzing information from adverse events, resident safety concerns, potential abuse allegations, and patterns/trends on the incident log within the QAA/QAPI program. Staff B stated the correct process was not followed. During an interview on 02/27/2026 at 1:13 PM, Staff A stated the collection of data/information and analysis of Resident 80's adverse event investigation was reviewed during a safety committee meeting and was not brought into QAA/QAPI. Staff A stated they did not review/analyze the safety committee's adverse events information during the QAPI committee meetings so all the QAA/QAPI committee members would be involved.Reference: WAC 388-97-1760(1)Cross Reference: F868, F689 for more information.

Based on interview and record review, the facility failed to ensure the Quality Assessment and Assurance (QAA) committee included the required members that met at least quarterly (once every quarter of the year or every three months) for 2 of 4 quarters (Q3 2025 and Q4 2025) reviewed for QAA. The failure to meet quarterly increased the facility's risk of unrecognized quality deficiencies, the facility's ability to effectively correct identified issues and ongoing unmet care needs regarding residents' quality of life.Findings included .Review of the facility's policy titled, Quality Assurance Performance Improvement (QAPI) Plan, dated 05/15/2025 showed, the facility's QAA/QAPI committee staff would include the Administrator, Director of Nursing Services (DNS), Infection Preventionist (IP)/QAPI coordinator and the Medical Director. The policy showed the committee would meet quarterly and prioritize/identify .areas of improvement and rank them by factors such as prevalence, risk, cost, relevance, responsiveness, feasibility, and continuity. Performance Improvement Projects (PIPs) will be determined from this list. The policy showed the IP/QAPI coordinator and committee staff were responsible/accountable for developing, leading and monitoring the QAPI program. Record review of the quarterly QAPI meeting documents, from the facility's last annual recertification survey on 12/16/2024 through to 02/27/2026, showed the facility conducted quarterly QAA/QAPI meetings for: Q1 (January, February and March 2025), included the required members. Q2 (April, May and June 2025), included the required members. Q3 (July, August and September), showed the Medical Director did not attend the 08/21/2025 and 09/18/2025 QAPI meetings. Q4 (October, November and December 2025), showed the Medical Director did not attend the 10/16/2025 QAPI meeting. During an interview on 02/23/2026 at 12:26 PM, Staff A, Administrator, and Staff B, DNS, stated that Staff GG was the IP/QAPI Coordinator and both the QAA/QAPI were done in the same meeting. During an interview on 02/27/2026 at 11:51 PM, Staff GG stated they oversaw the QAA/QAPI committee meetings, arranged the quarterly meetings and had the records of the QAPI meeting information/documents. Staff GG stated the Medical Director was one of the QAPI committee members that were required to attend quarterly and would try to have meetings more often than one time every three months. After reviewing the quarterly QAPI meeting documents with the surveyor, Staff GG stated the Medical Director did not attend the QAPI meeting in Q3 or Q4, like they were required to. During an interview on 02/27/2026 at 12:57 PM, Staff B stated the facility's process was to have quarterly QAA/QAPI meetings, which included the Medical Director. Staff B stated they would expect the Medical Director to be attending the quarterly QAA/QAPI meetings. During an interview on 02/27/2026 at 1:13 PM, Staff A stated they would expect the Medical Director to attend the QAPI meetings quarterly and if not, then not the right process for the required QAA/QAPI members. Reference: WAC 388-97-1760(1)Cross Reference: F867

Based on interview and record review, the facility failed to provide notification of injury to the Resident's Representative (RR) for 1 of 3 residents (Resident 1) reviewed for notification. This failure placed the resident at risk of not having their representative involved in health care decision making for timely care and services.Findings included. Review of a policy titled, Incident Report - Resident, dated 04/02/2018, showed when the facility became aware of an incident that involved a resident, a Resident Incident Report would be initiated by the person that first became aware of the incident. The report should include family notification. The notification should be completed in a timely manner and contact attempts should be recorded on the Incident Report and in the nursing progress notes. Resident 1Review of the medical record showed Resident 1 was admitted to the facility with diagnoses including heart failure, dementia with behavioral disturbance (distressing personality and behavior changes that occur alongside cognitive decline that include aggression, wandering, and hallucinations), and anxiety. The 09/23/2025 comprehensive assessment showed Resident 1 was dependent on two staff members for activities of daily living. The assessment also showed Resident 1 had a severely impaired cognition. During an interview on 12/04/2025 at 12:41 PM, the Resident Representative (RR) stated they were not notified of two injuries. The first injury involved Resident 1's toes. They stated Resident 1's socks were soaked with blood. The RR stated when they asked how the injury occurred; they were told it happened on night shift. The second injury involved a skin tear to Resident 1's left wrist. They stated it was more than a skin tear, it was a laceration that had steri-strips (thin, sticky bandages that help cuts or wounds stay closed as they heal) as a dressing. The RR stated they were not notified by the facility of either wound. Record review of a facility investigation dated 10/11/2025 at 5:00 AM, showed Resident 1 was found in their room with blood on the end of their sock to the right great toe. The injury was cleansed, and interventions were initiated to prevent further injury. The investigation report showed the provider, residents power of attorney, and Director of Nursing were notified of the injury on 10/14/2025, three days after the injury occurred. During an interview on 12/04/2025 at 12:34 PM, Staff C, Registered Nurse (RN), stated when a resident had a fall or injury, they assessed the injury, measured the wound, provided treatment, notified other shifts, the provider, and the Director of Nursing. They stated they would also notify the family. Staff C stated if they notified the family, they would have documented that information in the medical record, including if they left a voicemail. Staff C stated they did not remember calling the family to notify them of Resident 1's toe injury. Record review of a progress note dated 10/13/2025 at 11:30 AM, showed Staff D was called to Resident 1's room by a nursing assistant, who noticed a skin tear to the resident's left wrist while they were getting them up for lunch. Staff D assessed the skin tear that measured four centimeters (a unit of measurement), cleansed the site and applied steri-strips. A dressing was applied over the steri-strips to protect the area and prevent further injury. The progress note showed the Director of Nursing, provider, and resident care manager were notified. There was no documentation that the family had received notification of the injury. During an interview on 12/04/2025 at 12:29 PM, Staff D, RN, stated they did not remember notifying Resident 1's family of the skin tear. They stated the process following an injury included completing a risk management form, assessing the wound, and per protocol, entering a progress note into the medical record. They stated notification of the injury included notifying the provider, the resident care manager, the Director of Nursing, and the family. Staff D stated if the injury occurred on night shift, they would pass it on to the day shift nurse to notify the family. Staff D stated they were unsure if the family was notified of Resident 1's injury. Record review of a facility investigation dated 10/13/2025 at 11:30 AM, showed the date of the incident was 10/11/2025 at 5:00 AM. The investigation showed the provider, Director of Nursing, and Resident 1's power of attorney was notified on 10/14/2025, three days after the injury. During an interview on 12/04/2025 at 1:02 PM, Staff B, Director of Nursing, stated the process included providing notification to the family when a resident was injured. They stated the facility was unable to locate any documentation to verify that the RR was notified. Staff B stated the nursing staff did not follow the process. During an interview on 12/04/2025 at 1:12 PM, Staff A, Administrator, stated the process included notifying the family of the injuries, but they were unable to locate documentation of the notification. They stated they believed one injury had been reported to the family and would continue to search for that documentation. During a follow-up voicemail received on 12/09/2025 at 8:38 AM, Staff A stated one of the injuries (toe injury) had been brought to the facility's attention by the RR. They stated the RR had talked to the facility staff about the injury and that was the reason why nursing staff did not notify the RR of the injury. Reference: WAC 388-97-0320(1)(a)

Based on observation, interview and record review the facility failed to provide supervision to prevent elopement (leaving the facility unsupervised and undetected) for 1 of 3 residents (Resident 1) reviewed for accidents. This failure placed the residents at risk for exposure to the elements, serious harm and/or death.Findings included. Review of the facility policy titled Missing Resident/Elopement, dated 09/22/2023, showed residents who were at risk for wandering and/or elopement would be monitored, and staff would take necessary precautions to ensure their safety. Resident 1 Review of the medical record showed Resident 1 was admitted to the facility with diagnoses including Alzheimer's disease (a progressive brain disease that destroys memory and thinking skills), Dementia (a progressive disorder that impairs memory, thinking, language, and decline in cognitive abilities that affect daily life) and Post-Traumatic Stress disorder [(PTSD) a mental health condition that's caused by an extremely stressful or terrifying event]. The 08/05/2025 comprehensive assessment showed Resident 1 was independent for ambulation and required the assistance of one staff member for ambulation greater than 150 feet and activities of daily living. The assessment also showed Resident 1 had a severely impaired cognition. Record review of the facility investigation dated 08/30/2025, showed Resident 1 had attended a city parade (off campus) with facility staff and residents. When the parade ended, Resident 1 had wandered away from the group. The investigation showed staff were assisting other residents on the bus, they did not keep Resident 1 in their line of sight. Minutes had passed before staff members realized Resident 1 was missing. Record review of Resident 1's revised care plan dated 08/20/2024, showed they had wandering behaviors, were at risk for elopement and was to be kept in line of sight when they were out of the memory care unit (a unit that has enhanced security). During an interview on 09/24/2025 at 1:53 PM, Staff A, Nursing Assistant (NA), stated they were the only NA that accompanied the residents to the parade. Staff A stated when the parade had ended, they were assisting other residents back onto the bus and Resident 1 was left sitting on a bench. Staff A stated when they turned back around, Resident 1 was gone. Staff A stated they asked the other staff members where Resident 1 was, and they did not know. During an interview on 09/25/2025 at 12:19 PM, Staff B, Recreation Specialist, stated the process for taking residents on an outing included gathering a list of residents that were interested in attending. On the day of the parade some of the residents had cancelled. The activities department put an announcement on the facility radio asking if there were additional residents that wanted to attend. Staff B stated Resident 1 was brought to the lobby to attend with the group. Staff B stated they were aware that Resident 1 had a history of and current wandering behavior, however they were not concerned as the group had a NA accompanying the group to the parade. Staff B stated when the parade was over, they went to get the bus and returned to the area where they were watching the parade to begin loading residents onto the bus. Staff B stated that was when they noticed Resident 1 was missing. Staff B further stated they normally did not take residents from memory care unit as they should be observed one-on-one with a staff member when they were known to be at risk of wandering. During an interview on 09/24/2025 at 1:07 PM, Staff C, Director of Nursing Services, stated when planning to take a resident from the memory care unit the facility needed to ensure a plan for safety which could include a one-on-one supervision. Staff C stated Resident 1 had wandering behaviors and should have been kept in line of sight. Reference WAC: 388-97-1060(3)(g)

Based on observation, interview, and record review, the facility failed to prepare palatable, appetizing, and appealing meals for 8 of 15 residents (Resident 78, 48, 46, 39, 6, 20, 71, and 38) who voiced concerns regarding food quality during a Resident Council (a group of residents from each of the neighborhoods who meet to discuss and address concerns) meeting and other interviews. This deficient practice placed residents at risk for dissatisfaction with the food, a diminished dining experience and the potential for less than adequate nutritional intake. Findings included . Review of the facility document, titled Resident Council Minutes September 2024, showed meeting minutes documented multiple complaints regarding the food quality including the food needed more taste. Review of the facility document, titled Resident Council Minutes October 2024, showed complaints of food quality including reports of cold food. <Resident 78> Review of the medical record showed Resident 78 admitted to the facility on [DATE], and the comprehensive assessment, dated 11/20/2024, showed they had an intact cognition. During an interview, on 12/09/2024 at 2:40 PM, Resident 78 stated their diet was vegetarian, and the facility did not offer many options for this diet. Resident 78 stated the alternate offered to them instead of the menu meal at lunch and dinner was most often a baked potato and green salad. Resident 78 stated the cooks did not show a high skill level or critical thinking to create other alternatives. <Resident 48> Review of the medical record showed Resident 48 admitted to the facility on [DATE], and the comprehensive assessment, dated 10/21/2024, showed they had a moderately impaired cognition. During an interview, on 12/09/2024 at 3:28 PM, Resident 48 stated they did not like how most of the food was prepared because it has no flavor. <Resident 46> Review of the medical record showed Resident 46 admitted to the facility on [DATE], and the comprehensive assessment, dated 10/07/2024, showed they had a moderately impaired cognition. During an interview, on 12/09/2024 at 3:42 PM, Resident 46 stated the food is no good and they had discussed this with the dietician. Resident 46 stated they would prefer more plant-based alternatives. <Resident 39> Review of the medical record showed Resident 39 admitted to the facility on [DATE], and the comprehensive assessment, dated 11/21/2024, showed they had an intact cognition. During an interview, on 12/10/2024 at 9:38 AM, Resident 39 stated some of the food served at the facility does not taste good and the vegetables were usually overcooked. <Resident 6> Review of the medical record showed Resident 6 admitted to the facility on [DATE], and the comprehensive assessment, dated 09/30/2024, showed they had an intact cognition. During an interview, on 12/10/2024 at 10:46 AM, Resident 6 stated they did not like a lot of the food because it did not taste good. Resident 6 stated the facility serves a lot of chicken and they would like to see more of a variety. <Resident 20> Review of the medical record showed Resident 20 admitted to the facility on [DATE], and the comprehensive assessment, dated 09/06/2024 showed they had a moderately impaired cognition. During an interview, on 12/10/2024 at 12:57 PM, Resident 20 stated .the food doesn't have any flavor, and they provided their own condiments to help with palatability. During a Resident Council meeting, on 12/11/2024 at 11:14 AM, residents gathered to discuss concerns regarding quality of care and quality of life at the facility. The following concerns regarding the facility's food quality were stated during interviews: Resident 71 stated the facility serves .too many heats and eats (meals made of processed and/or frozen foods) .which is not healthy. Resident 71 stated, our meals are full of preservatives, and we shouldn't have to eat that stuff. Resident 38 stated the facility serves canned fruit instead of fresh, and they had recently been served canned pineapple pieces on their warm breakfast plate. Resident 38 stated, fruit like that should be served cold. During an interview, on 12/12/2024 at 1:36 PM, Staff E, Dietary Manager (DM), stated residents had complained about the lack of flavor in the food. During an observation, on 12/13/2024 at 12:21 PM, the posted meal for lunch was fish, fries, and mixed vegetables. A test tray was provided with the regular meal and an alternative meal. The regular meal plate showed a breaded fish fillet, previously frozen and white in color, with the breading layer being moist and soggy from sitting in vegetable water. The vegetables were previously frozen cauliflower, green beans, lima beans, and zucchini with an overcooked texture (mushy). The French fries were previously frozen, undercooked (cool to touch and grainy texture) and white in color. The alternative meal was a hamburger patty on a bun and a side salad (served on a warm plate). The lettuce in the salad was wilted and the tomato was warm to touch. During an interview, on 12/13/2024 at 12:37 PM, Staff E stated meal preparation should be done an hour before mealtime and plated 30 minutes before serving out. Staff E confirmed the test tray did not look appealing, and the regular menu meal was comprised of all previously frozen foods and were considered dull in color. Staff E stated the breaded fish should not have been served on the plate with excess moisture (from the vegetables), and the side salad should not have been served on a warm plate. Reference: WAC 388-97-1100 (1), (2)

AMENDED Based on observation, interview, and record review the facility failed to comprehensively assess and determine potential causative factors for recurrent urinary tract infections (UTIs) and provide UTI treatment consistent with professional standards of practice for 1 of 3 residents (Resident 17) reviewed for continuous urinary catheter (a flexible tube that inserted into the bladder to drain urine) use. This deficient practice placed residents at risk of unnecessary UTIs, antibiotic (medication used to fight infections caused by bacteria) use and delays in UTI treatment. Findings included . <Resident 17> Review of the medical record showed Resident 17 was admitted to the facility on [DATE] with diagnoses of neuromuscular dysfunction of the bladder (a condition that occurs when the nerves and muscles of the urinary system are damaged, resulting in bladder control issues), diabetes (disease that occurs when body is unable to regulate the amount of sugar in the blood), and presence of a suprapubic catheter (a tube that's inserted into the bladder through a small incision in the lower abdomen to drain urine). Review of the comprehensive assessment, dated 09/26/2024, showed Resident 17 had a moderate cognitive impairment and required the assistance of one person for Activities of Daily Living (ADLs) including catheter care. During an observation, on 12/09/2024 at 12:45 PM, Resident 17 was sitting in the recliner in their room and their urinary drainage bag (a bag attached to the urinary catheter to collect the urine drained from the bladder) was placed in a basin on the floor next to the chair (appropriately below the level of the bladder for drainage). The urinary bag had yellow urine inside and large pieces of mucous with sediment (solid material pieces) was observed in the tubing. There was a strong odor of urine in the room, but no indication of leakage from the urinary catheter or drainage bag. During an interview, on 12/09/2024 at 1:15 PM, Resident 17 stated they had been treated for a UTI on several occasions and their suprapubic catheter leaked frequently around the insertion site. Record review showed a urine sample was collected on 03/11/2024 and the resulted urine culture, dated 03/14/2024, showed the presence of Proteus mirabilis (the specific bacteria). Antibiotic treatment was initiated on 03/11/2024 (three days before the resulted culture was available). Record review showed a urine sample was collected on 07/03/2024 and the resulted urine culture, dated 07/08/2024, showed the presence of Proteus mirabilis. Antibiotic treatment was initiated on 07/10/2024 (two days after the resulted culture was available). Record review showed a urine sample was collected on 09/25/2024 and the resulted urine culture, dated 09/30/2024, showed the presence of Proteus mirabilis. Antibiotic treatment was initiated on 10/04/2024 (four days after the resulted culture was available). Record review showed a urine sample was collected on 11/10/2024 and the resulted urine culture, dated 11/13/2024, showed the presence of Proteus mirabilis. Antibiotic treatment was initiated on 11/16/2024 (three days after the resulted culture was available). During an interview, on 12/16/2024 at 10:30 AM, Staff W, Resident Care Manager (RCM), stated the facility's process was to notify the medical provider with urgent lab results, and completed urine cultures were not considered urgent. Staff W stated the medical provider would initiate new orders electronically when they had reviewed the resulted non-urgent labs. Staff W stated resulted urine cultures showing bacterial growth was considered abnormal and should be reviewed with the medical provider right away. During an interview, on 12/16/2024 at 11:45 AM, Staff C, Infection Control Registered Nurse (ICRN), stated the facility's medical provider had directed nursing staff to notify them via phone with urgent lab results and they would review other labs, including urine cultures at their next convenience. Staff C stated they were aware Resident 17 had several UTIs this year, and they had not completed a deep dive into the cause of them. Staff C further stated they had not provided infection control and prevention education for suprapubic catheter care. During an interview, on 12/16/2024 at 12:05 PM, Staff B, Director of Nursing Services (DNS), stated they were unaware the Licensed Nurses had been informed that resulted urine cultures were not considered urgent lab results that required a review timely. Staff B stated the process was to call the medical provider right away when abnormal lab results, including resulted urine cultures with bacterial growth, were available. Staff B stated the expectation for initiating antibiotic treatment for UTIs was right away. Reference: WAC 388-97-1060 (3)(c)

Based on observation, interview and record review, the facility failed to conduct a complete and thorough assessment for self-administration of medications for 1 of 2 residents (Resident 39) reviewed for safe self-medication administration. This deficient practice placed residents at risk for medication errors and adverse medication interactions. Findings included . Review of the facility policy, dated December 2012, titled Administering Medications showed residents were able to self-administer their medications once the resident was assessed by the Interdisciplinary Care Planning Team, including the physician, and determined to have the decision-making capacity to do so safely. <Resident 39> Review of the medical record showed Resident 39 admitted to the facility on [DATE] with diagnoses of chronic lung disease, heart disease, and dizziness. Review of the comprehensive assessment, dated 11/21/2024, showed Resident 39 had an intact cognition and required the assistance of one person for Activities of Daily Living (ADLs). During a concurrent observation and interview, on 12/13/2024 at 8:07 AM, Staff U, Registered Nurse, was providing medication administration assistance to Resident 39 when they noted an over the counter (OTC) bottle of Vitamin D 800 International Units [(IU) unit of measure] supplement at the resident's bedside. Staff U asked Resident 39 if they had been self-administering their Vitamin D supplement. Resident 39 stated yes, they had, and asked Staff U, how many times a day am I supposed to take it? Two or three? Staff U told Resident 39 they would obtain clarification on the directions for their Vitamin D Supplement. Staff U did not remove the bottle of Vitamin D supplement from Resident 39's bedside. During a follow-up interview, on 12/13/2024 at 8:12 AM, Staff U stated they were unaware Resident 39 was self-administering the Vitamin D supplement. Staff U stated Resident 39's record showed they self-administered their prescribed inhalers for chronic lung disease, and they were unaware of any other medications Resident 39 kept at their bedside. Review of the Self-Medication Administration Assessment, completed on 11/13/2024, showed Resident 39 was safe and capable of self-administering the following medications: prescription mouth wash, OTC muscle rub (topical cream used to relieve sore muscles), respiratory inhalers, calcium with Vitamin D supplements, and as needed Meclizine (a medication given to relieve dizziness and nausea). Review of the physician's orders for Resident 39 showed, as of 12/13/2024, the orders for Vitamin D supplement and Meclizine did not include a directive for Resident 39 to self-administer the medications or keep it at their bedside. Review of Resident 39's comprehensive care plan showed no goals or interventions for self-medication administration. During an interview, on 12/16/2024 at 1:00PM, Staff B, Director of Nursing (DNS), stated the process for residents to self-administer their medications included a complete and thorough assessment to determine if the resident was capable and safe, education provided regarding the medication directions and its use, an order from the physician, and a care plan to direct staff on how to support the resident. After reviewing Resident 39's medical record, Staff B stated the process for self-medication administration for Resident 39 was not followed. Reference: WAC 388-97-0440

Based on interview and record review, the facility failed to review and revise the care plan related to urinary tract infection (UTI) treatment and prevention for 1 of 3 residents (Resident 17) review for care plan accuracy and revision. This deficient practice placed residents at risk for unmet and unidentified care needs. Findings included . <Resident 17> Review of the medical record showed Resident 17 was admitted to the facility on [DATE] with diagnoses of neuromuscular dysfunction of the bladder (a condition that occurs when the nerves and muscles of the urinary system are damaged, resulting in bladder control issues), diabetes (disease that occurs when body is unable to regulate the amount of sugar in the blood), and presence of a suprapubic catheter (a tube that's inserted into the bladder through a small incision in the lower abdomen to drain urine). Review of the comprehensive assessment dated [DATE] showed Resident 17 had moderate cognitive impairment and required the assistance of one person for Activities of Daily Living (ADLs) including catheter care. Review of Resident 17's care plan showed the focus area relating to the suprapubic catheter and history of UTIs and the goal for Resident 17 to show no signs or symptoms of UTI was initiated on 08/15/2023 Review of the interventions in place to meet the goal were last revised and/or added on 11/13/2023. Review of the medical record showed Resident 17 was treated for UTIs with antibiotic (medications used to treat infections caused by bacteria) on 03/11/2024, 07/10/2024, 10/04/2024, and 11/16/2024 (a total of four times in the last year.) During an interview, on 12/16/2024 at 10:30 AM, Staff W, Resident Care Manager (RCM), stated they were aware Resident 17 developed UTIs, but did not realize the frequency they were being treated for infections. Staff W stated it was a part of the interdisciplinary team's responsibility to review recurring issues and identify new or revised goals and interventions for the resident. Staff W stated this process had not been completed in relation to Resident 17's frequent UTIs. During an interview, on 12/16/2024 at 11:45 AM, Staff C, Infection Control Registered Nurse (ICRN), stated they were aware Resident 17 had been treated for UTIs frequently, and they had not completed a deep dive into the cause of them. Staff C stated they had provided the nursing staff with infection control education in a general form, and education regarding UTIs and catheter care had not been provided. Staff C stated the nursing team was responsible for identifying areas on the residents' care plans that needed revision and updating, and it did not appear that process was followed regarding Resident 17's UTIs. During an interview, on 12/16/2024 at 12:05 PM, Staff B, Director of Nursing Services, stated it was a collaborated effort of the nursing team to revise and update care plans. Staff B stated this was recurring UTIs would be a concern that needed a deeper look and this did not happen regarding Resident 17. Reference: WAC 388-97-1020 (5)(b)

Based on interview and record review, the facility failed to ensure accuracy for the Pre-Admission Screening and Resident Review [(PASARR) a federally required form that is used to help ensure individuals were not inappropriately placed in nursing homes for long term care] and Level II comprehensive evaluations were obtained for 2 of 6 residents (Resident 10 and 70) reviewed for PASARR. This failure placed residents at risk for not receiving necessary mental health care and services. Findings included . <Resident 10> Resident 10 was admitted to the facility with diagnoses including major depressive disorder (MDD - a mood disorder of persistent feelings of sadness, loss of interest, changes in sleep affecting how a person feels, thinks and behaves), dementia (a progressive disease that destroys memory and other important mental functions), anxiety, and hallucinations. The 09/27/2024 comprehensive assessment showed Resident 10 was dependent on one to two staff members for activities of daily living (ADLs) and had a severely impaired cognition. Review of Resident 10's PASARR, updated 10/16/2023, showed the resident had serious mental illness indicators of MDD, anxiety, and hallucinations and a diagnosis of dementia. The form showed a Level II Behavioral Health Assessment was not indicated. <Resident 70> Resident 70 was admitted to the facility on [DATE], with diagnoses including anxiety, insomnia (difficulty falling asleep and/or staying asleep), and dementia. On 04/02/2024, Resident 70 was diagnosed with MDD. The 09/12/2024 comprehensive assessment showed Resident 70 required substantial/maximal assistance of one to two staff members for ADLs and had a severely impaired cognition. Review of Resident 70's PASARR, completed on 03/08/2024, showed the resident had a serious mental illness indicator of anxiety and a diagnosis of dementia. The form showed a Level II Behavioral Health Assessment was not indicated. Additional review showed Resident 70 did not have an updated PASSAR that included the diagnosis of MDD and the need for the required Level II Behavioral Assessment. During an interview on 12/16/2024 at 11:55 AM, Staff D, Psychiatric Social Worker, stated the process for updating PASSAR's included a quarterly review, when a resident had a significant change, and/or a new diagnosis in physical or mental conditions. Staff D stated Resident 10 should have had an updated PASSAR and sent for a Level II Behavior Health Assessment evaluation based on the resident's diagnoses. Staff D further stated Resident 70 should have had a new PASSAR completed when they were diagnosed with a new serious mental illness indicator of MDD and then sent for a Level II Behavioral Assessment evaluation. Reference WAC: 388-97-1975(1)(4)(9)

Based on observation, interview and record review, the facility failed to provide an environment that reflected the physical needs and preferences of 1 of 2 residents (Resident 6) reviewed for accommodation of needs. This deficient practice placed the resident at risk for a diminished quality of life and increased dependence on staff. Findings included . <Resident 6> Review of the medical record showed Resident 6 admitted to the facility on [DATE] with diagnoses of chronic kidney disease, chronic lung disease and muscle weakness. Review of the comprehensive assessment, dated 09/30/2024, showed Resident 6 had intact cognition, required the assistance of two people for transfers, toileting, and used an electric wheelchair for mobility. During a concurrent observation and interview, on 12/10/2024 at 11:33 AM, Resident 6 stated they were unable to access things on the side of their bed that was near the window. There was a pathway of less than two feet between Resident 6's bed and desk, and Resident 6 stated they would like to access and clean off their bulletin board (which hung in the window in front of the desk). Resident 6 stated their current room arrangement was not a set up that allowed them access. During a concurrent observation and interview, on 12/11/2024 at 2:35 PM, Resident 6 demonstrated their inability to maneuver their electric wheelchair around the end of their bed to access their desk. Resident 6 was able to reach the nearest corner of the desk but was unable to roll up to the desk to appropriately sit at the desk. Observations showed all items on the desk, including the bulletin board and all furniture to the left of the desk, were inaccessible to Resident 6. Resident 6 stated they asked their family to clear off the bulletin board, as they were unable to do so themselves, so they may hang up Christmas cards they receive. During an interview, on 12/13/2024 at 1:30 PM, Staff E, Psychiatric Social Worker, stated they assisted with the planned use of furniture for the residents when they admitted , but it was not their process to follow up with residents on their furniture needs after admission. Staff E stated they relied on the resident or staff for an adjustments of their furnture needs. During an interview, on 12/13/2024 at 2:30 PM, Staff V, Registered Nurse (RN), stated they had not noticed Resident 6's inability to access their desk or bulletin board and they relied on the residents or their families to request any accommodations. During an interview, on 12/16/2024 at 10:45 AM, Staff W, Resident Care Manager (RCM) stated they were unaware Resident 6 was unable to access areas in their room. Staff W stated they relied on the residents or their representatives to request an accommodation of needs. During an interview, on 12/16/2024 at 12:30 PM, Staff B, Director of Nursing (DNS), stated they were unaware Resident 6 could not access areas in their room. Staff B stated the expectation was for staff to observe and report issues and/or concerns regarding residents' environment. Staff B stated Resident 6 should have access to all areas of their room. Reference: WAC 388-97-0860 (2)

Based on interviews and record review the facility failed to ensure staff provided adequate pain management in a timely manner for 1 of 3 residents (Resident 1) who expressed a need for narcotic pain medication and did not receive it. Failure to provide narcotic pain medication resulted in harm to Resident 1 due to pain and emotional distress. Findings included . Resident 1. Review of the resident's medical record showed they were admitted to the facility with diagnoses which included cancerous tumor of the left kidney. Review of the quarterly assessment, dated 10/14/2022, showed the resident had no cognitive impairments; required extensive assistance with two staff for turning in bed, dressing, toilet use and personal hygiene; total dependence on staff for transfers; and required supervision with set up for meals. Review of the 11/04/2022 facility investigation, conducted due to the resident's complaint of pain and not receiving their ordered narcotic pain medication, documented by Staff A, Social Worker, showed a significant deviation in the resident's use of their narcotic pain medication from October 2022 to November 2022. Usually the resident took the narcotic pain medication two to three times daily. Between 10/29/2022 to 10/31/2022 it was only taken once. By 11/02/2022 the narcotic medication had resumed back to the previous administration pattern of two to three times daily. When the resident was questioned by Staff A on 11/04/2022 they stated they had run out of the narcotic medication over the previous weekend because no one reordered them. The resident stated, I had so much build-up pain over several days and I was very stressed. My anxiety was peaking with no relief. Review of Progress Notes dated 11/08/2022 by Staff B, Resident Care Manager, showed the resident had stated there was a negative effect on them related to their mental health and psychosocial harm due to the delay in receiving their narcotic pain medication. The resident's pharmacy was called on 11/02/2022 and they stated the narcotic pain medication had been ordered by the facility on 10/25/2022 and it would be delivered on 11/03/2022. It was not delivered on time due to a billing issue. Review of the resident's Medication Administration Record (MAR) showed there were physician's orders for narcotic pain medication two tablets every six hours as needed for pain. Between 10/01/2022 to 10/29/2022 the resident had received the medication twice daily for 19 days, three times daily for six days, and once daily for four days. There were no days during that time period when the resident did not receive the narcotic pain medication. On 10/30/2022 at 2:45 AM the resident was given the narcotic medication for a pain level of 7 (pain level scale of 0 being no pain and a 10 being the worst possible pain). The pain medication showed it was effective. The next dose of narcotic pain medication was not given until 10:00 AM on 11/01/2022 for a pain level of 7. The resident did not receive narcotic pain medication for 55.25 hours. Staff C, Registered Nurse, stated during a telephone interview on 12/08/2022 at 10:50 AM, that when she arrived to work the morning of 11/01/2022 the resident had run out of the narcotic pain medication and no one did anything. They stated all they had to do was call the pharmacy and pull the medication from the facility emergency kit, which they did on the morning of 11/01/2022. Staff C stated the resident had cancer and needed their narcotic medication. The resident had stated to Staff C that they were in pain and was asking where the narcotic medication was. The resident was enraged upset and yelling. Despite the MAR showing the resident's pain level being a 7 at 10:00 AM on 11/01/2022 Staff C stated the resident's pain level was 10 out of 10 and the 7 reflected the pain they were having a short time after the narcotic medication was administered. There was an adequate supply of the narcotic medication in the emergency kit. Staff C reported the incident to Staff A due to their concerns regarding the resident's behavior. Staff C stated the resident had recently been placed on Hospice services (type of health care that focuses on a terminally ill resident's pain and symptoms and attends to the emotional and spiritual needs at the end of life). Staff D, Agency Registered Nurse, stated during a telephone interview on 12/08/2022 at 1:45 PM, that he had worked the evening shift of 10/31/2022 and the resident's pain level at the beginning of the shift (between 2:00 to 3:00 PM) was a 3 out of 10. Staff D stated the resident's physician had been in the facility that evening (10/31/2022) and wrote an order at 7:58 PM for the narcotic pain medication and staff was to pull the medication from the facility emergency kit. Staff D stated they did not have access to the emergency kit thus they requested assistance from another Licensed Nurse (LN) who was working at that time. Staff D stated they did not receive the requested assistance from the LN, thus they passed the information to Staff E, Agency Registered Nurse, who worked the eight hour night shift beginning on 10/31/2022 to 11/01/2022. Staff D stated that later in their shift the resident stated they were in pain and wanted their narcotic pain medication for a pain level of 6 to 7. Staff E, stated during a telephone interview on 12/08/2022 at 11:38 AM, that when she arrived to work on the night shift beginning 10/31/2022 the resident did not have any narcotic pain medication. Staff E stated they were unaware the physician had been in the facility on the evening shift of 10/31/2022 and had ordered narcotic pain medication to be pulled from the facility emergency kit. Staff E stated they texted the physician during their shift and got an order for Tylenol which they administered to the resident at 1:20 AM on 11/01/2022 for a pain level of 7. Staff E stated the Tylenol was effective as the resident had stated they felt better. Staff F, Director of Nurses, stated during a telephone interview on 12/08/2022 at 2:00 PM that Staff D did have access on the medication key ring (which was passed from one shift LN to another to access the medication carts) to the facility emergency kit (which was located in the administration building). Staff F stated Staff D must not have been aware of that. Staff F stated the resident's pharmacy was closed during the night. Due to the pharmacy being closed at night staff could call a secondary consulting pharmacy service during the night to assist them in obtaining medication. Reference WAC 388-97-1060(1)

Based on interviews and record review, the facility failed to implement Abuse Prohibition policies including identification, training, investigation, reporting, prevention/protection, and screening, involving two of two residents (#'s 1, 2). This failed practice resulted in a lack of addressing ongoing sexual and mental abuse of Resident #1 for as long as two years, and placed all residents at risk for abuse. The lack of an effective system that ensured staff reported witnessed abuse to the State agency as required, patterns of abuse were identified, thorough investigations were completed, and interventions were put in place timely to prevent a pattern of abuse constituted an immediate jeopardy. On 12/30/2020 at 1:55 PM the facility was notified of an Immediate Jeopardy related to CFR 483.12, F607, Develop/Implement Abuse/Neglect Policies. The Immediate Jeopardy was not removed before the exit with the facility on 12/30/2020. Findings included . Review of the facility's operating procedure titled, Resident Abuse Prevention, dated 09/10/2018, showed the following procedures: A) Screening process - screen employees for a history of abuse, neglect, or mistreating residents. B) Training - train all employees on issues related to abuse prohibition practices such as: what consititutes abuse; how staff should report their knowledge related to allegations without fear of reprisal; in staff orientation and at least annually, the topics regarding prevention of abuse, staff/client relationships and ethical and professional standards, and resident occurrence reporting. C) Prevention - provide staff information on how and to whom they may report concerns, incidents, and grievances, without the fear of retribution, and provide feedback regarding the concerns they have expressed. Identify, correct, and intervene in situations in which abuse is more likely to occur. D) Identification - identify events, occurrences, patterns, and trends that may constitute abuse, and to determine the direction of the investigation. All possible incidents and allegations of abuse will be investigated and reported per facility policy. E) Investigation - Investigate different types of incidents and identify the staff responsible for the initital reporting, investigation of alleged violations, and reporting of results to the proper authorities. F) Protection - protect residents from harm during investigation. Review of the facility's operating procedure titled, Abuse and Neglect, dated 09/10/2018, showed the following procedures: All incidents of alleged or suspected abuse, personal and/or financial exploitation, or mistreatment, are reported and investigated in accordance with established federal and state rules. Any employee witnessing an incident of resident mistreatment, abuse, or having reasonable cause to suspect such an occurrence must report the incident or suspicion to the Licensed Nurse (LN) and State agency. Any supervisor who receives an alleged report of resident abuse must ensure that actions have been taken to protect residents. Ensure information has been gathered to complete the first phase of the investigation. Ensure alleged violations involving abuse are immediately reported to the Administrator, Director of Nursing Services, and State agency. All staff must know the reporting responsibilites as well as what constitutes resident abuse. Criminal History Background Checks protects residents from contact with persons who have been convicted, have a pending charge, a disqualifying crime, and/or negative action. Resident #1. Interviews were conducted on 12/17/2020 at 7:35 PM with Staff C, Nursing Assistant (NA); 12/17/2020 at 4:55 PM with Staff D, NA; 12/18/2020 at 1:30 PM with Staff E, Registered Nurse (RN); 12/18/2020 at 5:19 PM with Staff H, NA; 12/17/2020 at 1:50 PM with Staff I, NA; 12/16/2020 at 12:50 PM with Staff G, RN; 12/18/2020 at 9:27 AM with Staff J, RN; and 12/17/2020 at 6:13 PM with Staff K, RN. Staff stated they observed and/or were aware of incidents in which Staff A, NA was kissing the resident on the cheek/forehead, telling the resident she loved him, and at times asking him to kiss her. In addition, several staff was aware of an evening in which Staff A stated, with the resident present, that he got harder for her than any other resident. The stated observations occurred from approximately two years ago until November 2020. Despite staff knowledge of Staff A kissing the resident staff failed to identify the incidents as abuse and report as per facility policy. Review of facility staffing records showed Staff A worked full time in the facility until 12/09/2020 when she was placed on suspension, and later terminated. Review of the facility investigation showed it was not initiated, nor reported to the State agency until 12/10/2020. Staff education to prevent further abuse was not initiated until 12/16/2020. Resident #2. Review of a facility investigation report, dated 12/14/2020, showed the resident had given Staff M, NA, $50.00 following Staff M sharing with him she was having personal and financial problems. Staff M did not ask for the money, but when the resident offered it to her she accepted. Review of Staff M's personnel file showed an updated Crimnal History Background Check, dated 05/22/2020, required a Character, Competency, and Suitability (CCS) review to be performed by the facility to determine if Staff M could perform the duties of a NA to work with vulnerable adults. Staff M continued to work at the facility despite no CCS review being done by staff as required. At the time of the investigation beween 12/16-23/2020 Staff M no longer was employed with the facility. Refer to F600 - Abuse - for further information. Refer to F609 - Reporting of Alleged Violations - for further information Refer to F610 - Investigate/Prevent/Correct Alleged Violation - for further information Reference (WAC) 388-97-0640(2)

Based on interviews and record review, the facility failed to ensure one of three residents (#1), reviewed for abuse, was free from a pattern of sexual and mental abuse by Staff A, Nursing Assistant (NA). Although Staff A was observed to inappropriately kiss Resident #1 approximately two years ago, and almost every time Staff A cared for the resident since then; made sexually inappropriate statements around the resident's physical reaction to her; her insistence on being the only person to shower the resident; and telling the resident she loved him; the facility failed to identify and report abuse, ensure adequate supervision of the resident, and take appropriate action for a prolonged period of time to prevent further abuse. Despite a written statement of the inappropraite behavior over a year ago from a licensed nurse, the only action taken at that time was to tell Staff A this was inappropriate behavior. Multiple staff observed the behavior and expressed concerns, yet there was no timely action taken. The lack of an effective system that addressed the abusive behavior timely to protect the resident constituted an immediate jeopardy. On 12/30/2020 at 1:55 PM the facility was notified of an Immediate Jeopardy related to CFR.12(a)(1) F600, Free from Abuse/Neglect. The Immediate Jeopardy was not removed before the exit date. Findings included . Resident #1. Review of the resident's medical record showed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's comprehensive assessment, dated 10/26/2020, showed he had severe cognitive impairment. Review of the resident's plan of care, dated 10/27/2020, showed he had difficulty making decisions and had impaired decision making due to his dementia. Review of a facility investigation report showed 10 staff members were interviewed by administrative staff between 12/10-12/11/2020 regarding witnessing Staff A, NA kissing the resident and/or Staff A asking the resident to kiss her. Of the 10 staff interviewed eight staff responded with a yes. Staff C, NA, stated during perineal care Staff A stated, he (resident) has harder erections than any other resident here. Review of a written statement by Staff D, NA, dated 12/14/2020, showed Staff C told her Staff A would get upset if anyone else showered the resident. In addition, Staff C told Staff D that one evening when Staff C and Staff A were providing perineal care to the resident Staff A stated, he gets harder for me than any other resident. Staff C had stated that she wasn't sure who to go to or who to tell but that it was not right. Staff D reported the above to Staff E, Registered Nurse (RN), and that they (Staff D and Staff E) were in agreement everything be reported to Staff F, Director of Nursing (DON). Documentation stated Staff E had followed up with Staff D to state she had gone to Staff F and reported the incident. During a telephone interview with Staff C on 12/17/20 at 7:35 PM, she stated she had worked with Staff A for approximately three months in the memory care unit where the resident resided. She stated everytime they entered the resident's room Staff A would always give the resident a kiss on the cheek. She would always ask him, Do I get my good night kiss? .it was a daily thing. Staff C stated she would assist Staff A in transferring the resident to the shower and then Staff C would leave the shower area. If someone else gave the resident a shower Staff A would get upset stating, don't let her give him a shower, I am going to take my time. Staff C could tell Staff A got upset by the tone of her voice, comments she made, and her expressions, didn't seem normal to me. Staff C stated it took a little while to catch on to Staff A's behavior, why she wanted to be the only one to give him showers, give him kisses, like there was something else there .seemed obsessive over his cares and wanting to be the one doing it, got upset if she wasn't assigned to do it. Staff C stated one evening she and Staff A had just finished giving the resident perineal care and were pulling his disposable brief up when Staff A made the comment the resident got harder for her than any other resident. The statement by Staff A was made directly over the resident as she was performing care. She did not know who to report the incident to. If she reported it to administration she was afraid they would blow it off, they ignore a lot of things. She stated she finally reported it to Staff D before Thankgiving, either on 11/19 or 11/20/2020. Staff C stated she was interviewed regarding Staff A on either 12/10 or 12/11/2020. She stated took awhile for them to start looking into this. Staff D, NA, stated during a telephone interview on 12/17/2020 at 4:55 PM, regarding Staff A's behavior to the resident, that it seemed innocent at the beginning, like a grandpa situation. In November 2018 she would observe Staff A asking the resident for a kiss. Staff A would either bend down if the resident was sitting, or he would reach his head up to her and she would kiss him on the cheek. Staff G, Registered Nurse (RN), had addressed Staff A's behavior a long time ago, when she witnessed Staff G telling Staff A it was inappropriate behavior, but Staff A did not stop her behavior with the resident. Staff D stated that prior to Thanksgiving she was told by Staff C that she (Staff C) and Staff A were doing perineal care on the resident and Staff A stated, he (resident) gets harder for me than any other resident. Staff D stated she reported the information to Staff E that same day or the next day. During an interview with Staff E on 12/18/2020 at 1:30 PM, she stated that the resident would tell Staff A that he loved her and would kiss her on the cheek, which she stated was odd. On 11/22/2020 Staff E stated she sent an email to Staff F regarding rumors she heard about Staff A. Staff E stated for a few months before she reported to Staff F, she heard mainly from Staff D about Staff A kissing the resident, and stating the resident had gotten the hardest erection. She stated that on the weekend of 11/20/2020 she had tried to not schedule Staff A to work in the memory care unit anymore due to her behavior. Review of a written statement by Staff E, dated 11/22/2020, showed she spoke with Staff F regarding the behaviors of Staff A. Staff A seemed to favor the resident and Staff E had heard gossip about Staff A. Documentation stated Staff E had heard enough gossip about things spoken to/witnessed by staff to have concern. The written statement was given to Staff E on 11/23/2020. During a telephone interview on 12/18/2020 at 5:19 PM, Staff H, NA, stated that she witnessed Staff A kissing the resident on the forehead numerous times. Staff H also heard Staff A telling the resident she loved him. Staff H stated Staff A's behavior was more than casual, friendly, it's more tone of her voice, giving him more than caregiver should be doing, extra attention. Staff A would also state, I know things that no one else knows about (Resident #1), not sure what that is referring to. Staff H stated she did not bring this forward as she did not like tension and conflict. Staff I, NA, stated during an interview on 12/17/2020 at 1:50 PM, that she had witnessed Staff A pointing to her cheek and telling the resident to kiss her, which he did. Staff A would then brag about the resident kissing her. Staff I stated she was aware of the kissing thing with Staff A for approximately a few months. She also stated she heard Staff C make the comment that Staff A had stated the resident got harder for her than any other resident. Staff G stated during an interview on 12/16/2020 at 12:50 PM, that approximately two years ago she witnessed the resident being kissed on the cheek/forehead by Staff A. Staff G stated she spoke with Staff A at the time that she was crossing the line and was inappropriate. Staff J, RN, stated during an interview on 12/18/2020 at 9:27 AM, there were several kissing incidents involving Staff A and the resident that had occurred over a year ago. One incident she observed Staff A kissing the resident on the forehead saying she loved him. When Staff J confronted Staff A regarding unprofessional behavior, Staff A replied that she felt as though the resident was not getting support and love, and she was providing that to the resident. Staff J stated she emailed her concerns to Staff K, RN/Resident Care Manager on 11/22/2019. Review of the above email by Staff J to Staff K, dated 11/22/2019, showed Staff J witnessed on 11/22/2019 at 5:30 PM, Staff A hugging the resident and kissing his forehead. After dinner Staff J spoke with Staff A regarding physical affection toward the resident, such as kissing on the cheek, holding hands affectionately, and saying I love you, was inappropriate. The email stated Staff A responded she was just trying to show some affection to a man whose family never came to visit or hear the words I love you. Staff J informed Staff A that her actions toward the resident was not permitted. During a telephone interview on 12/17/2020 at 6:13 PM with Staff K, she stated she was informed by Staff J per email regarding Staff A's behaviors concerning the resident. Staff K stated she instructed Staff J to tell Staff A her actions were inappropriate and she needed to set up clear boundaries. Staff K stated she was informed by Staff D everyday that when Staff A works she kisses the resident. Staff K stated she sent Staff A home on suspension at approximately 7:00 PM on 12/09/2020. She stated she had addressed Staff A's behaviors a year ago with the former DON and Human Resources staff member and was told I couldn't use a staff member's mental health as a reason for concern. Reference (WAC) 388-97-0640(1) This is a repeat deficiency from Statement of Deficiencies dated 11/18/2019 and 10/08/2019.

Based on observation, interviews, and record review, the facility failed to provide adequate supervision and ensure care planned interventions were followed to prevent falls for 1 of 3 residents (#1) reviewed for falls. This failed practice resulted in actual harm to Resident #1 who fell during a transfer and sustained facial injuries necessitating a transfer to the emergency room for treatment. Findings included . Resident #1. Review of the resident's medical record showed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. and chronic low back pain. Review of the resident's plan of care, dated 09/07/18, showed the resident required extensive assistance by two staff for turning and transfers due to his limited mobility and range of motion, pain, and stroke history. Review of the nursing comprehensive assessment, dated 03/11/19, showed the resident had moderately impaired cognition, required extensive assistance with two staff for turning side to side, transfers, and dressing. A fall risk assessment, dated 03/08/19, showed the resident was at high risk for falls due to his poor balance. Review of a facility investigation report showed on 05/05/19 at 10:00 AM the resident was being transferred by Staff B, Nursing Assistant (NA), from the toilet to his wheelchair when he lost his balance causing him to lean forward. Staff B assisted the resident to the floor, however the resident hit his face on the edge of the sink counter sustaining a bruise and laceration to his right eye, and a laceration to the bridge of his nose. Due to the resident having a head injury and receiving blood thinner medication he was transferred to the emergency room . Review of hospital records, dated 05/05/19, showed the resident was diagnosed with [REDACTED]. On 06/04/19 at 10:40 AM Staff C, Rehab Manager, stated that the resident required two staff to assist him with transfers as he would lean back on his heels when he stood up causing balance issues. Staff B stated during a telephone interview on 06/07/19 at 10:15 AM that when he stood the resident up on 05/05/19 to pull up his pants his left foot slipped and his face hit the edge of the sink counter. Staff B stated he was aware the resident required two staff to transfer him but he was unable to find a second staff member to assist him with the transfer. Observation and interview with the resident on 06/04/19 at 3:00 PM showed he was lying in bed with no observed injuries to his face. He stated he was assisted by one NA at the time of the transfer off the toilet and lost his balance causing injuries to his eye and nose. Reference (WAC) 388-97-1060(3)(g) This is a repeat deficiency from the Statement of Deficiencies dated 01/14/19 and 09/13/18.