**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to 1) thoroughly evaluate and monitor the significant changes in a resident's respiratory condition and increased sedation from medications given for 1 of 3 residents (Resident 1) reviewed for change of condition; 2) accurately assess and notify the provider timely of wound changes for prompt medical evaluation for 1 of 3 residents (Resident 11) reviewed for skin conditions; 3) follow through with specialized services for 2 of 2 residents (Resident 34 and 57) reviewed for quality of care. This failed practice placed residents at risk of not receiving the care and services they needed to prevent a decline in their health and/or mobility. Additionally, Resident 1 experienced actual harm due to a delay in obtaining prompt medical treatment that resulted in hospital intervention and treatment for over sedation and aspiration pneumonia (a lung infection that occurs when stomach contents or mouth secretions are inhaled into the lungs). Resident 11 experienced harm when there was a delay in notification to the provider that a wound had worsened and caused severe pain. Findings included . <Resident 1> The medical record showed the resident was admitted on [DATE] with diagnoses including a left thigh bone fracture with surgical repair, Rheumatoid arthritis (a chronic autoimmune disease that attacks healthy cells and tissues located in the joints of both sides of the body), heart disease, chronic oxygen use and chronic pain. The 03/13/2025 admission assessment showed Resident 1 was alert and oriented and made their needs known. During an interview and concurrent observation on 05/05/2025 at 2:45 PM, Resident 1 stated they were in pain and hurt all over and felt they could not breathe and felt that they were not receiving their oxygen. The resident was lying in bed with oxygen cannula (a medical device that delivers through two prongs that fit into the nostrils) connected to the oxygen concentrator. Resident 1's face showed their skin was gray, ashen (white) in color, pale and flakey. The residents' lips were dry with gummy/sticky substances at the corners of their mouth. Resident 1 was slow to respond to questions and closed their eyes and opened them between answering questions and spoke in a low soft voice. During an interview on 05/05/2025 at 2:50 PM, Staff I, Licensed Practical Nurse (LPN), stated that they informed staff of Resident 1's concerns with pain and shortness of breath. During an observation on 05/05/2025 at 3:00 PM, Staff C was in the resident's room and stated the resident's blood pressure and oxygen level were good at 93% (normal levels are 92% and above). During an interview on 05/05/2025 at 3:05 PM, Staff U, Advanced Registered Nurse Practitioner (ARNP), stated they thought the resident was experiencing some symptoms. Staff U stated Resident 1 might be having a stroke, had been responding slowly to their questions, and drowsy. Resident 1's oxygen level was at 94%. Review of the 05/05/2025 progress notes, documented at 3:20 PM, showed Staff U wrote an order for an additional Oxycodone (narcotic pain medication) dose for Resident 1's increased pain. Review of a progress note on 05/05/2025 at 3:38 PM showed new orders from Staff U for laboratory orders, a chest x-ray and an electrocardiogram (EKG-process of recording of heart beating). Review of a 05/05/2025 at 9:52 PM progress note showed no respiratory lung assessment documented and oxygen levels were at 94%. During an observation and concurrent interview on 05/06/2025 at 8:17 AM, Resident 1 was in their bed with the head of the bed at a 35-degree angle in which the resident had to partially lean forward to reach their over bed table to pick up items such as food on their tray then they had to lay their head back on the bed to swallow their food. Resident 1 was confused as to where they were and the day and season of the year. The resident had their oxygen nasal cannula connected to the oxygen concentrator. Resident 1's skin was pale white to their face with dry lips and oral mucus membranes. The resident complained of pain, shortness of breath and being weak. When the Surveyor immediately notified Staff EE, LPN, they stated it was their second day on that particular assignment at the facility and they were unfamiliar with resident conditions and would get information from the computer. Review of the 05/06/2025 at 8:41 AM progress note showed Resident 1 was in no distress and their oxygen level was 92%. Review of the 05/06/2025 at 1:00 PM progress note showed Resident 1 was observed to be lethargic (drowsy). Resident 1's blood pressure was 88/46 (normal blood pressure 120/80), oxygen level 61% (normal is 92% and above) oxygen. Resident 1 was sent to the hospital. The progress notes also stated the chest x-ray, EKG and laboratory request were not completed on 05/05/2025 from Staff U. Review of the 05/06/2025 Hospital emergency room (ER) physician's report showed the resident was confused and had been weaker than usual. According to the Emergency Medical Services (EMS) ER report the resident was unresponsive when they arrived at the facility. The ER physician's review of Resident 1's medications showed high risk medications to include Seroquel (an anti-psychotic medication), Gabapentin (an anti-convulsant medication used for pain) and Oxycodone (opioid [class of drugs used to reduce pain] narcotic pain reliever). The 05/06/2025 report showed Resident 1 experienced an opioid overdose due to the medication given together in a close amount of time and the accumulation of side effects produced by the resident's medications. Resident 1 was given Narcan (medication that blocks opioid receptors in the brain to reverse the overdose). Additionally, the 05/06/2025 hospital ER report showed Resident 1 had developed a respiratory sepsis (infection) which was diagnosed as Aspiration Pneumonia. During an interview on 05/08/2025 at 9:58 AM, Staff T, Registered Nurse (RN), stated they realized the nursing staff did not immediately act upon changes in Resident 1's condition. Additionally, the facility failed to monitor side effects of the multiple medications given to Resident 1 and would recommend changes. <Resident 11> Review of Resident 11's medical record showed they admitted on [DATE] with diagnoses to include end stage renal disease (your kidneys have failed and can no longer effectively filter waste and excess fluid from your blood) and osteomyelitis (a bone infection). The 02/12/2025 comprehensive assessment showed the residents 'cognition was moderately impaired and required substantial to maximum staff assistance with bed mobility and transfers. The assessment also showed Resident 11 was at risk for developing pressure injuries ( PIs- areas of skin and tissue damage caused by prolonged pressure, friciton, or sliding). Record review of a progress note titled Situation, Background, Assessment, and Recommendation (SBAR- a form used to communicate changes to the provider) dated 03/29/2025 showed Resident 11 acquired a PI to their coccyx (tailbone) measuring 1.0 centimeter (cm, a unit of measure) by 1.0 cm. The SBAR further showed the provider responded with new intervention orders. The March 2025 provider orders showed no new orders since 02/10/2025 had been initiated. Record review of the outside wound care consultant 04/14/2025 wound assessment showed the left coccyx wound was closed but remained high risk with new orders to use house emollient (softens and smooths dry, rough, or flaky skin) cream during perineal (the area between the genitals and the rectum) care and as needed. Record review of the April 2025 orders showed no new or updated orders were initiated for the coccyx wound on 04/14/2025. Record review of a communication form (a form used by nursing staff to communicate changes to the interdisciplinary team) dated 05/04/2025 showed Staff L, Licensed Practical Nurse, (LPN), stated Resident 11's coccyx wound was worsening and presented with eschar (a thick, dead tissue that forms over a wound, espicially after an injury). Staff L requested Resident 11 be seen by the outside wound consultant when they were in the facility for wound rounds on 05/05/2025. Further review of the record showed no evaluation or assessment of the worsening of the coccyx wound and no notification to the provider. During an interview on 05/07/2025 at 1:57 PM, Staff L stated the wound on Resident 11's coccyx was an unstageable PI related to the eschar covering the wound bed and they were unable to see what the wound looked like underneath the eschar. Staff L stated they were not sure why the communication form did not get addressed. During an interview on 05/07/2025 at 3:06 PM, Staff D, Resident Case Manager (RCM), stated they were unaware the area to Resident 11 's coccyx was opened, I thought it was all healed. An observation and concurrent interview on 05/07/2025 at 3:38 PM, with Staff C, RCM and Staff D, showed Staff D removed the foam dressing from Resident 11 's coccyx. The coccyx had a wound with eschar, full thickness skin loss, and surrounding the wound bed was red and moist tissue. Staff D and Staff C both stated they were not sure what stage the wound was but if they had to say they would stage it as an unstageable PI related to not being able to see the wound bed. Measurements of the wound were measured as: area 7.73 cm, length 3.28.cm, width 2.65 cm. An observation and concurrent interview on 05/07/2025 at 3:45 PM, showed Resident 11 lying in bed on their back. Resident 11 stated it is so painful to sit and lay on my bottom. The resident stated the medication helped but the wound still hurt them during the changing of their wound dressing. Record review of the May 2025 treatment medication record (TAR) showed Staff C had documented they completed the wound treatment for Resident 11's coccyx wound on 05/05/2025. During an interview on 05/07/2025 at 4:28PM, Staff C stated they signed that they completed the wound care on Resident 11 on 05/05/2025. Staff C stated they did not actually see the wound or do the wound care. Staff C stated they assumed the wound care consultant would be doing the wound care as Mondays were the days they came into the facility. Staff C looked at the outside wound consultant's notes from 05/05/2025 and stated, it does not look like she addressed the coccyx wound. Record review of the outside wound consultant 05/05/2025 wound assessment notes for Resident 11 showed no assessment of the coccyx wound. During an interview on 05/08/2025 at 8:09 AM, Staff L stated they could not remember exactly when the wound started changing. Staff L stated the process for an existing wound that worsened would be to notify the wound consultant and place a note in the binder for the doctor to review. Staff L stated they had asked the RCMs what to do and they stated to put it on the communications form and that they had done that on maybe Friday, Saturday or Sunday they would have to look they could not remember. Staff C stated they only did a visual on the wound and did not do an assessment or obtain measurements. Staff C stated they should have done a better assessment, measured the wound and called the provider for further orders on 05/04/2025. During an interview on 05/08/2025 at 8:24 AM, Staff A, Administrator, stated the process for communication forms from the nursing staff was they addressed all communication forms each morning in the morning meeting. Staff C stated Staff L's communication of Resident 11's coccyx wound worsening should have been addressed in the morning meeting on 05/05/2025. Staff A stated the expectation for Staff L was to do a complete assessment of Resident 11's coccyx wound including measurements and to notify the provider. Staff A stated the RCMs were responsible for doing an immediate follow-up on 05/05/2025 and the process was not followed. An observation and concurrent interview on 05/08/2025 at 8:39 AM showed Resident 11 lying in their bed on their back moaning oh it hurts, oh it hurts. Resident 11 stated their pain to their bottom was so painful and they just could not stand it. During an interview on 05/08/2025 at 8:58 AM, Staff V, Nursing Assistant (NA), stated they had seen the wound on Resident 11's coccyx on 05/05/2025 and it had looked the same as last week, it had looked the same for about three weeks. Staff V stated their process was to notify the nurse for any skin issues or changes and with Resident 11 they must notify the nurse every time the dressing comes off which is often, so the nurses were aware of the changes to the wound. During an interview on 05/08/2025 at 3:13 PM, Staff W, NA, stated they had seen the wound on Resident 11's coccyx the evening before (05/07/2025) and it had black areas and was open. Staff W stated they had also seen it the Friday before and the wound had been like that for about three weeks. Staff W stated the nurses were aware of the change in the wound because they had to go and get the nurse to place a new dressing when it came off. Staff W stated their process for any wound that was new or had changes was to immediately tell the nurse on the floor and all the nurses were aware of how Resident 11's wound looked. Staff W stated Resident 11 has had an increase in pain and they have had to reposition Resident 11 a lot more recently because it helped with the pain they had on their bottom. During an interview on 05/08/2025 at 3:18 PM, Staff Y, LPN, stated they had seen the wound to Resident 11's coccyx on Tuesday (05/06/2025) and they were unable to see the wound bed because there was a white, soft scab covering it. Staff Y stated they did not know how to stage a PI and they did not notify the provider because it was just a scab. During an interview on 05/08/2025 at 3:22 PM, Staff D stated they were responsible for entering new orders from the 04/14/2025 outside wound consultant visit. Staff D stated the order was missed. Staff D stated they became aware of Resident 11's coccyx wound on 05/07/2025 (3 days after the communication form was written). Staff D stated they and Staff C were responsible for reviewing communication forms from nursing staff during morning meetings. Staff C stated they missed the communication about Resident 11's coccyx wound on 05/05/2025 because they had worked the night before and arrived late. Staff C stated Staff D was on the floor that morning, and since the RCMs were not at the meeting, the communication for Resident 11's wound just got missed. Record review on 05/08/2025 of a Skin and wound evaluation opened by Staff C on 05/07/2025 showed the assessment was blank (four days after communication from Staff L on the worsening of Resident 11's coccyx wound.) During an interview on 05/08/2025 at 3:51 PM with Staff D and Staff C, Staff C stated they did not know how to assess the wound on Resident 11's coccyx. Staff C stated they waited for the outside wound consultant to call and complete their tele health (using technology like phone or video calls to deliver healthcare services remotely) assessment of the wound before they finished their assessment or changed any orders. Both Staff C and Staff D stated they were unaware identifying the stage of a wound was within their scope of practice as a nurse and should get some training. During an interview on 05/09/2025 at 9:23 AM, Staff U, Advanced Registered Nurse Practitioner, stated the process for a significant change in wound was to call them or the on-call provider for further orders immediately. Staff U stated the four-day delay in notifying a provider or completing an assessment was a delay in treatment because a wound could change quickly. Staff U stated a complete assessment of the wound should have been done immediately, and the correct process was not followed for Resident 11. During an interview on 05/09/2025 at 11:18 AM, Staff A stated Staff L should have completed a change in condition and notified the provider for further orders. Staff A stated the inter disciplinary team was responsible for reviewing all communications from the prior day/eve in the morning meetings and they did not do that. Staff A stated they expect immediate action on any significant change with wounds. Staff A stated there was a delay in treatment for Resident 11 from 05/04/2025 to 05/09/2025 and the overall process was not followed correctly for Resident 11. <Resident 34> Review of the resident's medical records showed they admitted with diagnoses to include Alzheimer's disease (a brain disorder that slowly destroys a person's memory and thinking skills) and malnutrition (an imbalance between the nutrients your body needs to function and the nutrients it gets). The 03/10/2025 comprehensive assessment showed Resident 34's cognition was severely impaired and had not experienced behaviors during the assessment period. The assessment showed Resident 34 was independent upon staff for their activities of daily living (ADLs, basic skills needed daily to maintain your health and wellbeing). An observation on 05/05/2025 at 12:19 PM, showed Resident 34 in the dining room, sitting in their wheelchair (w/c), leaning down towards their left side. Resident 34 was being assisted with their meal and the NA attempted to reposition the resident to an upright position but then went right back to leaning to their left side. Review of a 10/25/2024 physical therapy (PT) note showed Resident 34 was seen for a left sided lean. The note showed Resident 34 would have a wedge placed to the left side of the back rest of their w/c to assist with positioning. An observation and concurrent interview on 05/06/2025 at 10:08 AM, showed Resident 34 was observed sitting in their wheelchair (w/c), during an activity, leaning over to their left side with their head lying on a white bed pillow. The white pillow was resting on the arm rest of the w/c, and Resident 34's shoulder and left arm were resting in the seat, alongside them. The white pillow had a wet area the size of a softball from where Resident 34 had been lying and had drooled. Staff I, LPN, stated Resident 34 at times would sit straight up and then just gradually start tilting favoring their left side. Staff I stated staff had to assist and reposition the resident to sit up straight when they would lean over to their left side. Staff I stated they used the white pillow for positioning the resident. Staff I did not attempt to reposition Resident 34 to an upright position. There was no wedge observed in the w/c. Staff I stated they had not seen a wedge for Resident 34. An observation on 05/07/2025 at 10:11 AM, showed Resident 34 sitting outside on the patio, in their w/c, with their head resting on a white bed pillow, to their left side. Resident 34 had headphones on listening to music. Staff were not observed attempting to reposition Resident 34 to an upright position. There was no wedge observed in the w/c. During an interview on 05/08/2025 at 11:57 AM, Staff P, Physical Therapy Assistant/Rehab Director, stated Resident 34 was no longer using the wedge in the w/c due to the resident was throwing out the wedge and refusing to use it all the time. Staff P stated they could not find a care plan for the wedge or for the repositioning of the resident, when they were observed leaning to their left side. Staff P stated they did not know where the staff would have documented that the resident was throwing out or refusing the wedge. During an interview on 05/08/2025 at 2:50 PM, Staff D, Resident Care Manager (RCM), stated Staff P would communicate specialized equipment changes to them and then they would update the residents' care plan so staff would know what care to provide. Staff D stated conversations with the PT are falling through the cracks and the wedge was missed. I did not know anything about the wedge. Staff D stated they were not aware of Resident 34's wedge for their w/c so that did not get care planned, therefore staff were unaware Resident 34 was to use it and were unable to document on it. Staff D stated Resident 34 was now leaning more so needed a new PT evaluation. <Resident 57> Review of the resident's medical records showed they admitted with diagnoses to include dementia, liver transplantation (to remove a diseased or injured liver and replace it with a healthy liver from another person), and chronic hepatitis (inflammation of the liver). The 03/26/2025 comprehensive assessment showed Resident 57's cognition was severely impaired and was dependent upon staff for ADLs. Review of Resident 57's 12/23/2024 hospital discharge orders showed Instructions for Follow-up Providers .Patient should be referred to a nearby gastroenterologist (a medical doctor who specializes in conditions affecting the digestive system)/hepatologist (a medical doctor who specializes in conditions affecting the liver and the bile ducts) to manage the liver transplant and immunosuppression (drugs that prevent your immune system from attacking healthy cells and tissues by mistake) therapy. Review of Resident 57's 05/2025 physician orders showed orders on 12/31/2024 for a referral to Gastroenterology for Resident 57's diagnoses of long-term use of immunosuppressants, liver transplantation, hepatitis, and liver cancer (a disease resulting from uncontrolled growth and division of abnormal cells). This order was discontinued and reordered on the evening of 05/05/2025. Review of the provider's note dated 01/19/2025, showed for staff to continue with the current therapies for Resident 57's liver transplantation and routine follow-up with hepatologist. During an interview on 05/08/2025 at 2:43 PM, Staff D stated they did not have a reason for why the referrals were not followed through with other than I have been busy, and it was not in my vision .I just need to find time to work on them. During an interview on 05/08/2025 at 3:55 PM, Staff A, Administrator, stated they expected referrals to be followed through on within a week, but my expectations were more like three to four days. During an interview on 05/09/2025 at 8:42 AM, Staff B, Director of Nursing Services, stated they would have expected referrals to be processed and followed up on immediately and should not have taken this long. Reference WAC 388-97-1060(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the supervised fall risk residents received adequate supervision of one staff assistance in the dining room, and proper use of fall prevention devices for 1 of 5 residents (Resident 218) reviewed for falls. Resident 218 experienced harm when they fell forward out of their wheelchair when staff forgot to place the drop-down seat into the reclining position after transferring the resident to their wheelchair and sustained an injury to their left forehead that required hospital intervention for control of bleeding and stitches. Findings included . <Resident 218> Review of the medical record showed Resident 218 was admitted to the facility on [DATE] with diagnoses to include dementia (the loss of thinking, remembering, and reasoning to the extent that interferes with daily living), epilepsy (a brain condition that causes recurring seizures), lack of coordination, and repeated falls. The comprehensive assessment dated [DATE] showed Resident 218's cognition was severely impaired, dependent on staff for activities of daily living (ADL, fundamental tasks individuals perform daily for personal care) and was on hospice (a program that gives special care to people who are near the end of life). Review of the care plan dated 01/19/2025 showed Resident 218 was at risk for falls related to their cognitive loss, lack of safety awareness, and history of seizures with fall. Further review showed interventions which included ensuring appropriate footwear was in place, engage the drop seat (a reclining seat that prevents a resident from going forward) wheelchair for positioning, and monitoring Resident 218's whereabouts frequently, and assist them away from cluttered areas. Review of the facilities incident reporting log dated 04/13/2025 showed Resident 218 had a fall in the dining room that resulted in an injury. During an interview on 05/09/2025 at 11:29 AM, Staff L, Registered Nurse (RN), stated they were alerted to a resident who fell and needed assistance immediately. Upon entering the dining room, Staff L stated they found Resident 218 lying on their left side and was bleeding from their forehead. Staff L, RN stated that it took four staff members to transfer Resident 218 back into their wheelchair, wheel them to their room, and put the resident in bed. Staff L stated they had performed first aid to a laceration on Resident 218's forehead and called the hospice nurse. Staff L stated shortly after the hospice nurse arrived, they spoke to the physician about the resident's laceration and the continued bleeding. The hospice physician ordered Resident 218 to be sent to the emergency room for a higher level of evaluation and treatment. Review of the local hospital records dated 04/13/2025 at 9:32 AM showed that Resident 218's encounter visit was due to an unwitnessed fall when the resident sustained a three-centimeter (a unit of measure) laceration to the left forehead. Further review showed the resident responded to voice, had no pain and back to baseline for discharge to the facility. During an interview on 05/09/2025 at 11:59 AM Staff N, Nursing Assistant (NA), stated the post-fall procedure was that staff were to report the incident to a nurse and filled out a statement form by the end of shift. Staff N stated everyone on the floor was to fill out a witness form, so the facility knew where and what everyone was doing during the incident. During an interview on 05/12/2025 at 2:05 PM Staff O, NA, stated they were present during the incident with Resident 218. Staff O stated they had provided care to the resident, transferred the resident to their drop seat wheelchair, and then sat the resident in the dining room for breakfast. Staff O stated that they had forgotten to place the drop-down seat into the reclining position after transferring Resident 218 to their wheelchair and they had fallen forward a fall. Staff O stated the resident was sent to the emergency room for laceration to the forehead and came back to the facility with dissolvable stitches. During an interview on 05/09/2025 at 12:32 PM, Staff A, Administrator, acknowledged the investigation had not been completed. Reference: WAC 388-97-1060 (3)(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents at risk for weight loss were reviewed for of 1 of 5 sampled residents (Resident 1) reviewed for nutrition. Resident 1 experienced harm as they had a 18.67% significant, unplanned, weight loss from 03/13/2025 to 04/22/2025 (40 days) and was found to have low protein levels and skin issues. This placed residents at risk for unplanned weight changes, health complications and nutritional decline. Findings included . <Nutritional Assessments> Review of the facility's 05/01/2023 Food and Nutrition Services Policies and Procedures showed that residents were assessed on admission and routinely thereafter. The residents' goals, diet order, reason for their diet order and components of the diet were discussed with the residents as well as their likes and dislikes. The dietician completed comprehensive or on-going assessments of any residents with nutritional concerns. Residents with dietary concerns were assessed at least monthly. <Weights> Review of the facility's 06/15/2022 Weight policy, showed residents were weighed on admission, then weekly for four weeks, and then monthly thereafter. Significant weight change management would be reviewed by the licensed nurse for assessment. All significant weight changes must be communicated to the physician and the dietitian. All recommendations would be assessed by the Interdisciplinary team and noted in the progress notes and the care plan. <Resident 1> Review of the medical record showed the resident admitted to the facility on [DATE] with diagnoses to include skin breakdown (Moisture Associated Skin Dermatitis (MASD) skin irritation or erosion caused by prolong exposure to moisture such as urine or stool), protein caloric malnutrition (when a person does not consume enough proteins and calories to meet their nutritional needs), post-surgery of a fractured left thigh bone after a fall and Rheumatoid arthritis(a chronic autoimmune disease that attacks healthy cells and tissues located in the joints of both sides of the body) and a Urinary Tract infection(UTI). Review of the 03/13/2025 comprehensive assessment showed the resident was alert and oriented and weighed 175. 8 pounds. The diet showed Resident 1 was ordered a Lacto-ovo-vegetarian diet (this diet consisted of acceptable amounts of milk products and eggs but no animal meat products). During an observation on 05/05/2025 at 7:48 AM, Resident 1's skin to their tail bone was bright red with purple areas of skin color and redness to the sacrum (triangular bone at the base of the spine) and peeled brown skin to each side of the sacrum. During an interview and concurrent observation on 05/05/2025 at 12:20 PM, Resident 1 was in bed with the over the bed table placed in front of them and their lunch meal on the table. The resident stated they had not had much of an appetite and had lost some weight but were unsure of the amount of weight loss. The resident had eaten a quarter of their lunch meal and stated they had enough. Resident 1 stated they were not on a weight loss plan. Resident 1 stated that since they had been admitted to the facility, they had experienced two episodes of UTIs and had not felt the same since they felt weak and unable to participate with therapies. During an interview on 05/05/2025 at 12:45 PM, Staff W, Nursing Assistant, (NA), stated they do not offer other food if a resident does not want to eat. Staff W stated if the resident wanted something else they would ask the kitchen. Review of Resident 1's facility weights showed: Resident 1's height was five foot seven inches. • 03/13/2025 at 12:10 PM 175.8 pounds • 04/22/2025 at 1:46 PM 143.0 pounds • 05/01/2025 at 2:13 PM 151.6 pounds • 04/29/2025 at 11:05 AM 151.6 pounds Review of the total weight loss percentage from 03/13/2025 to 04/22/2025 (40 days) was 18.67% (34.8 pound weight loss), a significant weight loss. Review of the percentage of weight gain from 04/22/2025 and 05/01/2025 was 8.6 pounds. Review of the total weight loss percentage from 03/13/2025 to 05/01/2025 (49 days) was 13.77% (a 32.4 pound eight loss), significant weight loss. Review of Resident 1's 03/10/2025 care plan showed the resident was at nutritional risk related to poor intake at times. The care plan goal was that the resident would consume 75% to 100% of two meals a day. Care plan interventions included encouragement of 100% consumption of all fluids, honor the resident's food preferences within meal plan and evaluate for proper consistency of diet. A review of the 03/14/2025 Nutrition progress note showed a Nutrition Assessment was completed. There were no other nutritional assessments or progress notes after the 03/14/2025 assessment as of 05/05/2025. The Nursing Assistant Task charting from 04/09/2025 through 05/05/2025 showed the documented meals consumed by Resident 1 ranged from 25% to 75%. Review of Resident 1's 05/06/2025 hospital emergency room (ER) visit showed laboratory blood work that the resident had a low protein level of 2.3 (normal reference range is 3.4-5.0), Sodium (an electrolyte) was 132 (normal reference range 135-145). Resident 1 tested positive for pneumonia (respiratory infection) due to aspiration of food and fluids according to the 05/06/2025 physician's emergency room report. Resident 1 was sent to the ER on [DATE] at 1:00 PM due to breathing difficulties and non-responsiveness. During an interview on 05/07/2025 at 10:03 AM, Staff U, Advanced Registered Nurse Practitioner (ARNP), stated they were unaware Resident 1 had weight loss and had not been eating well. Staff U stated Resident 1's skin issue would affect their nutrition. Staff U stated Resident 1 probably had fluid buildup in their lungs due to not being out of bed and not moving around much that affected the resident's respiratory issues. During an interview on 05/07/2025 at 10:45 AM, Staff C, Resident Case Manager (RCM), stated they were to inform the Interdisciplinary Team (IDT) about resident's skin issues and weight loss. The dietician, RCMs, and the ARNP were to be involved. Resident 1 was not included for the nutrition at risk discussion for weight loss. Staff C stated there was no report to the IDT concerning Resident 1's significant weight loss. During an interview on 05/09/2025 at 11:17 AM, Staff Q, Registered Dietician, stated they were not aware of Resident 1's weight loss. Staff Q stated they did their assessment and the resident's weight was 175.6 pounds. Staff Q stated Resident 1's documented intake was normal and had no swallowing or chewing issues. Staff Q stated the facility may have not accurately weighed the resident potentially showing a discrepancy in the process. Staff Q stated they completed the comprehensive nutrition assessment within seven days from admission. Staff Q stated they were onsite at the facility one day a month but did have weekly nutrition at risk meetings over the phone with the staff. Staff Q stated that the information on weights and food consumption was not always accurate and if a resident refused meals there was no further documentation of why they refused or what was offered to the residents in place of a meal. Staff Q stated there was a lack of accuracy in the information given and they would try to get clarity. Staff Q stated they did recently notice on 05/03/2025 that Resident 1 was not eating their 75% food consumption. Staff Q stated Resident 1 also had skin issues and there were gaps in information about skin issues and how quickly they were caught and acted upon. Staff Q stated there was not a robust type of meeting, there were missing parts of information about the residents' condition and the care for the residents needed to be better. During an interview on 05/09/2025 at 11:50 AM, Staff A, Administrator, stated they realized the lack of through nutritional at risk and resident weight reviews. Staff A stated they recognized the situation and had to work on the discrepancy. Reference WAC 388-97-1060-(3)(h)