Every finding on record at Woodard Creek Health & Rehabilitation

Based on observation, interview, and record review, the facility failed to ensure residents were permitted to exercise their rights when the facility obtained consent from family members for the placement of wander-guard devices without establishing that the family members had legal authority to make decisions on behalf of 2 of 3 residents (Residents 1 and 6) reviewed for resident rights. This failure caused actual psychosocial harm to Resident 1 by significantly compromising the resident's psychosocial well-being, as evidenced by persistent emotional distress, including crying; repeated statements of feeling imprisoned, trapped, and desperate; and expressions of suicidal ideation when the resident was prevented from attending church. This failure placed residents at risk for loss of autonomy, emotional distress, and diminished quality of life.Findings included.Resident 1Resident 1 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus and a fracture to the lumbar vertebra. The quarterly Minimum Data Set (MDS), dated [DATE], documented Resident 1 had moderate cognitive impairment and was independent with most activities of daily living (ADLs).Review of the care plan, dated 06/27/2027, documented Resident 1 was their own responsible party. The care plan, dated 06/29/2026, documented Resident 1 was at risk for elopement due to confusion, impaired judgement, and poor safety awareness. A bracelet that alarms (a wander guard), which alarms when a resident is near the exit doors, was placed on the resident. The resident will frequently remove the wander guard. Staff will identify pattern of wandering as purposeful or aimless and intervene as appropriate. Staff will notify the residents responsible party promptly of any attempted elopement.During concurrent interview and observation on 08/19/2026 at 4:35 pm, Resident 1 was observed sitting in their bed in their room. Resident 1 was pleasant and open to talking. The resident explained in detail how they ended up in the facility, including their hospitalization prior to admission. The resident was alert and oriented to person, place, time, and situation. The resident discussed details of their stay in the facility including an episode when they left the facility in June. Resident 1 said they never intended on eloping from the facility but fell and could not get back up. Resident 1 said staff had found the resident after their fall. Since this event, the resident has had to wear a wander guard that sounds an alarm when they are near the exit doors. Resident 1 said the bracelet made the resident feel like a prisoner and like they were an illegal. The resident was weeping and distressed when discussing the wander guard. Resident 1 said they learned their lesson and had no intention of leaving the facility independently. Resident 1 said they do want to be able to go to church, which is a few blocks away. Resident 1 said they want the freedom to walk around the facility without the doors alarming. Resident 1 said they want to be able to go to church with their family member (FM) 1, but the facility will not let FM 1 go to church with resident or let FM 1 visit. Resident 1 continued to weep while discussing FM 1. Resident 1 explained FM 2, who is married to FM 3, does everything FM 3 tells them to do. Resident 1 stated they did not trust or like FM 3 much. Resident 1 explained there were challenges with their family dynamics and there had been allegations against FM 1, which they felt were not true.During concurrent interview and observation on 08/25/2026 at 4:39 pm, Resident 1 said they wanted to go home and stated they felt like a prisoner in the facility due to the wander guard. Resident 1 said they did not consent before the wander guard was placed on them. They said they would never have consented to wearing the wander guard. Resident 1 said they were their own decision maker, and their family should not make decisions for them. Resident 1 said again they did not trust FM 3's decisions. Resident 1 said they felt like an illegal wearing the wander guard and did not want to wear it. Resident 1 said they did not have any intention on leaving the facility and they learned their lesson after the incident happened in June. Resident 1 said where would I go? I don't have a home I can go to due to the current state of their home. The resident appeared distressed when speaking about their home and the wander guard.Throughout the day on 08/25/2026, 08/26/2026, 08/27/2026, and 08/31/2026, Resident 1 was observed walking independently with their walker, visiting with friends, going to meals, and participating in activities. The resident consistently remembered recent conversations and showed good recall.During an interview on 08/31/2026 at 6:30 pm, Resident 1 said they hoped they could get their wander guard off and was hoping someone could convince the facility to remove the bracelet. Resident 1 said they feel like a prisoner and illegal.Review of progress notes, dated 06/15/2026, documented Resident 1 was missing from the facility. FM 1 was called and reported the resident was safe and with a family friend and would be returning to the facility.Review of emergency room Notes, dated 06/15/2026, documented Resident 1 was found outside after leaving the facility without properly signing out. The resident had fallen down a hill and needed to be evaluated by the hospital.Review of progress notes, dated 06/19/2026, documented Resident 1 returned from the hospital. Resident 1 was found to have sepsis (systemic infection) from a urinary tract infection. A wander guard was placed on their right wrist.Review of progress notes, dated 06/19/2026, documented Resident 1 scoring on a memory test showed severe memory impairment and fell within the dementia category. The note documented the resident would need assistance with outdoor activities and supervision when walking on uneven surfaces.Review of Elopement Risk Evaluation, dated 06/19/2026, documented Resident 1 was alert with cognitive impairment, was mobile with device, had verbal expressions to leave facility, a history of elopement and wandering attempts, and family voiced resident may leave the facility. The evaluation determined Resident 1 was at risk for elopement and wander bracelet was in place on the resident's right wrist with consent from a FM.Review of progress notes, dated 06/20/2026, documented Resident 1 said they were going to go to church with FM 1. Resident 1 was educated on the pros and cons of leaving the building. The resident was told if they left it would be considered leaving against medical advice (AMA). FM 1 was contacted and told Resident 1's leaving would be an AMA. FM 1 decided not to bring Resident 1 to church.Review of progress notes, dated 06/21/2026, documented Resident 1 was cognitively intact.Review of progress notes, dated 06/22/2026, documented consent was received from FM 3 to place a wander guard on Resident 1's right wrist.Review of progress notes, dated 06/24/2026, documented Resident 1 was cognitively intact.Review of progress notes, dated 06/25/2026, documented Resident 1 was cognitively intact.Review of progress notes, dated 06/27/2026, documented Resident 1 had stated they were going out to church that evening. Resident 1 had slid the wander guard off of their wrist. Resident 1 was placed on a 1:1 observation.Review of progress notes, dated 06/29/2026, documented 15-minute monitoring due to wandering and the Wander guard was in place.Review of progress notes, dated 06/30/2026, documented Resident 1 was cognitively intact.Review of progress notes, dated 07/01/2026, documented Resident 1 was cognitively intact.Review of progress notes, dated 07/03/2026, documented Resident 1 was oriented to person. Oriented to place. Cognitive status varies.Review of progress notes, dated 07/04/2026, documented FM 1 was educated, due to Resident 1's cognitive impairment that it was not advisable for the resident to leave the facility. FM 1 continued to sign out the resident. The note document Resident 1 was noted to have significant cognitive impairment, wander precautions in place and a history of eloping. The facility does not believe leaving with the son is in the resident's best interests based on current cognitive status and safety risk factors. The facility spoke with FM 3 regarding Resident 1 leaving with FM 1. FM 3 agreed Resident 1 could leave if FM 1 followed the facility rules of signing out the resident when they left and returned. FM 3 was informed the facility did not recommend leaving the facility, but the family allowed the outing. FM 1 agreed with the plan.Review of progress notes, dated 07/06/2026, documented Resident 1 was cognitively intact.Review of progress notes, dated 07/08/2026, documented Resident 1 was cognitively intact.Review of progress notes, dated 07/12/2026, documented Resident 1 was cognitively intact.Review of progress notes, dated 07/16/2026, documented Resident 1 was cognitively intact.Review of progress notes, dated 07/17/2026, documented Resident 1 was cognitively intact.Review of progress notes, dated 07/18/2026, documented FM 1 picked up Resident 1 for church and returned at the expected time.Review of progress notes, dated 07/24/2026, documented adult protective services (APS) involvement related to concerns regarding Resident 1's home environment, finances and FM 1.Review of progress notes, dated 07/27/2026, documented Resident 1 said they would kill themselves in front of the ombudsman (resident advocate) because they could not attend church. Resident 1 was placed on suicidal ideation alert and placed on 15-minute checks.Review of progress notes, dated 07/27/2026, documented Resident 1 said they had no intention of hurting themselves and was just sad and frustrated about not being able to attend church with FM 1 on that Saturday. Resident 1 was placed on alert for suicidal ideation and on 15-minute checks.Review of behavioral health progress notes, dated 08/11/2026, showed Resident 1 was oriented to person, place, time, and situation; demonstrated intact memory recall; and engaged in a coherent discussion regarding their living and financial situation with the behavioral health professional documenting Resident 1 demonstrated awareness of facility routines and rules and navigates complex family and social dynamics. Resident 1 was described as calm and cooperative, maintained good eye contact, and displayed no unusual behaviors or psychomotor abnormalities. The note documented that Resident 1 had strong religious beliefs and had maintained an active membership in a supportive church community for 13 years. Resident 1 stated, I feel like I'm in prison, and described feeling like a criminal because of the facilities restrictions. When feeling desperate about the restrictions, Resident 1 stated, I want to kill myself and I want to die. The note further documented recent suicidal ideation, including a threat to kill themselves in front of the ombudsman if they were not permitted to attend churchReview of progress notes, dated 08/12/2026, documented Resident 1's wander guard was on their right arm.Review of progress notes, dated 08/14/2026, documented Resident 1 was on 15-minute checks due to a high risk of elopement as evidenced by cutting off their wander guard and expressing a plan to leave the facility.Review of progress notes, dated 08/19/2026, documented Resident 1 told the medical provider they have not been allowed to go to church, and misses it. Patient found a lot of comfort in [their] faith. Patient states feel like is a prisoner here. The provider noted Resident 1 was very tearful, reporting low mood. Is no longer able to see/visit with FM 1 causing Resident 1 to be very sad.During an interview on 08/19/2026 at 3:53 pm, Staff I, licensed practical nurse (LPN), said Resident 1 was on 15-minute checks due to them cutting off their wander guard. Staff I was not aware of any incidents when Resident 1 left the building since the June incident.During an interview on 08/20/2026 at 3:52 pm, Staff J, said Resident 1 was on 15-minute checks because they cut off their wander guard. Staff J said there had been no incidents of the resident leaving the building.During an interview on 08/20/2026 at 3:57 pm, Staff X, NA, said Resident 1 has not made any attempts to leave the building since the June incident. Staff X said Resident 1 does try and remove the wander guard.During an interview on 08/20/2026 at 4:15 pm, Staff K, LPN, said Resident 1 has not had any attempts to leave the facility since the June incident.During an interview and record review on 08/27/2026 at 4:45 pm, Staff I, LPN, said Resident 1 had an emergency contact he would call for any decisions made about the resident's care. Staff I said Resident 1 threatens to leave the facility and has a history of leaving the facility. Staff I maintained Resident 1 did not make sound decisions so the emergency contact would need to be notified. When asked to verify who Resident 1's responsible party was, Staff I verified it was Resident 1 but added he would still contact the emergency contact, pointing to FM 1 on in the resident's medical record.During an interview on 08/31/2026 at 2:34 pm, Staff F, Social Service Director, said Resident 1 had cognitive deficits and their memory was not the best. Staff F said the facility had filed for guardianship but could not say whether or not Resident 1 agreed to this plan. Staff F said Resident 1 was technically their own decision maker. Staff F said the resident was happy to stay at the facility. Resident 1 said they would like to go to church but needed a staff person or a safe party to go with her. Staff F said FM 1 was not allowed to sign the resident out of the facility. Staff F acknowledged one episode of elopement citing the June incident. Staff F was unfamiliar with Resident 1's feeling about the wander guard and had not asked the resident how the bracelet made the resident feel.During an interview on 08/31/2026 at 4:02 pm, when asked who Resident 1's decision maker was, Staff B, Registered Nurse (RN) and Director of Nursing said there was none in place. Staff B said FM 3 was involved in Resident 1's care. Staff B said they have to protect Resident 1 from FM 1's poor decisions and actions. Staff B said the facility filed for guardianship of the resident but could not say if the resident agreed to this. Staff B said Resident 1 verbally agreed to the wander guard but could not find evidence this occurred. Staff B acknowledged FM 3 gave consent for the wander guard. Staff B said he was not aware of the resident's distress related to the wander guard. Staff B stated Resident 1 had 1 episode of elopement and has not been reassessed to determine an ongoing need for the wander guard. Staff B acknowledged Resident 1 was their own decision maker and should have been asked for consent to use the wander guard. Staff B said it was too bad how Resident 1 felt related to the wander guard and would assess the resident immediately for continued use. Staff B said FM 1 was allowed to come to the facility and could check the resident out if they followed the signing out directions. Staff B said he would educate staff on this. Resident 6Resident 6 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (COPD - a chronic lung disease which makes it difficult to breathe). The quarterly MDS, dated [DATE], documented Resident 6 had moderate cognitive impairment and required partial to moderate assistance from staff with ADLs.Review of Care plan, dated 06/28/2026, documented Resident 6 was their own responsible party. The resident was at risk for elopement due to confusion, impaired judgement, and decreased safety awareness. A wander guard was placed on the left ankle.Review of Elopement Risk Evaluation, dated 05/05/2026, documented Resident 6 was alert with cognitive impairment, mobile with a device, had diagnoses which predisposed the resident to elopement, and verbalized a plan to leave the facility. A consent was obtained from FM 4.Review of Progress notes, dated 05/05/2026, document Resident 6 had a wander guard bracelet applied.Review of Resident 6's progress notes did not show evidence of attempts or desire to leave. Progress notes consistently documented the resident as corporative.During an interview on 08/27/2026 at 4:40 pm, Resident 6 said they make their own decisions. Resident 6 said they did not have many health complaints so there was not much to worry about. The resident denied concerns with the wander guard bracelet and said they did not think about it much.During concurrent interview and observation on 08/27/2026 at 4:45 pm, Staff I said he would contact FM 4 for Resident 6 even though the resident was their own decision maker. Staff I explained sometimes he had to make the decision whether to contact the emergency contact for medical decision making but did not do this for all residents who are their own decision makers, just those who do not make good decisions. When asked if Resident 6 wandered, Staff I said no and denied Resident 6 had a wander guard in place. Staff I said, I would be signing it off if he did. When shown the Treatment Administration Record and the care plan noting the placement of a wander guard, the staff did not have a comment. At that time, Resident 6 was asked about their wander guard. It was observed on the resident's left ankle. Staff I said Resident 6 does wander throughout the facility, must have voiced an intention to leave the facility and was an elopement risk.During an interview on 08/31/2026 at 2:34 pm, Staff F, said Resident 6 was their own decision maker and FM 4 should not be giving consent.During an interview on 08/31/2026 at 4:02 pm, Staff B, said he would re-evaluate the need for a wander guard. Staff B said consent should be obtained from Resident 6 since they are their own responsibility party.Reference: (WAC) 388-97-0180(2)

Based on interview and record review, the facility administration failed to efficiently and effectively ensure compliance with state and federal regulatory requirements to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The failure to ensure oversight had the potential to cause physical, mental and psychological harm, serious injuries, unmet needs, and dissatisfaction with their quality of life.Findings included.A review of citations from 08/31/2025 to 08/31/2026 showed a pattern of repeat citations as follows:F578 cited 05/31/2026 and 08/31/2026F585 cited 05/31/2026 and 08/31/2026F610 cited 09/02/2025, 05/31/2026 (cited at an immediate jeopardy) and 08/31/2026F641 cited 05/29/2026 and 08/31/2026F645 cited 05/29/2026 and 08/31/2026F657 cited 09/04/2025 and 08/31/2026F686 cited 05/29/2026 and 08/31/2026F689 cited 09/04/2025, 03/02/2026 (cited at a harm level), 05/29/2026 and 08/31/2026F695 cited 05/29/2026 and 08/31/2026F725 cited 05/29/2026 and 08/31/2026F838 cited 05/29/2026 and 08/31/2026F842 cited 03/02/2026, 05/29/2026 and 08/31/2026 On 08/31/2026 at 7:39 pm, Staff A, Administrator, said they have had a pattern of repeat citation. Staff A said they have tried to use their Quality Assurance program to try and improve their processes. Staff A said they have support from their corporation. Staff A said they were trying to get the right people in the right places. Staff A said they had identified issues such as grievances as still out of compliance and were going to start a performance improvement process on the concerns. Reference WAC 388-97-1620(1),(2)(ii)

Based on interview and record review, the facility failed to inform residents of their right to accept or refuse treatments for 2 of 3 residents (1 & 6) reviewed for consent. The facility failed to implement a system to ensure Advanced Directives (AD) were in place for 3 of 3 residents (1, 6, & 8) reviewed for AD. This failure placed residents at risk of losing their right to have their stated preferences/decisions honored regarding medical treatment and end-of-life care.Findings included.ConsentResident 1Resident 1 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus and a fracture to the lumbar vertebra. The quarterly Minimum Data Set (MDS), dated [DATE], documented Resident 1 had moderate cognitive impairment and was independent with most activities of daily living (ADLs).Review of Resident 1's care plan, dated 06/27/2027, documented Resident 1 had not formulated a Power of Attorney (POA) and remained their own responsible party. The care plan, dated 06/29/2026, documented Resident 1 was at risk for elopement due to confusion, impaired judgement, and poor safety awareness. A bracelet that alarms (a wander guard) when a resident is near the exit doors wander guard is placed on the resident. The resident will frequently remove the wander guard.On 08/19/2026 at 4:35 pm, Resident 1 was observed sitting in their bed in their room. Resident 1 was pleasant and open to talking. The resident explained in detail how they ended up in the facility, including their hospitalization prior to admission. The resident discussed details of their stay in the facility including an episode when they left the facility in June. Resident 1 said they never intended on eloping from the facility but fell and could not get back up. Staff found the resident after their fall. Since this event, the resident has had to wear a wander guard. This bracelet makes the resident feel like a prisoner and like they are an illegal'. The resident was weeping and distressed when discussing the wander guard. Resident 1 said they learned their lesson and had no intention of leaving the facility independently. Resident 1 said they did want to be able to go to church, which is a few blocks away. They want the freedom to walk around the facility without the doors alarming. Resident 1 explained family member (FM) 2, who is married to FM 3, does everything FM 3 tells them to do. Resident 1 stated they did not trust or like FM 3 much.On 08/25/2026 at 4:39 pm, Resident 1 verbalized they want to go home because they feel like a prisoner in the facility due to the wander guard. Resident 1 said they did not consent before the wander guard was placed on them. They said they would never have consented to wearing the wander guard. Resident 1 said they were their own decision maker, and their family should not make decision for them. Resident 1 said they did not trust FM 3's decisions. Resident 1 said they felt like an illegal wearing the wander guard and did not want to wear it. Resident 1 said after the incident in June, the resident learned their lesson and would not do that again. Resident 1 said where would I go? I don't have a home I can go to. The resident appeared distressed when speaking about their home and the wander guard.Throughout the day on 08/25/2026, 08/26/2026, 08/27/2026, and 08/31/2026, Resident 1 was observed walking independently with their walker, visiting with friends, going to meals, and participating in activities. The resident consistently remembered recent conversations. The resident did not require assistance from staff on any observed occasion.On 08/31/2026 at 6:30 pm, Resident 1 said they hope they can get their wander guard off and was hoping someone could convince the facility to remove the bracelet. Resident 1 said they feel like a prisoner and illegal.emergency room Notes, dated 06/15/2026, documented Resident 1 was found outside after leaving the facility without properly signing out. The resident had fallen down a hill and needed to be evaluated by the hospital.Progress notes, dated 06/17/2026, documented FM 1 said he had paperwork to prove he was the POA. The facility stated they would need to see the paperwork and Resident 1 would continue to make their own decisions until deemed unable. Staff explained to FM 1, even if the resident makes decisions others feel is unsafe, they still have the right to make that decision.Elopement Risk Evaluation, dated 06/19/2026, documented Resident 1 was alert with cognitive impairment, was mobile with device, had verbal expressions to leave facility, a history of elopement and wandering attempts, and family voiced resident may leave the facility. The evaluation determined Resident 1 was at risk for elopement and a wander guard bracelet was placed on Resident 1's wrist with the consent from a FM.Progress notes, dated 06/22/2026, documented consent was received from FM 3 to place a wander guard on Resident 1's right wrist.On 08/27/2026 at 4:45 pm, when asked who makes decisions for Resident 1, Staff I, licensed practical nurse (LPN) said the resident has an emergency contact he would call for any decisions made about the resident's care. Staff I said Resident 1 threatens to leave the facility and has a history of leaving the facility. Staff I maintained Resident 1 did not make sound decisions so the emergency contact would need to be notified. When asked to verify who Resident 1's responsible party was, Staff I verified it was Resident 1 but added he would still contact the emergency contact, pointing to FM 1, the first contact, in the resident's medical record.On 08/31/2026 at 2:34 pm, Staff F, Social Service Director, said Resident 1 is technically their own decision maker right now and should be the one to make their own decisions. Staff F said Resident 1 should have been the one to give the consent for the wander guard. Staff F said the facility filed for guardianship of the resident but could not say if the resident wants this.At 4:02 pm, when asked who Resident 1's decision maker was, Staff B, Registered Nurse (RN) and Director of Nursing said there is none in place. Staff B said FM 3 was involved in Resident 1's care. Staff B said they had to protect Resident 1 from FM 1's poor decisions and actions. Staff B said Resident 1 verbally agreed to the wander guard but could not find evidence this occurred. Staff B acknowledged FM 3 gave consent for the wander guard. Staff B said he was not aware of the resident's distress related to the wander guard. Staff B said the facility filed for guardianship of the resident but could not say if the resident agreed to this. Staff B acknowledged Resident 1 was their own decision maker and should have been asked for consent to use the wander guard.Resident 6Resident 6 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (COPD - a chronic lung disease which makes it difficult to breathe). The quarterly MDS, dated [DATE], documented Resident 6 had moderate cognitive impairment and required partial to moderate assistance from staff with ADLs.Care plan, dated 06/28/2027, documented Resident 6 had not formulated a POA and remains their own responsible party. The resident is a risk for elopement due to confusion, impaired judgement, and decreased safety awareness. A wander guard is placed on the left ankle.On 08/27/2026 at 4:40 pm, Resident 6 said they make their own decisions. Resident 6 said they do not have many health complaints so there is not much to worry about. The resident denies concerns with the wander guard bracelet and said they do not think about it much.Elopement Risk Evaluation, dated 05/05/2026, documented Resident 6 was alert with cognitive impairment, mobile with a device, had diagnoses which predisposed the resident to elopement, and verbalized a plan to leave the facility. A consent was obtained from FM 4.Progress notes, dated 05/05/2026, document Resident 6 had a wander guard bracelet applied.A review of Resident 6's progress notes did not show evidence of attempts or desire to leave. Progress notes consistently documented the resident as corporative.On 08/27/2026 at 4:45 pm, Staff I said he would contact FM 4 for Resident 6 even though the resident is their own decision maker. Staff I explained sometimes he has to make the decision whether to contact the emergency contact for medical decision making. Staff I said he does not do this for all residents who are their own decision makers, just those who do not make good decisions. Staff I denied Resident 6 wanders outside the facility. On 08/31/2026 at 2:34 pm, Staff F, said Resident 6 was their own decision maker and FM 4 should not be giving consent.At 4:02 pm, Staff B, said he would re-evaluated the need for a wander guard. Staff B said consent should be obtained from Resident 6 since they are their own responsibility party.ADResident 1Care plan, dated 06/27/2026, documented Resident 1 has not formulated a POA and remains their own responsible party. Staff will review and educate resident/family on advanced directive options as needed.Progress notes, dated 06/17/2026, documented FM 1 said he had paperwork to prove he was the POA. The facility stated they would need to see the paperwork and Resident 1 would continue to make their own decisions until deem unable.Progress notes, dated 06/22/2026, documented Resident 1 elects FM 1 to be their health care surrogate should they become incapacitated.No AD was filed in Resident 1's record.Resident 6Care plan, dated 06/28/2026, documented Resident 6 has not formulated a POA and remains their own responsible party. Staff will review and educate resident/family on advanced directive options as needed.Progress notes, dated 05/05/2026, documented Resident 6 elects FM 4 to be their health care surrogate should they become incapacitated.No AD was filed in Resident 6's record.Resident 8Resident 8 was admitted to the facility on [DATE] with diagnosis of diabetes mellitus. The admission MDS, dated [DATE], documented Resident 8 had no cognitive impairment and was dependent on staff with ADLs.The care plan, dated 08/20/2026, documented Resident 8 had cognitive impairment with increased risk for confusion, impaired judgement, and decreased safety awareness.Resident Information, undated, lists FM 5 as the responsible party for Resident 8.Progress notes, dated 08/20/2026, documented Resident 8 elects FM 5 to be their health care surrogate should they become incapacitated.No AD was filed in Resident 8's record.On 08/31/2026 at 2:34 pm, Staff F, said AD paperwork should be completed for these residents or should have the AD documents in the clinical record.At 4:02 pm, Staff B, said social services should follow up on all AD.Reference: WAC 388-97-0280(3)(c)(i)(ii) -0300(1)(b)(3)(a)-(c)

Based on interview and record review the facility failed to ensure staff were evaluated by the facility for competency with skills and techniques prior to working with residents with BiPAP (bilevel positive airway pressure - a non-invasive breathing device that delivers two distinct air pressure levels-higher when you inhale and lower when you exhale-to help people get air into and out of their lungs easily) for 5 of 5 Licensed Nurses (K, L, M, E, C, & G) reviewed for competency with BiPAP use. The facility failed to ensure staff were competent with skills and techniques prior to working with residents and completed yearly for 4 of 5 staff (Y, R, S & Z) staff reviewed for competencies with activities of daily living (ADLs). This failure placed residents at risk for clinical complications and diminished quality of life. Findings included.Resident 2Review of Trilogy Evo Ventilator: Home Caregiver Manual, dated 07/2019, documented the device provides invasive and non-invasive, positive pressure ventilation to adults. It is a medical device intended for use by qualified, trained personnel under the direction of a physician according to technical specifications.Resident 2 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (COPD - a chronic lung disease which makes it difficult to breathe). The admission minimum data set (MDS), dated [DATE], documented Resident 2 had no cognitive impairment and required partial to moderate assistance with activities of daily living.Review of care plan, dated 08/13/2026, documented Resident 2 had COPD and obstructive sleep apnea (OSA) with increased risk of shortness of breath and respiratory compromise. The care plan showed staff will assist the resident as needs with BiPAP machine.On 08/24/2026 at 11:51 am, Resident 2's power of attorney (POA), Collateral Contact 1, CC 1, said Resident 2 required the use of a BiPAP ventilator during the night. CC 1 brought the BiPAP into the facility on [DATE]. CC 1 said that the facility staff took apart the BiPAP without knowing how to properly put it back together then claimed there was a missing piece. CC 1 said the BiPAP was functioning appropriately and cleaned prior to bringing the device to the facility. CC 1 said there was no missing piece when she brought in the device. CC 1 said staff did not know how to put the device back together. This caused a delay in using the machine because the respiratory therapy (RT) company who manages the device could not come to the facility until 08/20/2026. CC 1 said over the past several days, many staff have voiced they did not know how to use the BiPAP.At 1:51 pm, CC 1 said Staff B, registered nurse and Director of Nursing, stated he was unaware of their concerns with BiPAP and lack of staff training. CC 1 said Staff B stated they would address the issues. After she voiced her concerns, staff continue to state they did not know how to use the device.On 08/24/2026 at 2:24 pm, Collateral Contact A, respiratory therapist, said she has concerns with how the facility is handling the device. When she came to the facility on [DATE], she put the machine back together and offered to show staff how to manage the device. Staff were uninterested in learning about the device and declined her offer for education. Collateral Contact A posted some information on management of the device to the wall in the room with contact information.On 08/24/2026 at 3:32 pm, Staff L, licensed practical nurse (LPN), said he had gotten no training on how to care for Resident 2's BiPAP. Staff L said there has been no training at the facility on how to care for any BiPAP and has never had a competency to see if they could competently care for a BiPAP machine. Staff L said he did not know who to contact if there were issues with the machine. He could not find direction in the TAR or the care plan.On 08/24/2026 and 08/25/2026, competencies and education of staff related to care of Resident 2's device were requested.On 08/25/2026 at 3:59 pm, CC 1 said there continued to be issues with the BiPAP alarming. The staff did not know how to address the alarms, so the CC 1 had to show them.One-on On Coaching Record, was completed 08/25/2026, for Staff K, LPN.One-on On Coaching Record, was completed 08/25/2026, for Staff L, LPN.One-on On Coaching Record, was completed 08/25/2026, for Staff M, LPN.One-on On Coaching Record, was completed 08/25/2026, for Staff E, registered nurse (RN).One-on On Coaching Record, was completed 08/25/2026, for Staff C, RN and staff development.One-on On Coaching Record, was completed 08/25/2026, for Staff G, LPN.On 08/31/2026 at 2:04 pm, Staff C, said they did not have education on competencies completed on the named staff until it was requested. Staff C said they started in their role recently and she has needed to develop the education program. Staff C said if a vendor comes onsite and offers education, she expects staff should be eager to receive the education and notify her that the vendor is onsite so she can make sure the education is disseminated. On 08/31/2026 at 4:02 pm, Staff B, RN and Director of Nursing, said staff did not have competencies or education on BiPAP completed until 08/25/2026 despite having the devices in the facility prior to this time.Resident 4Resident 4 was admitted to the facility on [DATE] with diagnoses of amyotrophic lateral sclerosis (ALS - a neurological disease which kills the cells of the brain and spinal cord that control voluntary muscle movement) and repertory failure. The quarterly minimum data set (MDS), dated [DATE], documented Resident 4 had no cognitive impairment and was dependent on staff with activities of daily living (ADLs).On 08/27/2026 at 3:00 pm, Resident 4 was observed sitting in their bed. Resident 4's arms and legs were immobile aside from their right hand, which was used to control a mouse on a computer used to communicate. Resident 4 spoke by inputting words into the computer. Resident 4 appeared solely dependent on staff for mobility. Resident 4's communication showed they were cognitively intact. Resident 4 described an incident where a staff member made them wait a long time for care. When they received care, the staff attempted to feed them without dentures and while lying flat in the bed. Resident 4 said staff are not trained in how to feed them and do not know what they are doing when they first assist the resident with feeding.At 3:45 pm, Staff S, nursing assistant (NA), confirmed that staff do not get trained how to assist Resident 4 with feeding before they have to feed the resident independently.Review of an alleged abuse investigation, dated 08/23/2026, documented the resident reported Staff Y, NA, was rough and pulled at the residents arms during repositioning. Staff Y also tried to feed the resident without dentures and while lying flat.Review of competencies, undated and unsigned, did not show that Staff Y was determined to be competent in feeding a resident or repositioning a resident.Review of a Certified Nursing Assistance Competency Checklist documented all competencies for Staff R, NA, on 08/07/2026. The competencies did not indicate how they were validated.Review of a Certified Nursing Assistance Competency Checklist documented all competencies for Staff S were completed on 08/09/2026. The competencies did not indicate how they were validated.Review of competencies for Staff Z, NA showed the competencies were undated and unsigned On 08/31/2026 at 2:04 pm, Staff C, said she has needed to develop a staff development program since starting recently. Staff C said that their had not been a consistent process in place. Staff C said that they have watched the NAs without them knowing while assisting resident with feeding but have not specifically trained with Resident 4, despite the resident having a unique condition of ALS.Reference: (WAC) 388-97-1680 (2) (a-c)

Based on observation, interview and record review, the facility failed to conduct a thorough investigation of an allegation of abuse, neglect, injuries of unknown origin, and medication errors for 7 of 8 sampled residents (4, 5, 12, 13, 14, 17 & 22) reviewed for abuse and neglect. This failure placed residents at risk of not receiving needed care and services and a diminished quality of life.Findings included.Resident 4 Resident 4 was admitted to the facility on [DATE] with diagnoses of amyotrophic lateral sclerosis (ALS - a neurological disease which kills the cells of the brain and spinal cord that control voluntary muscle movement) and respiratory failure. The quarterly minimum data set (MDS), dated [DATE], documented Resident 4 had no cognitive impairment and was dependent on staff with activities of daily living (ADLs).On 08/27/2026 at 3:00 pm, Resident 4 was observed sitting in their bed. Resident 4 arms and legs were immobile aside from their right hand, which was used to control a mouse on a computer used to communicate. Resident 4 spoke by inputting words into the computer. Resident 4 appeared solely dependent on staff for mobility. Resident 4's communication showed they were cognitively intact. Resident 4 described an incident where a staff member made them wait a long time for care. When they received care, the staff attempted to feed them without dentures and while laying flat in the bed. Resident 4 was upset by this interaction. Resident 4 said the staff member also pulled their head back, to reposition them, so hard it hurt their throat. Resident 4 said staff were not trained in how to assist them to eat and did not know what they were doing when they first assisted the resident with feeding.At 3:45 pm, Staff S, nursing assistant (NA), came into Resident 4's room during the conversation. Staff S said it takes a long time to assist Resident 4 with each call light. Staff S confirmed that staff do not get trained how to assist Resident 4 with feeding before they have to feed the resident independently.Review of the Alleged Abuse investigation, dated 08/23/2026, documented resident had reported that Staff Y, NA, was rough and pulled at the resident's arms during repositioning. Staff Y also tried to feed the resident without dentures and while laying flat. Resident 4 was diagnosed with ALS and takes 45 minutes to 1 hour to reposition and assist with feeding. The resident has increased care needs and time is prolonged with each step of their care. The NA, an agency staff, was removed from work and asked not to come back. The resident was found without injury. The resident could not accurately describe the details of the incident. The NA denied pulling at the resident's arm. The NA denied trying to feed the resident while lying flat. The investigation did not address used of Resident 2's dentures. The rough handling was likely the resident's perception of care compared to how the other NAs care for them. The NA was new and not aware of residents expectations of how the care should be provided. The NA was new to the resident but she was providing standard of care and it was perceived by the resident as rough handling. Abuse and neglect ruled out. There were no staff interviews about the care Staff Y provided. Resident interviews did not address residents who needed assistance with eating or asked about Staff Y's care. The sample resident interview showed a resident voiced concerns about inconsistent care due to the way the NA's were scheduled. The incident did not show documentation this concern was followed up on.On 08/31/2026 at 5:02 pm, Staff B, Registered Nurse (RN) and Director of Nursing, said Resident 4 was very particular with which NAs cared for them. Staff B said they would spend the whole day with the resident and they would still complain. Staff B stated that they do not have specialized training in caring for Resident 4 and their needs related to their ALS diagnosis or the communication needs. Staff B could not find additional interviews related to Staff J's care or follow up on the concerns voiced in the sample resident interviews.Resident 5 Resident 5 was admitted to the facility on [DATE] with a diagnosis of dementia. The quarterly MDS, dated [DATE], documented Resident 5 had severe cognitive impairment and was dependent on staff with ADLs and wheelchair mobility.Review of a fractures investigation, dated 07/20/2026, documented Resident 5 was found to have a fracture of the 5th metatarsal (a long bone in the foot) on the right foot. The resident could not recall what had occurred. The root cause was determined to be cognitive impairment and decreased safety awareness due to dementia. The report documented it was possible the resident bumped their foot. It was determined there was no evidence of equipment malfunction, staff error, neglect, or failure to follow the care plan. Abuse and neglect were ruled out. The investigation did not show staff or resident interviews were included. No evidence was provided to demonstrate that an equipment malfunction had been rue out. On 08/31/2026 at 5:02 pm, Staff B, said there were no staff or resident interviews included in investigation. Staff B agreed that the investigation was not thorough.Resident 12Resident 12 was admitted to the facility on [DATE] with a diagnosis of diabetes mellitus. The admission MDS, dated [DATE], documented Resident 12 had no cognitive impairment and was dependent on staff with ADLs. Review of a Medication Error investigation, dated 08/11/2026, documented Staff EE, RN, gave medication to Resident 12 upon request and to help Staff FF, the current cart nurse out. After the medication was administered, Staff FF told Staff EE they had already given the medication to the resident but had not signed the medications off. Resident 12 was assessed and it was determined they could be monitored at the facility. No outcome was noted. Abuse and neglect were ruled out. The investigation did not identify or document education to Staff FF regarding signing of medication upon administration. The investigation did not include the medication administered or interviews with staff and residents.On 08/31/2026 at 5:02 pm, Staff B, said there was no documentation of the medications administered, education to Staff FF, or staff or resident interviews. Staff B acknowledged the investigation was not thorough.Resident 13Resident 13 was admitted to the facility on [DATE] with a diagnosis of congestive heart failure. The admission MDS, dated [DATE], documented Resident 13 had moderate cognitive impairment and required partial to moderate assistance from staff with ADLs. Review of a Grievance, dated 08/16/2026, documented Resident 13 had very little care. There was an overall decline noted by family. The resident was never treated for a urinary tract infection (UTI). IV (intravenous - in the vein) therapy was initiated but antibiotics were never started. Resident 13 did not get a shower. Staff did not wake the resident for meals. Resident 13 had very little physical therapy. The resident lost 7 pounds. Resident 13 became delirious and was found by family sprawled across [their] bed trying to get up independently. Once, the resident was covered in feces. The resident was transported to the hospital and found to be septic (an infection in the body). The grievance was converted to an incident report.Review of a Grievance, dated 08/16/2026, documented Resident 13 experienced many incidents of neglect during their 12 day stay at the facility. Staff did not wake the resident for meals. Resident 13 had very little physical therapy. Resident 13 did not get showers. The facility did not treat the resident for a UTI even after they put in an IV for antibiotics. There was blood draining from the IV insertion point. On the morning of 08/16/2026, the resident was found covered in feces, did not have a brief on, and was moaning laying horizontally in bed. There were more concerns that were listed on the grievance.Review of an Alleged Neglect investigation, dated 08/17/2026, documented Resident 13's family complained about their care. The resident was not started on antibiotics, and they decided to take the resident to the hospital for this reason. Social services would follow up with the family. The investigation found the resident had confusion and hallucinations on 08/10/2026. A UA (urine analysis) was ordered and resulted 08/13/2026. The results were positive but the white blood cells (WBC) were normal. The culture and sensitivity came back but it was not noted what the results were. The resident was seen by the provider on 08/13/2026 and a UA was sent out with positive results. It was agreed the resident would be on short term antibiotics and an IV was placed. The facility was waiting on a kidney function test to properly dose the antibiotics. On 08/16/2026 the family took Resident 13 to the hospital. The allegation of neglect is possibly related to miscommunication between the nursing staff and family. It was believed antibiotics were not needed because the resident did not show clinical symptoms of a UTI. Neglect was ruled out. Staff and the provider denied acute signs of infection. The investigation did not address the additional concerns voiced in the grievance including weight loss, lack of showers, no assistance with eating, not waking the resident to eat, incontinence care and an overall decline in the resident's cognition. No family interviews were completed after the grievance was filed. The sample resident interviews did not include the individual concerns addressed in the complaint. No staff interviews were included.On 08/31/2026 at 5:02 pm, Staff B acknowledged the investigation was not thorough and could not find staff interviews.Resident 14Resident 14 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (COPD - a chronic lung disease which makes it difficult to breathe). The admission MDS. dated 07/17/2026, documented Resident 14 had severe cognitive impairment and required substantial to maximal assistance with activities of daily living.Review of an Alleged Neglect investigation, dated 07/16/2026, documented Resident 14's family expressed concerns about oxygen therapy and incontinence care. The investigation documented there was no neglect because the resident would remove his own clothes and nasal cannula. Staff would try and diligently attend the resident throughout the day. Staff stated they had gone in and provided care for the resident on the day in question. The investigation did not include staff interviews. On 08/31/2026 at 5:02 pm, Staff B acknowledged the investigation was not thorough and could not find staff interviews.Resident 17Resident 17 was admitted to the facility on [DATE] with a diagnosis of spinal stenosis (narrowing of spinal canal). The annual MDS, dated [DATE], documented Resident 17 had no cognitive impairment and required some assistance from staff with ADLs. Progress notes, dated 08/03/2026, documented Resident 17 was found in their room with a straw and a fine white powdered substance. The resident stated it was a pain pill they were administered and crushed. The nurse confirmed the substance was administered whole.Review of Incidents, dated August 2026, did not show documentation of an incident that was reported to the State Agency on 08/03/2026. No 5-day follow-up was submitted to the State Agency.No investigation was provided related to the 08/03/2026 incident.On 08/31/2026 at 5:02 pm, Staff B acknowledged there was no investigation and it was not reported within 5 days to the State Agency. Staff B said they reported the incident to adult protective services (APS) and did not realized they needed to follow up with the State Agency. Resident 22Resident 22 was admitted to the facility on [DATE] with a diagnosis of uterine (uterus/womb) cancer. The quarterly MDS, dated [DATE], documented Resident 22 had no cognitive impairment and was dependent on staff with ADLs. Review of a Verbal Aggression investigation, dated 08/05/2026, documented there was a verbal altercation between a visitor and Resident 22. Sample residents interviewed were asked if they had ever heard of a resident being yelled at. Two residents answered, 'yes, they had heard of a resident being yelled at'. No follow up was documented related to those responses. On 08/31/2026 at 5:02 pm, Staff B, said there was no follow up on the concern about residents being yelled at.Reference WAC 388-97-0640(5)(6)(a)(b)

Based on observation, interview and record review, the facility failed to ensure resident care plans were reviewed, revised, and accurately reflected resident care needs for 3 of 3 sampled residents (1, 4, & 5) reviewed for care plan revisions. This failure placed residents at risk for unmet care needs and a diminished quality of life.Findings included.Resident 1Resident 1 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS), dated [DATE], documented Resident 1 had moderate cognitive impairment and was independent with most activities of daily living (ADLs).Care plan, dated 07/27/2026, documented Resident 1 was at risk for psychosocial well-being due to suicidal ideation. Staff would allow the resident to discuss positive and negative feelings towards placement at the facility, provide supportive mental health services and monitor the resident every 15 minutes.Progress notes, dated 07/27/2026, documented Resident 1 said they would kill themselves in front of the ombuds because they could not attend church. Resident 1 was placed on suicidal ideation alert and placed on 15-minute checks.On 08/31/2026 at 4:02 pm, Staff B, registered nurse (RN) and Director of Nursing, said Resident 1 was on 15 minutes checks when the resident had suicidal ideation, but the checks had been discontinued. Staff B said the care plan should have been revised.Resident 4Resident 4 was admitted to the facility on [DATE] with diagnoses of amyotrophic lateral sclerosis (ALS - a neurological disease which kills the cells of the brain and spinal cord that control voluntary muscle movement) and respiratory failure. The quarterly minimum data set (MDS), dated [DATE], documented Resident 4 had no cognitive impairment and was dependent on staff with activities of daily living (ADLs).Review of a Care plan, dated 04/02/2026, documented Resident 4 had been diagnosed with ALS, a terminal illness, and would experience a gradual decline over time. Staff would provide ADL assistance as needed. The care plan, dated 04/15/2026, documented Resident 4 had a communication impairment with decreased ability to express needs, understand information, participate in conversations, and effectively interact with others. Staff would encourage the resident to continue to state thoughts even if the resident was having difficulty and observe non-verbal cues. Review of a Care plan, dated 07/02/2026, documented the resident required 1:1 assistance with feeding and should be sitting upright.On 08/20/2026 at 3:57 pm, Staff X, nursing assistant (NA), said Resident 4 took a long time to help each time they answered their call light. They said it took a minimum of 20 minutes to help the resident and they had specific health needs.On 08/27/2026 at 3:00 pm, Resident 4 was observed sitting in their bed. Resident 4's arms and legs were immobile aside from their right hand, which was used to control a mouse on a computer used to communicate. Resident 4 spoke by inputting words into the computer. The computer screen showed the words and phrases the resident was wanting to express. Resident 4 appeared solely dependent on staff for mobility. Resident 4's communication showed they were cognitively intact. Resident 4 expressed frustration that staff did not seem familiar with their care needs when the staff was new. This included how to move the resident and how to feed the resident. Resident 4 said staff were untrained in how to care for the resident and their condition, ALS. At 3:45 pm, Staff S, NA, came into Resident 4's room during the conversation. Staff S said it takes a long time to assist Resident 4 with each call light. Staff S estimated it takes a minimum of 20 minutes to assist them when answering a call light and at least an hour when assisting with feeding. Resident 4 agreed with this estimation. Staff S said thank goodness I knew something about ALS before she started at the facility because she got no training related to the disease and how to care for Resident 4. Staff S said Resident 4 had unique needs compared to the other residents and staff were not given direction on how to care for the resident.At 5:02 pm, Staff B, said Resident 4 required a lot of time from the NAs and was particularly difficult for the new staff. Staff B said staff get very frustrated caring for the resident due to their high level of care. Staff B acknowledged the care plan did not reflect the communication needs including the use of a computer to talk or the length of time to be expected when caring for the resident. Staff B said their care plan was not individualized related to the progression of ALS and the current status of the resident.Resident 5Resident 5 was admitted to the facility on [DATE] with a diagnosis of dementia. The quarterly MDS, dated [DATE], documented Resident 5 had severe cognitive impairment and was dependent on staff for ADLs and wheelchair mobility. a Fractures investigation, dated 07/20/2026, documented Resident 5 was found to have a fracture of the 5th metatarsal (a long bone in the foot) on the right foot. The resident could not recall what had occurred. The root cause was determined to be cognitive impairment and decreased safety awareness due to dementia. It is possible the resident bumped their foot.The care plan did not address the injury of unknown origin and the fracture to the right foot.At 5:02 pm, Staff B, said the care plan should have been revised to reflect Resident 5's injury.Reference: WAC 388-97-1020(2)(a)

Based on observation, interview and record review, the facility failed to ensure BiPAP (bilevel positive airway pressure - a non-invasive breathing device that delivers two distinct air pressure levels-higher when you inhale and lower when you exhale-to help people get air into and out of their lungs easily) orders were complete and in place, to include the prescribed pressure settings, checking, refilling and cleaning of the humidifier reservoir, and identifying what solution was to be used in the humidifier for 4 of 4 residents (2, 3, 4, & 9) reviewed. These failures placed residents at risk for ineffective assisted ventilation, shortness of breath, decreased oxygen saturation and other respiratory complications. Findings included.Review of Trilogy Evo Ventilator: Home Caregiver Manual, dated 07/2019, documented the device provides invasive and non-invasive, positive pressure ventilation to adults. It is a medical device intended for use by qualified, trained personnel under the direction of a physician according to technical specifications.Resident 2Resident 2 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (COPD - a chronic lung disease which makes it difficult to breathe). The admission minimum data set (MDS), dated [DATE], documented Resident 2 had no cognitive impairment and required partial to moderate assistance with activities of daily living.Review of the care plan, dated 08/13/2026, documented Resident 2 had COPD and obstructive sleep apnea (OSA) with increased risk of shortness of breath and respiratory compromise. The care plan documented staff would assist the resident as needed with BiPAP machine.During interview on 08/24/2026 at 11:51 am, Resident 2's power of attorney (POA), Collateral Contact 1, CC 1 said that Resident 2 required the use of a BiPAP ventilator during the night. CC 1 said that they brought the BiPAP into the facility on [DATE]. CC 1 said that the facility staff took apart the BiPAP without knowing how to properly put it back together then claimed there was a missing piece. CC 1 said that the BiPAP was functioning appropriately and cleaned prior to bringing the device to the facility. CC 1 said there was no missing piece when she brought in the device. CC 1 said the staff did not know how to put the device back together. CC 1 said this caused a delay in using the machine because the respiratory therapy (RT) company who managed the device could not come to the facility until 08/20/2026. CC 1 said that on 08/20/2026, after the machine was put back together, CC 1 waited for the staff to come put on the device and she had to ask for it to be done. Then, the device alarmed continuously without staff answering the alarm. CC1 said that she then reset it and it went off again. CC 1 said that she let it go for a while to see how long it would take for staff to answer the alarm. Then, she waited well past midnight before anyone came to start the device and reset it. CC 1 said staff only came in after she finally asked for help. CC 1 said over the previous several days, many staff had voiced they did not know how to use the BiPAP.During concurrent interview and observation on 08/24/2026 at 1:51 pm, CC 1 said Staff B, Registered Nurse and Director of Nursing, stated that he was unaware of their concerns with BiPAP and lack of staff training. CC 1 said that Staff B stated they would address the issues. After she voiced her concerns, staff continue to state they did not know how to use the device. CC 1 said they wanted to ensure Resident 2 was getting benefit from the device. CC 1 showed a log on the BIPAP device. The log showed when the device beeps and is not benefiting Resident 2. This can occur when there is an adjustment needed with the face mask. CC 1 showed an example of how the device beeped on 08/23/2026 from 1:15 am to 1:56 am. Resident 2 said he had the same concerns and did not feel completely safe to stay in the facility. CC 1 said she knew the facility was not documenting the issues with the BiPAP because a staff member showed her the records and there were no notes.During an interview on 08/25/2026 at 3:59 pm, CC 1 said there continued to be issues with the BiPAP alarming. CC 1 said that staff did not know how to address the alarms, so CC 1 had to show them. CC 1 said they were supposed to dump and refill the water every three days, change the mask once a month, and clean the mask with a warm cloth every morning. CC 1 said that the facility had not inquired about this information. Review of the admission Nursing Evaluation, dated 08/10/2026, documented Resident 2 had a BiPAP set to home settings and CC 1 would bring the device into the facilityReview of the Treatment Administration Record (TAR), dated August 2026, documented staff would clean the mask every morning, put the BiPAP on at bedtime, and change the BiPAP once a week (does not note what is to be changed).Review of RT notes, dated 08/20/2026, documented the unaffiliated respiratory therapy company came onsite to the facility. Resident 2's BiPAP was put back together after it was disassembled at the facility. The note documented staff were confusing the device with a CPAP (a continuous positive airway pressure device) and lacked competency in caring for the device. The note said the onsite nurse said they understood how to use the machine despite being unable to put the machine back together and calling the device a CPAP. The note said information was posted above the resident's bed on how to use and contact the company.Review of Device Alarms log, dated 08/20/2026 to 08/21/2026, showed the alarm sound most of the time between 11:00 pm and 12:00 am. The log showed the alarm was continuous throughout most of the hour between 12:00 am and 1 am.Review of Device Alarms log, dated 08/22/2026 to 08/23/2026, showed the alarm was sounding continuously from about 11:15 pm to about 01:00 am. The log showed the alarm sounded continuously from 1:15 am to 1:45 am. The alarm sounded continuously again from about 4:45 am to about 5:15 am.Review of Progress notes, dated 08/23/2026, documented the BiPAP machine was beeping most of the night. They were able to make it work until about 5:00 am, when the resident declined to have the mask in place anymore as they were awake for the day.Review of Device Alarms log, dated 08/23/2026, showed the alarm was continuous from about 9:30 pm to 10:15 pm.Review of Physician Orders, as of 08/24/2026, did not show orders for the BiPAP or the settings.Review of Device Alarms log, dated 08/24/2026 to 08/25/2026, showed the alarm was continuous from about 11:45 pm to 1:15 am.On 08/24/2026 at 2:24 pm, Collateral Contact A, respiratory therapist, said she had concerns with how the facility is handling the device. When she came to the facility on [DATE], she was not greeted by staff. She was told the resident room was down the hall and had to find the room herself. Collateral Contact A put the machine back together and offered to show staff how to manage the device. Staff were uninterested in learning about the device and declined her offer for education. Collateral Contact A posted some information on management of the device to the wall in the room with contact information. Collateral Contact A said staff were rude and she was concerned about how Resident 2's respiratory care would be managed at the facility. Collateral Contact A said the resident was not safe being cared by the facility.On 08/24/2026 at 3:32 pm, Staff L, licensed practical nurse (LPN), said he had gotten no training on how to care for Resident 2's BiPAP. Staff L said there has been no training at the facility on how to care for any BiPAP and has never had a competency to see if they could competently care for a BiPAP machine. Staff L said he did not know who to contact if there were issues with the machine. He could not find direction in the TAR or the care plan.On 08/31/2026 at 4:02 pm, Staff B, said staff did not have competencies on BiPAP completed until 08/25/2026 despite having the devices in the facility prior to this time. Staff B said they care plans, physician orders, and nursing orders did not reflect all the details required to care for the devices. This included the type of water used in the device, how to clean the mask, and when to change the mask and tubing. Staff B was unaware the BiPAP showed a log of the alarm times and did not know staff were not answering the device alarms.<Resident 3>Resident 3 was admitted to the facility on [DATE] with diagnoses of paraplegia and COPD. The annual MDS, dated [DATE], documented Resident 3 had no cognitive impairment and was dependent on staff with ADLs. Care plan, dated 05/15/2026, documented Resident 3 is at risk for respiratory complications due to COPD. The resident will use a CPAP/BiPAP at night during sleep. The TAR, dated August 2026, documented Staff will change the tubing once a week, clean the mask every evening, and apply the CPAP at the rate of 5-20 cm H20 at bedtime.On 08/31/2026 at 4:02 pm, Staff B, said they did not have how to clean the mask, when to change the water or what type of water to use included in the orders. Staff B acknowledged it was not clear if the resident had a BiPAP or CPAP on the care plan.<Resident 4>Resident 4 was admitted to the facility on [DATE] with diagnoses of amyotrophic lateral sclerosis (ALS - a neurological disease which kills the cells of the brain and spinal cord that control voluntary muscle movement) and repertory failure. The quarterly minimum data set (MDS), dated [DATE], documented Resident 4 had no cognitive impairment and was dependent on staff with activities of daily living (ADLs).Care plan, dated 08/25/2026, documented Resident 4 does declines to use the BiPAP as they no longer use the device.On 08/27/2026 at 3:00 pm, Resident 4 said she does not use BiPAP anymore because it takes too long for staff to assist them while using the device and to put the device on. Resident 4 said they often wait a long time for help.The TAR, dated August 2026, documented Staff apply the BiPAP at night, to clean the mask every evening, and to change the distilled water every night at bedtime.Progress notes, dated 08/25/2026, documented the resident refuses the use of the BiPAP and wishes no longer to use the device. The resident denied difficulty with breathing at night.The physician orders did not include orders for a BiPAP or setting.On 08/31/2026 at 4:02 pm, Staff B, said he did not know Resident 4 did not want to use the BiPAP because they had to wait to long for assistance. Staff B acknowledged the staffing in difficult in this section. Staff B said they did not note how to clean the mask or have orders for the BiPAP use and settings in the orders.<Resident 9>Resident 9 was admitted to the facility on [DATE] with diagnoses of OSA. The quarterly MDS, dated [DATE], documented Resident 9 had no cognitive impairment and required supervision from staff with ADLs. Care plan, dated 04/01/2026, documented Resident 9 is at risk for respiratory complications due to OSA. Staff will assist the resident with setting up the BiPAP device.The TAR, dated August 2026, documented staff will change the tubing once a week, clean the mask every evening, and apply settings at rate of 125 at night.On 08/31/2026 at 4:02 pm, Staff B, said they did not have orders for when to change the water or what type of water to use included in the orders.Reference: (WAC) 388-97-1060 (3)(j)(vi)

Based on observation, interview and record review, the facility failed to ensure sufficient staffing levels were met to provide care planned care and services for residents. This failure placed residents at risk for unmet physical, mental and psychosocial needs, a decline in health status and a diminished quality of life.Findings included.Resident 1Resident 1 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS), dated [DATE], documented Resident 1 had moderate cognitive impairment and was independent with most activities of daily living (ADLs).On 08/25/2026 at 4:39 pm, Resident 1 said the staff did not do anything for them. Resident 1 said that they make their own bed and lay the linens to be picked up on the floor, and the linens sit there all day. Resident 1 said they wait a long time for assistance from staff. Resident 1 said their roommate waits a long time for their assistance as well. They explained the NAs are split between the two halls, and they cannot see when their call light is on. Resident 1 said the facility does not have enough staff.On 08/31/2026 at 6:30 pm, Resident 1 said Did you see my linens on the floor all day? Resident 1 said it took hours for someone to pick up the linens on their floor. Resident 1 said staffing was bad that day and they had to wait a long time for help.Resident 2Resident 2 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (COPD - a chronic lung disease which makes it difficult to breathe). The admission minimum data set (MDS), dated [DATE], documented Resident 2 had no cognitive impairment and required partial to moderate assistance with activities of daily living.On 08/24/2026 at 1:51 pm, Resident 2 said they waited a long time for the staff to answer their BiPAP (bilevel positive airway pressure - a non-invasive breathing device used to help people get air into and out of their lungs easily) alarm. Resident 2 said that it keeps them and their roommate up at night. Resident 2's power of attorney (POA), Collateral Contact 1, CC 1 said she had to wait for more than an hour on 08/20/2026 for staff to come in and address the alarming of their BiPAP. She eventually went to find staff to address the alarm. Resident 2 and CC 1 said the facility did not have enough staff. Resident 3Resident 3 was admitted to the facility on [DATE] with diagnoses of paraplegia (partial or complete loss of sensation or movement to lower half of body). The annual MDS, dated [DATE], documented Resident 3 had no cognitive impairment and was dependent on staff with ADLs. On 08/19/2026 at 3:20 pm, Resident 3 said staffing was a challenge at the facility. Resident 3 said that they pulled their regular staff to other units to help cover. Resident 3 said that the staff they use to replace the regular staff do provide the same level of care. Resident 3 said that they do not introduce themselves or wear nametags. Resident 3 said that they are not as caring. Resident 3 said that they are losing good staff due to the staffing. Resident 3 said they did not necessarily wait a long time for the call light, but they do have to wait once they have been told they will come back and help them. Resident 3 said the facility does not always replace staff who call out. Resident 4Resident 4 was admitted to the facility on [DATE] with diagnoses of amyotrophic lateral sclerosis (ALS - a neurological disease which kills the cells of the brain and spinal cord that control voluntary muscle movement) and repertory failure. The quarterly minimum data set (MDS), dated [DATE], documented Resident 4 had no cognitive impairment and was dependent on staff with activities of daily living (ADLs).08/27/2026 at 3:00 pm, Resident 4 was observed sitting in their bed. Resident 4's arms and legs were immobile aside from their right hand, which was used to control a mouse on a computer used to communicate. Resident 4 spoke by inputting words into the computer. Resident 4 appeared solely dependent on staff for mobility. Resident 4's communication showed they were cognitively intact. Resident 4 said she did not use the BiPAP anymore because it takes too long for staff to assist them while using the device and to put the device on. Resident 4 said they wait a long time for help. Resident 4 said they had to wait upwards of two hours for care at times. Resident 4 said recently, they did not get fed until 8:00 pm. Resident 4 said, the prior Tuesday, they saw their nursing assistant (NA) three times the whole shift. For vitals, the meal, and at bedtime. Resident 4 said that while the NAs were in the room with them, the nurse would come in and interrupt their care and tell the NA they were needed elsewhere and this happened a lot. Resident 4 said they get frustrated by the interruptions. Resident 4 said a nurse came in while the NA was assisting the resident with the bedpan and it angered the resident so much, they yelled at the nurse. Resident 4 said the facility does not have enough staff.Resident 7Resident 7 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], documented Resident 7 had no cognitive impairment and required partial to moderate assistance from staff with ADLs. On 08/25/2026 at 5:00 pm, Resident 7 said it takes a long time to have staff answer call lights. Resident 7 said the NAs have a split assignment on the 100 wing and the 400 wing. Resident 7 said staff could not see the call lights when they were down the 100 wing. Resident 7 said all the shifts were bad but they dreaded the nights. Resident 7 said they are losing good staff because they are frustrated about the scheduling. Resident 7 said they had been incontinent due to the delay in care. Resident 7 felt the staff just did not take the time and care anymore. The resident said a few months ago they were getting showers, hair washed, and nails done but none of that happens anymore.On 08/19/2026 at 4:02 pm, Staff U, NA, and Staff V, NA, said they did not know where the NA was who was covering Resident 1, Resident 7, and Resident 4's room was. They said they had not seen them all shift and were looking for them.At 5:53 pm, Staff W, NA and Staff V said Resident 1's NA was scheduled to care for residents around the corner, down the 100 hall, so it would be difficult to monitor the resident, who was on every 15-minute checks. Staff W and Staff V said it is very hard to cover the hall that is split between the 100 wing and the 400 wing.On 08/20/2026 at 3:52 pm, Staff J, said Resident 1 was on 15-minute checks because they cut off their wander guard. Staff J said it was hard for the NA's to do 15-minute checks because they were split between the 100 wing and 400 wing.At 3:57 pm, Staff X, NA, said the staffing assignments schedule had some residents down the 100 wing and some down the 400 wing making it difficult to see call lights and do 15-minute checks. Staff X said that she was responsible for Resident 4, who also took a minimum of 20 minutes of care so she would not be able to do 15-minute checks on Resident 1 while in this resident's room. Staff X could not t see down the 400 wing while in the 100 wing.On 08/27/206 at 1:13 pm, Staff N, LPN, said they have a good set of NAs but an NA called out sick this day so they were short staffed.At 3:06 pm, Staff S, NA, said it was hard to complete her tasks when they split the wing between the 100 wing and the 400 wing. Staff S said they had five residents to assist with eating and it could be busy. Staff S was responsible for nine residents in total.At 3:45 pm, Staff S, said Resident 4 takes a long time to assist Resident 4 with each call light. Staff S estimated it took a minimum of 20 minutes to assist them when answering a call light and at least an hour when assisting with eating. Resident 4, who was present during the interview, agreed with this estimation. Staff S agreed Resident 4 had unique needs compared to the other residents and it just takes much longer to assist them. Staff S said they were assigned five residents who require assistance with her assignments. With Resident 4 taking an hour to assist, there was no way they could assist all of these resident's timely and without their food getting cold. Staff S said this was not fair to the resident's waiting to get assistance. Staff S agreed with Resident 4's concerns about long call lights and disruption by the nurses. Staff S said she had witnessed this and it had happened to her while she had been working. On 08/31/2026 at 1:25 pm Staff BB, NA, said they had to pick up Resident 1, Resident 4, and Resident 7 mid-way through the shift because someone had not shown up for work. Staff BB said that no one had cleaned Resident 4 all day. Staff BB said it was really busy down the hall and it took a long time with Resident 4 due to their complex needs. Staff BB said that if the hallway was split with the 100 wing and the 400 wing it was crazy. Staff BB said she had voiced her concerns about staffing.At 1:40 pm Staff O, LPN, said that staffing could be really difficult down this wing. Staff P said that an NA did not show up this day, so they just had to improvise. Staff O said that Resident 4 takes up a lot of time for the NA taking much longer than any other residents. Staff O said Resident 4 even requires more of her time because the resident has to swallow one pill at a time. Staff O said Resident 4 needs a lot of time and extra attention.Review of Staffing schedules, undated, showed staff were split between the 100 wing and the 400 wing on 08/08/2026, 08/09/2026, 08/11/2026, 08/12/2026, 08/20/2026, 08/21/2026, 08/22/2026, and 08/23/2026. No float staff were noted on 08/09/2026 - 08/11/2026, 08/12/2026 -08/14/2026 on the evening shift, 08/15/2026, 08/16/2026 on the am shift, 08/20/2026 - 08/21/2026, 08/22/2026 on the am shift, and 08/23/2026.On 08/31/2026 at 4:02 pm, Staff B, Registered Nurse (RN) and Director of Nursing, said Resident 4 takes a long time to help. Staff B said staff were quitting because the resident takes so long and so much is being expected of them. Staff B said that it takes up to an hour to provide assistance with eating and personal care. Staff B said that staff have five residents to feed on the same assignment as Resident 4. Staff B said there were no acuity concerns as part of their staffing assignments. Staff B said they try and have a float assist with Resident 4 as much as possible. Staff B said they try and fill in with agency but agency is unreliable.7:34 pm, Staff A, Administrator, said they look at acuity as part of their staffing. Staff A acknowledged Resident 4 takes a lot of NAs time to met their care needs. Staff A said they try and use a float and restorative nursing to help with feeding Resident 4.Reference: (WAC) 388-97-1080 (1)

Based on observation, interview and record review, the facility failed to ensure medically related social services to attain and/or maintain the highest practicable physical, mental, and psychosocial well-being of residents was provided for 2 of 9 sampled residents (1 & 2) reviewed for behavioral health services and discharge planning. This failure placed residents at risk of having unmet social service needs, delay discharge, and a diminished quality of life.Findings included.Resident 1Resident 1 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS), dated [DATE], documented Resident 1 had no cognitive impairment and was independent with most activities of daily living (ADLs). The MDS documented Resident 1 had moderately severe depression. The quarterly Minimum Data Set (MDS), dated [DATE], documented Resident 1 had moderate cognitive impairment and was independent with most activities of daily living (ADLs). The MDS documented Resident 1 had moderately severe depression. Review of the care plan, dated 04/20/2026, documented Resident 1 was expected to have a long-term short stay until housing situation is resolved. Resident 1 said staff would refer to community resources and review and update discharge plans with the resident as needed. The care plan, dated 06/25/2026, documented Resident 1 had indicators of depression, scoring 15/27 on the PHQ-9 (a 9-question tool used to screen for the severity of depression). The care plan showed staff would attempt to involve the resident in activities, respecting their choices and preferences. The care plan, dated 07/27/26, documented Resident 1 was at risk for psychosocial well-being due to suicidal ideation. The care plan showed staff would allow the resident to discuss positive and negative feelings towards placement at the facility, provide supportive mental health services and monitor the resident every 15 minutes. The care plan documented Resident 1 was their own decision maker. On 08/19/2026 at 4:35 pm, Resident 1 was observed sitting in their bed in their room. Resident 1 was alert and oriented to person, place, time, and situation. The resident discussed an episode when they left the facility in June. Resident 1 said they never intended on eloping from the facility but fell and could not get back up. Staff found the resident after their fall and they were hospitalized . Since this event, the resident has had to wear a bracelet that alarms (a wander guard) when they are near the exit doors. This bracelet makes the resident feel like a prisoner and like they are an illegal. The resident was weeping and distressed when discussing the wander guard. Resident 1 said they learned their lesson and have no intention of leaving the facility independently. Resident 1 said they do want to be able to go to church, which is a few blocks away. They want the freedom to walk around the facility without the doors alarming. Resident 1 said it is their wish to return home but the home needs to be cleaned up before they can leave. Resident 1 said family member (FM) 1 said they would try and have someone help clean up the home. The resident is unsure if they will able to accomplish this. Resident 1 explains they understand why they cannot return home at this time but feels like they are being held like a prisoner at the facility. Resident 1 was clear they do not want to stay at the facility permanently because they feel like they can manage at home with appropriate services.On 08/20/2026 at 4:59 pm, Staff B said they are going to bring Resident 1 to their home next week to check the status of the home. Staff B said they are really advocating for Resident 1.On 08/25/2026 at 4:39 pm, Resident 1 said they went to their home with facility staff today and it was a mess, worse than it had been before they were admitted to the facility. Resident 1 was upset and weeping when discussing the state of their home. Resident 1 verbalized how much they wanted to go home and stated they feel like a prisoner in the facility due to the wander guard. Resident 1 said that FM1 had said he would clean up the home but he does not have the time do this. The resident appeared distressed when speaking about their home and the wander guard. Resident 1 said the staff does not do anything for them anyways. They make their own bed and lay the linens to be picked up on the floor, and the linens sit there all day. The resident said they are independent with the use of a walker and brings themself to the bathroom.On 08/27/2026 at 4:30 pm, Resident 1 asked if the State Agency could help clean up their house. Resident 1 said they need some help getting their house cleaned up so they can return home. When asked if they knew Collateral Contact B, social services specialist, who would be their case manager, Resident 1 said they were not familiar with him. Resident 1 said they felt they had no help getting back into their home and would like Collateral Contact B to be contacted to see if he could help.On 08/28/2026 at 11:59 am, Collateral Contact B said they did not have an open case with Resident 1. Collateral Contact B said FM 1 was difficult to contact. Collateral Contact B said that the facility was petitioning for guardianship which complicated matters.At 1:42 pm, Collateral Contact B said the facility was not recommending the resident return home because the home is unsafe, there are concerns about their cognition, and the resident requires 24-hour supervision.On 08/31/2026 at 6:30 pm, Resident 1 said they feel like a prisoner and illegal in the facility. The resident said they want to go home. Resident 1 said what are they [the facility] helping me with? The resident accurately listed some of their medications saying this was all they helped them with but felt like their medications could be handled at home.Social Service Quarterly Note, dated 06/02/2026, documented a change in Resident 1's cognitive status from no cognitive impairment to moderate cognitive impairment. Resident 1's SLUMS (a screening tool used to check for early signs of mild cognitive impairment) score is noted to have signs of dementia. Advanced Directives section documented facility applied for guardianship. Resident 1's PHQ-9 score fluctuates. Level II PASRR (a screening tool used to identify behavioral healthcare needs) was in progress. The facility was purchasing glasses for the resident. The resident had consented to behavioral health services. While the note was dated 06/02/2026, the SLUMS and change in cognitive impairment assessment occurred after this date. emergency room Notes, dated 06/15/2026, documented Resident 1 was found outside after leaving the facility without properly signing out. The resident had fallen down a hill and needed to be evaluated by the hospital.Progress notes, dated 06/17/2026, documented a care conference was conducted with FM 2 and FM 3. Resident 1 was not present. FM 2 and FM 3 expressed concerns with how FM 1 treats Resident 1. Adult Protective Services (APS) was involved. FM 2 and FM 3 stated they wanted to be Resident 1's Power of Attorney (POA).Progress notes, dated 06/19/2026, documented Resident 1 returned from the hospital. Resident 1 was found to have sepsis from a urinary tract infection. A wander guard was placed on their right wrist.Progress notes, dated 06/19/2026, documented Resident 1 scoring on a memory test showed severe memory impairment and fell within the dementia category. The resident will need assistance with outdoor activities and supervision when walking on uneven surfaces.Progress notes, dated 06/20/2026, documented Resident 1 said they were going to go to church with FM 1. Resident 1 educated on the pros and cons of leaving the building. The resident was told if they left it would be considered leaving against medical advice (AMA). FM 1 was contacted and told Resident 1 leaving would be an AMA. FM 1 decided not to bring Resident 1 to church.Activities - Resident Preferences Evaluation, dated 06/23/2026, documented it was very important for the resident to go outside and get fresh air and to participate in religious services.PHQ-9, dated 06/25/2026, documented Resident 1 experienced the following symptoms over the previous 2 weeks, scoring moderately severe depression:- Little interest or please in doing things never or 1 day.- Was feeling down, depressed, or hopeless 7-11 days (half or more of the days).- Had trouble falling or staying asleep or sleeping to much 12-14 days (nearly every day).- Felt tired or had little energy 12-14 days.- Had a poor appetite or overeating 7-11 days.- Felt bad about themselves 2-6 days (several days).- Trouble concentrating on things 2-6 days.- Moving or speaking slowing so that other people noticed or the opposite - being so fidgety or restless that they moved around a lot more than usual 12-14 days.-Thoughts they would be better off dead never or 1 day.History and Physical, dated 06/27/2026, did not address Resident 1's PHQ- 9.Progress notes, dated 06/27/2026, documented Resident 1 had stated they were going out to church this evening. Resident 1 had slid the wander guard off of their wrist. Resident 1 was placed on a one to one observation.Progress notes, dated 07/04/2026, documented FM 1 was educated, due to Resident 1's cognitive impairments it was not advisable for the resident to leave the facility. FM 1 continued to sign out the resident. The resident was noted to have significant cognitive impairment, wander precautions in place and a history of eloping. The facility did not believe leaving with FM 1 was in the resident's best interests based on current cognitive status and safety risk factors. The facility spoke with FM 3 regarding Resident 1 leaving with FM 1. They agreed Resident 1 could leave if FM 1 followed the facility rules of signing out the resident when the leave and return. FM 3 was informed the facility did not recommend leaving the facility, but the family allowed the outing. FM 1 agreed with the plan.Progress notes, dated 07/23/2026, documented FM 1 met with staff and brought their lawyer. FM 1 said they should be making Resident 1's decisions but admitted they had no paperwork to prove this. Staff educated FM 1 on the facility rules about signing the resident in and out if they leave the facility. FM 1 would have to come to the resident's unit to sign the resident out. FM 1 was agitated but the conversation ended on a good note. FM 1 explained he did not have time to clean Resident 1's house.Progress notes, dated 07/24/2026, documented adult protective services (APS) told the facility Resident 1's home was uninhabitable.Progress notes, dated 07/27/2026, documented Resident 1 said they would kill themselves in front of the ombuds because they could not attend church. Resident 1 was placed on suicidal ideation alert and placed on 15-minute checks.Progress notes, dated 07/27/2026, Resident 1 said they had no intention of hurting themselves and was just sad and frustrated about not being able to attend church with FM 1 on that Saturday. Resident 1 on alert for suicidal ideation and on 15-minute checks.PHQ- 9, dated 07/27/2026, documented Resident 1 experienced the following symptoms over the past 2 weeks, scoring minimal depression. The PHQ-9 only included 2 of the 9 questions:- Little interest or please in doing things never or 1 day.- Was feeling down, depressed, or hopeless 2-6 days.There was no follow up on Resident 1's suicidal ideation until 08/11/2026. Progress notes, dated 08/11/2026, from behavioral health provider diagnosed Resident 1 with depression and anxiety disorder. The notes documented recent suicidal ideation with threats to kill [themself] in front of the ombudsman if not allowed to go to church. The resident stated, I want to kill myself and I want to die when feeling desperate about restrictions. The resident is oriented to person, place, time, and situation with intact memory recall. Resident 1 feels strong religious beliefs and had an active church membership for 13 years with supportive church community. Resident 1 described feeling like a criminal. The resident demonstrated awareness of facility routines and rules, navigates complex family and social dynamics, and engages coherent discission related to their living and financial situation. Resident 1 displays coherent speech and shows no psychomotor abnormalities. Resident 1 states I feel like I'm in prison when discussing their restrictions. The resident is calm and cooperative, maintains good eye contact, and has no unusual behaviors. Recommendation included starting Duloxetine 20 mg daily for depression and anxiety. Follow up with behavioral health in 2 weeks. Follow up on eyeglasses prescription. Continue suicide precautions daily. The behavioral health provider identified target behaviors as poor safety awareness, confusion and/or restless after family visits, isolation, boredom, verbal aggression, wandering or exit seeking and medication non-compliance.Progress notes, dated 08/14/2026, documented Resident 1 was on 15-minute checks due to a high risk of elopement as evidenced by cutting off their wander guard and expressing a plan to leave the facility.Progress notes, dated 08/19/2026, documented Resident 1 told the medical provider they had not been allowed to go to church, and misses it. Patient found a lot of comfort in [their] faith. Patient states feel like is a prisoner here. The provider noted Resident 1 was very tearful, reporting low mood. Is no longer able to see/visit with FM 1 causing Resident 1 to be very sad. Declines medication at this time.On 08/19/2026 3:53 pm, Staff I, licensed practical nurse (LPN), said he did not know anything about Resident 1 having a history of suicidal ideation.At 4:02 pm, Staff U, NA, and Staff V, NA, said they did not know about Resident 1 having a history of suicidal ideation.On 08/20/2026 at 3:52 pm, Staff J, said she did not know about Resident 1 having a history of suicidal ideation.At 3:57 pm, Staff X, NA, said she did not know about Resident 1 having a history of suicidal ideation.At 4:15 pm, Staff K, LPN, said he did not know about Resident 1 having a history of suicidal ideation.On 08/31/2026 at 2:34 pm, Staff F, Social Services Director, Staff F said the resident was happy to stay at the facility. Staff F said Resident 1's house was not safe to discharge to. Staff F said that FM 1 had said he was going to clean it, but he had not. Staff F said they have not worked with Collateral Contact B to see if there were any resources to help the resident clean their house. Staff F was not aware Resident 1's case was closed. Staff F said they had care conferences without Resident 1 despite them being their own decision maker. Staff F said they had relied of FM 2 and 3 to make some decisions for Resident 1 despite being their own decision maker. Staff F said Resident 1 would like to go to church but needs a staff or a safe party to go with her. Staff F said FM 1 was not allowed to sign the resident out of the facility. No safe party had been accommodated for Resident 1 to go to church. Staff F was unfamiliar with Resident 1's feeling about the wander guard and had not asked the resident how the bracelet made the resident feel. Staff F said the facility filed for guardianship, but she could not say if Resident 1 agreed to this. Staff F said she was not aware of Resident 1's comments about feeling like a prisoner or distress about staying in the facility. Staff F acknowledged there was no follow-up to the behavioral health visit.At 4:02 pm, Staff B, registered nurse (RN) and Director of Nursing, Staff B said he was not aware of the resident's distress related to the wander guard. Staff B said it was too bad how Resident 1 felt related to the wander guard and would assess the resident immediately for continued use. Staff B said FM 1 had stated FM 1 was unreliable and had not followed through on promises made to the resident. Staff B acknowledged the facility had not attempted to utilize resources to attempt to honor Resident 1's wishes. Staff B said the facility filed for guardianship, but he could not say if Resident 1 agreed to this. Staff B acknowledged there was a lack of follow-up to the behavioral health visit recommendations.Resident 2Resident 2 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (COPD - a chronic lung disease which makes it difficult to breathe). The admission minimum data set (MDS), dated [DATE], documented Resident 2 had no cognitive impairment and required partial to moderate assistance with activities of daily living.Care plan, dated 08/14/2026, documented Resident 2 would return to the community after discharge. Staff will refer to community resources as indicated by the resident and resident representative. Staff will review and update discharge plans with the resident when needed.On 08/24/2026 at 11:51 am, Resident 2's power of attorney (POA), Collateral Contact 1, CC1 said Resident 2 required the use of a BiPAP (bilevel positive airway pressure - a non-invasive breathing device that delivers two distinct air pressure levels-higher when you inhale and lower when you exhale-to help people get air into and out of their lungs easily) during the night. CC 1 said that staff have communicated to her that they did not know how to use the machine. CC 1 said this had created stress and anxiety for Resident 2 and CC 1 during the resident's stay at the facility. Additionally, Resident 2 ended up with a pressure ulcer (PU) to the sacrum after admission which was upsetting to CC 1. CC 1 was very upset about all that was going on and felt Resident 2 was not safe to stay at the facility. CC 1 asked to speak to Staff B, registered nurse (RN) and Director of Nursing, but was told he was busy. CC 1 found out the facility had a care conference without inviting her to the meeting. CC 1 was at the facility often. CC 1 said they had a wrong number for her and corrected it in the record. CC 1 told social services they were worried because they did not know what the treatment plan was and what the plan for discharge was, which was scheduled for 09/02/2026. No new care conference was held. CC 1 felt like staff did not believe she was the POA and was told anyone can say they're the POA.At 1:51 pm, Resident 2 said they had concerns about their stay at the facility and did not feel completely safe to stay in the facility. Resident 2 said they had pain related to the PU they developed at the facility. Resident 2 could not remember the care conference that was held. The resident could not recall anyone discussing the plan of care with them.During concurrent interview and observation on 08/27/2026 at 2:00 pm, Resident 2 was observed in their room sitting in their wheelchair. Resident 2 was upset and said that because they had an episode, similar to the one they were hospitalized with, where their thinking was altered and it was scary for the resident. Resident 2 said that it had finally subsided after they were on their BiPAP for a while. Resident 2 said staff had not called CC 1 upon request and the resident felt alone. Resident 2 denied social services had visited with them and was concerned about their discharge.On 08/28/2026 at 1:16 pm, CC 1 said there continued to be concerns about use of the BiPAP. CC 1 said Resident 2 reported to her they did not feel safe in the facility. CC1 said the resident had an episode where their thinking was altered and they were scared. CC 1 said staff did not call the her upon Resident 2's request. CC 1 said they had a lot of concerns about Resident 2's discharge. CC 1 was told he would be discharging 09/02/2026. CC 1 said she could not take care of Resident 2 alone in the home anymore and needed care givers. CC 1 said no one had helped her with this process or talked to her about Resident 2's pending discharge. CC 1 expressed being very upset and anxious about the lack of communication. CC 1 said Resident 2 went to social services around 08/24/2026 and asked for a meeting with social services. CC 1 said the staff present said they would have to schedule a meeting but there were no times available to schedule a meeting. CC 1 said no one had gotten back to her request for a meeting.Hospital History and Physical, dated 08/06/2026, documented Resident 2 had an episode of confusion, fearfulness, paranoia, and felt like people were trying to harm them when they had removed their BiPAP device at night. CC 1 was identified as a part of the resident's care. Resident 2 was diagnosed with a catheter associated urinary tract infection.Hospital demographics, identified and listed Resident 2's POA/CC 1 and correct phone number.Progress notes, dated 08/10/2026, documented Resident 2 was alert and oriented but had some confusion. admission consents were signed by the CC 1Progress notes, dated 08/11/2026, documented CC 1 gave consent for a room change.Progress notes, dated 08/11/2026, documented an interdisciplinary team met to discuss discharge plans. The note documented Resident 2 lived with the CC 1. The note documented education on caregiver training, stair training, and care transfer training was required with an expected discharge date of 09/02/2026.Progress notes, dated 08/17/2026, documented social services spoke with CC 1 about concerns with the resident's care. The note showed CC 1's phone number was updated in the medical record.Progress notes, dated 08/18/2026, documented an interdisciplinary team meeting to discuss discharge plans. The note showed CC 1 wanted the resident to return home with care givers with an expected discharge date of 09/02/2026.Progress notes, dated 08/25/2026, documented an interdisciplinary team meeting to discuss discharge plans. The note showed CC 1 wanted the resident to return home with care givers. The note showed a Medicaid application was needed with expected discharge date of 09/01/2026.On 08/31/2026 at 2:34 pm, Staff F, Social Service Director, said there was a care conferences held for Resident 2. Staff F said Resident 2's supposed POA was not present because they could not get a hold of her. Staff F said they were not given a correct phone number for her. Staff F said they eventually got the correct number. Staff F said that CC 1 told her they would need care givers in the home. Staff F said there had been no new care conference with CC 1. Staff F said CC 1 had been very upset about Resident 2's care and they have tried to defuse the situation. Staff F did not detail efforts to defuse the situation and could not show documentation that concerns were addressed. Staff F said the resident needed to complete a Medicaid application, and she had just spoken with the business office about it. Staff F said Resident 2 would remain on skilled services and have 79 days left of potential skilled service. Staff F said they had not communicated this, or the potential discharge date with CC 1.At 5:02 pm, Staff B, registered nurse (RN) and Director of Nursing agreed Resident 2 and CC 1 have had many concerns and felt they had been addressed. Staff B agreed that not all staff had been educated on the use of the BiPAP and the staff caring for the PU had knowledge deficits.Reference: (WAC) 388-97-0960 (1)

Based on observation, interview and record review, the facility failed to follow the accident protocols for 1 of 3 residents (Resident 1), reviewed for elopement and suicidal ideation risk. This failure placed residents at risk for additional elopements, injury, and diminished quality of life.Findings included.Resident 1 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS), dated [DATE], documented Resident 1 had moderate cognitive impairment and was independent with most activities of daily living (ADLs). The MDS mood score showed the resident had moderately severe depression. The MDS showed Resident 1 said they always felt lonely or isolated from those around them.Review of care plan, dated 06/22/2026, documented Resident 1 was at risk for elopement due to confusion, impaired judgement, and poor safety awareness. A bracelet that alarms (a wander guard) when a resident is near the exit doors wander guard is placed on the resident. The resident will frequently remove the wander guard. Review of care plan, dated 07/27/2026, documented Resident 1 was at risk for psychosocial well-being due to suicidal ideation. Staff will allow the resident to discuss positive and negative feelings towards placement at the facility, provide supportive mental health services and monitor the resident every 15 minutes.During interview and concurrent observation on 08/19/2026 at 4:35 pm, Resident 1 was observed sitting in their bed in their room. Resident 1 was pleasant and open to talking. The resident was alert and oriented to person, place, time, and situation. Resident 1 said they had had to wear a wander guard since an incident when they left the building in June. Resident 1 said that the bracelet made the resident feel like a prisoner and like they were an illegal. Resident 1 said that the situation made them want to die but they would keep living for their family.During interview and concurrent observation on 08/25/2026 at 4:39 pm, Resident 1 verbalized how much they wanted to go home and stated that they felt like a prisoner in the facility due to the wander guard. Resident 1 said they did not consent before the wander guard was placed on them. Resident 1 said that they felt like an illegal wearing the wander guard and did not want to wear it. Resident 1 appeared distressed when speaking about their home and the wander guard.Review of emergency room Notes, dated 06/15/2026, documented Resident 1 was found outside after leaving the facility without properly signing out. The showed that the resident had fallen down a hill and needed to be evaluated by the hospital.Review of an Elopement Risk Evaluation, dated 06/19/2026, documented Resident 1 was alert with cognitive impairment, was mobile with device, had verbal expressions to leave facility, a history of elopement and wandering attempts, and family voiced resident may leave the facility. The evaluation determined Resident 1 was at risk for elopement and wander bracelet in place on right wrist.Review of Resident 1's Treatment Administration Record, dated August 2026, documented staff would check and document placement of the wander guard every shift. Placement of the wander guard was documented 47 out of 55 opportunities as NA. Review of Progress notes, dated 07/27/2026, documented Resident 1 said they would kill themselves in front of the ombuds (resident advocate) because they could not attend church. Resident 1 was placed on suicidal ideation alert and placed on 15-minute checks.Review of Progress notes, dated 07/27/2026, Resident 1 said they had no intention of hurting themselves and was just sad and frustrated about not being able to attend church with their family member that Saturday. Resident 1 on alert for suicidal ideation and on 15-minute checks.15 Minute Safety Check, dated 07/27/2026, was blank from 12:00 pm to 5:00 pm.15 Minute Safety Check, dated 07/28/2026, was missing from 12:00 am to 6:00 am.15 Minute Safety Check, dated 07/29/2026, was missing from 12:00 am to 6:00 am.15 Minute Safety Check, dated 07/27/2026, was missing from 6:00 pm to 12:00 am.Review of Progress notes, dated 08/11/2026, from behavioral health provider, diagnosed Resident 1 with depression and anxiety disorder. The notes documented recent suicidal ideation with threats to kill [themself] in front of the ombudsman if not allowed to go to church. The resident stated, I want to kill myself and I want to die when feeling desperate about restrictions. Resident 1 described feeling like a criminal. Resident 1 states I feel like I'm in prison when discussing their restrictions.15 Minute Safety Checks, dated 08/11/2026, were blank from 6:00 am to 6:45 pm.15 Minute Safety Checks, dated 08/15/2026, were blank from 7:00 am to 2:30 pm and missing from 6:00 pm to 12:00 am.Review of Progress notes, dated 08/14/2026, documented Resident 1 was on 15-minute checks due to a high risk of elopement as evidenced by cutting off their wander guard and expressing a plan to leave the facility.Review of Progress notes, dated 08/19/2026, documented Resident 1 stated they feel like is a prisoner here. Resident 1 was very tearful, reporting low mood.On 08/19/2026 at 12:04 pm, Staff DD, anonymous staff, said Resident 1 was cutting off their wander guard and had a history of wandering. Staff DD said due to staffing, it was impossible to monitor the resident safely. On 08/19/2026 from 2:39 PM to 4:02 pm, Resident 1 was not in their room and not in a visible area in the unit.At 3:53 pm, Staff I, licensed practical nurse (LPN), said Resident 1 is on 15-minute checks due to them cutting off their wander guard. Staff I said they usually have a form to document the 15-minute checks, but they did not have one today. Staff I said he does not do the checks, the nursing assistants (NA) do the checks and reports to him. Staff I said he did not know anything about Resident 1 having a history of suicidal ideation. At 4:02 pm, Staff U, NA, and Staff V, NA, said they did not know Resident 1 was on 15-minute checks. Staff V said she had not seen Resident 1 in some time stating it was at least an hour since they had seen them. Staff U and Staff V did not know about Resident 1 having a history of suicidal ideation.At 4:25 pm, Staff V said she had found Resident 1 in the dining room which was quite a distance from the unit. At 5:53 pm, Staff W, NA, said they did not know Resident 1 was on 15-minute checks. Staff W and Staff V said Resident 1's NA was scheduled to care for residents around the corner, down the 100 hall, so it would be difficult to monitor the resident every 15 minutes. Staff V said they had been looking for Resident 1's NA for a long time and could not find them. Staff V had not seen the NA in their hall since the beginning of the shift. Staff V said you could not do 15-minute checks on Resident 1 while she was in the dinning room and care for your residents because of the distance between the two locations. On 08/20/2026 at 3:52 pm, Staff J, said Resident 1 is on 15-minute checks because they cut off their wander guard. There have been no incidents of the resident leaving the building. Staff J said it is hard for the NA to see Resident 1 when they assignments are split with the 100 hall. Staff J said she did not know about Resident 1 having a history of suicidal ideation.At 3:57 pm, Staff X, NA, said the staffing assignments schedule had some residents down the 100 hall and some down the 400 hall making it difficult to see call lights and do 15-minute checks. She was also responsible for a resident who also took a minimum of 20 minutes to care for so she would not be able to do 15-minute checks on Resident 1 while in this resident's room. At 4:15 pm, Staff K, LPN, said Resident 1 had not had any attempts to leave the facility since the June incident. Staff K did not know about Resident 1 having a history of suicidal ideation.On 08/24/2026 at 3:32 pm, Staff L, LPN, said the facility did not have any way staff were alerted to residents at risk for elopement, who live in a different hall. Staff L said they talked about residents at risk for elopement in the stand-up meeting but there was no posting or signs alerting staff to what the residents' look like or their names. Staff L said he knew there were residents at risk for elopement currently. He said there were a few, but he could not name or describe who the resident's were. On 08/31/2026 at 4:02 pm, Staff B, Registered Nurse (RN) and Director of Nursing, said 15-minute checks were discontinued but the care plan still reflected safety checks in place. Staff B acknowledged staff should clearly document and complete 15-minutes checks. Staff B said he was aware staff struggled to complete 15-minute checks due to staffing. Staff B acknowledged staff should be aware of who is an elopement and suicidal ideation risk. Reference: (WAC) 388-97-1060 (3)(g)

Based on observation, interview and record review, the facility failed to ensure identification and monitoring of pressure ulcers (PU) were in place to prevent worsening of the wound for 1 of 3 sampled residents (3) reviewed for PU. This failure placed residents at risk of developing avoidable pressure injuries and a diminished quality of lifeFindings included.Resident 2 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (COPD - a chronic lung disease which makes it difficult to breathe). The admission minimum data set (MDS), dated [DATE], documented Resident 2 had no cognitive impairment and required partial to moderate assistance with activities of daily living. The MDS documented Resident 2 did not have a PU.Care Plan, dated 08/13/2026, documented Resident 2 was at risk for PU due to impaired skin integrity, chronic health conditions, and incontinence. The resident had a pressure reducing mattress. The staff would assess the resident for skin breakdown and turn and reposition the resident often.On 08/24/2026 at 1:53 pm, Resident 2 said they had a PU to their coccyx (tailbone area). Resident 2 said they had pain in this area. Resident 2 was worried how the staff were caring for the wound and was concerned it would get infected. Resident 2's power of attorney (POA)/Collateral Contact 1 (CC 1), said the staff told her around 08/20/2026 that Resident 2 had a PU to the coccyx. CC 1 was concerned the staff were not taking care of the wound properly. Progress notes, dated 08/20/2026, documented Resident 2 was noted to have a PU. Excoriation to the coccyx.Progress notes, dated 08/21/2026, documented Resident 2 was noted to have a PU. Excoriation to the coccyx.Physician Orders, dated 08/22/2026, documented cleanse coccyx with normal saline, pat dry, and apply a bordered dressing. Change the dressing daily. Progress notes, dated 08/22/2026, documented Resident 2 was noted to have a PU. Excoriation to the coccyx.Progress notes, dated 08/23/2026, documented Resident 2 was noted to have a PU. Excoriation to the coccyx.Skin Observation Weekly, dated 08/14/2026, documented Resident 2's skin was warm with normal turgor (elasticity) and had a reddened area to the groin. On 08/27/2026 at 2:15 pm, Resident 2 was observed sitting in their wheelchair. Staff P, licensed practical nurse (LPN), assisted the resident in position to observe the PU. Staff P observed the wound to Resident 2's coccyx and identified the wound as a PU. Staff P said the wound was a Stage 2 (a partial-thickness skin loss that exposes the middle layer of the skin) PU. The PU was clean, dry, and intact without redness. The resident reported pain to the PU while sitting. Resident 2's wheelchair was observed to have a pressure relieving cushion in place. At 2:30 pm, Staff K, LPN, said he was Resident 2's nurse and had been the one to initially discover the wound. Staff K could not describe the characteristic of the wound, explain if the wound was a PU or describe the staging of the wound. Staff K said the documentation about the wound was in the clinical record. On 08/31/2026 at 4:02 pm, Staff B, Registered Nurse (RN) and Director of Nursing, said there was no proper documentation related to the identification and characteristics of the wound in the clinical record. Staff B said he felt there were some knowledge deficits with Staff K and pressure ulcers. Staff B said they would update the clinical record and educate Staff K.Reference WAC 399-97-1060(3)(b)

Based on observation, interview, and record review the facility failed to ensure residents received proper assistive devices to maintain vision for 1 of 3 residents (1) reviewed for vision services. This failure placed residents at risk of continued impaired vision and potentially limit activities or safely navigating their environment. Findings included. Resident 1 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS), dated [DATE], documented Resident 1 had moderate cognitive impairment and was independent with most activities of daily living (ADLs).Care plan, dated 01/16/2026, documented Resident 1 had vision impairment related to diabetic retinopathy. Staff would ensure glasses were clean and worn as resident tolerated.On 08/25/2026 at 4:39 pm, Resident 1 said they had an eye appointment in July to replace their lost glasses. They were told it would take two weeks to get the new glasses. Resident 1 said it had been seven weeks since they had heard anything about the glasses. Resident 1 said without their glasses, it effected their ability to read. No glasses were observed in the resident's room.Progress notes, dated 06/11/2026, documented Resident 1 filed a grievance about missing glasses. Resident 1 said they used their glasses for everything. Staff A, Administrator, was notified and the facility would potentially reimburse [them] for new glasses.Optometrist Progress Notes, dated 07/6/2026, documented Resident 1 complained of blurry vision. A new prescription for glasses was provided.Behavioral Health notes, dated 08/11/2026, documented Resident 1 has visual impairment due to missing prescription glasses contributing to functional limitations and frustration. Resident 1 enjoys bible study participation and religious reading which is a coping strategy for their mental health.On 08/27/26 at 1:30 pm, Staff CC, Activities Director, said the Activities Department had glasses for resident to try and help with reading. They had tried to offer Resident 1 reading glasses but none of them had met their needs. On 08/31/2026 at 3:36 pm, Staff F, Social Service Director, said Resident 1's glasses went missing. Staff F said Resident 1 had an eye appointment, and she submitted the request for the facility to pay for the glasses. Staff F said nothing happened so she recently requested this again. At 4:02 pm, Staff B, Registered Nurse (RN) and Director of Nursing, said he was aware Resident 1 did not have glasses and they had not been replaced for some time.7:34 pm, Staff A, Administrator, said the glasses should have been replaced and would ensure Resident 1 it would happen.Reference WAC 388-97-1060(3)(a)

Based on interview and record review the facility failed to ensure Pre-admission Screening and Resident Reviews (PASRR, a screening tool used to identify behavioral healthcare needs) were completed for 3 of 4 residents (1, 10, & 11) reviewed for PASRR. This failure placed residents at risk for inappropriate placement, unmet behavioral healthcare needs and diminished quality of life.Findings included. Resident 1 Resident 1 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS), dated [DATE], documented Resident 1 had moderate cognitive impairment and was independent with most activities of daily living (ADLs). Level 1 PASRR Review, dated 07/06/2026, documented Resident 1 had a mood disorder and exhibited functional limitations related to a behavioral health disorder. This required a Level 2 PASRR referral to determine whether specialized services are required. No Level 2 PASRR was included in Resident 1's medical record. On 08/31/2026 at 3:36 pm, Staff F, Social Service Director, said Resident 1 should have a PASRR Level 2 assessment. Staff F said there was no documentation showing they have attempted to obtain a PASRR Level 2 for the resident. Resident 10 Resident 10 was admitted to the facility on [DATE] with diagnoses including dementia and anxiety. The quarterly MDS, dated [DATE], documented Resident 10 had no cognitive impairment and was dependent on staff with most ADLs. Level 1 PASRR Review, dated 04/01/2025, documented Resident 10 had an anxiety disorder and exhibited functional limitations related to a behavioral health disorder. This required a Level 2 PASRR referral to determine whether specialized services are required. No Level 2 PASRR was including Resident 10's medical record. At 3:36 pm, Staff F, said Resident 10 should have a PASRR Level 2 assessment. Staff F said there is no documentation showing they had attempted to obtain a PASRR Level 2 for the resident. Resident 11 Resident 11 was admitted to the facility on [DATE] with diagnoses including dementia and depression. The significant change MDS, dated [DATE], documented Resident 11 was dependent on staff for ADLs. Level 1 PASRR Review, dated 06/12/2026, documented Resident 11 had a mood disorder and exhibited functional limitations related to a behavioral health disorder. This required a Level 2 PASRR referral to determine whether specialized services were required. No Level 2 PASRR was included in Resident 11's medical record. On 08/31/2026 at 3:36 pm, Staff F, said Resident 1 should have a PASRR Level 2 assessment. Staff F said there was no documentation showing they had attempted to obtain a PASRR Level 2 for the resident. Reference: (WAC) 388-97-1975(6)

Based on interview and record review, the facility failed to ensure resident assessments accurately reflected their health status and/or care needs for 1 of 18 sampled residents (1) whose Minimum Data Sets (MDS, an assessment tool) were reviewed. The failure placed residents at risk for diminished quality of life and unidentified and/or unmet care needs.Findings included.Resident 1 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (body can't control amount of sugar in blood properly) and a fracture to the lumbar spine. The quarterly MDS, dated [DATE], documented Resident 1 had moderate cognitive impairment and was independent with most activities of daily living (ADLs). The MDS indicated Resident 1 had no episodes of wandering.Progress notes, dated 06/15/2026, documented Resident 1 was missing from the facility and had not signed out. The resident was later found outside after a fall and transported to the hospital.On 08/27/2026 at 1:00 pm, Staff H, Licensed Practical Nurse and MDS nurse, stated that Resident 1's MDS should have reflected the episode of wandering. Staff H said they considered this an episode of elopement. Staff H said the MDS was coded in error. At 4:02 pm, Staff B, registered nurse (RN) and Director of Nursing, said Resident 1 did have an episode of wandering and eloping. Staff B acknowledged the MDS should reflect the resident's status.Reference (WAC) 388-97-1000(b)(d)

Based on observation, interview and record review, the facility failed to initiate, thoroughly investigate, and resolve a grievance for 1 of 4 sampled residents (Resident 2) reviewed for grievances. This failure placed the residents at risk for emotional distress, a denial of personal rights, and a diminished quality of life. Findings included.Resident 2 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (COPD - a chronic lung disease which makes it difficult to breathe). The admission minimum data set (MDS), dated [DATE], documented Resident 2 had no cognitive impairment and required partial to moderate assistance with activities of daily living.On 08/24/2026 at 11:51 am, Resident 2's power of attorney (POA), Collateral Contact 1 (CC 1) said Resident 2 required the use of a BiPAP (bilevel positive airway pressure - a non-invasive breathing device that delivers two distinct air pressure levels-higher when you inhale and lower when you exhale-to help people get air into and out of their lungs easily) during the night. CC 1 brought the BiPAP into the facility on [DATE]. CC 1 stated that the facility staff took apart the BiPAP without knowing how to properly put it back together then claimed there was a missing piece. CC 1 state that the BiPAP was functioning appropriately and clean prior to bringing the device. CC1 stated that this caused a delay in using the machine because the respiratory therapy (RT) company who managed the device could not come to the facility until 08/20/2026. CC 1 stated that on 08/20/2026, after the machine was put back together, she waited well past midnight before anyone came to start the machine. CC 1 said staff only came in after she finally asked for help. CC 1 said staff communicated to her that they did not know how to use the machine. Additionally, Resident 2 ended up with a pressure ulcer (PU) to the sacrum after admission. CC 1 was very upset about all that was going on and felt Resident 2 was not safe to stay at the facility. CC 1 said they asked to speak to Staff B, Registered Nurse (RN) and Director of Nursing, but was told he was busy. During observation and interview at 1:51 pm, CC 1 stated when they did meet with Staff B, he was aggressive and arrogant towards them. CC 1 said Staff B stated they were unaware of the issues with the BiPAP and PU. CC 1 said Staff B stated that they would address the issues. CC 1 stated that she continued to have concerns about the staff's ability to use the BiPAP as staff continue to state they did not know how to use the device after she met with Staff B. CC 1 wanted to ensure Resident 2 was getting benefit from the machine. CC 1 showed a log on the BIPAP machine. The log showed when the machine beeps. This occurred when there was an adjustment needed with the face mask and the machine is not delivering properly. CC 1 showed an example of how the machine beeped on 08/23/2026 from 1:15 am to 1:56 am. CC 1 stated that her concerns had not been resolved. Resident 2 stated that he had the same concerns and did not feel completely safe to stay in the facility.A review of the grievance log showed no grievance was filed for CC 1's concerns.On 08/31/2026 at 4:02 pm, Staff B, said he felt he immediately addressed the concerns related to Resident 2's care. Staff B acknowledged all staff were not training in caring for the BiPAP machine. Staff B said there was a knowledge gap in identifying PUs and the documentation was not in place to clearly identify the PU. Staff B said these concerns should have been addressed through the grievance process.At 7:19 pm, Staff A, Administrator, said they had identified they were not completing grievances as they should. Staff A said they were going to start a performance improvement process on the grievance process.Refer to WAC 388-97-0460(2)

Based on interview and record review, the facility failed to ensure the facility assessment (document describing resident population and needs to determine staff and other resources necessary to competently care for residents) was updated to accurately determine and identify the resources needed to care for residents with amyotrophic lateral sclerosis (ALS - a neurological disease which kills the cells of the brain and spinal cord that control voluntary muscle movement). This failure placed the residents at risk for unmet care needs and a diminished quality of life.Findings included.Resident 4 was admitted to the facility on [DATE] with diagnoses of amyotrophic lateral sclerosis (ALS - a neurological disease which kills the cells of the brain and spinal cord that control voluntary muscle movement). The quarterly minimum data set (MDS), dated [DATE], documented Resident 4 had no cognitive impairment and was dependent on staff with activities of daily living (ADLs).08/27/2026 at 3:00 pm, Resident 4 was observed sitting in their bed. Resident 4 arms and legs were immobile aside from their right hand, which was used to control a mouse on a computer used to communicate. Resident 4 spoke by inputting words into the computer. The computer screen showed the words and phrases the resident was wanting to express. Resident 4 appeared solely dependent on staff for mobility. Resident 4's communication showed they were cognitively intact. Resident 4 said expressed frustration that staff do not seem familiar with their care needs when the staff is new. This included how to move the resident and how to feed the resident. Resident 4 said staff are untrained in how to care for the resident and their condition, ALS. At 3:45 pm, Staff S, NA, said it takes a minimum of 20 minutes to assist them when answering a call light and at least an hour when assisting with feeding and personal cares due to Resident 4's complex needs and method of communication. Staff S said thank goodness I knew something about ALS before she started at the facility because she got no training related to the disease and how to care for Resident 4. Staff S agreed Resident 4 has unique needs compared to the other residents and staff are not given direction on how to care for the resident.On 08/31/2026 at 5:02 pm, Staff B, registered nurse and Director of Nursing, said Resident 4 requires a lot of time from the NAs and was particularly difficult for the new staff. Staff B said staff get very frustrated caring for the resident, due to their high level of care. Staff B said they had not considered training staff specifically in caring for a resident with ALS.At 7:34 pm, Staff A, Administrator, said that they did not include ALS as part of the facility assessment. Staff A said that this was something they should look at due to Resident 4's complex needs.No associated WAC reference

Based on observation, interview and record review, the facility failed to ensure medical records were complete and accurate for 2 of 7 residents (1 & 2) reviewed for suicidal ideation, elopement and respiratory care. This failure placed residents at risk for incomplete and inaccurate medical records and unmet care needs.Findings included.Resident 1Resident 1 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus and a fracture to the lumbar vertebra. The quarterly Minimum Data Set (MDS), dated [DATE], documented Resident 1 had moderate cognitive impairment and was independent with most activities of daily living (ADLs).Review of a care plan, dated 07/27/2026, documented Resident 1 was at risk for psychosocial well-being due to suicidal ideation. The care plan showed staff would allow the resident to discuss positive and negative feelings towards placement at the facility, provide supportive mental health services and monitor the resident every 15 minutes.Progress notes, dated 07/27/2026, showed Resident 1 said they had no intention of hurting themselves and were just sad and frustrated about not being able to attend church with Family Member 1 on that Saturday. The note showed Resident 1 was on alert for suicidal ideation and on 15-minute checks.Progress notes, dated 08/14/2026, documented Resident 1 was on 15-minute checks due to a high risk of elopement as evidenced by cutting off their wander guard and expressing a plan to leave the facility.No 15-minute checks were documented in the clinical record.On 08/31/2026 at 6:13 pm, Staff B, registered nurse (RN) and Director of Nursing, confirmed Resident 1 was on 15-minute checks on 2 separate occasions. Staff B said Resident 1's 15-minute checks were not documented in the clinical record.Resident 2Resident 2 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (COPD - a chronic lung disease which makes it difficult to breathe). The admission minimum data set (MDS), dated [DATE], documented Resident 2 had no cognitive impairment and required partial to moderate assistance with activities of daily living.On 08/24/2026 at 1:51 am, Resident 2's power of attorney (POA), Collateral Contact 1 (CC 1) said Resident 2 was put on 15-minute checks due to the concerns voiced about their care.No 15-minute checks were included in Resident 2's record.At 6:13 pm, Staff B, confirmed Resident 2 was on 15-minute checks. Staff B said Resident 2's 15-minutes checks were not documented in the clinical record.Reference WAC 399-97-1720(1)(a)(i)-(iv), (b)

Based on observation, interview, and record review, the facility failed to identify, report and thoroughly investigate allegation of abuse/neglect for 5 of 8 sample residents (Resident 78, 37, 94, 100, & 131) reviewed for abuse and 20 supplemental residents (Resident 25, 53, 143, 4, 144, 150, 31, 45, 86, 80, 148, 149, 112, 99, 110, 69, 116, 10, 44, & 38) whose reported allegations of potential abuse and neglect were identified upon review of the facility's grievance log. The allegations identified included verbal abuse, rough handling, residents being fearful of staff, lack of incontinence care, not responding to call lights for multiple hours or turning call lights off and leaving without providing the requested care, and failure to provide help with bathing and hygiene for up to a week. Although the facility was aware of these alleged issues, they were not identified, reported, or investigated as potential allegations of abuse or neglect. Instead, they were identified as care and call light concerns and considered grievances. The failure to identify and thoroughly investigate the allegations of potential abuse and neglect allowed the alleged perpetrator(s) to have continued access to residents prior to determining if abuse or neglect occurred. This failure placed residents at serious risk for unidentified abuse and/or neglect and a diminished quality of life and constituted an Immediate Jeopardy (IJ). On 05/22/2026 at 2:28 PM, Staff A, Administrator was notified of an Immediate Jeopardy at CFR 483.12(2)-(4) F610, Alleged Violations-Investigate/Prevent/Correct, related to the facility's failure to identify allegations of abuse and neglect, ensure alleged abuse and neglect were reported, thoroughly investigated and residents were kept safe during the investigations. The facility removed the immediacy on 05/27/2026 with an onsite verification from investigators by conducting resident interviews, reporting and investigating allegations of abuse or neglect, suspending staff pending investigation conclusions, placing residents on monitoring for psychosocial harm, implementing daily manager rounds where managers visit their assigned residents, reading grievances out loud and reviewing call light times in the daily stand-up meeting, educating all staff regarding abuse policies/procedures and thorough investigations, and having the call light vendor come onsite to validate function. These actions ensured an effective system was in place to safeguard, protect and prevent residents that were at risk for abuse/neglect.Findings included . The facility policy titled, Abuse, revised 10/20/2022, showed under the section titled Identification, staff were encouraged to identify, correct, and intervene in situations which abuse, neglect and/or misappropriation of resident property was more likely to occur. Immediately following ensuring the resident's safety, staff were to report any allegation or observation of abuse to their supervisor, director of nursing, administrator or facility leadership member. Under the section titled Investigation, designated staff would immediately review and investigate all allegations or observations of abuse. Under the section titled Reporting, the organization would immediately report all alleged violations involving neglect, abuse, including injuries of unknown source, mistreatment and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator or his or her designee. Resident 131 Resident 131 was admitted to the facility on [DATE]. According to the 5-Day Minimum Data Set (MDS, an assessment tool), dated 05/18/2026, Resident 131 was cognitively intact, frequently incontinent of both bowel and bladder, was dependent on staff for toileting hygiene and required continuous oxygen delivery. Resident 131 had a provider order, dated 05/14/2026, for continuous oxygen to maintain SpO2 (Peripheral capillary oxygen saturation, an estimate of the amount of oxygen in the blood) greater than 92% every shift. On 05/17/2026 at 1:57 PM, Resident 131 said they had sat in their diaper over a couple of hours that day, that they had been wet (with urine) and had had a bowel movement as well. Resident 131 said they alerted staff with their call light and it took over an hour to have their call light answered, and they called their sister (Collateral Contact 8) to let her know they needed help. Resident 131's sister then said they had been concerned Resident 131's call light was not working so they had called the reception desk and spoke with a staff member who said they would get someone right away to assist Resident 131. Resident 131 said they knew they had waited two hours for assistance because they hit their call light around 9 AM and called their sister for help at 10:51 AM, this was confirmed by Resident 131's sister's cellular phone call history. On 05/17/2026 at 2:53 PM, Staff A, Administrator, was made aware of the above allegations. Staff A said they would start an investigation and with the alleged two hour wait for care, most likely would report the allegation to the State office and place staff on leave. On 05/20/2026 at 2:36 PM, Resident 131 said they were not doing very good, needed oxygen, had hit their call light, and was feeling shaky (Resident 131s hand were observed to be shaking and they were not receiving supplemental oxygen). Observation showed the call light was not on in the hallway. Resident 131 was observed to hit their call light button, and the call light was still not visible in the hallway. On 05/20/2026 at 7:53 AM, Staff S, Licensed Practical Nurse, was alerted Resident 131 was requesting oxygen and had reported feeling shaky. Staff S went to Resident 131's room and applied oxygen via nasal cannula. Staff S reported Resident 131's SpO2 had been at 80% when he entered the room and checked it. Staff S was asked to press Resident 131's call light button, was observed to adjust the call light cord on the wall and then push the button which then was observed to have triggered the light in the hallway. Resident 131 said they were sure they had pushed the call light button that morning when they had started feeling funny. On 05/20/2026 at 10:45 AM, Staff S, when asked about Resident 131's call light not functioning, said he had observed that it had been disconnected and that was why he had adjusted it before pushing the call light button. Staff S said the call light unplugs from the wall and when the connection is broken the light on the wall comes on and the light in the hall goes on, but this had not happened when Resident 131's call light was disconnected. On 05/20/2026 at 10:49 AM, Resident 131 said sometimes their call light worked and sometimes it did not. On 05/21/2026 at 8:17 AM, the facility provided the facility investigation with supporting documentation as it pertained to Resident 131's alleged two hours wait for care. The investigation documentation showed the facility call light report (a record of call light wait times) had been reviewed by the facility and did not show Resident 131 had used the call light during the time in question. In the investigation documentation Staff F, Certified Nursing Assistant (CNA), had reported that when he was made aware Resident 131 needed care he had attempted to locate a second staff member before providing care, sometime mid-morning. Under the section titled conclusion, it was documented the allegation was not supported by objective evidence sufficient to verify a two-hour delay in care, that it remained unclear how long the resident waited before the CNA informed the resident he would locate a second staff member, and this was because Resident 131 had not activated the call light. Review of the investigation did not show the call light had been inspected to ensure it was functioning properly or that Resident 131 had been interviewed. Under incident description of the investigation it was documented it was Resident 131's daughter who had called the front desk to request help in their room, not their sister. On 05/21/2026 at 9:39 AM, Staff AA, Director of Maintenance, was asked how the facility would know if a call light had become disconnected from the wall. Staff AA said the light in the hallway would come on if it was disconnected. Staff AA explained when the call light cord became disconnected it would come apart a little bit, and the Resident would then push the call light button and the call light would not work. Staff AA, said if the call light was disconnected and the light went off in the hallway, staff would come and turn off the call light in the room and then leave the room and then the resident would be left with a call light that would not work due to the disconnection not being identified. Staff AA said staff may not know to check the connection of the call light cord. On 05/21/2026 at 10:23 AM, Staff AA, regarding the call light disconnecting and staff responding and turning the light off but not checking the cord connection, said this was a known issue. Staff AA said they would get work orders regarding the call light getting disconnected once a month or something like that. When asked if they had educated staff regarding the potential issue with call lights becoming disconnected, Staff AA said once a month they would verbally provide education to CNAs and nursing staff but sometimes the staff were busy. Staff AA said he would verbally provide education but not written education, and he did not keep track of who he had educated. Staff AA said facility staff would come and go (indicating staff turnover), so he did not educate everyone. On 05/22/2026 at 1:29 PM, Staff A, Administrator, Regarding Staff AA reporting call light cords becoming disconnected was a known issue and being reported at least once a month, Staff A was asked if the call light was inspected as part of the investigation into Resident 131's reported two hours wait for care after reporting she had used her call light button. Staff A said the call light had not been inspected as part of the investigation and should have been, especially, having been a known issue. Regarding Resident 131's incident where they could not reach staff when requiring oxygen due to the call bell not functioning, Staff A said education had started after the incident. When asked if Resident 131 had been interviewed as part of their investigation, Staff A said he did not have a statement for Resident 131 and he would expect the Resident to have been interviewed as part of the investigation and for there to be a statement documenting the interview. On 05/29/2026 at 10:09 AM, Resident 131 was asked if it was their sister that called the facility to request help for them in their room or was it their daughter as the investigation indicated. Resident 131 said it was their sister who had called the facility to request help for them, and said, I don't have a daughter. On 05/29/2026 at 10:18 AM, Staff L, Interim Director of Nursing Services, said the investigation documentation indicating it was Resident 131's daughter who had called the facility to request assistance rather than their sister did not meet her expectations. When asked if a resident reported an allegation of abuse or neglect should the resident be interviewed as part of an investigation, Staff L said, yes, it was the expectation to interview the resident. The following grievances were reviewed with Staff A, Administrator, on 05/21/2026 at 10:39 AM. Staff A confirmed each of the following grievances were an allegation of abuse/neglect or acknowledged the facility's failure to obtain further information about the reported events precluded the facility from ruling abuse and neglect out. (e.g. failure to follow up with a resident who alleged poor call light response to determine how long it was before staff responded, what was the resident's need, and determining what, if any, outcome/affect it had for the resident.) Resident 25 In a grievance, dated 04/05/2026, Resident 25 reported that care was not consistently provided over the weekend. The resident reported that during evening shift they requested assistance with being changed, were told staff would return, and staff did not return to provide the requested care. Resident 25 also reported that a scheduled shower was not provided despite repeated reminders to staff. Resident 53 In a grievance, dated 04/05/2026, Resident 53 reported that care over the weekend was not the best and that there were long call light wait times and incontinent care was not provided frequently enough. In a grievance, dated 04/07/2026, Resident 53 reported they had requested a brief change and were told by the aide they would come back to do it because they had left someone on the floor. Resident 53 said the aide never returned to change her. Resident 143 In a grievance, dated 4/07/2026, Resident 143 reported waiting more than 30 minutes for assistance to the bathroom after activating the call light, and experienced urinary incontinence while waiting. Resident 143 made it clear that she was not usually incontinent Resident 4 In a grievance, dated 4/06/2026, Resident 4 reported requesting a bed bath due to feeling weak and being told staff would return to provide care. The resident reported the bed bath was not provided, the resident's brief was not changed, and the resident remained in a wet brief while waiting for assistance. The resident further reported feeling ignored by staff and expressed significant concerns regarding interactions with a specific nursing assistant. In a grievance, dated 04/16/2026, Resident 4 reported a nurse came to administer medications, but the resident requested the nurse return later after eating. Resident 4 reported the nurse never returned and the medications were not administered. Resident 144 In a grievance, dated 04/09/2026, Resident 144 reported that a walker had been placed out of reach and that it took a long time to obtain assistance. The resident also reported concerns regarding a recent surgical incision, pain management concerns, and reported not feeling safe. In a separate grievance, dated 04/09/2026, Resident 144 reported experiencing long call light wait times when requesting assistance. Resident 150 In a grievance, dated 04/10/2026, Resident 150 reported experiencing symptoms of low blood sugar and activated the call light to request assistance. The resident reported there was no response from staff for approximately 45 minutes. The resident reported that after yelling out to staff walking by the room, staff responded and checked the resident's blood sugar, which reportedly read low. Resident 31 In a grievance, dated 04/13/2026, Resident 31 reported waiting more than one hour for a response to the call light and reported not being assisted out of bed for breakfast. Resident 45 In a grievance, dated 04/14/2026, Resident 45 reported waiting approximately two to three hours for assistance after activating the call light. The resident reported needing to be changed and remaining in pain while waiting. Resident 86 In a grievance, dated 04/14/2026, Resident 86 reported it took too long to get help. Resident 86 said he noticed the aides come in the room and turn the call light off before addressing their needs. Resident 80 In a grievance, dated 04/14/2026, Resident 80 reported concerns regarding pain medication administration and alleged an agency nurse was rude. The resident reported receiving pain medication during the afternoon and reported the next dose was not received until approximately eight hours later. Resident 148 In a grievance, dated 04/19/2026, Resident 148 reported remaining in urine for approximately two hours while waiting for assistance. The resident also reported concerns regarding staff not wearing name badges and reported feeling scared when a male staff member entered the room to provide care. Resident 149 In a grievance, dated 04/22/2026, Resident 149 reported waiting approximately one and one-half hours for a response to the call light during evening shift. Resident 112 In a grievance, dated 04/22/2026, Resident 112 reported a female aide attempted to reposition them by herself, but the position was uncomfortable. The female aide left to get a second aide to assist, but when the male aide came, the female aide did not assist him. The resident reported she was a two person assist with bed mobility. Resident 99 In a grievance, dated 04/24/2026, Resident 99 reported not receiving scheduled showers during the week of 04/20/2026 through 04/24/2026. The resident reported staff stated they would return to provide the showers but never returned. Resident 110 In a grievance, dated 04/29/2026, Resident 110 reported long call light response times. After reviewing the above grievances on 05/21/2026 at 10:55 AM, Staff A, Administrator, indicated it was not necessary to review further grievances as he could see the pattern (of failure to identify allegations of abuse and neglect and/or obtain enough information to rule abuse and neglect out.) In an interview on 05/21/2026 at 2:42 PM, Staff A, Administrator, confirmed the following grievances were also allegations of abuse and neglect and/or the facility failed to rule abuse and neglect out. Resident 69 In a grievance, dated 05/06/2026, Resident 69's wife reported the resident had not received a shower since admission on [DATE]. Resident 116 In a grievance, dated 05/11/2026, Resident 116 reported not receiving bathing or hygiene care since admission on [DATE]. Resident 10 In a grievance, dated 05/10/2026, a resident's husband reported concerns regarding a nurse being rude and disrespectful toward the resident and family members. The grievance alleged the interaction caused emotional distress to the resident for several hours. Resident 44 In a grievance, dated 05/11/2026, Resident 44 reported being left unattended in a mechanical lift for more than 30 minutes while staff sought assistance from another staff member. Resident 38 In a grievance, dated 05/19/2026, Resident 38 reported remaining in the same clothing for seven days without being changed. On 05/22/2026 at 12:13 PM, Staff A, Administrator, stated the facility had dropped the ball related to the facility's grievance process and identification of abuse/neglect allegations and had reached out to his boss to come help work on the investigations and to educate him and the facility managers on conducting investigations. Resident 78 Resident 78 was admitted to the facility on [DATE]. Review of the Quarterly MDS, dated [DATE], showed the resident was cognitively intact. On 05/17/2026 at 2:15 PM, Resident 78 reported that approximately three to four nights earlier, at about 2:00 AM., an unfamiliar female CNA changed her roommate and then approached her bed and abruptly pulled back her covers and instructed her to get up and go to the bathroom. The resident said she pointed to the dry erase board (which had care instructions written on it) and informed the aide she was a check and change, but reports the aide just laughed and told her she could change herself and directed her to go into the bathroom. Resident 78 said she went into the bathroom and changed herself but couldn't adequately clean herself and lacked the dexterity to fastened the side tabs on the brief. The resident said she ultimately put on a pull-up she believed to belonged to her roommate. Resident 78 said throughout the process the aide stood in the doorway to the room with the door open and the bathroom door open. Resident 78 indicated she felt like she was nothing and didn't deserve to have assistance. Resident 78 said she reported to staff the next morning but no on had followed up with her about the incident. On 05/17/2026 at 2:57 PM, Resident 11, Resident 78's roommate, corroborated the incident. Resident 11 stated, I heard it. The way the aide spoke to (Resident 78) was like a sergeant in the Army. Resident 11 confirmed the CNA made Resident 78 get up and go to the bathroom and change herself like a drill sergeant. Review of the electronic health record showed there was no documentation of the incident present. Review of the facility grievance log showed a grievance was entered on 05/17/2026 by Staff B, Director of Nursing Services, on behalf of Resident 78, with an incident date of 05/13/2026. Review of the grievance record on 05/21/2026 at 10:39 PM showed the grievance details stated, 05/13/2026 day shift CNA was rude, used tone and approach that was perceived as disrespectful. The sections titled Summary of Investigation, Summary of Findings, and Summary of Actions Taken were blank. When asked if anyone had interviewed Resident 78, Staff A, Administrator, said no. Staff A was then provided with the initial interview with Resident 78 so they could follow up. On 05/22/2026 at 2:51 PM, a copy of the facility's new investigation into Resident 78's allegation was provided. The investigation included the information this writer provided to Staff A, Administrator, but no interviews conducted by the facility with Resident 78, her roommate, other residents, or staff members who may have had knowledge of the event. The investigation also did not identify the alleged perpetrator or any attempts the facility made to identify the alleged perpetrator. On 05/22/2026 at 5:13 PM, when asked if the facility had interviewed Resident 78 or Resident 11 (Resident 78's roommate) who was present at the time of the event, Staff A stated, No. When asked if an investigation can be thorough if the alleged victim and a witness who had stated they overheard what occurred were never interviewed, Staff A stated, No. Resident 37 Resident 37 was admitted to the facility on [DATE], and recently had been hospitalized for a joint replacement surgery from 05/01/2026 to 05/05/2026. The Quarterly MDS, dated [DATE], showed during the assessment period Resident 37 was cognitively intact, and was always continent of bowel, occasionally incontinent of urine (less than 7 episodes of incontinence). Review of Resident 37's urine records, from 05/06/2026 to 05/18/2026, showed only one to two urinations a day charted by staff, of incontinent episodes. Review of Resident 37's bowel records, from 05/06/2026 to 05/18/2026, showed Resident 37 was now incontinent of bowel. During an interview on 05/17/2026 at 2:14 PM, Resident 37 reported they were only changed two times a day, could wait hours and thought they should be changed more. Resident 37 said that morning they thought they had waited about two to three hours to get changed, and during the day it could take longer than that. On 05/17/2026 at 5:16 PM, Staff A, Administrator, was notified of the allegation of neglect by surveyor. Review of Resident 37's continence care plan, showed an intervention initiated 06/09/2025 for female nursing staff to provide personal cares per resident request. Review of Resident 37's allegation of neglect investigation on 05/17/2026, showed the investigation had no details listed of Resident 37's level of consciousness (left blank), mobility (left blank), and no mental status (no selected boxes). Staff statements showed Staff Z, CNA, said they had traded rooms as Resident 37 said they needed to have a female staff come and change their brief, so they traded with Staff Y, CNA. This statement did not have any more details, such what time Resident 37's brief was first identified as soiled and needing to be changed, or how long it took before Staff Y replaced them. Staff Y's statement, said they had been notified by Staff Z about Resident 37's brief needing to be changed at around 10:00 AM, it did take an extended amount of time, and changed Resident 37 around 11:30 AM with another CNA. No other staff interviews were completed. For like residents interviewed, six were listed on the forms but only four interviews were completed. None of the other residents were asked about delays in cares or about incontinent care. During the interview with Resident 37, they expressed the facility would benefit from an extra care staff member working as a float and included a statement of, I know that sometimes the facility does have care staff floating, but sometimes they have to be reassigned to cover additional staffing concerns. Further review of this investigation, showed a summary of findings, date 05/19/2026, was added that documented they could not confirm the exact length of time Resident 37 waited as two to three hours, the call light report confirmed multiple activations with varying response intervals but did not establish a single continuous two to three hour unanswered request for care (the allegation was not about the call light being on for two to three hours, but that it took that long to receive care from staff). It also documented Resident 37 understood their care may take longer due to needing a two person assist. This investigation did not explain what steps were being taken to improve delays related to Resident 37 being a two person assist currently, or that the care plan had shown Resident 37 required a female CNA assignment for brief changes. The investigation had the conclusion, dated 05/19/2026, that the allegation was unsubstantiated. During an interview on 05/20/2026 at 11:32 AM, Resident 37 was asked about their call light. Resident 37 said that made them nervous, they were not sure it was lighting up outside. Resident 37 was seen with a grey and round soft touch call light, reporting it was for their arthritis. Resident 37 attempted to turn the light on, the light outside of the room was not lit up. Resident 37 attempted again, and the light turned on. Resident 37 stated, Shoot, I thought it was on all the time. That could be why some of my response times are long. It's hard to press because of my arthritis. I have this call light specifically for my arthritis and expressed the call light response times might be represented incorrectly, they sometimes wait 45 minutes and squeeze it again. On 05/22/2026 at 12:33 PM, Staff X, Administrator in Residency, was interviewed with Staff A, Administrator present. Staff X said for allegations, they would notify the administrator in the facility and would assist them in determining if it was an allegation; if it was an allegation, they would report to it to the state. Staff X said the very first step was to remove the staff from the situation, so the resident could not be abused or neglected, and then to get all the facts of what happened, obtain like resident interviews, and educate staff if necessary. Staff X said neglect was the failure to act, to prevent harm, discomfort, or pain to a resident. When asked if a resident needed to feel neglected to have be neglected, Staff X said no. During this interview, Staff X was asked their process for interviewing other residents. Staff X said they would typically look at the particulars of the allegation, if it was based on a specific need, then residents with a similar need. If the allegation was based on staff, Staff X said then like residents were based on other residents the staff interacted with. Staff X said they probably would do an audit trail, it depended on the situation. Regarding Resident 37, Staff X said the other like residents were chosen because they were on the same assignment as the Certified Nursing Assistant (CNA) that was suspended, and this was based only on location of the residents (not care needs). When asked why they did not intentionally select residents based on incontinence needs (which could have been on same hall), Staff X said the reason they chose the like residents they did, was because the allegation was that the CNA had done this thing, and they wanted to see if there was a pattern of the CNA providing the same substandard care. When asked about two of the like residents having no recorded responses, Staff X said the residents were unavailable, they thought they had decided not to reattempt to interview those residents, and they felt they had sufficient data based on the other residents interviewed. Regarding the questions asked to residents, not asking about delays in care, and asked how they were identifying delays in care without asking, Staff X said they were identifying delays in care, they were covering the possibility with delays in care with updated training on not turning call lights off until the need was met. During this interview, Staff X and A were asked if Resident 37 had directly been asked about the two to three hour wait that morning for their brief to be changed. Staff A acknowledged the statement in the investigation did not indicate it was asked directly. When asked if Resident 37 was asked if they had any issues with their call light, Staff A said based on the investigation they were reading, no. Staff X said through recent training and vigilance, they were aware there were long call light times, were trying to look at it systemically to create an environment without call light issues, and the call light was to stay on until the need was met. When asked if the investigation looked at Resident 37's medical history, their cognition, and documented this, both Staff A and X said no. When asked if the investigation looked at Resident 37 being continent before their recent surgery, and if this was a risk factor or an area for improvement, Staff X said they looked at it as an area of improvement, they were looking at call light response times. During this interview, Staff X and A were asked about the assigned CNA's statement, Staff Y, which documented, it did take us an extended time, but we did get in there to get her taken care of and said the wait was from 10:00 AM to 11:30 AM. Staff X confirmed the resident was documented to have waited one and one half hour. When asked what steps had been taken to determine the root cause of why it took 1.5 hours to change Resident 37, Staff X said they believed, based on their investigation, the staff had answered the call light, went to find a second staff to assist, probably got pulled away, then Resident 37 restarted their call light. When asked if this investigation looked at staffing, Staff X said they did not look at staffing based on this investigation. They had observed a lot of staff on the floor, and based on their observation, they did not think this was the issue. During this interview, Staff X and A were asked about follow up with the male CNA, Staff Z, who had to trade assignments, so Resident 37 could have a female CNA. When asked if there was any follow up with Staff Z on how long Resident 37 was needing their brief changed before he was able to find the female CNA, Staff Y, to trade rooms with him, Staff A said they had interviewed Staff Z, it was near shift change, and they should have added that to their statement. Staff A stated, I should have put it was right at the beginning of shift. When asked what time Staff Z's shift started, Staff A said 6:30 AM. When asked if that meant Resident 37 needed assistance starting approximately around 6:30 AM, Staff A said they would need to reach back out to the male CNA and get a further statement on that. During this interview, Staff A and X were asked about if they had interviewed other staff on general delay in care questions. Staff A said they usually interviewed only the involved CNA, each investigation it depended. Staff A said they did not interview the assigned nurse in this investigation. When asked how the facility was ensuring the CNAs had all the tools needed to care for the residents, Staff A said that without interviewing them, they

Based on observation, interview, and record review, the facility failed to ensure necessary treatment and services were provided to prevent the development of avoidable pressure ulcers (PU), and to promote wound healing and prevent further decline of existing PUs for 2 of 3 residents (Residents 11 and 14) reviewed for pressure injuries. Specifically, the facility failed to thoroughly assess resident specific risk factors, develop and implement preventative measures, and timely identify, assess, monitor, treat, and notify the provider of newly developed PUs that direct care staff had knowledge of. These failures placed residents at risk for unidentified wound development and/or deterioration, delayed treatment, and intervention. Resident 11 experienced harm when they developed an unstageable PU (full thickness skin loss, where the true depth is obscured by necrotic/dead tissue in the wound bed) to the right ear, resulting in pain and bleeding. Findings included . Resident 11 Resident 11 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS, an assessment tool), dated 04/06/2026, showed the resident was cognitively intact, was at risk for PU development, and did not have a PU during the assessment period. Review of a Braden Scale assessment, dated 04/16/2026, showed the resident scored 17, indicating risk for PU development. During observation and interview on 05/17/2026 at 3:02 PM, Resident 11 reported her right ear hurt because there was an open area that developed under the oxygen tubing. Observation of the right ear showed there was a moist reddish-brown crust present to the top middle aspect of the right ear. The open area could not be visualized due to the crust/scabbing and the large amount of an unknown semi-transparent ointment that had been applied. Resident 11 reported the area had been present for approximately 30 days and was provided by her aides (Certified Nursing Assistants) at her request. During an interview on 05/17/2026 at 3:07 PM, when asked if the nurse was aware of the area, Resident 11 said she didn't think so, because no one had had come to look/assess it. During observation and interview on 05/18/2026 at 11:12 PM, observation of Resident 11's right ear showed the scab now encompassed the oxygen tubing. The resident's hair above the ear was now coated with a mixture of ointment and red crusted debris. While discussing with Resident 11 she lifted her oxygen tubing off the right ear and said Ouch and repeated that the area was sore. Observation of the oxygen tubing showed a reddish-brown scab was still attached to it after it was removed from the right ear. During an interview on 05/18/2026 at 11:18 PM, when asked if the nurse(s) identified the area while performing her weekly skin checks, Resident 11 said staff did not perform weekly skin checks on her. When asked what she would say if documentation indicated weekly head-to-toe skin assessments had been completed, Resident 11 stated, That would be a blatant lie. During observation and interview on 05/19/2026 at 3:17 PM, the ointment and crusted debris previously observed in the resident's hair were no longer present. Resident 11 reported staff had washed her hair the previous evening. When asked whether a nurse had seen the area, Resident 11 stated no. Review of the electronic health record (EHR) showed no documentation identifying the pressure injury, no physician notification, no wound assessment, no monitoring, and no treatment orders related to the right ear wound. Review of the May 2026 Treatment Administration Record (TAR) showed no treatment orders or monitoring related to the area. Review of weekly skin assessment documentation dated 04/24/2026, 05/01/2026, 05/08/2026, and 05/15/2026 showed no alteration in skin integrity was identified. During observation and interview on 05/20/2026 at 4:37 PM, Staff A, Administrator, and Staff B, Director of Nursing Services, accompanied the surveyor to Resident 11's room. Staff A confirmed the presence of an open area with scabbing on the resident's right ear. Staff H, Licensed Practical Nurse/Unit Manager, assessed the area and identified a 0.5 centimeter (cm) x (by) 0.5 cm x 0.1 cm unstageable PU with light drainage and a wound bed that was 100 percent slough (wound debris - byproduct of inflammation). Following assessment of the wound, the following 05/20/2026 wound orders were obtained: Cleanse the right ear PU with wound cleanser, pat dry, apply Medi Honey and cover with a dry dressing daily and as needed. Place pressure-relieving foam on the resident's oxygen tubing to relieve pressure. Monitor skin integrity each shift. Refer to contracted wound care specialist for evaluation and treatment. During an interview on 05/20/2026 at 4:40 PM, Staff A and Staff B confirmed no skin issues had been identified during the previous weekly skin assessments, including the assessment completed on 05/15/2026. When asked whether staff awareness of the area should have resulted in nursing awareness, assessment, interventions, physician notification and treatment orders, Staff A stated, yes and Staff B nodded affirmatively. Additionally, Staff B confirmed Certified Nursing Assistants were not permitted to provide ointments to residents and was unable to identify the type of ointment that was provided/applied. Staff A and Staff B further confirmed that if staff had observed the area, applied ointment, cleaned the area, and/or washed ointment and blood from the resident's hair, nursing staff should have been notified, and the condition should have been documented and addressed. Both confirmed this had not occurred. A wound care note, dated 05/27/2026, documented Resident 11 had a 0.8 cm x 0.4 cm x 0.2 cm Stage 3 (characterized by full-thickness skin loss, exposing subcutaneous fat) medical device-related PU to the back of the right ear. The wound bed was assessed to be 100% granulation tissue (new tissue) with moderate drainage and treatment orders were revised. Resident 14 Resident 14 was admitted to the facility on [DATE]. The Significant change in status MDS, dated [DATE] documented Resident 14 was moderately cognitively impaired and had 1 unstageable pressure ulcer due to coverage of wound bed by slough and/or eschar (dead tissue). A review of the EHR showed and an order, dated 04/02/2026, for wound care to coccyx pressure ulcer (skin and tissue damage over the tailbone caused by prolonged pressure, friction, or shear) every day shift and there was a discontinue date of 04/15/2026. In addition to providing wound care the order said to monitor signs and symptoms of infection or worsening and to notify the provider. A review of the April 2026 TAR showed blank boxes with no documentation on 04/09/2026, 04/13/2026, 04/14/2026, and 04/15/2026. A review of the EHR showed an order, dated 04/16/2026, for wound care to coccyx pressure ulcer every day shift. In addition to providing wound care the order said to monitor signs and symptoms of infection or worsening and to notify the provider. A review of the April 2026 TAR showed blank boxes with no documentation on 04/16/2026, 04/20/2026, 04/23/2026, and 04/26/2026. A review of the May 2026 TAR showed blank boxes with no documentation on 05/04/2026, 05/06/2026, and 05/14/2026. On 05/21/2026 at 11:28 AM, Staff H, Licensed Practical Nurse/Unit Manager said the blanks on the TAR mean the orders were not charted on. When asked if the care was provided, Staff H said she would have to reach out to the nurses to see if the wound care was provided but looking at the TAR, she could not tell if it was provided or not. Staff H said she would expect the nurses to complete the order and chart it as completed. On 05/21/2026 at 1:59 PM, Staff B, DNS, said she saw the blank boxes on the TAR and said she would expect the nursing staff to document if the resident refused care and/or document if the wound care was provided. Reference WAC 388-97-1060(3)(b)

Based on interview and record review, the facility failed to ensure 4 of 8 residents (Resident 78, 131, 94 & 37) reviewed for abuse and neglect were free from verbal abuse or neglect. The facility failed to ensure there was adequate supervision and sufficient staff to meet the care needs of the residents. The facility's investigations substantiated verbal abuse involving Resident 78 and substantiated neglect involving Residents 131, 94, and 37. These failures subjected Resident 78 to potential psychosocial harm and resulted in delayed provision of necessary care and services for Residents 131, 94, and 37. Findings included . Review of the facility's policy titled, Abuse, undated, showed the facility was to recognize and respect that each resident had the right to be free from abuse and neglect. Neglect was defined as the failure of the facility, its employees or service providers, to provide goods and services to a resident that was necessary to avoid physical harm, pain, mental anguish, or emotional distress. Resident 94 Resident 94 was admitted to the facility on [DATE]. The Medicare 5 Day Minimum Data Set (MDS, an assessment tool), dated 05/11/2026, showed Resident 94 was cognitively intact. They were on the 200's hallway. An investigation for Resident 94 was opened on 05/18/2026. Per the investigation, Resident 94 and their family had reported Resident 94 accidently wet their pants while waiting for staff. Resident 94 had told the interviewer that staff had gone into the room and informed them they were caring for another resident at that time. On 05/28/2026, the facility created an addendum to their previous report and substantiated the allegation of neglect. They acknowledged the delays that occurred were related to staffing. During an interview on 05/28/2026 at 9:13 AM, Staff L, Interim Director of Nursing Services/Infection Preventionist (DNS/IP), confirmed that neglect was substantiated for Resident 94. Resident 37 Resident 37 was admitted to the facility on [DATE], and recently had been hospitalized for a joint replacement surgery from 05/01/2026 to 05/05/2026. The Quarterly MDS, dated [DATE], showed during the assessment period Resident 37 was cognitively intact, and was always continent of bowel, occasionally incontinent of urine (less than 7 episodes of incontinence). They were on the 200's hallway. An investigation for Resident 37 was opened on 05/17/2026. Per the investigation, Resident 94 reported they had gone 2-3 hours without their brief changed on 05/17/2026. During an interview on 05/28/2026 at 10:49 AM, Staff L, Interim Director of Nursing Services/ Infection Preventionist (DNS/IP), confirmed that neglect was substantiated for Resident 37. Resident 78 Resident 78 was admitted to the facility on [DATE]. Review of the Quarterly MDS, dated [DATE], showed the resident was cognitively intact. On 05/17/2026 at 2:15 PM, Resident 78 reported that approximately three to four nights earlier, at about 2:00 AM, an unfamiliar female Certified Nursing Assistant (CNA) changed her roommate and then approached her bed. Resident 78 stated the CNA abruptly pulled back her covers and instructed her to get up and go to the bathroom. Resident 78 stated she informed the CNA that she was a check and change resident and pointed to the dry-erase board identifying her care needs. Resident 78 reported the CNA laughed, refused to provide assistance, told her she could change herself, and ordered her to go into the bathroom. Resident 78 stated she attempted to change herself but was unable to adequately cleanse herself because she could not reach all necessary areas and lacked the dexterity to fasten the tabs on her brief. Resident 78 stated she ultimately used a pair of pull-up briefs belonging to her roommate. Resident 78 reported the CNA remained in the doorway with both the room door and bathroom door open and provided no assistance. When asked how the incident made her feel, Resident 78 stated, Like I'm nothing, like I didn't deserve the assistance. Resident 78 stated she reported the incident to a female staff member but could not recall the staff member's name. Resident 78 further stated no one had followed up with her regarding the allegation. On 05/17/2026 at 2:57 PM, Resident 11, Resident 78's roommate, corroborated the incident. Resident 11 stated, I heard it. The way she spoke to Resident 78 was like a sergeant in the Army. Resident 11 stated the CNA made Resident 78 get up and go to the bathroom and change herself like a drill sergeant and stated, She treated Resident 78 like she was nothing. Review of Resident 78's clinical record showed no documentation regarding the alleged incident and no indication the resident had been assessed or monitored for psychosocial impact. Review of the facility's unusual occurrence, incident, and accident log revealed no entry related to the allegation. Review of the facility grievance log showed a grievance was entered on 05/17/2026 by Staff B, Director of Nursing Services, on behalf of Resident 78, with an incident date of 05/13/2026. The grievance was categorized as a customer service interaction. Review of the grievance record on 05/21/2026 at 10:39 PM showed the grievance details stated, 05/13/2026 day shift CNA was rude, used tone and approach that was perceived as disrespectful. The sections titled Summary of Investigation, Summary of Findings, and Summary of Actions Taken remained blank. In an interview on 05/21/2026 at 10:39 AM, Staff A, Administrator, acknowledged no interviews had been conducted and no one had followed up with Resident 78 regarding the allegation. Staff A acknowledged the allegation should have been treated as an allegation of abuse and that an investigation should have been initiated, reported, and logged. Review of the facility's investigation and root cause analysis showed the facility ultimately substantiated verbal abuse. The facility documented immediate interventions and suspended a suspected CNA pending investigation. However, the CNA suspended by the facility did not match Resident 78's description of the alleged perpetrator. As of survey, the alleged perpetrator had not been identified. Resident 78 confirmed it was the first time she had seen the aide and that she had not seen the aide again following the incident. Resident 131 Resident 131 was admitted to the facility on [DATE]. The Medicare 5-Day MDS, dated [DATE], showed Resident 131 was cognitively intact, was frequently incontinent of both bowel and bladder and was dependent on staff for toileting hygiene. An investigation for Resident 131 was opened on 05/17/2026. Per the investigation, Resident 131 stated they had an incontinent episode of both bowel and bladder and it took two hours for the Certified Nursing Assistant (CNA) to come answer their call light. The facility investigation found the allegation was not supported by objective evidence to verify a two-hour delay in care due to the call light record not showing a call during the time period in question. The investigation documented the CNA had reported they believed delays in providing care may have occurred while assisting another resident and while trying to locate a second staff member for a two person assist. On 05/27/2026, the facility provided an investigation addendum, showing the initial allegation of neglect was substantiated, concluding abrupt staffing changes created delays in patient care delivery. On 04/26/2026 at 10:05 AM, Staff X, Administrator in Residency, confirmed Resident 131's neglect had been substantiated. Reference F690, F610, F725 Reference WAC 388-97-0640(1)

Based on interview and record review, the facility failed to ensure residents who fell were assessed/evaluated for increased supervision and/or that a resident-specific fall prevention care plan was implemented for 1 of 3 residents (3) reviewed for falls. These failures put residents at risk for further injury, pain, and a decreased quality of life. Resident 3, who was assessed as a known high fall risk, was on blood thinning medication and had severe cognitive impairment, experienced harm when they had an unwitnessed and unsupervised fall, sustained a left hip fracture and experienced extreme pain as evidenced by the resident's grimacing and yelping when rolled to their left side.Findings included.Resident 3 was admitted to the facility on [DATE] with diagnoses including dementia and metabolic encephalopathy (A brain dysfunction caused by metabolic disturbances). The admission minimum data set (MDS), an assessment tool, dated 10/31/2025, documented Resident 3 has severe cognitive impairment and is dependent on staff for assistance with activities of daily living (ADLs).Review of the resident's care plan, dated 10/27/2025, documented Resident 3 was at risk for falls related to advanced dementia. The resident would wear non-skid socks while out of bed, use the bed in the lowest position, and staff would remind the resident to use the call light.Review of a fall assessment, dated 10/27/2025, documented Resident 3 was a high risk for falls due to a history of falls, incontinence, and used of anticoagulant (prevents clots) medication.Review of nursing progress note, dated 12/10/2025, documented Resident 3 had an unwitnessed fall to the ground in the dining room. It was believed the resident dropped a stuffed animal and reached to grab it. It was unclear if the resident hit their head and was on Eliquis (an anticoagulant used to prevent blood clots). The resident was reporting pain to the left hip and thigh. There was redness to the left hip. Neurological exam was normal. The resident had severe dementia and was difficult to assess. Orders included a stat (immediate) x-ray to rule out a fracture and oxycodone 5 milligrams (mg) every six hours as needed for pain.Review of progress notes, dated 12/10/2025 at 1:18 PM, documented the resident was found on the floor and was pointing to a stuffed kitty. The resident was assisted into the wheelchair with a Hoyer (mechanical lift) and transferred to bed. The resident yelped when attempting to put the Hoyer sling under left hip. A check of Resident 3's skin was completed and no bruising or redness noted. An x-ray was ordered. During position change in the bed [the resident] would grimace and yelp when rolled to [their] left side.Review of progress notes, dated 12/10/2025 at 3:15 PM, documented Resident 3 fell in the dining room. The resident complained of left leg pain. No displacement of the leg was noted. A Hoyer lift was used to put the resident back to bed. The resident showed signs of pain in the left leg, so an x-ray was ordered and the family was notified. Review of progress notes, dated 12/10/2025 at 8:40 PM, documented pain noted.Medication Administration Record (MAR) documented the following:Eliquis 5 mg was given at 5:00 PM. The medication was not held after the fall.Pain level is documented as 0/10 or no pain throughout the AM and PM shifts.Tylenol 650 mg is given at 5:09 PM. Pain level is not noted.Oxycodone 5 mg is given at 8:01 PM for pain of a 7/10.Review of Radiology Results Report, dated 12/10/2025 at 8:15 PM, documented the resident as having a left hip fracture.Review of Hospitalist History & Physical Examination, dated 12/11/2025, documented Resident 3 was in severe pain after the fall. Options were discussed with family.Review of hospital records showed the resident passed away on 12/17/2025, at the hospital.During an interview on 02/18/2026 at 2:42 PM, Staff F, Licensed Practical Nurse, said Resident 3 fell in the dining room. They used a Hoyer to get the resident up off the floor and in to bed. The resident was in pain but did not recall signs of any injury. This is why they used the Hoyer for transfer. The resident could not verbalize pain, but it was obvious by the resident's facial expressions. The resident did get Tylenol during his shift. Staff F was aware the resident was on Eliquis. During an interview on 02/27/2026 at 11:38 AM, Collateral Contact 3 (CC3), Family Member, said Resident 3 fell somewhere around 12:00 PM - 1:00 PM on 12/10/2025. CC3 said Resident 3 was lifted and moved from the dining room into bed, when they likely already had a fracture to their leg. CC3 felt the resident was not immobilized properly to prevent further injury to the leg. The resident was in pain during this time, as witnessed by CC3. CC3 insisted that the resident get pain medication during this time. The resident needed quite a lot of pain medication once they got to the hospital due to the residents' uncontrolled pain. Resident 3 did not have an x-ray until around 9 PM. Staff never suggested or offered to send the resident to the hospital sooner. The Ambulance crew said staff did not know details about the fall. The staff caring for the resident at the time of the fall had left for the day without following through. The resident passed away on 12/17/2025.On 03/02/2026 at 5:03 PM, Staff B, Director of Nursing services and Registered Nurse, said the resident fell and it was uncertain if they hit their head. The provider was notified as they were present in the facility. Staff B said Resident 3 was on Eliquis and this was a medication of concern with a resident fall with an unknown head injury status. Staff B said there was lack of documentation on the status of the resident after the fall. The resident should have gone to the hospital if there was a concern with a head injury or with increased pain. Staff B could not speak to if staff immobilized the resident's injury.

Based on observation, interview and record review, the facility failed to ensure staff followed the resident's care plan when providing care by not having two staff present for bed mobility for one of four sampled residents (1) reviewed for accident hazards. This failure placed residents at risk for injury and a diminished quality of life. This caused harm to Resident 1 when she was rolled off the bed to the floor during care. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses including stroke, muscle [CONDITION(S)], and contractures (permanent tightening of muscles, tendons, and skin). The Quarterly Minimum Data Set, (MDS) an assessment tool, dated 08/02/2021, documented the resident had severe cognitive impairment and required extensive assistance with bed mobility. Resident 1's alteration in Activity of Daily Living and Mobility care plan, dated 06/30/2017, had an intervention with an effective date of 01/27/2021 that documented, BED MOBILITY: 2 person ext[ensive]. Nursing progress note, dated 08/16/2021 at 12:35 AM, documented, [Resident 1] had a witnessed fall 08/15/2021 at 8:40 PM during evening shift. The patient fell in her room from the left side of her bed. Bed was raised at approximately four feet from the ground while [Staff D, Nursing Assistant (NA)] was completing peri care . Patient rolled off the left side of the bed, landed on her right hip, and then hit the right side of her head . Patient has purple bruise 3 x 3 inches to right hip and bump 1 x 1 inch to right side of head. Facility investigation witness statement for Staff D, dated 08/16/2021 (not timed), documented, when asked if she knew what Resident 1's care plan said about her bed mobility prior to the fall, Staff D said, I know she is a two person. It says so on the white board. I saw it. I thought it was ok. She is not too heavy. I've done it alone a thousand times. Nursing progress note, dated 08/17/2021 at 10:00 PM, documented, [Resident 1] has increased pain on current shift. Nursing progress note, dated 08/18/2021 at 7:48 AM, documented, [Resident 1] complains of right hip pain, ongoing bruising observed as well. Progress notes noted at 12:29 PM, Bruise noted to right hip . resident reports any movement of right lower extremity causes increased pain. Provider note, dated 08/19/21 at 7:41 AM, documented, Nursing reports . right hip pain which began after (ground level fall) on 08/16/2021. Nursing progress note, dated 08/20/21 at 1:10 PM and 9:37 PM, documented Resident 1 indicated pain along entire right side of the body most severe when repositioned in bed. On 09/13/21 at 9:52 AM, Resident 1 was observed laying on a lipped mattress. When asked if she was hurt after the fall, the resident stated, Yes, my back. When asked how bad, Resident 1 stated, little bad. When asked about how often staff had turned her with one person, Resident 1 stated, Lots of times one person. On 09/29/21 at 10:03 AM, when asked about staff providing a two person assist of a resident care with one person, Staff E, Registered Nurse (RN) and Unit Supervisor, stated, No, it's never acceptable. When asked if the resident had increased pain from the fall, Staff E said Resident 1 did have an increase in pain, and indicated the resident did not have a fracture from the fall. Reference WAC 388-97 -1060 (3)(g)

Based on interview and record review, the facility failed to ensure resident environment was safe and free from hazards when a resident received a significant burn from hot coffee for 1 of 10 sampled residents (#1) reviewed for accident hazards. This failure placed residents at risk for injury and a diminished quality of life. This caused harm to Resident #1 when hot coffee spilled on the resident causing a blister. Findings included . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set, an assessment tool, dated 05/29/19, documented the resident was cognitively intact and required supervision with eating. The Unusual Occurrence Report, dated 08/24/19, documented Resident #1 sustained a 0.3 cm x 0.3 cm blister to the right upper thigh, and quoted Resident #1 as saying it made me tear up a little due to the pain. The report showed staff provided first aide, updated the resident's care plan, and implemented coffee lids. A progress note, dated 08/27/19, documented Resident #1's right thigh blister worsened, measuring 3.1 cm x 10 cm x 0.1 cm. The Physician Orders, dated 08/27/19, documented Resident #1's blister to have a daily application of 1% [MEDICATION NAME] cream, cover with a foam adhesive dressing and a referral to the wound team. On 09/04/19 at 9:50 AM, Resident #1 said he was holding a cup of coffee and his left hand gave out, spilling the coffee on his lap. Resident #1 said the coffee was very hot and resulted in a blister to his thigh. Resident #1 said the facility should have monitored the temperature, and stated, Coffee doesn't need to be that hot. Resident #1 said he the blister was healing now. At 10:30 AM, Staff C, Director of Dietary Services, said they did not have a process in place to monitor temperatures of hot beverages prior to Resident #1's burn, but they are taking temperatures now. On 09/05/19 at 11:30 AM, Staff B, Director of Nursing Services and Registered Nurse, said Resident #1 sustained a burn related to spilling coffee on his thighs. Staff B said they did not have a process in place to regularly monitor the temperatures of hot beverages prior to Resident #1's burn. Staff B said the facility does not have a policy addressing the expectation of monitoring hot beverages prior to being served to residents. Reference WAC 388-97-1060(3)(g)

Based on interview and record review, the facility failed to ensure residents were free from significant medication errors when diabetic medication orders were incorrectly transcribed and incorrectly administered and the resident was hospitalized with [DIAGNOSES REDACTED] (low blood sugar) for 1 of 3 sampled residents (#1) reviewed for unnecessary medications. This failure placed residents at risk for low blood sugar and health complications and a diminished quality of life. This caused harm to Resident #1 who needed to be hospitalized . Findings included . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The initial Minimum Data Set (MDS), an assessment tool, dated 01/30/19, documented Resident #1 had no cognitive impairment and required limited assistance from staff with dressing, toileting , transferring and walking. Resident #1's medical provider, on 01/29/19, ordered glimepiride (a medication used to control diabetes) 4 mg daily. The order was placed in the electronic medical record (EMR) by Staff B, registered nurse (RN), on 01/28/19, directed staff to administer glimepiride before meals, three times daily. The medication label on the medication package directed staff to administer glimepiride four (4) mg once daily. Staff gave four (4) mg of glimepiride to Resident #1 three (3) times daily, for a total of 12 mg daily, from 01/30/19 to 02/02/19. The medical record showed, on 02/03/19, Resident #1 was found alert but unable to speak, unable to grip hands, and his pupils were fixed. Resident #1 blood sugar was 28 (indicating [DIAGNOSES REDACTED]/low blood sugar). Resident #1 was transferred to the hospital. Resident #1 required hospitalized from [DATE] to 02/09/19 and was diagnosed with [REDACTED]. On 02/22/19 at 11:45 PM, Staff C, licensed practical nurse, said Staff B transcribed the dose of glimepiride for three (3) times daily instead of once daily, and the incorrect dose was administered for a number of days to Resident #1. Staff D, RN, said nursing staff who administered the medication to Resident #1 should have identified the discrepancy in the dose from the medication label and the order in the EMR. At 12:08 PM, Staff A, Director of Nursing Services, said this error should have been identified sooner, and Resident #1 was lucky to be alive. Reference WAC 388-97-1060 (3)(k)(iii)

Based on interview and record review, the facility failed to provide care and services for 1 of 3 sampled residents (#1) reviewed for medication errors according to professional standards of care. The facility did not properly secure prepared medications that resulted in a significant medication error when Resident #1 took another resident's medication and required life-saving interventions and hospitalization . This caused harm to Resident #1. Findings include: According to Fundamentals of Nursing, 7th Edition, 2011 (Taylor, Lillis, LeMone & Lynn), page 739, (Lippincott, Williams and Wilkins), After beginning to prepare drugs for administration, do not leave them unattended. If it is imperative to leave for a short time, place the drugs that have been prepared in a locked area, such as in the medication cart. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set, an assessment tool, dated 7/28/17, indicated the resident required assistance of two (2) people for bed mobility and transfers. An Unusual Occurrence Report, dated 8/23/17, documented Licensed Nurse (LN) B, Floor Nurse, entered Resident #1's room with another resident's medications. LN B set the medications on the table and bent down to take off Resident #1's leg wraps. Resident #1 took the medications while LN B was bent down. Resident #1 ingested 6mg of [MEDICATION NAME] (a blood thinner that can cause major and/or fatal bleeding), 5mg [MEDICATION NAME] (used to induce sleep), 2.5mg Requip (used to treat [MEDICAL CONDITION] symptoms), 10mg [MEDICATION NAME] (a sedative), 0.4mg tamslosin (used to treat enlarged prostate), and 50mg [MEDICATION NAME] (used to lower heart rate and high blood pressure). A nursing note, dated 8/23/17 at 11:19 p.m., documented, Patient inadvertently took wrong medication this evening. Patient's blood pressure was taken and was 74/48, patient was lethargic, with slurred speech, and difficult to keep awake. Patient was transferred 911 to (a local hospital). A witness statement, dated 8/24/17 and signed by LN B, documented, I went into (Resident #1's) room again after I had already given him his medication to look for my glucometer I left behind. I had another resident's medication in my hand when I went back. Resident #1 asked me if I could take off his leg wraps. I set the med cup on the edge of the table. I took his leg wraps off and as I went to leave I realized the cup was gone. Hospital records documented Resident #1 was admitted to the emergency department after receiving another patient's medications. Resident #1 required continuous medications to maintain a life sustaining blood pressure. On 9/6/17 at 3:45 p.m., LN A stated, (LN B) should not have brought another resident's medication with her into (Resident #1's) room. This could have been prevented by labeling the medications and securing them in the medication cart. On 9/6/17 at 4:30 p.m., the Administrator said the incident could have been prevented if LN B would not have brought the medication in the room with her. The facility failed to follow proper medication administration procedures and allowed a medically fragile resident to ingest medications that caused a life threatening low blood pressure resulting in harm to Resident #1. Refer to F-333 Reference WAC 388-97-1620(2)(b)(ii)

Based on interview and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 3 sampled residents (#1) reviewed for medication errors. This failure to follow medication administration procedures resulted in Resident #1 taking another resident's medications requiring life-saving interventions and hospitalization . This caused harm to Resident #1. Findings include: Resident #1 was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. Resident #1's Minimum Data Set, a comprehensive assessment tool, dated 7/28/17, documented Resident #1 required assistance of 2 people with bed mobility and transfers. Resident #1's medical record documented hypotensive blood pressures (a blood pressure reading lower than 90 for the top number and/or 60 for the bottom number) for 23 of the 34 days reviewed. Resident #1's Medication Administration Record [REDACTED]. An Unusual Occurrence Report, dated 8/23/17, documented LN B entered Resident #1's room with another resident's medications. LN B set the medications on the table and bent over to take off Resident #1's leg wraps. Resident #1 took the medications while LN B was bent over. Resident #1 ingested 6mg of [MEDICATION NAME] (a blood thinner that can cause major or fatal bleeding), 5 mg [MEDICATION NAME] (medication used to help induce sleep), 2.5 mg Requip (medication used to treat symptoms of [MEDICAL CONDITION]), 10 mg [MEDICATION NAME] (sedative used to treat trouble sleeping), 0.4mg tamslosin (medication used to treat enlarged prostate), 50mg [MEDICATION NAME] (medication used to lower heart rate and treat high blood pressure). A nursing note, dated 8/23/17 at 11:19 p.m., documented, Patient inadvertently took wrong medication this evening. Patient's blood pressure was taken and was 74/48, patient was lethargic, with slurred speech, and difficult to keep awake. Patient was transferred 911 to (a local hospital). A witness statement, dated 8/24/17 and signed by LN B, documented, I went into Resident #1's room again after I had already given him his medication to look for my glucometer I left behind. I had another resident's medication in my hand when I went back. Resident #1 asked me if I could take off his leg wraps. I set the med cup on the edge of the table. I took his leg wraps off and as I went to leave I realized the cup was gone. Hospital records documented Resident #1 was admitted to the emergency department after receiving another patients medications. Resident #1 required the placement of a central line (invasive procedure where a catheter is placed into a large vein in the neck) and continuous medications to maintain a life sustaining blood pressure. Resident #1 was admitted to the intensive care unit for continued monitoring. On 9/6/17 at 3:45 p.m., LN A stated, LN B should not have brought another residents medication with her into Resident #1's room. This could have been prevented by labeling the medications and securing them in the medication cart. On 9/6/17 at 4:30 p.m., the Administrator (ADM) said the incident could have been prevented if LN B would not have brought the medication in the room with her. The facility failed to follow proper medication administration procedures and allowed a medically fragile resident to ingest medications that caused life threatening low blood pressure resulting in harm to Resident #1. Reference WAC 388-97-1060(3)(k)(iii)

Based on interviews and record review, the facility failed to consult with the physician and notify the legal decision maker in a timely manner regarding significant changes in condition for 1 of 4 sampled residents (#1) reviewed for notification. This failure prevented the physician and legal decision maker from being aware of , and be included in, decisions to relieve Resident #1's continued distress and pain. Findings include: On 3/24/17, review of former Resident #1's record indicated she was admitted to the facility on [DATE] with multiple health conditions including severe cognitive loss, dementia, worsening heart failure, and the inability to make her own care decisions. Resident #1 had pain due to right wrist fracture. On 3/11/17 at 6:46 a.m., Licensed Nurse (LN) A wrote a progress note indicated the resident had not received an intervention for her pain. This information was not provided to the physician and the resident's representative. An interview with the nurse conducted by the DNS on 3/13/17, showed the nurse did not administer the medications as ordered, and did not call to inform of the resident's physician on duty about the deterioration in condition, unrelieved pain, cough or air-hunger. On 3/13/17 at 5:00 p.m., during interview with the Resident Care Manager she said: It was surprising the nurse did not intervene (on Resident #1's behalf) better . The DNS indicated she did not know why the nurse did not follow our process. Review of the facility investigation document dated 3/13/17 (referencing 3/11/17) indicated LN A did not call and consult with the physician because I wasn't sure what they would tell me to do .I was under the impression, the family didn't want her on stronger medication .I had a lapse in judgment. The facility failed to ensure consultation with the physician and notification of legal decision maker occurred which prevented them from being involved with the resident's end-of-life comfort care and wishes. Refer to F-309

Based on interview and record review, the facility failed to ensure 1 of 4 sampled residents (#1), received necessary care and services related to pain management and shortness of breath. This failure prevented the resident from attaining and/or maintaining the highest practicable level of function which resulted in poor pain management and unrelieved shortness of breath that caused harm to Resident #1. Findings include: On 3/24/17, review of former Resident #1's record indicated she was admitted to the facility on [DATE] with multiple health conditions including severe cognitive loss, dementia, heart failure and [MEDICAL CONDITION]. Since January 2017, the resident was receiving comfort care and required extensive assistance with all daily living tasks. She was assessed on 3/6/17 with a significant change in condition due to worsening heart failure. Resident #1 had pain due to right wrist fracture. According to the record, on 3/11/17 at 6:46 a.m., Licensed Nurse (LN) A wrote a progress note that the resident was awake and yelling 7 out of 8 hours last night .would not keep her oxygen on .was coughing continuously .yelled about the pain in her right wrist .pain medication (given at the beginning of the shift) did not help with pain but did have the side-effect of stopping her coughing .yelling she was not able to breathe when she was coughing .reminded multiple times to keep her oxygen on and did not sleep until 5:45 a.m., will continue to monitor. The nurse documented she administered [MEDICATION NAME] (a combination medication with [MEDICATION NAME] and [MEDICATION NAME], a narcotic) at the beginning of her shift which relieved the resident's cough, but not the pain. The resident continued to yell about not being able to breathe when she was coughing and was reminded multiple times to keep her oxygen on. The head of the bed was elevated to help with oxygen intake. No other interventions or treatments were documented as offered to this resident. Review of the Medication Administration Record (MAR) dated 3/11/17 failed to show the resident received the breathing treatment available to relieve the resident's cough and consequent air-hunger, as prescribed four times a day as needed. On 3/15/16, a document completed by the Director of Nursing Services (DNS) was reviewed. The document noted the nurse had told her that she had administered the [MEDICATION NAME] at the beginning of the shift. The MAR and the PRN (as needed) Result and Documentation Report, did not show the medication was administered to the resident. Document review indicated the medication was given on 3/10/17 at 7:27 a.m., and at 2:28 p.m., each time by a nurse other than LN A. Review of the MAR showed the resident had a PRN order for a [MEDICATION NAME] nebulizer (a combination medication of [MEDICATION NAME][MEDICATION NAME] which relax muscles in the airways and increases air flow to the lungs). This medication could have been administered 4 times per day for cough. In review it was noted the medication was last administered to Resident #1 on March 2nd resulting in 9 days of no breathing treatments when needed. The facility investigation report dated 3/13/17, documented the DNS confirmed the nurse did not administer the medications as ordered and did not call the physician on duty to inform him/her of Resident #1's deterioration in health, unrelieved pain and not being able to breathe prior to the resident's passing. On 3/15/2017 at 5:00 p.m., during interview with the Resident Care Manager she said: It was surprising the nurse did not intervene (on Resident #1's behalf) better . The DNS indicated the nurse did not follow the process.

Based on observation, interview and record review it is determined the facility failed to provide routine social services follow up to assess for changes and/or needs of resident (#1) after discharge from a hospital mental health program for 1 of 1 current residents sampled. As a result of this failure resident (#1) developed increased depression and attempted suicide. Findings include: Resident #1 is a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident #1 ' s last scheduled annual (6/20/2015) MDS (Minimum Data Set-an assessment tool) was completed as a significant change MDS. On this MDS, Section D was completed via a resident interview, where resident #1 reported most days she had symptoms of depression including having little or no pleasure or interest in things, feeling down or depressed, as well as having thoughts of being better off dead or of hurting self in some way. Further, in section I of the MDS, it was marked to confirm [DIAGNOSES REDACTED]. The Care Area Summary for this MDS included triggered areas for Psychosocial Well-Being and Mood State care planning. Record review noted that resident #1 had been receiving routine Geriatric Mental Health treatment from May, 2014 until discharged from program due to completion of treatment in May, 2015. No changes were made on the care plan at this time to include social services to provide routine follow up with resident #1 who was high-risk for self-harm and newly discharged from the mental health program. Progress notes from social services received on 02/05/16 dated April 2015 through January 27, 2016 indicated that prior to the resident #1 ' s attempt at self-harm, there were no routine social service visits provided and resident #1 was not seen by social services from 6/22/15 through 10/13/15 and again not seen from 10/20/2015 through 1/20/16, the day resident #1 returned to nursing home from the hospital. Notes documented by social services on 4/13/15 and 6/22/15 indicate resident #1 voiced to social services that she would be better off dead and had a desire for her life to be over . It is also noted on the social services note dated 6/22/15 that the assessment done for severity of depression indicated moderately severe depression . Social Service intervention on the care plan was 1:1 for support, socialization, coping and to monitor mood PRN (dated 2/27/15). A quarterly MDS was done on 9/18/15. It was indicated on this MDS in Section D (Mood) that resident #1 was interviewed and resident #1 answered that there continued to be symptoms of depression some days. Further, it was documented on this MDS in Section D yes , that staff and/or provider were made aware resident #1 had potential for self-harm. The most recent MDS dated [DATE] indicates Section D was completed after staff observed, rather than interviewed, resident #1 for mood. It was documented that resident #1 was observed to have depression symptoms most days. On January 16, 2016, resident #1 was found to have obtained scissors and had cut her left arm in a suicide attempt. Resident #1 was transported to the hospital where she required suturing of the self-inflicted injury, and was admitted for observation for psychiatric care. Resident #1 returned to the facility on [DATE]. In an interview with resident #1 on 2/3/16 at 11:25 a.m. resident #1 stated I ' m doing ok and when asked to see her arm, resident #1 quickly showed surveyor left arm where there are healing marks to the arm. In an interview with Social Services Staff C on 2/3/16 at 2:30 p.m. the Staff C was unable to provide any information on the treatment resident #1 had been receiving including where and how often and there were no notes available to Social Services Staff C from the mental health professionals (notes were obtained by facility after investigators were in facility). Care plan updates were discussed with Social Services Staff C who stated there was a safety sweep of her room done to be sure no sharp objects are available to her since she got back and that there was a safety plan/contract with resident #1 who was supposed to agree she would use coping skills and/or notify staff if there were feeling of increased depression or ideas of self-harm. Social Services Staff C was unable to provide social services counseling notes since resident #1 had been released from Geriatric Mental Health Program (5/14/2015) and before resident #1 attempted self-harm.

Based on record review and interview the facility failed to comprehensively assess and ensure timely notification of a physician regarding a change in condition for 1 of 5 (#1) residents. Failure to communicate the resident's condition to a phsyician caused harm to Resident #1 when treatment was delayed and she was sent to the hospital for urinary tract infection. Findings include: Resident #1 was a long term resident of the facility. She had [DIAGNOSES REDACTED]. According to Minimum Data Set (MDS an assessment tool used by the facility) she was alert and oriented and able to make her needs known. She required the assistance of staff to meet her needs to include toileting and was generally incontinent. Document review indicated Resident was ordered [MEDICATION NAME] (anti-biotic) on 7/9/14 for a urinary tract infection [MEDICAL CONDITION]. [MEDICATION NAME] was completed on 7/16. On 7/18 nursing documented, "Resident complaining of burning upon urination with abdominal pain. Urine is cloudy with clear coloring and has a strong odor. Resident ended a [MEDICATION NAME] therapy for UTI on 7/16. On routine pain management medication." There was no indication the physician was notified of the resident's complaint of pain with urination or the condition of the urine. After 7/18 there was no documentation of any assessment regarding urinary issues. On 7/22, according to nursing note written at 10:01, "MD (physician) called with new order to start [MEDICATION NAME] 100mg po (by mouth) BID (2 times a day) for 10 days for UTI. Obtain a UA (urine analysis) sample first prior to starting [MEDICATION NAME] therapy. UA with C&S (culture and sensitivity) order." There was no documentation to indicate why the physician was called for the order, as there was nothing in the documentation to indicate resident had any symptoms of a UTI. On 7/23, according to the documentation written at 00:01 the UA was collected and sent to the lab. Documentation also indicated the resident had no difficulty voiding and voided sufficient quantity. [MEDICATION NAME] was started as ordered. Documentation on 7/23 at 23:33 reported, "Resident very lethargic and slurring speech was unclear when RN (registered nurse) was giving 1600 (4p.m.) medications. RN called PCP (primary care physician) at 16:30 (4:30p.m.) and waited for return call back. Vital signs at 1600 BP (blood pressure) 110/80, P (pulse) 90, R (respirations) 20, SAT (oxygen saturation) 89-94%. At 1830 (6:30p.m.) retried calling PCP d/t (due to) no return call at this time. PCP returned call by 1900 (7p.m.) gave report to MD regarding resident lethargy and speech. On call PCP gave orders to hold all medication and to continue to monitor. Resident still unresponsive and her vitals at 2000 (8p.m.) was 112/68, P 70, R 18, SAT 85%. RN called PCP and got order to call 911 and send resident to ER (emergency room )." Resident was admitted to the hospital and diagnosed with [REDACTED]. There was no documentation to indicate what was done for the resident between 4p.m. and 8p.m. There was no evidence of further assessment of the resident between 4p.m. and 8p.m. Resident #3 was interviewed in her room on 7/30. She was alert and oriented and in no obvious distress. When asked about her recent visit to the hospital she said she went because she had a UTI. She stated, "I had a UTI for a long time but I could not convince the staff of it." "I have chronic pain, and I am always in pain so they thought it was my normal pain and I could not convince them I was miserable." Resident also stated she had been recently treated for [REDACTED]. She said they finally sent her to the hospital because she became lethargic and they were concerned. She had no concerns regarding her care since return to the facility and denied current pain related to UTI. LN (licensed nurse) A was interviewed on 7/30 while at her medication cart. She stated she documented her assessment of the resident in the chart on 7/23. She stated she assessed the resident every hour and she had a fever because they already knew she had a UTI. She had no explanation why her assessments were not documented as she contended, or why she waited so long to re-call the PCP when she got no response after the initial call. In the exit interview on 7/30, LN B stated she had been there the evening when Resident #3 was sent to the hospital and had assessed the resident. She stated the resident was responsive but would not respond to LN A. LN B acknowledged Resident was lethargic and had slurred speech. She admitted she did not document her assessment of the resident but would make a late entry. In the exit interview on 7/30, the DNS (Director of Nurses) said the documentation made by LN A was incorrect and did not reflect the resident accurately. She stated the resident was not unresponsive, she just did not respond to LN A. DNS and LN B indicated the lack of response from the resident was because of behaviors, "If she does not like you she will not talk to you, and LN A was a new nurse, so the resident did not respond to her." .

Based on interview, observation and record review, it was determined the facility failed to ensure 1 of 3 (#1) residents received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with a comprehensive assessment and plan of care. This failure caused harm to Resident #1 when she was left on a bed pan for over 8 hours. Findings include: All interviews took place 11/6/13 unless otherwise noted. Resident #1 had [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS) (tool used by the facility to assess residents) she was alert and oriented and able to make her needs known. Resident #1 required assistance of 2 staff and a mechanical lift for transfers and with mobility/positioning in the bed. She had a Foley catheter in place (tube that drains urine out of the bladder) and was generally continent of bowel. Resident #1 had history of pressure areas, ulcerations and abrasions to her buttocks. Review of the medical record, the progress noted written 10/21/13 at 11:25 indicated on 10/21/13 Resident #1 was found on the bed pan around 6:30a.m. and it was unclear how long she had been on the bed pan. Resident #1 had altered sensation related to disease process and stated she was unaware of the bed pan still being underneath. "Her skin was assessed and she was noted to have bilateral [DIAGNOSES REDACTED] (redness), blanching quickly to left, and non blanchable to right side. Closed blisters/bumps (no fluid blisters), 5 x 1 cm bumps to left outer buttock. [DIAGNOSES REDACTED] bilateral is 10cm length x 5 cm width. Resident grimaces with palpation of pressure areas. Open areas scattered across 5cm's bilaterally 5 x 0.5cm. No signs or symptoms of infection. Sanguineous (blood colored) scant drainage to open areas with moist pink bed, compound barrier applied to all reddened areas. Morning NAC instructed to turn every 2 hours from side back to side." In a nursing note written 11/5/13 at 01:24 it was written, "...this nurse observed three open areas of skin all in a line, the largest of which 0.5cm x 0.5cm on the right buttock that were bleeding. The resident stated that it was uncomfortable, but declined pain medication. .....NAC's have been instructed to turn side to side and avoid the back." Resident #1 was observed on 11/6/13 between the hours of 8:30a.m. and 11:50 a.m. During the time observed she was always on her back in her bed. Staff did come in around 9:00a.m. to pull her up in the bed to eat her breakfast. There was no evidence she was turned side to side even though she was to be re-positioned every two hours side to side according to the plan of care. She was not in any distress. When interviewed she could not stay on topic and did not recall being left on the bed pan for an extended period of time. She denied pain or discomfort. In an interview with S-A, she said the resident was on an air bed and she had been pulled up for breakfast. She did not know resident needed to be re-positioned side to side. S-A did agree Resident #1 was not able to adequately re-position herself in the bed to off load pressure from her buttocks.

Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable level of physical, mental and psychosocial well being for 1 of 3 residents (#1) when they failed to accurately assess hip pain and failed to take timely action to investigate the cause of her pain. This failure caused harm to Resident #1 when evaluation and treatment was delayed after the resident's exhibited increased pain and decreased physical function of the right hip which required hospitalization and she was diagnosed with [REDACTED]. Findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was cognitively intact. The record indicated she required assistance of one staff for transfers. On 8/30/13 at 10:37 pm, the Licensed Nurse (LN) documented, "a little after 10 pm, resident was noted to be out of bed and walking around confused. A skin tear was observed to her right wrist." At 11:20 pm, LN A documented "new skin tear caused when arm/wrist bathroom door when I found her confused and wobbly roaming her room and hit door before I got to her." According to facility documentation, approximately 10 minutes after Resident #1 was found walking by herself with a newly repaired left [MEDICAL CONDITION], the resident had complained of right hip pain (non-surgical hip) in addition to left hip pain and had required narcotic pain medication. On 8/31/13 at 10:52 am, the LN documented Resident #1 continued with soreness in her right hip and "no deformity or injury observed. Pain is with transfers." The resident required narcotic pain medication and required two staff person for transfers with a slider board because she was to be toe touch weight bearing on her left side, and because of the "soreness to right buttock/hip." On 9/30/13, Physical Therapist (PT) A was interviewed. She stated she had seen Resident #1 for therapy the morning after she was admitted (8/31/13). PT A stated Resident #1 stated, she was very sore in her right hip, because she had gotten up in the night and had fallen. PT A stated she went to the Charge Nurse (CN) A who looked at Resident #1's chart and said "I think she was confused, there's nothing here in the chart that states she fell ." Physical Therapist (PT) A documented "she did evaluate the patient and she did state she had fallen. The patient said she fell in the evening and wasn't sure who helped her up but that it was staff." She (Resident #1) was able to move and bear weight on the right hip but not on her left (surgical site). She discussed with the Dr. and the nurse about the pain. She reports the nurse called the hospital to follow up if she had fallen there and they did not have any report of her falling at the hospital. PT A stated the resident was limited in her abilities due to the increased pain in the right hip. PT A said she continued to report to nursing Resident #1's pain in her right hip and got no response, found the Nurse Practitioner (NP) managing the resident and reported it to her. PT A stated the NP also voiced her concerns to staff and ordered an x-ray. The PT A was aware that the resident was sent later to the hospital at the beginning of the week. On 9/2/13, the MD documented the resident was seen with Resident #1's family member, who also brought to the MD's attention Resident #1 was reporting complaints of pain in her right side. The resident reported to the MD, "she felt as if her bottom was not straight under her." The MD documented the pain was concerning and could be because of a fracture. Resident #1 was sent to a hospital on [DATE] for an evaluation related to condition changes. The facility was notified by the hospital, Resident #1 was diagnosed with [REDACTED]. Review of additional documentation revealed, Nursing Assistant (NA) A documented as saying Resident #1 "I never heard that she fell until Saturday (8/31/13) when she was working with PT (physical therapy). The patient said she fell and her hip hurt. I looked at it with the therapist but nothing was wrong and no bruise when we looked. The nurse looked at it too. " NA B documented that she was told "the patient was walking by herself and that she hit her arm on the door. We looked at her to make sure she didn't get hurt anywhere on her head. I know she kept walking alone and was confused." On 10/14/13, Resident #1 was interviewed sitting in her wheelchair at another facility. She stated she recalled the fall situation at the facility. Resident #1 stated she knew she was groggy, having just had surgery, anesthesia and pain medications. She awoke the night she was admitted , saw her walker across the room from her bed, and could not find her call light. She said she got up to get her walker, walked a few steps, became dizzy, and fell into the door jamb of the bathroom striking her right hip and side. Resident #1 stated, " Some guy, although I don't know who, saw me walking and yelled, "She's going to fall" which I did." Resident #1 clenched her fists and began shaking them, "It makes me so angry, they just kept telling me when I told them I fell -you're just imagining things. Over and over, they said I imagined it. It really hurt, my blood pressure went sky high and I had to be sent out to the hospital because of it, and I know I made my left hip worse too." They said I should have remembered to use my call light, they made me feel like it was my fault, which maybe it was, but I would holler for them, which they didn't like either. "Now, I'm here, I can't do as much therapy as I want because I have two broken legs. " Resident #1 began to cry, "I was my husband's care taker at home, he has Alzheimers, now he is at a different facility, and I am stuck here, not able to do much therapy, because the doctor says I can't walk on it, and not able to be with him-we haven't been apart for over [AGE] years." On 10/14/13 and 10/17/13, Resident #1's family members were interviewed. Each stated Resident #1 had notified them of her right hip pain after falling and injuring her wrist, which each saw, but neither were notified by the facility. Each requested the facility investigate. One family member stated several days after Resident #1 was sent to the hospital, he was notified an investigation was done, and the facility staff stated they had done nothing wrong because the resident was confused and had not fallen. Although the facility was told of the resident's report of a fall, the facility failure caused a delay in treatment when the allegation was not identified as a potential violation, record, investigate and report in accordance with State law to rule out neglect or mistreatment and implement interventions to protect the resident from further injury. The facility initiated an investigation after the resident was discharged from the facility and they were made aware of the resident's fracture.