Does FIR LANE CARE have any serious inspection findings?

Yes, FIR LANE CARE has 1 Immediate Jeopardy citation on record, which represent the most serious type of deficiency. The facility has 79 total deficiencies from recent inspections.

What are the staffing levels at FIR LANE CARE?

FIR LANE CARE has a four-star staffing rating from CMS with 0.63 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is FIR LANE CARE located?

FIR LANE CARE is located in SHELTON, WA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does FIR LANE CARE have?

FIR LANE CARE has 135 certified beds.

Who owns FIR LANE CARE?

FIR LANE CARE is a for profit - limited liability company facility and is part of the CALDERA CARE chain.

What questions should families ask when visiting FIR LANE CARE?

Families visiting FIR LANE CARE should ask about staff retention and training programs, what corrective actions were taken after fines, how serious violations have been addressed. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does FIR LANE CARE compare to other nursing homes?

FIR LANE CARE has a 1-star overall rating, which is below average compared to other nursing homes in WA. Families should carefully review inspection findings and consider alternatives.

FIR LANE CARE

Name: FIR LANE CARE
Address: 2430 NORTH 13TH STREET, SHELTON, WA, 98584, US
Telephone: (360) 426-1651
Rating: 1.0

2430 NORTH 13TH STREET, SHELTON, WA 98584 · (360) 426-1651

For profit - Limited Liability company 135 Beds CALDERA CARE Data: November 2025 1 Immediate Jeopardy citation

Trust Grade

0/100

#172 of 190 in WA

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Last Inspection: June 2025

Inspected within the last 6 months. Data reflects current conditions.

Overview

Fir Lane Care in Shelton, Washington has a Trust Grade of F, which indicates significant concerns regarding the quality of care provided. Ranking #172 out of 190 facilities in Washington places it in the bottom half, and as #2 out of 2 in Mason County, it means there is only one other option that is better. The facility's situation is worsening, with the number of reported issues increasing from 23 in 2024 to 29 in 2025. While staffing received a relatively strong rating of 4 out of 5 stars with a 58% turnover rate, which is above the state average, the overall quality measures are concerning, scoring only 2 out of 5. Additionally, the facility has faced $159,534 in fines, which is higher than 82% of other facilities in the state, suggesting ongoing compliance problems. There have been serious incidents, such as a resident suffering a significant burn due to unsupervised access to a heater, and another resident not receiving critical seizure medication, leading to hospitalization. Overall, while some staffing aspects are positive, the facility has significant safety and compliance issues that families should carefully consider.

Trust Score: F
In Washington: #172/190
Safety Record: High Risk
Inspections: Getting Worse
Staff Stability: 58% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: $159,534 in fines. Lower than most Washington facilities. Relatively clean record.
Skilled Nurses: Each resident gets 37 minutes of Registered Nurse (RN) attention daily — about average for Washington. RNs are the most trained staff who monitor for health changes.
Violations: 79 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★★★★☆

4.0

Staff Levels

★★☆☆☆

2.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

↔

Stable

2024: 23 issues

2025: 29 issues

The Good

4-Star Staffing Rating · Above-average nurse staffing levels
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in staffing levels, fire safety.

The Bad

1-Star Overall Rating

Below Washington average (3.2)

Significant quality concerns identified by CMS

Staff Turnover: 58%

12pts above Washington avg (46%)

Frequent staff changes - ask about care continuity

Federal Fines: $159,534

Well above median ($33,413)

Significant penalties indicating serious issues

Chain: CALDERA CARE

Part of a multi-facility chain

Ask about local staffing decisions and management

Staff turnover is elevated (58%)

10 points above Washington average of 48%

The Ugly 79 deficiencies on record

1 life-threatening 3 actual harm

Aug 2025 3 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the Resident Representative of multiple falls for 1 of 3 (Resident 3) residents reviewed. This failure placed residents and their representatives at risk of not being able to participate in resident care decisions, providing support, delayed medical treatment, and a diminished quality of life.Findings included.Resident 3 was admitted on [DATE] with a diagnosis of a stroke with hemiplegia (paralysis affecting one side of the body). The Minimum Data Set, an assessment tool, dated 06/27/2025, showed Resident 3 required substantial assistance for bed mobility, transfers and had severe cognitive impairment.On 08/14/2025 at 3:32 PM, Resident 3's representative said when they met with facility staff about discharge, a staff member told them Resident 3 had five falls since admission. Resident 3's representative said they had been notified of one fall since Resident 3 had been admitted to the facility but had not been made aware of multiple falls, I did not know he had been falling; I was here every day, I don't know why they didn't tell me?Review of the facility incident report, dated 06/24/2025 at 2300 (11:00 PM), showed Resident 3 fell and was found on the floor next to their bed. The report showed Resident 3 sustained a scratch on their arm. Facility staff initiated neurological checks and obtained vital signs. The report showed the physician and Director of Nursing were notified on 06/25/2025. The report had a conclusion note, dated 06/26/2025, that showed the family and physician were notified.Review of the facility incident report, dated 06/26/2025 at 23:05 (11:05 PM), showed Resident 3 was found prone (face down) parallel to the bed. The report showed no notifications completed. In the notes section of the report, dated 06/27/2025, showed the family and physician were notified.Review of the facility incident report, dated 06/27/2025 at 04:45 (4:45 AM), showed Resident 3 was found prone on floor parallel to the bed. The report showed the family member was notified on 06/27/2025 at 12:47 PM.Resident 3's progress note, dated 06/27/2025, showed the resident discharged home with family member.On 08/20/2025 at 2:49 PM, Staff E, Regional Clinical Nurse, said they had reviewed the incident reports and completed the conclusion/note section of the report. Staff E said they had not contacted the family member to notify them of the falls. Staff E said they did not remember the details of the incident reports but assumed they asked the staff if the family had been notified. Staff E acknowledged they would not have interviewed the licensed nurses that were assigned at the time of the falls due to the falls occurring on night shift. Staff E said the expectation was that the staff notify the resident's representative at the time of the fall unless they had requested to not be notified.Reference WAC 388-97-0320

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to accurately document and reconcile controlled substances for 2 of 3 (Resident 1 and 2) residents reviewed. This failure placed residents at risk for misappropriation of medications, missed medications and possible diversion of controlled substances.Findings included.<Policy>Review of the facility's undated policy titled, Med Administration, showed that staff were to prepare medication for administration and log out the drug on the controlled drug declining inventory page in the bound Controlled Substance Record Book and include the date, time, number/amount of drug and signature. The policy showed that staff were to document all controlled drugs had been counted at each change of shift.<Resident 1>Resident 1 was admitted to the facility on [DATE] with a diagnosis of malnutrition.Resident 1's physician orders, dated 08/06/2025, showed an order to administer dronabinol (controlled substance used to stimulate appetite) 5 milligrams two times a day for malnutrition. On 08/13/2025 at 10:20 AM, Staff A, Registered Nurse, was observed preparing Resident 1's dronabinol medication for administration. Staff A documented the medication on the declining inventory page in the Controlled Substance Record Book, including the date, time, and amount. The inventory page was observed to have an entry dated 08/10/2025 at 2022 (10:22 PM) immediately before Staff A's entry of 08/13/2025 at 10:20. When asked why there was no documentation for 08/11/2025 and 08/12/2025, Staff A said, oh I guess I forgot to document those days, but I did administer the medication. Staff A proceeded to enter documentation for 08/11/2025 and 08/12/2025. Staff A said they had not counted the dronabinol at the change of shifts on 08/10/2025, 08/11/2025 and 08/12/2025, because they only had counted the medications that were in the medication cart and the dronabinol was stored in a medication refrigerator.Resident 1's Medication Administration Record, dated 08/01/2025 through 08/31/2025, showed Resident 1's dronabinol was administered two times a day from 08/01/2025 through 08/12/2025 and one time on 08/13/2025.Review of Resident 1's inventory page for their dronabinol in the Controlled Substance Record Book, showed one administration time on 08/04/2025 and 08/06/2025, three entries on 08/10/2025 and one entry date on 08/11/2025 and 08/12/2025.<Resident 2>Resident 2 was admitted to the facility on [DATE].Resident 2's physician orders showed an order for oxycodone (controlled substance for pain) every six hours as needed for moderate to severe pain.Review of the facility incident report, dated 07/11/2025, showed the staff discovered documentation on Resident 2's inventory page for their oxycodone in the Controlled Substance Record book that did not have the time documented. The report further showed Resident 2 was not in the facility on multiple days the medication was documented to have been administered. The report showed the facility concluded there were irregularities identified in the Controlled Substance Record Book and concerns for potential controlled substance diversion activity and/or misappropriation of the resident's medication. On 08/21/2025 at 12:23 PM, Staff B, Director of Nursing, said they expected staff to document the date and time they administer the medication in the electronic medical record and in the Controlled Substance Record Book at the time of administration. Staff B said the staff should be reviewing all the pages of the Controlled Substance Record Book and ensuring the medication count is correct during each shift change and not just counting the medications located in the medication cart. Staff B said there were multiple documentation errors, and the licensed nurses had not followed the procedure for documenting and reconciling controlled substances.Reference WAC 388-97-1300 (1)(b)(i-ii)

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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Based on interviews, observations and record review, facility staff failed to perform hand hygiene during medication administration for 2 of 3 (Staff C and D) staff reviewed for infection control. This failure placed residents at risk for the spread of infection and a diminished quality of life. Findings included.Review of the facility's undated policy, Handwashing/Hand Hygiene, showed hand hygiene was indicated: immediately before touching a patient, after touching a resident, after touching the resident's environment and immediately after glove removal.On 08/14/2025 at 3:32 PM, Collateral Contact 1 (CC1) said they visited their family member daily and when the nurses came in the room to give the resident their medications, they did not wash their hands coming and/or going. CC1 said they didn't wear gloves when administering eye drops and/or wash their hands when they finished.On 08/20/2025 at 10:43 AM, Staff C, Registered Nurse (RN), was observed entering Resident 4's room without performing hand hygiene. Staff C took Resident 4's blood pressure, and temperature using a thermometer on the forehead. Staff C exited the room without performing hand hygiene, took their pen out of their pocket and documented on their paper. Staff C proceeded to perform hand hygiene and then pulled their keys out of their pocket, opened the medication cart, took the medications out of the cart, used the computer mouse to document in the electronic medical record and entered Resident 4's room without performing hand hygiene. Staff C administered the medications to the resident, collected their used drinking cup and paper pill container and exited the room without performing hand hygiene. Staff C proceeded to the medication cart and used the computer mouse to document in the electronic medical record.08/20/2025 at 11:18 AM, Staff C, RN, entered Resident 5's room without performing hand hygiene, placed their hands around the resident's head to speak into their ear, held their arm to place the blood pressure cuff on the resident's arm and proceeded to take their blood pressure and temperature with the thermometer on the forehead. Staff C exited the room without performing hand hygiene, obtained the pen from their pocket and documented on their paper. Staff C gathered Resident 5's medications from the medication cart and entered the resident's room without performing hand hygiene. Staff C adjusted the resident's linens, moved their pillows, and their bedside table. Staff C put on gloves and administered the resident's eye drops, removed the gloves and without performing hand hygiene proceeded to apply a medication patch to the resident's back. Staff C exited the room without performing hand hygiene, took the keys out of their pocket and opened the medication cart and placed the keys back in their pocket.On 08/20/2025 at 12:42 PM, Staff D, Licensed Practical Nurse, was observed entering Resident 6's room after performing hand hygiene and donning a gown and gloves. A sign on Resident 6's door showed enhanced barrier precautions (infection control measure to prevent spread of infection) were in place. Staff D was observed preparing to administer intravenous (medications administered in the veins) medication. Staff D used a syringe to flush the resident's intravenous access site in their arm and attempted to prepare the intravenous solution for administration before discovering it would not mix adequately. Staff D proceeded to remove their gown and gloves and exited the room without performing hand hygiene. Staff D removed keys from their pocket, opened the medication cart, assessed the contents of the cart, closed the cart and proceeded down the hallway.On 08/21/2025 at 12:23 PM, Staff B, Director of Nursing, said staff were expected to perform hand hygiene when entering and exiting resident rooms, after removing gloves and before and after touching residents and/or their environment.Reference WAC 388-97-1320 (1)(c)

Jun 2025 20 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to honor resident rights related to medical appointments for 1 of 1 resident (Resident 70) reviewed for resident rights. This failure placed residents at risk of delay in care, emotional upset, and a diminished quality of life. Findings included . Resident 70 was admitted to the facility on [DATE]. The admission Minimum Data Set Assessment, dated 04/29/2025, showed Resident 70 was understood and understands, and was cognitively intact. Review of an email dated 05/16/2025 at 11:25 AM, by Staff L, Transportation, showed Resident 70 had an appointment scheduled for 06/04/2025 with Neurology. During an interview on 06/06/2025 at 12:54 PM, Resident 70 said they were promised diagnostic testing when they came to the facility, as they were unsure of why they were no longer able to walk. Resident 70 reported they were supposed to have a nerve conduction test done on their lower spine, but transportation was not arranged and the appointment was canceled. Resident 70 said they had not been informed by the facility, and had only found out because they looked at their email and discovered the appointment had been canceled. Resident 70 said the appointment was rescheduled for 07/09/2025, and they did not want to wait another month (to get possible answers). During an interview on 06/06/2025 at 1:38 PM, Staff L, Transportation, said they had made an error and had not scheduled transportation for Resident 70, and the appointment was canceled due to the lack of transportation. During an interview on 06/06/2025 at 2:09 PM, Resident 70 said they had been waiting for that appointment for a month, and were upset that it was canceled. Resident 70 stated, I can't wait another month, someone needs to get on the phone and raise hell to get me an earlier appointment. I want to find out what the heck is wrong with me. During an interview on 06/09/2025 at 9:42 AM, Staff B, Director of Nursing Services, when asked if it met expectations that Resident 70 had missed an appointment because of a lack of transportation, said no. Reference WAC 388-97-0180(1-4) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident 52 was admitted to the facility on [DATE] and has a diagnosis of depression. Resident 52's Quarterly MDS, dated [DATE] documented the resident was cognitively intact and was dependent to moderate assist with activities of daily living. Resident 52's EHR documented Sertraline, an antidepressant, was ordered on 02/24/2025 and the consent was signed on 03/21/2025. On 06/09/2025 at 9:49 AM Staff C, RCM/RN said we should have had a consent done when the order was placed. I am not sure why this was missed. On 06/09/2025 at 11:07 AM Staff B, Director of Nursing Service said the expectation was for the resident provide consent before the medication was given. Reference WAC 388-97-0300 (3)(a) Based on interview and record review the facility failed to ensure residents and/or resident representatives were informed and provided consent before administering psychotropic (mind altering) medication for 2 of 6 sampled residents (Residents 52 and 283) reviewed for right to be informed about treatment decisions. This failure placed residents and/or resident representatives at risk of not being fully informed of the risks and benefits before making decisions about medications and a diminished quality of life. Findings included . 1) Resident 283 admitted to the facility on [DATE]. The admission Minimum Data Set, (MDS, an assessment tool), dated 05/27/2025, documented Resident 283 was severely cognitively impaired. Resident 283 had a court appointed guardian (appointed legal representative who makes decisions). A review of consents in the Electronic Health Record (EHR) showed there were consents for the medications Mirtazapine, Risperidone and Lorazepam, all psychotropic medications. All three consents documented Resident 283's guardian had given verbal consent for these medications on 05/23/2025. The May 2025 Medication Administration Record documented both Mirtazapine and Risperidone had been administered to Resident 283 on 05/22/2025. On 06/06/2025 at 8:55 AM, in a phone interview, Resident 283's guardian said facility staff had not alerted them to Resident 283's arrival on 05/22/2025 and consents were not obtained for medications until 05/23/2025. Resident 283's guardian said the facility did not fax them the medication consents until 05/23/2025, at which point she crossed out the date on the consents (05/22/2025) and inserted the date of 05/23/2025 noting on the consents that verbal consent was not obtained on 05/22/2025. Resident 283's guardian said they then faxed the corrected consents back to the facility. Resident 283's guardian provided copies of the corrected consents with the fax date of 05/23/2025. On 06/06/2025 at 11:19 AM, Staff C, Resident Care Manager(RCM)/Registered Nurse(RN), said the expectation was for consents of psychotropic medications to be obtained prior to the first dose being given. Staff C said the evening nurse had not called Resident 283's guardian on 05/22/2025 when Resident 283 arrived at the facility and that she herself had faxed the consents the next day (05/23/2025) and believed they had already been filled out by the evening nurse. When asked if it met her expectations that Resident 283 received medications prior to their guardian giving consent, Staff C said consents should be obtained prior to medication administration.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0605 (Tag F0605)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure psychotropic medications (any drug that affects the brain activities associated with mental processes and behavior) were regularly monitored, documented on and/or monthly pharmacist recommendations were acted upon timely, for 2 of 5 residents (Residents 54 &19) reviewed for unnecessary medication. This failure placed residents at risk of unnecessary medication usage, increase in side effects without intervention, and a diminished quality of life. Findings included . 1) Resident 54 was admitted to the facility on [DATE] with diagnoses of depression, anxiety disorder, dementia with psychotic disturbance, and psychosis (disconnection from reality). The Quarterly Minimum Data Set Assessment (MDS), dated [DATE], showed Resident 54 was cognitively intact. Review of the electronic health record (EHR), showed Resident 54 was taking scheduled psychotropic medications including antipsychotic (a class of psychotropic medication primarily used to manage psychosis) and antidepressant (a class of medications used to treat major depressive disorder, anxiety disorders, chronic pain, and addiction) medications. Review of Resident 54's May 2025 Medication Administration Record (MAR), showed missing documentation for the behavior monitor of delusions, hallucinations, and paranoia on 05/07/2025, 05/13/2025, 05/14/2025, and 05/23/2025. Resident 54's side effect monitor for antipsychotic medications had missing documentation on 05/07/2025, 05/13/2025, 05/14/2025, and 05/23/2025. Resident 54's antidepressant side effect monitor had no documentation found for May or June 2025. During an interview on 06/05/2025 at 12:40 PM, Staff C, Resident Care Manager (RCM)/Registered Nurse, said psychotropic medications should have side effect monitoring done, and their expectation was for it to be documented. When asked about Resident 54's antidepressant side effect monitor and no documentation for May or June 2025, Staff C said this did not meet expectations. When asked about Resident 54's antipsychotic side effect monitor having missing documentation in May 2025, Staff C said this did not meet expectations. Regarding Resident 54's behavior monitor for delusions, hallucinations, paranoia having missing documentation in May 2025, said this did not meet expectations. During an interview on 06/09/2025 at 9:42 AM, Staff B, Director of Nursing Services, was asked what their expectation was for psychotropic medications being monitored for adverse side effects. Staff B said they should be monitored daily, every shift. When asked about behavior monitors, said they should be monitored daily, every shift. 2) Resident 19 was admitted to the facility on [DATE] with diagnoses of bipolar disorder (episodes of extreme mood swings) and depression. Review of the Medicare 5 Day MDS, dated [DATE], showed Resident 19 was understood and understands, and was cognitively intact. Review of the EHR showed Resident 19 was taking two antidepressants, one antipsychotic, and one mood stabilizer medication. Review of Resident 19's orders showed they were taking a mood stabilizer called lamotrigine, which is an anticonvulsant medication, once a day for bipolar disorder. Review of Resident 19's EHR showed no adverse side effects monitoring for this medication. Review of Resident 19's EHR showed they were taking an antipsychotic medication for bipolar disorder, which required the use of the Abnormal Involuntary Movement Scale (AIMS, tool used to monitor for drug induced movement disorder) for monitoring. AIMS testing was completed on 10/07/2024 and 04/16/2025. Review of the Monthly Pharmacist Recommendation Binder, showed Resident 19 restarted an antipsychotic medication in February, and there was a recommendation signed on 02/20/2025 for staff to make sure the AIMS had been done. During an interview on 06/06/2025 at 10:30 AM, Staff D, RCM/Licensed Practical Nurse, after looking in the EHR, said they did not see any side effect monitoring done for Resident 19's lamotrigine medication and they would expect there to be. When asked about the recommendation signed off on 02/20/2025 for an AIMS, said it looked like it was not done, and the 04/16/2025 AIMS test would not be considered timely. Staff D said their expectations was for recommendations to be followed through on and done timely. Reference WAC 388-97-0620 (1)(a) ,1060 (3)(k)(i) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure allegations of abuse were reported to the State Agency within 24 hours for 1 of 2 resident (Resident 3) reviewed for abuse. This failure placed residents at risk of incidents not being reported and at risk for abuse and neglect. Findings included . Resident 3 admitted to the facility on [DATE]. The admission Minimum Data Set (an assessment tool), dated 03/21/2025, documented Resident 3 was severely cognitively impaired. A social services progress note, dated 05/16/2025, documented that Resident 3 had stated, they hit me. Review of the facility investigation logs showed the allegation was not reported to the State Agency until 05/19/2025, 3 days after the allegation. On 06/04/2025 at 2:15 PM, Staff B, Director of Nursing Services, said an allegation of abuse should be reported to the State Agency within two 2 hours. Regarding Resident 3's allegation on 05/16/2025 not being reported to the State Agency until 05/19/2025, Staff B said it did not meet her expectations. Reference WAC 388-97-0640 (5)(a) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident 67 was admitted to the facility on [DATE]. Review of the admission MDS, dated [DATE], showed the resident was cognitively intact, had Stage 3 (Full-thickness skin loss in which fat is visible in the ulcer) and Stage 4 (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) pressure injuries, required substantial to maximal assistance with bed mobility, and had an indwelling urinary catheter. A Urinary Incontinence and Indwelling Catheter care area assessment, completed 03/04/2025, documented Resident 67 required an indwelling catheter secondary to Stage 3 and Stage 4 pressure injuries to the sacrum and right buttock. Review of the urinary catheter care plan, revised 04/17/2025, showed there was no indication or justification for use documented. The goals were identified as: will remain free from urinary tract infections and other catheter related complications; and will have the catheter removed in the absence of indications for use. On 06/05/2025 at 10:32 AM, Staff S, Resident Care Manager, said Resident 67's care plan should have identified the purpose of the indwelling catheter was to prevent contamination of the resident's Stage 3 and 4 pressure ulcers to promote wound healing, but acknowledged it did not. Based on interview and record review, the facility failed to ensure person centered care plans were completed to address all aspects of resident care for 3 of 24 sampled residents (Resident 69, 67, and 19) reviewed for comprehensive care plans. These failures placed residents at risk for inconsistent and/or inadequate care and treatment and a diminished quality of care. Findings included . 1) Resident 69 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS, an assessment tool) dated 03/20/2025 documented the resident was cognitively intact. A review of the Electronic Heath Record (EHR) showed Resident 69 had a focus of therapeutic nutritional risk care plan with a goal and interventions initiated on 03/05/2025. On 06/09/2025 at 10:07 AM, Staff W, Dietician, said while looking at the Resident 69's theraputic nutrition care plan that it needed to be updated and said, thank you for pointing that out. Staff S said she would add information such as a history of refusal, encourage food and fluid intake, provide a supplement as ordered, inadequate nutrition and weight loss may be unavoidable, inability to consume adequate nutrition, refusal of purposed interventions, psych provider to assessed, and honor their wishes as a [age of resident in years] old. On 06/09/2025 11:07 AM, Staff B, Director of Nursing, said her expectation would be that the care plan be patient specific based on their needs.3) Resident 19 was admitted to the facility on [DATE] and had a diagnosis of anemia (low levels of red blood cells or hemoglobin). The Medicare 5 Day MDS, dated [DATE], showed Resident 19 was cognitively intact, and wore corrective lenses for moderately impaired vision. Review of the EHR showed Resident 19 was hospitalized from [DATE] to 04/14/2025. Review of Resident 19's care plans showed their anemia diagnosis was listed as a potential cause for risk for falls and risk for nutrition, but there was not a specific care plan for anemia with goals and interventions to prevent rehospitalization. There was no information related to anemia on risk factors, signs/symptoms or monitoring considerations, and it did not include any information on the recent blood transfusions. Review of Resident 19's alteration in sensory/communication related to visual disturbance care plan did not mention any information on them wearing glasses or their needs related to wearing glasses. During an interview on 06/02/2025 at 10:50 AM, Resident 19 reported they wore glasses, had trouble reading even with their glasses on, and needed assistance by staff to read. Resident 19 said their last hospitalization was for a blood transfusion. Review of a provider note from 05/28/2025 documented Resident 19 was hospitalized on [DATE] for multiple concerns including acute-chronic anemia receiving blood transfusion. Review of other progress note from 05/29/2025 at 4:32 PM, showed Resident 19 had a blood transfusion that day and documented, Resident just returned from clinic, he states it went well and he feels great. Will continue to monitor for adverse effects of transfusion and Nurse reported that he tolerated well, two units packed RBC's [red blood cells] received, 6.6 hgb [hemoglobin], 18.9 hct [hematocrit] pre-infusion. Will call back once post-infusion labs are received. During an interview on 06/06/2025 at 10:30 AM, Staff D, RCM/Licensed Practical Nurse, reviewed Resident 19's EHR and said there was not a specific care plan for anemia (with goals and interventions) or blood transfusions, and there should be. During an interview on 06/09/2025 at 9:42 AM, Staff B, DNS, said they expected care plans to be updated with changes, quarterly with MDS assessments, and on admission with baseline. When asked about Resident 19's care plans and anemia diagnosis, Staff B did agree that blood transfusions were not included in the care plan. When asked how the facility updated care plans to prevent future hospitalizations, Staff B said they should be reviewing the care plan on return from the hospital. When asked if blood transfusions should be added to the care plan, Staff B said they would add a history of blood transfusions. When asked if Resident 19's glasses usage should have been added to the care plan, Staff B said yes. Reference WAC 388-97 -1020(2)(c)(d), (5)(b) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) On 06/05/2025 at 8:06 AM, during a medication administration observation and record review, it was noted that Resident 450 had a current order for Aspirin 81 mg tablet, in a chewable form. On 06/05/2025 at 8:15 AM, Staff Q, LPN, provided Resident 450 with a small plastic cup with multiple medications in it, including the chewable Aspirin. Resident 450 was observed taking all the medications with a drink of water, including the chewable medication. On 06/05/2025 at 8:36 AM, Staff Q, regarding the chewable medication being swallowed and not chewed, said Resident 450 requests to take them all together. Staff Q said she had to give them the chewable form of the medication, rather than the non-chewable form, because that was how it was ordered. On 06/09/2025 at 10:48 AM, Staff C, RCM/RN, when asked what the process was if a resident preferred a medication in a different form, said staff could get orders from the doctor to change it to the right form, such as with chewable aspirin, and staff could contact the doctor. When it was explained staff had reported Resident 450 preferred their tablets be taken in non-chewable forms and had been given their chewable tablet with other medications, Staff C said her expectation was that staff would get the order changed. 4) On 06/04/2025 at 12:20 PM, during a medication cart observation, when looking at the controlled substance book (book for documenting quantity of control substances) it was noted that a small clear plastic bag with a white pill in it was pinned to the book with a paper clip. The bag had writing on it with a resident's name, Oxy and 2.5 written on it. When asked about the pill, Staff J, RN, said a nurse failed to waste (destroy) it appropriately. On 06/04/2025 at 12:55 PM, Staff C, RCM/RN, when asked when staff should waste a controlled substance not being used, said immediately. After being informed of the assumed controlled substance pill that was found paper clipped to the narcotic book, Staff C said her expectation was this would not happen. On 06/04/2025 at 1:00 PM, Staff C went to the medication cart to talk with Staff J. Staff J told Staff C that the night shift nurse did not know what had happened with the pill, and Staff J had told the night nurse she would take care of it on her shift. Staff J said she wasn't sure what happened but assumed because the order was for ½ a tablet of the controlled substance, the medication was provided by pharmacy as a whole tablet, this was possibly the half leftover, and it should have been wasted. Staff C said it looked as though they didn't have ½ tablets of this medication to provide to the resident and the leftover medication should have been destroyed. Reference WAC 388-97-1620(2)(b)(i)(ii),(6)(b)(i) Based on interview and record review, the facility failed to meet professional standards of practice by failing to follow medication administration times, to follow up with the provider, to waste controlled substances timely, and/or to ensure medications were in an appropriate form for 3 of 21 sampled residents (Residents 54, 333, & 450) and 1 of 3 medication carts (Medication Cart A3) reviewed. This failure placed residents at risk of medication complications and a diminished quality of life. Findings included . 1) Resident 54 was admitted to the facility on [DATE] with a diagnosis of hypothyroidism (thyroid gland does not produce enough hormones). The Quarterly Minimum Data Set Assessment (MDS), dated [DATE], showed Resident 54 was cognitively intact. Resident 54's electronic health record (EHR) had an order for levothyroxine for thyroid disorder, to be given in the morning scheduled for 6:00 AM. Resident 54's hallway was scheduled to receive breakfast at approximately 8:15 AM daily. Resident 54's 6:00 AM levothyroxine medication administration times were reviewed, from 05/01/2025 through 06/04/2025, and showed the following dates with administration times over 1 hour past 6:00 AM: 05/01/2025- 12:41 PM 05/02/2025- 10:20 AM 05/05/2025- 11:03 AM 05/06/2025- 8:42 AM 05/07/2025- 11:14 AM 05/08/2025- 11:13 AM 05/09/2025- 9:08 AM 05/12/2025- 10:47 AM 05/13/2025- 12:56 PM 05/14/2025- 1:58 PM 05/15/2025- 10:58 AM 05/16/2025- 10:57 AM 05/19/2025- 11:04 AM 05/20/2025- 7:23 AM 05/21/2025- 9:29 AM 05/22/2025- 9:57 AM 05/23/2025- 10:41 AM 05/24/2025- 7:33 AM 05/26/2025- 10:17 AM 05/27/2025- 8:49 AM 05/28/2025- 9:13 AM 05/29/2025- 12:58 PM 05/30/2025- 8:41 AM 06/02/2025- 7:13 AM 06/03/2025- 10:02 AM 06/05/2025- 8:26 AM 06/04/2025- 9:17 AM During an interview on 06/04/2025 at 3:41 PM, Resident 54 said they were getting their thyroid medication after breakfast and it was supposed to be given before breakfast on an empty stomach, scheduled for 6:00 AM. During an interview on 06/05/2025 at 12:40 PM, Staff C, Resident Care Manager/Registered Nurse (RCM/RN), when asked if levothyroxine had specific timing, said it should be given on an empty stomach, at the same time every day, and for Resident 54 at 6:00 AM. When asked about levothyroxine being given greater than one hour after 6:00 AM, for 27 of 36 days reviewed, Staff C said it should be given within an hour. During an interview on 06/09/2025 at 9:42 AM, Staff B, Director of Nursing Services (DNS), when asked about levothyroxine being given over one hour past 6:00 AM, for 27 of 36 days reviewed, said it did not meet expectations if it was given after meals. When administration times of 12:00 PM and 1:00 PM were brought up, Staff B said this did not meet expectations. 2) Resident 333 was admitted to the facility on [DATE] with a diagnosis of hypertension (high blood pressure). The admission MDS, dated [DATE], showed Resident 333 was cognitively intact. Review of Resident 333's EHR showed they had an order for lisinopril (blood pressure medication), ordered on 05/22/2025, for 20 milligrams (mg) by mouth two times a day for hypertension, with hold parameters for a systolic blood pressure (top number) less than 100. Review of Resident 333's May MAR, from 05/22/2025 through 05/31/2025, showed on 05/27/2025 the evening dose was held for a blood pressure (BP) of 97/49 and the evening dose was held 05/31/2025 for a BP of 89/64. Review of a progress note, dated 05/31/2025, showed a nurse had documented, BP 89/64. Resident states she was taking lisinopril 20 mg once a day while at home, and would like to go back to doing so. Review of Resident 333's June MAR, from 06/01/2025 through 06/04/2025 morning, showed the following BP readings connected to the lisinopril order: 06/01/2025, AM BP 103/59 (medication held); PM BP 108/67 06/02/2025, AM BP 118/82, PM BP 102/62 06/03/2025, AM BP 110/68, PM BP 106/66 06/04/2025, AM BP 116/70 During an interview on 06/03/2025 at 8:37 AM, Resident 333 said they had been given too much of their blood pressure medication at this facility, and at home they only took 20 mg a day and now were receiving that dose twice a day. During an interview on 06/04/2025 at 9:58 AM, Resident 333 said their blood pressure readings were still low, and their blood pressure had never been this low. When asked if they were still getting the medication twice a day, said they did not know if they were as the staff did not tell them what they were giving. During an interview on 06/06/2025 at 10:30 AM, Staff D, RCM/Licensed Practical Nurse (LPN), reviewed Resident 333's EHR and confirmed there was a progress note on 05/31/2025 about Resident 333 reporting they were receiving the wrong dose. Staff D said this was not communication with the provider, there was no follow up seen in the EHR, and there should have been.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review, the facility failed to ensure pressure injuries (PIs) were consistently assessed, and ordered pressure redistribution measures and equipment were in place and functional for 1 of 4 residents (Resident 67) reviewed for PIs. The failure to ensure an ordered low air loss mattress was in place and functional and to routinely assess identified PIs, detracted from the ability to determine if current treatments and interventions were effective and appropriate. This failure placed residents at risk for prolonged wound healing, unidentified decline, and development of avoidable PIs. Findings included . The National Pressure Injury Advisory Panel (NPUIP) provided the following PI stage descriptions: - PI- localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device, because of intense and/or prolonged pressure or pressure in combination with shear. - Stage 1 Pressure Injury: Non-blanchable erythema (redness) of intact skin. - Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis. - Stage 3 Pressure Injury: Full-thickness skin loss in which adipose (fat) is visible in the ulcer. - Stage 4 Pressure Injury: Full-thickness skin and tissue loss with exposed or directly palpable fascia (connective tissue), muscle, tendon, ligament, cartilage or bone in the ulcer. - Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar (tissue death). Resident 67 was admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS, an assessment tool), dated 02/26/2025, showed the resident was cognitively intact, required substantial to maximal assistance with bed mobility, was at risk for PI formation and had two Stage 3 and one Stage 4 PI present on admission. During the assessment period, Resident 67 also received PI care, and had pressure reducing devices in place to their bed and wheelchair. <Monitoring Function of Pressure Redistribution Devices> Resident 67 had an order, dated 04/02/2025, for an alternating low air loss (LAL) mattress for pressure redistribution. On 06/03/2025 at 10:46 AM, Resident 67 was observed lying on a LAL mattress with pillows under both hips, both thighs and one pillow under their back. When asked why there were pillows, Resident 67 explained they were there to hold them up, because without the pillows in place they could feel the bed frame and it caused their tailbone to be sore. Observation of the LAL mattress pump showed two red flashing lights were activated. One was for low pressure and the other for power failure. When asked how long they had been able to feel the bed frame through the LAL mattress, Resident 67 stated, Since I got here. On 06/04/2025 at 12:16 AM, Resident 67 was observed lying in bed with pillows positioned under both hips and thighs. There was no pillow positioned behind their back. Resident 67 said nothing had changed and staff had not noticed the red flashing lights or taken any action to fix the LAL mattress. Observation of the LAL mattress pump display panel showed both red flashing lights were still activated for low pressure and power failure. On 06/04/2025 at 12:34 PM, Staff S, Licensed Practical Nurse, observed Resident 67 in bed and confirmed there were pillows positioned under the resident's bilateral hips and thighs. Resident 67 stated, I need the pillows to boost me up off the bed, otherwise my tailbone gets sore because it hits the frame. When asked to look at the LAL mattress pump display panel, Staff S confirmed the presence of two red flashing alert lights indicating the mattress had low pressure and a power failure. Staff S said they would notify maintenance. On 06/05/2025 at 2:37 AM, Resident 67 was observed with a new and functional LAL mattress in place. <Assessment and Monitoring of PIs> Review of the admission Evaluation, dated 02/19/2025, showed Resident 67 was assessed with the following skin conditions: a) A 5.5-centimeter (cm) x 6 cm unstageable PI to the right heel. b) Moisture-Associated Skin Damage (MASD, damage caused by prolonged exposure to moisture) to the left heel. c) A 5.8 cm x 4.5 cm unstageable eschar to the bottom of the left foot. d) A 5.5 cm x 4 cm Stage 3 PI to the right buttock. e) MASD to the left gluteal cleft. A 02/19/2025 progress note documented Resident 67 had PIs to both heels. A 02/20/2025 progress note documented the resident reported the pain related to PIs on both heels was well controlled. A 02/24/2025 provider note documented Resident 67 had unstageable PIs to the right and left heels. During an interview on 06/04/2025 at 12:39 PM, Staff S, Resident Care Manager, said Resident 67's weekly wound measurements/assessments were being performed by a consulting wound care company. Review of the initial wound care consult, dated 02/25/2025, showed they assessed Resident 67 as having a Stage 4 PI to the left lateral heel, a Stage 3 PI to the sacrum, and a Stage 3 PI to the right buttock. There was no mention or assessment of the PI to the resident's right heel. Review of subsequent wound care consults, dated 03/04/2025, 03/11/2025, and 03/18/2025, showed no mention or assessment of Resident 67's right heel PI. A 03/02/2025 progress note documented Resident 67 was on antibiotic therapy for heel wounds. A 03/03/2025 progress note documented wound care was provided for bilateral (both right and left foot) heel pressure ulcers. A 03/04/2025 progress note documented wound care was provided to bilateral heels and the dressings were changed. A 03/09/2025 progress note documented that Resident 67's heel dressings were changed. A 03/09/2025 progress note documented that the resident's bilateral heel pressure ulcer dressings were clean, dry, and intact. A 03/14/2025 progress note documented Resident 67 received antibiotic therapy for bilateral heel wounds. A wound care consult, dated 04/01/2025 documented Right heel was not a PU [pressure ulcer], it is hyperkeratosis (abnormal thickening of the outer layer of skin). Review of the hospital wound care notes, dated 02/17/2025, showed Resident 67 was assessed with unstageable PIs to the right and left heel (with associated photographs) and a deep tissue injury to the left gluteal cleft/coccyx. During an interview on 06/09/2025 at 11:44 AM, Staff B, Director of Nursing Services, and Staff A, Administrator, confirmed Resident 67 was assessed upon admission to have PIs to their bilateral heels, which was consistent with the discharging hospitals assessments. Additionally, Staff A and B confirmed facility staff documented the presence of heel wounds to both heels, through 03/14/2025. When asked if there was any documentation to show Resident 67's right heel PI had been measured/assessed/monitored since admission Staff B said No, not that I can see. Reference WAC 388-97-1060 (3)(b) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review, the facility failed to ensure residents admitted with indwelling catheters (a flexible tube inserted into the bladder through the urethra to drain urine) were assessed for catheter removal as soon as possible, and to ensure clinical condition/ justification existed for continued use for 1 of 1 resident (Resident 67) reviewed for urinary catheters. These failures placed residents at risk for unnecessary catheterization, urinary tract infections, and a decreased quality of life. Findings included . Review of the facility's Indwelling Catheters policy, revised December 2024, showed all residents with indwelling catheters required a medical justification for their initiation and continued use. A Bladder Data Collection/Evaluation and/or the Catheter Justification Evaluation was required for all residents with an indwelling catheter. The assessment would determine the reason/ justification for use, if any factors were reversible, and a plan of care developed to document the justification of continued catheterization beyond 14 days. The interdisciplinary team would discuss the appropriateness of catheterization with the provider and obtain an order including a justification for continued use or to discontinue the catheter. Resident 67 was admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS, an assessment tool), dated 02/26/2025, showed the resident was cognitively intact, had Stage 3 (Full-thickness skin loss in which fat is visible in the ulcer) and Stage 4 (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) pressure injuries, required substantial to maximal assistance with bed mobility, was dependent on staff for toileting and had an indwelling urinary catheter. On 06/03/2025 at 9:01 AM, Resident 67 said they did not have a urinary catheter prior to their recent hospitalization. When asked why the catheter was still in place, Resident 67 said they believed it was because they were difficult to get out of bed, and they preferred not to use a bed pan because they were uncomfortable. A urinary catheter care plan, revised 04/17/2025, had an identified goal of removing the resident's catheter in the absence of indications for continued use. Review of the electronic health record showed no diagnosis of obstructive uropathy (blockage of urine flow anywhere in the urinary system), neurogenic bladder (a condition where nerve damage disrupts the normal function of the bladder, leading to problems with urination), benign prostate hyperplasia (enlarged prostate) or urinary retention. A 02/25/2025 wound care consult documented Resident 67 had Stage 3 pressure injuries to the sacrum and right buttock. A 04/01/2025 wound care consult documented Resident 67's right buttock pressure injury was resolved and Stage 3 to the sacrum was 0.5 x 0.4 x 0.1 centimeters and healing. A 04/22/2025 wound care consult documented Resident 67's sacrum pressure injury was closed. A Bladder Data Collection and Evaluation, dated 05/28/2025, showed residents with a catheter were required to have at least one of the following conditions: a) A terminal illness or severe impairment and movement that caused intractable pain. b) Stage 3 or 4 pressure injuries in an area affected by incontinence that would prevent ulcer(s) from healing. c) Untreatable urethral blockage causing urinary retention (documented post void residual of greater than 200 milliliters) and staff were unable to perform intermittent catheterization. d) A documented medical justification for catheterization. Review of the evaluation showed none of the above conditions were identified/documented. On 06/05/2025 at 10:32 AM, Staff C, Resident Care Manager/Registered Nurse, indicated the initial justification for continued catheter use was the presence of Stage 3 pressure injuries to the right buttock and sacrum, but confirmed both had resolved as of 04/22/2025. Staff C stated, We should have contacted the doctor and asked for orders to do a trial discontinuation [of the catheter]. Staff C then confirmed that this had not occurred. Reference WAC 388-97-1060 (3)(c) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) Resident 283 admitted to the facility on [DATE]. The admission MDS, dated [DATE], documented Resident 283 was severely cognitively impaired. Resident 283 was on hospice services (end of life care). Resident 283 had orders for morphine (pain reliever) oral solution, by mouth every 1 hours as needed for breakthrough pain; dyspnea (shortness of breath). Review of Resident 283's MAR, from 05/22/2025 through 06/05/2025, showed morphine was administered with documented pain on 05/24/2025, 05/26/2025, 05/27/2025, 05/28/2025, 05/29/2025, 05/30/2025, 06/01/2025, 06/02/2025 and 06/05/2025. Resident 283's May 2025 and June 2025 MARs also showed staff were ordered to provide NPI to reduce pain and document the effectiveness. Interventions included repositioning, relaxation, diversional activities and redirection. Staff were instructed to document the NPI intervention and effectiveness as needed. There was no documentation NPIs had been attempted. On 06/06/2025 at 11:19 AM, Staff C, RCM/RN, said NPIs should be implemented any time a resident complains of pain, and staff should always try NPIs before medication. When asked if NPIs for Resident 283 had been attempted with morphine given for pain management, Staff C reviewed the EHR and said that NPIs were not documented, and staff should have tried and documented NPIs. Staff C said staff could also document attempted NPIs in progress notes but was unable to locate documentation that NPIs had been attempted. Reference WAC 388-97-1060 (3)(k)(i) Based on interview and record review, the facility failed to ensure medications were necessary by providing residents with non-pharmacological interventions (NPIs, non-medication interventions) for pain management, documenting side effect monitors, and/or to reassess the necessity of medication on admission for 3 of 7 residents (Residents 333, 54, & 283) reviewed for unnecessary medication and pain. This failure placed residents at risk of receiving medication not clinically indicated, increased pain, and a diminished quality of life. Findings included . Review of the facility's policy titled, Pain Management, dated with a revision date of 06/2024, showed staff were to determine the appropriate interventions to manage the pain and side effects, and appropriate interventions should include pharmacological as well as non-pharmacological interventions. Staff should evaluate and document effectiveness of pain management interventions in the medical record. 1) Resident 333 was admitted to the facility on [DATE] with a diagnosis of fracture of the pubis (pelvic fracture). The Minimum Data Set Assessment (MDS), dated [DATE], showed Resident 333 was cognitively intact and had constant pain. Review of the electronic health record (EHR), showed Resident 333 had an order for omeprazole daily, for gastroesophageal reflux disease (GERD). Review of Resident 333's diagnosis list showed this was not an active diagnosis. Review of the Medication Administration Record (MAR), from 05/22/2025 through 06/03/2025, showed Resident 333 had as needed acetaminophen (non-opioid pain medication) given for pain on 05/25/2025, 05/28/2025, 05/30/2025, and 06/02/2025. Resident 333 had as needed morphine (opioid pain medication) given for pain from 05/22/2025 through 06/03/2025. Resident 333's NPI order had no documentation for 05/22/2025 through 06/03/2025. Additionally, Resident 333's side effect monitor order was as needed for pain medication, and had no documentation on the MAR from 05/22/2025 through 06/03/2025, despite receiving as needed pain medication daily. During an interview on 06/03/2025 at 8:37 AM, Resident 333, when asked about NPI and pain management, said they had pain and it was only addressed at the facility with medication. During an interview on 06/04/2025 at 9:58 AM, Resident 333 said they were not told what they had been getting with medication administration and found out they were being given something for acid reflux (GERD), despite not having this condition. During an interview on 06/06/2025 at 10:30 AM, Staff D, Resident Care Manager/ Licensed Practical Nurse (RCM/LPN), said NPI should be offered as a first line of defense. Staff D reviewed Resident 333's MAR for May and June 2025, and confirmed Resident 333 did not have any documented NPI. When asked if there should be documented NPI usage, Staff D said yes. Staff D reviewed Resident 333's diagnosis list and confirmed there was no diagnosis of GERD. When asked how the facility reviews medications for residents on admission who do not have a diagnosis for the medication ordered, to ensure it is necessary, Staff D said they could ask the provider if it was necessary or talk to the resident about it. During an interview on 06/09/2025 at 9:42 AM, Staff B, Director of Nursing Services (DNS), when asked their expectation for NPI usage with pain medication, said NPIs should be offered prior to administration of as needed medications and documented on whether effective or not. When asked if it met expectations that Resident 333 did not have documented NPIs with pain medication given, said no. 2) Resident 54 was admitted to the facility on [DATE] with diagnoses of healed traumatic fracture and left hip pain. The Quarterly MDS, dated [DATE], showed Resident 54 was cognitively intact. Review of Resident 54's May 2025 MAR, showed as needed acetaminophen was given on 05/02/2025, 05/04/2025, 05/06/2025, 05/08/2025, 05/09/2025, 05/14/2025, 05/15/2025, 05/16/2025, 05/17/2025, 05/18/2025, 05/20/2025, 05/21/2025, 05/22/2025, 05/24/2025, 05/26/2025, 05/27/2025, 05/28/2025, and 05/30/2025. Resident 54's order for NPI showed no documentation for all of May 2025. During an interview on 06/05/2025 at 12:40 PM, Staff C, RCM/ Registered Nurse (RN), said their expectation was for NPI to be in place and for other things to be tried besides just giving medication. Staff C said pain interventions were ordered for residents. Staff C reviewed the EHR and confirmed that Resident 54 received as needed acetaminophen in May 2025 and there was no documentation of NPI usage. During an interview on 06/09/2025 at 9:42 AM, Staff B, DNS, when asked if it met expectations that Resident 54 did not have documented NPIs with pain medication given, said no.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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. Based on observation and interview, the facility failed to store and label medications appropriately and discard expired medications for 2 of 5 medication carts (Medication Carts A2 & A3) reviewed. These failures placed residents at risk of receiving expired or less effective medications, and inappropriate access to medication. Findings included . 1) Observation of Medication Cart A2 on 06/04/2025 at 11:57 AM, showed an unattended bottle of Tylenol on top of the cart. In addition, a bottle of Day Time Cold and Flu Relief was located within the cart with an expiration date of 12/2024. Located within the cart drawers, were a nystatin (antifungal) cream and clotrimazole (antifungal) cream, both without resident names and labels. Staff I, Licensed Practical Nurse, said the bottle of Tylenol on top of the cart came from central supply, and the employee that delivered it had left it unattended and it was a new staff member. Staff C, Resident Care Manager/Registered Nurse (RCM/RN), looked at the bottle of Day Time Cold and Flu medication and confirmed it was expired. 2) Observation of Medication Cart A3 on 06/04/2025 at 12:20 PM, showed 4 opened bottles of nystatin powder without resident names or labels. Staff J, RN, confirmed the lack of identifiers and threw the bottles in the garbage. On 06/04/2025 at 12:55 PM, Staff C, RCM/RN, said her expectation was that expired medications in the medication cart would be taken out of the cart and destroyed. Regarding Tylenol being left unattended on the medication cart, Staff C said it did not meet her expectations. Regarding the medications found without resident names and labels, Staff C said it did not meet her expectations, medications should have residents names and be labeled. Reference WAC 388-97-1300(2)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected 1 resident

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. Based on interview and record review the facility failed to store food for residents in accordance with professional standards for 5 of 5 refrigeration/freezer units (A1/A2, A3, B3, Walk in Cooler and Walk in Freezer) reviewed for food service safety. The failure to maintain documented refrigerator temperature logs placed residents at risk of foodborne illness (caused by the ingestion of contaminated food or beverages), unsanitary conditions, and diminished quality of life. Findings included . Review of the following refrigerator temperature logs located on A1/A2 hall, A3 hall, B3 hall, Walk in Cooler and Walk in Freezer in the kitchen, documented missing refrigerator/freezer temperatures: Snack Refrigerator since February 25th, 2025 (logs started on 02/25/2025): 02/25/2025 Hall A1 & A2- no temperatures recorded. 02/26/2025 Hall A1, A2, A3 & B3- no temperatures recorded. 02/27/2025 Hall A1 & A2- no temperatures recorded. 02/28/2025 Hall A1 & A2- no temperatures recorded. A3 Hall no temperatures recorded on: 03/06/2025, 03/23/2025, 03/29/2025, 04/03/2025, 04/10/2025, 04/11/2025, 04/13/2025, 04/17/2025, 04/18/2025, 04/24/2025, 04/25/2025, 04/26/2025 & 05/11/2025 A1 and A2 Hall no temperature records on: 03/22/2025, 03/23/2025, 03/26/2025, 03/29/2025, 04/03/2025, 04/04/2025, 04/10/2025, 04/11/2025, 04/13/2025, 04/24/2025,04/25/2025, 04/26/2025, 05/11/2025 & 04/22/2025. B Hall no temperatures recorded on: 03/23/2025, 03/26/2025, 03/29/2025, 04/04/2025, 04/04/2025, 04/09/2025, 04/10/2025, 04/11/2025, 04/13/2025, 04/17/2025, 04/18/2025, 04/24/2025, 04/25/2025, 04/26/2025 & 05/25/2025. Walk in Cooler Temperature Log March 2025 through May 2025-no temperatures recorded on temp log on: 03/01/2025 Mid time and PM time. 03/02/2025 Mid time and PM time. 03/03/2025 Mid time and PM time. 03/08/2025 Mid time and PM time. 03/09/2025 Mid time and PM time. 03/10/2025 Mid time and PM time. 03/15/2025 Mid time and PM time. 03/17/2025 Mid time and PM time. 03/18/2025 Mid time and PM time. 03/19/2025 Mid time and PM time. 03/23/2025 Mid time. 03/24/2025 Mid time and PM time. 03/25/2025 Mid time and PM time. 03/26/2025 Mid time and PM time. 03/27/2025 Mid time and PM time. 03/28/2025 PM time. 03/29/2025 PM time. 03/30/2025 Mid time and PM time. Walk in Freezer Temperature Log March 2025 through May 2025-no temperatures recorded on temp log on: 03/01/2025 Mid time and PM time. 03/02/2025 Mid time and PM time. 03/03/2025 Mid time and PM time. 03/08/2025 Mid time and PM time. 03/09/2025 Mid time and PM time. 03/10/2025 Mid time and PM time. 03/15/2025 Mid time and PM time. 03/17/2025 Mid time and PM time. 03/18/2025 Mid time and PM time. 03/19/2025 Mid time and PM time. 03/23/2025 Mid time. 03/24/2025 Mid time and PM time. 03/25/2025 Mid time and PM time. 03/26/2025 Mid time and PM time. 03/27/2025 Mid time and PM time. 03/28/2025 PM time. 03/29/2025 PM time. 03/30/2025 Mid time and PM time. On 06/04/2025 at 12:59 PM, Staff N, Dietary Manager, said the kitchen refrigerators and the unit/snack refrigerators were the responsibility of the kitchen staff. Staff N said all refrigerators should have been checked daily. When shown the missing dates on the temperature logs, Staff N said they were hired in March 2025 and the missing temperature dates were a problem that was identified immediately. Staff N said there were a lot of holes (missing temperatures) and the missing dates should have been filled in. Reference WAC 388-97-1100 (3), 2980. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review, the facility failed to ensure staff-maintained infection control practices during dressing changes for 1 of 3 wound cares observed, during meal tray delivery for 1 of 5 meal tray observations, and that regular temperature checks of the washing machines were complete for washing machines for for 1 of 1 laundry room reviewed for infection control. This failure placed residents at risk for the spread of infection and a diminished quality of life. Findings included . <Logs for Washer Temperatures> A Review of the Washer Temperature Logs showed no documentation on: -February 2025 blanks on the 1st, 2nd, 16th and 29th - 31st -May 2025 a blank on the 26th On 06/04/2025 at 1:03 PM Staff X, Housekeeping and Laundry Manager said the washer temperatures were checked to ensure proper standards for equipment, to make sure the laundry was sanitized, and it killed the germs. Staff X said she would in-service the staff and make sure the temperatures were done in the future. On 06/05/2025 at 12:19 PM Staff A, Administrator said her expectation for the blanks on the temperature logs were that they should have been done. <Hand hyigene during meal tray delivery> On 06/02/2025 at 11:46 AM, the lunch meal cart arrived on the unit. The dining room was served first. On 06/02/2025 at 11:58 AM, Staff O, Certified Nursing Assistant (CNA), started delivering meal trays to resident rooms. Staff O entered room [ROOM NUMBER], set meal tray on bedside table, removed the lid from the plate and then touched the resident's bed, sheets and bed remote control. Staff O left the room and did not complete hand hygiene. On 06/02/2025 at 11:58 AM, Staff O entered room [ROOM NUMBER], set meal tray on bedside table, removed the lid from the plate and cup, and then touched the resident (assisting resident with sitting up) and the resident's bed, sheets and bedside table. Staff O left the room and did not complete hand hygiene. On 06/02/2025 at 12:00 PM, Staff O entered room [ROOM NUMBER], set meal tray on bedside table, removed the lid from the plate. Staff O picked up the bed remote control off the floor and placed it on resident's bed, next to the resident. Staff O then touched the resident (assisting resident with sitting up) and the resident's blanket. Staff O left the room and did not complete hand hygiene. On 06/02/2025 at 12:03 PM, Staff O entered room [ROOM NUMBER], set meal tray on bedside table. Staff O touched the bedside table, the resident's blanket and then the hand crank at the end of the bed. Staff O then went to the bedside table and took off the plate cover, lid cover, picked up the resident's utensils and handed them to the resident. Staff O left the room and did not complete hand hygiene. On 06/02/2025 at 12:05 PM, when asked when should hand hygiene be completed, Staff O said every two passes. Staff O said they only completed hand hygiene once during the whole pass. On 06/06/2025 at 9:24 AM, Staff P, Registered Nurse Unit Manager, said staff should be washing their hands before grabbing a meal tray and when staff leave the residents room or helping another resident before delivering the next tray. Observation of Staff O's, CNA, lack of hand hygiene was explained. Staff P said they had heard the conversation and did not know where the two pass hand hygiene requirement came from. Staff P said staff should have completed hand hygiene before and after every meal tray pass. On 06/06/2025 at 10:22 AM, Staff B, Director of Nursing Services, said hand hygiene should be completed before and after every meal tray delivery. When observations of Staff O's, CNA, lack of hand hygiene was explained, Staff B said it did not meet expectation for hand hygiene. <Wound Care Observation> An observation of wound care on 06/05/2025 at 1:53 PM, showed Staff I, Licensed Practical Nurse, put on a gown and mask, then opened a medication cart with keys, removed gloves, then entered a resident's room. Staff I then put a plastic cup of medication on the bedside table and put gloves on (no hand hygiene observed prior to putting gloves on). Staff I then took the resident's sock off their foot and used a tube of normal saline to soak off the dressing that was in place, removed dirty dressing and placed in a garbage bag. Staff I then wiped the wound with gauze, removed gloves, washed hands at the sink and put on new gloves. Staff M, CNA, held the resident's leg up in the air, and Staff I with gloved hands took over holding resident's leg, Staff M then took resident's leg back and Staff I resumed wound care (No glove change and hand hygiene was observed after holding residents' leg and before they resumed wound care). On 06/06/2025 at 11:09 AM, Staff C, Resident Care Manager/Registered Nurse, said the expectation was that staff perform hand hygiene before putting gloves on and after removing gloves. Regarding staff holding the resident's leg then continuing with wound care, Staff C said staff should have changed gloves and performed hand hygiene and put on new gloves before proceeding with wound care. Reference WAC 388-97-1320(1)(a)(c)(3) .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) Resident 75 was admitted to the facility on [DATE]. Review of the admission MDS, dated [DATE], showed the resident was cognitively moderately impaired. Review of Resident 75's EHR documented them as Responsible Party. A progress note by Staff F, SSD, dated 06/03/2025, documented he provided the family with paperwork and contact information so they could begin the process of becoming Resident 75's legal representative. On 06/06/2025 at 10:49 AM, Staff F said Resident 75 did not have an advanced directive. Staff F said he did not offer information to Resident 75 or their family about establishing a POA during the initial care conference, and said the information was not provided until recently in June 2025. On 06/09/2025 at 11:07 AM, Staff B, DNS, said her expectation was that advanced directives be addressed on admission, including offering information about formulating a POA. Reference WAC 388-97-0300 (1)(b), (3)(a-c) Based on interview and record review, the facility failed to ensure they informed and provided written information to residents on their right to formulate an advance directive (written instruction for the provision of health care when the individual is incapacitated, such as a living will or durable power of attorney (POA) for health care) for 3 of 4 residents (Residents 70, 333, & 75) reviewed for advance directives. This failure placed residents at risk for not having their choice of who to care for them when incapacitated, of not having their health care wishes honored, and a diminished quality of life. Findings included . 1) Resident 70 was admitted to the facility on [DATE]. The admission Minimum Data Set Assessment (MDS), dated [DATE], showed Resident 70 was understood and understands, and was cognitively intact. Review of the electronic health record (EHR) on 06/03/2025, showed Resident 70 was considered their own decision maker, but there was no documentation of them having been offered or declining the formulation of an advance directive. During an interview on 06/04/2025 at 8:29 AM, Staff K, Social Services Assistant, said advance directives should be reviewed on admission, with any evaluation, or if something happens. At 8:31 AM, Staff F, Social Services Director (SSD), joined the interview. Staff F said if a resident was their own person, this was care planned. Staff K said that for Resident 70, there was not documentation of them being offered an advance directive and they should put this in a progress note. Staff K said that they ask residents if they have a POA. When asked if they had offered residents the opportunity to formulate an advance directive, both Staff F and Staff K indicated they understood they had not met this requirement. Review of a progress note, dated 06/04/2025 at 8:39 AM, showed social work had brought POA paperwork to Resident 70, and Resident 70 had stated, I don't want anyone to have power to make decisions, I just want them to be able to get information. During an interview on 06/04/2025 at 12:18 PM, Resident 70 was asked about advance directives. Resident 70 said the facility had not talked to them about designating a decision maker if they were to become incapacitated, they would want their son or daughter to make the decisions, and if they were provided a form to elect their son or daughter to make decisions when incapacitated, that yes they would be interested in that. During a joint interview on 06/04/2025 at 3:12 PM, Staff A, Administrator, and Staff B, Director of Nursing Services (DNS), were both interviewed. Staff B said advance directives should be reviewed on admission, quarterly, and should be care planned. When asked if it met expectations that social work reported they did not always document conversations asking if residents wanted a POA, Staff A and B said no. When asked about their expectation for residents who were their own decision makers, not being offered the right to formulate an advance directive, Staff B said they should be offered. 2) Resident 333 was admitted to the facility on [DATE]. Review of the admission MDS, dated [DATE], showed Resident 333 was cognitively intact. Review of the EHR on 06/03/2025, showed Resident 333 was considered their own decision maker, but there was no documentation Resident 333 was offered or declined the formulation of an advance directive. During a joint interview on 06/04/2025 at 8:31 AM, Staff F, SSD, and Staff K, Social Services Assistant, were asked about Resident 333. Staff F said Resident 333 was their own person (decision maker) and there was no documentation of them being offered the opportunity to formulate an advance directive. During an interview on 06/04/2025 at 9:54 AM, Resident 333 was asked if the facility went over formulating an advance directive and if they had declined. Resident 333 said they did not remember declining and their husband would make decisions. After getting an explanation of an advance directive, Resident 333 said if they became unable to make their own decisions, they would want their husband to make decisions.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Grievances (Tag F0585)

Could have caused harm · This affected multiple residents

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. Based on interview and record review the facility failed to have a system in place that ensured grievances were initiated, logged, addressed, and timely resolved in response to residents' complaints verbalized during Resident Council (RC) meeting for 4 of 6 months (December 2024, January, February and April 2025) The failure to initiate, log, investigate verbalized concerns, inform residents of their findings and actions taken, if any, prevented the facility from identifying care trends and determining if actions taken were effective in resolving the reported issues. These failures resulted in residents verbalizing the same complaints for multiple months without resolution, and placed residents at risk of feeling frustrated, unimportant and unheard, and a decreased quality of life. Findings included . <Facility Policy> Review of the facility's Resident Council policy, revised 01/23/2023, showed the staff member who recorded the RC meeting minutes would report concerns/grievances to the Administrator and/or the department head responsible. A response would be provided in writing to concerns/grievances brought up in RC in accordance with the facility's grievance policy and procedure. Review of the Facility's Grievances policy, revised February 2024, showed it was staff's responsibility to encourage residents/resident representatives to discuss all grievances so issues may be resolved. Staff would initiate a resident grievance report for all concerns and forward them to the grievance officer. If grievance was an allegation of abuse, neglect or misappropriation it would be immediately investigated. If it was not an allegation of abuse, neglect or misappropriation, the grievance would be read at the daily stand-up meeting, logged in the grievance log and forwarded to the appropriate department for resolution. The department head would then communicate with the resident/resident representative within five days and attempt to resolve the issue. Once resolved, the grievance would be discussed in the daily stand-up and the grievance report would be provided to Social Work. The grievance officer would then follow up with the resident/resident representative to ascertain if they were satisfied with the resolution of the reported concern. Review of the RC minutes from December 2024 - May 2025 (6 months) showed the following concerns were verbalized by residents in the RC meetings. The December (12/04/2024) RC minutes showed residents reported the following concerns: a) When not eating in the dining room liquids are not always provided with residents' meals and when liquids are requested from staff they are not brought right away. The minutes did not identify who or how many residents had verbalized the concern about the provision of beverages with meals. Review of the grievance log showed no grievances related to the provision of beverages/liquids with meals were logged. The January (01/01/2025) RC minutes showed residents reported the following concerns: a) TVs are too loud and keep others awake. b) Privacy curtains are not being closed when they should be. c) Staff were not getting drinks for residents on room trays right away. (repeat complaint, 2nd month) The RC minutes did not identify: a) How many or which residents verbalized concerns about not being provided drinks with meals right away. b) Which TVs were too loud or which residents were being kept awake. c) Who and/or how many residents expressed concern about privacy curtains not being closed or the specific circumstance(s) related to the concern. (e.g. was the resident(s) exposed when the privacy curtain was left open and in view of others, if so, what effect, if any, did it have on the resident etc.) Review of the grievance log showed no grievances were logged addressing the above reported concerns. The February (02/12/2025) RC minutes showed residents reported the following concerns: a) If a drink is on the tray card, then it should be on the tray. (repeat complaint, third month) b) Still having issues with TVs being too loud. (Repeat complaint, 2nd month) The RC minutes did not identify: a) Who or how many residents were not receiving drinks that were documented on their tray cards to receive, or whether it was a physician ordered beverage (e.g. protein shake for wound healing) or a resident preference (e.g. prefers cranberry juice with lunch). b) Which TVs were too loud or which residents were kept awake. Review of the grievance log showed no grievances were logged addressing the above reported concerns. The March (03/05/2025) RC minutes showed no specific complaints were verbalized. The April (04/02/2025) RC minutes showed residents reported the following concerns: a) Under Old Business it was documented that call light response time was too long (although this was not recorded in March 2025 RC minutes) b) Call light response time needs to be improved. c) Residents need haircuts (facility did not currently have a visiting barber/stylist). The RC minutes did not identify: a) Who or how many residents complained about call light response time, how long they waited, what the resident need was, or what outcome, if any, there was for the resident (e.g. a continent resident needed to void, because assistance did not come for 45 minutes, the resident was incontinent etc.) b) Who and/how many residents were requesting haircuts. Review of the grievance log showed no grievances were logged addressing the above reported concerns. The following residents were in attendance during a meeting with RC on 06/04/2025 at 3:30 PM: Resident 52, President; Resident 2; Resident 54; Resident 39; Resident 72; and Resident 58. During the meeting residents said staff did not act promptly upon grievances brought forward in the meetings, and did not follow up with them individually or as a group to inform them how they planned to correct the issue(s) or to find out if the action taken was effective. Residents 52, President, 39 and 54 said beverages with meals was still an issue that had not been resolved, but indicated they just stopped bringing it up every month. Resident 54 indicated call light response time was still a problem although improved. Resident 52, President, nodded in agreement but expressed the RC tried to keep the meeting positive and give staff credit for incremental improvement, even if the issue is not fully resolved. On 06/06/2025 at 1:33 PM, Staff B, Director of Nursing, said the residents with complaints about beverages with meals, tray cards not being followed, privacy curtains not being closed, and poor call light response time should have been identified so abuse/neglect could be ruled outn with follow-up questioning, and grievances should have been generated and logged on their behalf. When asked if that had occurred Staff B stated, No. Reference WAC 388-97-0460 .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0628 (Tag F0628)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure notification to the Office of the State Long-Term Care Ombudsman (resident advocates) occurred for residents transferred to the hospital, for 2 of 2 residents (Residents 19 & 25) reviewed for hospitalization. This failure placed residents at risk of a lack of advocacy and possible unidentified or unmet care needs. Findings included . Resident 19 was admitted to the facility on [DATE]. They were transferred to the hospital on [DATE] and again on 04/05/2025. Resident 25 was admitted to the facility on [DATE]. They were transferred to the hospital on [DATE]. On 06/04/2025 at 9:14 AM, a request was made with the social services department for documentation of ombudsman notifications for Resident 19's hospitalizations on 02/07/2025 and 04/05/2025, and Resident 25's hospitalization on 05/29/2025. During an interview on 06/04/2025 at 2:20 PM, Staff F, Social Services Director, said they had not provided the ombudsman with any notifications of residents being hospitalized since February. During an interview on 06/04/2025 at 3:10 PM, Staff A, Administrator, said their expectation was for monthly ombudsman notifications with resident hospitalization. During an interview on 06/05/2025 at 11:45 AM, Staff F showed they had now sent the ombudsman notifications for hospitalizations and confirmed this was not done before. Reference WAC 388-97-0120 .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0645 (Tag F0645)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . 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 prior to admission and/or accurately reflected residents' mental health diagnoses for 7 of 8 residents (Residents 67, 53, 69, 78, 44, 54, & 19) reviewed for PASRR. These failure placed residents at risk for inappropriate placement, unmet behavioral healthcare needs and diminished quality of life. Findings included . 1) Resident 67 was admitted to the facility on [DATE]. Review of the 02/26/2025 admission Minimum Data Set (MDS, an assessment tool), showed the resident was cognitively intact, had a diagnosis of anxiety disorder and received antianxiety medication on seven of seven days during assessment period. Review of the 02/19/2025 admission/transfer orders showed an order for lorazepam (an antianxiety medication) every six hours as needed (PRN), for anxiety for 14 days. Review of the electronic health record (EHR) showed the 14-day PRN lorazepam order had been repeatedly renewed and was still in use. A Level I PASRR, dated 02/18/2025, showed Resident 67 had mental health diagnoses, and determined a Level II PASRR referral (in depth evaluation used to determine residents' need for nursing facility services, and whether specialized services are needed) was not required. On 06/06/2025 at 2:43 PM, Staff F, Social Services Director (SSD), said Resident 67's 02/18/2025 Level I PASRR was inaccurate and should have identified the resident's diagnosis of anxiety disorder and referral for a Level II PASRR evaluation. 2) Resident 53 was admitted to the facility on [DATE] with a diagnosis of schizophrenia, depression and anxiety. The Quarterly MDS, dated [DATE], documented the resident was cognitively intact. A review of the EHR showed a Level I PASRR, dated 01/22/2025, was triggered for schizophrenia, depression and anxiety and was referred for Level 2 for Serious Mental Illness (SMI). Additionally, the review showed progress notes, dated 01/22/2025, written by social services, said Level II referral sent due to new guidance. On 06/06/2025 at 10:49 AM Staff F, SSD, provided an email he sent to follow-up on the Level 2 referrals within the facility, but it did not list Resident 53 specifically. 3) Resident 69 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], documented the resident was cognitively intact. A review of the EHR showed a Level I PASRR, dated 03/03/2025, which listed no SMI Indicators. A review of Resident 69's medications showed an order for Risperidone (an antipsychotic), dated 05/05/2025, related to delusional disorder (a mental illness where individuals hold firm, false beliefs despite evidence to the contrary). On 06/06/2025 at 10:49 AM, Staff F, Social Services Director, said the PASRR should be updated for a new diagnosis. Staff F said the PASRR had not been updated for Resident 69's new diagnosis of delusional disorder but he would update it. 4) Resident 78 was admitted to the facility on [DATE] with diagnoses that included delusional disorder and hallucinations unspecified (the experience of perceiving things that are not real, without a clear cause being identified). The PASRR Level I, dated 05/09/2025, documented no SMI indicators. 5) Resident 44 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder, delusional disorder, depression, dementia and unspecified psychosis. The PASRR Level I, dated 02/15/2024 and 02/23/2024, documented Resident 45 required a Level II referral due to SMI. The EHR showed no documentation a Level II evaluation referral had been made, or a Level II invalidation had been completed. On 06/06/2025 at 9:24 AM, Staff P, Registered Nurse Unit Manager, said Social Services oversees PASRR's evaluations and making sure they were competed correctly. Staff P was asked to look up Resident 78's PASRR Level I and mental health diagnoses. Staff P said the mental health diagnoses were not on the PASRR Level I and this should have been caught. On 06/06/2025 at 9:59 AM, Staff F, SSD, said it was their duty to review all Level I evaluations for accuracy and to refer Level I's as needed to the PASRR evaluators. Staff F said Resident 78's PASRR Level I was incorrect, should have been corrected and referred for a Level II. Staff F reviewed Resident 44's Level I and said they could not confirm if a Level I evaluation was referred or if the facility had received a Level II invalidation/recommendation. On 06/06/2025 at 10:22 AM, Staff B, DNS, said Resident 78's Level I should have been corrected and Resident 44's Level I should have been referred to the PASRR evaluators for a Level II. Surveyor: Stoneway, [NAME] 6) Resident 54 was admitted to the facility on [DATE] with diagnoses including depression, anxiety, psychosis, and dementia with psychotic disturbance. The Quarterly MDS, dated [DATE], showed Resident 54 was able to be understood and understands, and was cognitively intact. Review of the EHR showed Resident 54 was taking two antidepressants and one antipsychotic medications. Review of Resident 54's Level 1 PASRR from 11/27/2024 showed psychotic disorder was not selected. The form did not select that a Level 2 PASRR evaluation was required. The form was not redone until 06/03/2025. Review of the EHR showed the diagnosis of psychosis was added to Resident 54's diagnosis list on 12/07/2024. During an interview on 06/05/2025 at 1:13 PM, Staff F, SSD, when asked if Resident 54's Level 1 PASRR, dated 11/27/2024, was accurate said no it was not accurate. Staff F said a Level 1 PASRR should be updated if there was a change in diagnosis. When asked about a diagnosis of psychosis having been added to Resident 54's chart on 12/07/2024, Staff F said yes, the Level 1 PASRR should have been redone. When asked if it met expectations that the Level 1 PASRR, from 11/27/2024 to 06/03/2025, had not referred for a Level 2 PASRR, Staff F said no this did not meet expectations. 7) Resident 19 was admitted to the facility on [DATE] with diagnoses of depression, bipolar disorder, and post-traumatic stress disorder (PTSD). Review of the Medicare 5 Day MDS, dated [DATE], showed Resident 19 was understood and understands, and was cognitively intact. Review of the EHR showed Resident 19 was taking two antidepressants, one antipsychotic, and one mood stabilizer medication. Review of Resident 19's Level 1 PASRR, dated 01/22/2025, showed they had SMI indicators selected, specifically Mood Disorders-Depressive or Bipolar. That specific section had listed diagnostic codes (shows what the resident had a diagnosis of, since they may or may not have one or both diagnoses, or have another mood disorder not listed), with only depression listed (bipolar was not listed). During an interview on 06/05/2025 at 1:13 PM, Staff F, SSD, reviewed Resident 19's Level 1 PASRR, dated 01/22/2025, and said they did not see indication for PTSD on the form. During an interview on 06/05/2025 at 10:30 AM, Staff D, Resident Care Manager/Licensed Practical Nurse, was asked to review Resident 19's Level 1 PASRR from 01/22/2025. Staff D said the box for mood disorder or depression was selected, with depression bolded. When asked what mental health diagnoses Resident 19 had, Staff D said bipolar, PTSD, and depression. Reference WAC 388-97-1915 (1)(2)(a-c) .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure routine assessment and monitoring of skin conditions and implementation of interventions for 1 of 2 residents (Resident 67) reviewed for non-pressure skin, to provide bowel care in accordance with physicians' orders and facility protocol for 4 of 8 residents (Residents 67, 41, 45 & 283) reviewed for bowel management, and to effectively communicate, collaborate, and implement coordinated hospice plans of care for 2 of 2 (Residents 26 & 11) reviewed for Hospice services. These failures placed residents at risk for unidentified decline and/or delayed treatment and healing of non-pressure skin conditions, abdominal pain, decreased appetite, other negative outcomes related to untreated constipation, and unmet end of life care needs related to hospice services. Findings included . <Facility Policy> Review of the facility's Management of Constipation policy, revised November 2023, showed constipation was defined as three or more days without a bowel movement (BM). When a resident was identified with no BM for eight shifts or 64 hours, the LN would assess the resident and determine if the bowel protocol would be initiated. The protocol to relieve constipation was as follows: a) Administer Milk of Magnesia (MOM) after eight shifts of no BM. b) Administer a bisacodyl suppository, if no results from MOM. c) Administer a fleet enema, if no results from the bisacodyl suppository. <Bowel Management> <Resident 67> Resident 67 was admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS, an assessment tool) showed the resident was cognitively intact and was constipated during the assessment period. On 06/03/2025 at 8:55 AM, Resident 67 complained that they occasionally suffered from constipation. Review of the Electronic Health Record (EHR), showed Resident 67 had the following 02/19/2025 bowel care orders: a) Administer MOM if there is no BM on the third day. b) Bisacodyl suppository as needed for Constipation if no results from MOM after 12 hours. c) Fleet enema as needed for Constipation if no results from bisacodyl suppository in 4-6 hours. If there are no results from the enema, notify MD. Review of the March and April 2025 bowel records and Medication Administration Records (MARs), showed Resident 67 went the following periods without a BM, and was not administered as needed bowel medication as ordered: a) No BM from 03/15/2025 - 03/18/2025 (11 shifts); No PRN bowel medication was administered. b) No BM from 03/20/2025 - 03/24/2025 (12 shifts); No PRN bowel medication was administered. c) No BM from 04/19/2025 - 04/22/2025 (12 shifts); No PRN bowel medication was administered. On 06/05/2025 at 10:22 AM, Staff S, Resident Care Manager, confirmed Resident 67 went the above-mentioned periods without a BM. When asked if facility nurses administered the resident's as needed bowel medication after three days without a BM as ordered Staff S stated, No. <Resident 41> Resident 41was admitted to the facility on [DATE]. Review of the Quarterly MDS, dated [DATE], showed the resident was cognitively intact and did not have constipation during the assessment period. On 06/03/2025 at 11:49 AM, Resident 41 said they would occasionally get constipated. Review of the EHR, showed Resident 41 had the following 12/15/2023 bowel care orders: a) Lactulose, administer if no BM on third day. b) Bisacodyl suppository as needed for Constipation if no results from MOM after 12 hours. Review of the February and May 2025 bowel records and MARs, showed Resident 41 went the following periods without a BM and was not administered as needed bowel medication as ordered: a) No BM from 02/26/2025 - 02/29/2025 (12 shifts); No PRN bowel medication was administered. b) No BM from 05/17/2025 - 05/20/2025 (12 shifts); No PRN bowel medication was administered. On 06/09/2025 at 3:14 PM, Staff B, Director of Nursing, confirmed Resident 41 went to the above-mentioned periods without a BM. When asked if facility nurses administered the resident as needed bowel medication after three days without a BM as ordered Staff B stated, No. <Resident 45> Resident 45 was admitted to the facility on [DATE]. The Significant Change MDS, dated [DATE], documented Resident 45 was severely cognitively impaired. Resident 45 had no documented bowel movement on 05/05/2025-05/08/2025 (4 days), 05/17/2025-05/20/2025 (4 days), 05/22/2025-05/25/2025 (4 days), or 05/29/2025-06/02/2025 (5 days). The EHR documented no initiation of the bowel protocol for the 05/05/2025-05/08/2025, 05/17/2025-05/20/2025, or 05/22/2025-05/25/2025. A progress note, dated 06/02/2025, documented the bowel protocol was initiated on 06/02/2025, 5 days after no bowel movement (greater than 64 hours). The MAR/TAR for May and June 2025 documented Milk of Magnesia had been administered once on 05/22/2025, noted first day of no bowel movement as 06/02/2025, 5 days after no bowel movement. On 06/06/2025 at 9:24 AM, Staff P, Registered Nurse Unit Manager, said the dashboard in the EHR, would alert staff if a resident had gone more than 64 hours without a bowel movement. On the third day (72 hours) without a bowel movement, staff would offer/administer Milk of Magnesia. If it produced no result, 24 hours later they would offer/administer a suppository. If no result after another 24 hours, staff would offer/administer a fleet enema. Staff P reviewed all dates with no bowel movement and said the bowel protocol should have initiated for all the dates. At 10:22 AM, after being provided with all the dates with no bowel movement for Resident 45, Staff B, DNS, said the bowel protocol should have been started and should have been documented for all episodes. <Resident 283> Resident 283 admitted to the facility on [DATE]. The admission MDS, dated [DATE], documented Resident 283 was severely cognitively impaired. Resident 283 was a Hospice patient. Review of Resident 283's care plan showed alteration in bowel elimination, constipation related to decreased mobility, medication side effects with the goal of a normal bowel movement at least every third day. Review of Resident 283's orders showed the following bowel medication orders to treat constipation: Order dated 05/22/2025, Bisacodyl Rectal Suppository, insert one suppository rectally every 24 hours as needed for constipation. Order dated 05/23/2025, Fleet Enema, insert one application rectally every 24 hours as needed for constipation if no results from Dulcolax in 4-6 hours. If there were no results from enema, notify MD. No order for Dulcolax was found. Review of Resident 283's bowel records documented no bowel movement from 05/28/2025 through 06/03/2025, 7 days. Further record review showed Resident 283 did not have a suppository administered until 06/03/2025. On 06/06/2025 at 11:19 AM, Staff C, Resident Care Manager/Registered Nurse, said the ordered bowel medications came from the Hospice provider. When asked if it met expectations that a suppository was not administered until the seventh day of no bowel movement, Staff C said it was difficult when someone was passing away and not eating or moving much. Staff C said usually bowel meds were given on the third day of no bowel movement, and staff should have checked with Hospice to see when they should have given the suppository. <Hospice Services> <Resident 26> Resident 26 was admitted to the facility on [DATE]. Review of the Significant change MDS, dated [DATE], showed the resident had severe cognitive impairment, a terminal diagnosis and was on Hospice services. Review of the EHR showed Resident 26's Hospice intake, terminal diagnosis, current coordinated Hospice plan of care or any hospice visit notes were not present in the resident's record. There was also no indication or documentation what disciplines Hospice was to provide (e.g. Registered Nurse, home health aide, Chaplain, Master Social Worker, music therapy etc.,) and at what frequency. On 09/06/2025 at 11:10AM, when asked how do staff knew what disciplines Hospice was providing and at what frequency Staff B, Director of Nursing, said the information should be documented in the Hospice plan of care. When asked if they could find a Hospice plan of care in the resident's record Staff B stated, No. When asked if they knew what disciplines had visited Resident 26, when, and what was done during the visit from the information in Resident 26's EHR Staff B, said no. <Resident 11> Resident 11 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented Resident 11 was rarely/never understood, severely cognitively impaired, was on hospice and had a terminal diagnosis. Resident 11 was placed on hospice services on 01/13/2025. The EHR had minimum hospice documentation, which included uploaded files on: 02/06/2025 Hospice Physician Order- Hospice MD prescribed Paxlovid (COVID-19 treatment) 02/07/2025 Hospice Physician Order- Hospice MD prescribed Paxlovid 02/07/2025 Medication Review 03/17/2025 Medication Review 03/31/2025 Medication review. 05/29/2025 Hospice Physician Order- increase in Lorazepam (an antianxiety medication). Progress notes documented dated: 02/11/2025 Resident 11's bathing would discontinue Mondays but would continue on Wednesdays and Saturdays. 02/19/2025 Ativan (an antianxiety) was stopped for comfort measures. 05/30/2025 Per hospice order and increase in Lorazepam. No other hospice documentation was found including the most recent individualized hospice plan of care, hospice election form, the Physician certification/recertification of the terminal illness, visitation notes (log in sheets), or progress notes stating care provided to the resident. On 06/09/2025 at 9:27 AM, Staff R, Registered Nurse, said they used to have binders located at the nurse's station with all hospice information. Staff R said all contact information for hospice wass located in the EHR and staff could send referrals to hospice via the EHR. Staff R looked through all the binders located at the nurse's station and could not locate a hospice binder for Resident 11. At 9:37 AM, Staff S, Licensed Practical Nurse, said all hospice information was kept in the EHR of the resident's hospice binder. Staff S provided a hospice binder. Upon review of the hospice binder the only information found was a resident Facesheet (demographics), POLST (Physician Orders for Life-Sustaining Treatment, is a portable medical order that helps people with serious illnesses communicate their wishes for end-of-life care to medical providers) and Advance Directive (legal documents that allow individuals to outline their preferences for healthcare decisions). No hospice care plan, hospice election form, Physician certification, visitation notes or progress notes were found. At 11:10AM, Staff B, DNS, said the point of contact for all hospice residents were the assigned unit managers. When asked how RCM's knew what disciplines were required and at what frequency for hospice services, Staff B said it should be documented in the hospice plan of care. When asked how that information was provided to the floor staff, Staff B said it should be loaded into the EHR. Staff B said all hospice documentation including plan of care, visit notes, and progress notes should be in EHR. When asked to review Resident 11 and Resident 26's hospice documentation, Staff B said they could not locate any hospice documentation for Resident 11 or Resident 26, including hospice plan of care, hospice election form, the Physician certification/recertification of the terminal illness, visitation notes (log in sheets), or progress notes stating care provided to the resident. <Non-pressure Skin Monitoring> <Resident 67> During an interview on 06/04/2025 at 12:07 AM, Resident 67 began vigorously scratching her right shoulder and right and left hips. Observation showed a palm sized area with linear abrasions with a scant amount of blood present at each location. Resident 67 indicated there was another area on their back and explained that their antibiotic had been making them itchy for a few months. The resident said they used to receive Benadryl, but the nurse informed them the order was no longer in place. A generalized rash to bilateral (both) arms and trunk care plan, initiated 03/31/2025, directed staff to apply moisturizer to dry flaky skin, cue resident to avoid scratching, and monitor for spreading of the rash. A 03/04/2025 wound consultant note documented Resident 67 had a significant rash and recommended discontinuing their Keflex (an antibiotic) and starting the resident on doxycycline (an antibiotic). The consultant also recommended administering Benadryl every six hours as needed for itching. A 03/11/2025 wound care consult documented Resident 67 complained of a pruritis (the sensation of an unpleasant urge to scratch the skin) and identified a rash to the resident's back. The wound care consultant recommended applying hydrocortisone (anti-inflammatory cream) 1% to the residents back for seven days and to administer Benadryl (an antihistamine) every six hours as needed for itching. Review of the March 2025 MAR and Treatment Administration Record (TAR) showed the 03/11/2025 recommendation for Benadryl and hydrocortisone were not implemented. Nor was there direction to staff to monitor the abrasions to the residents left lower back. A 04/30/2025 nurses note documented the resident had a six-centimeter (cm) x 11 cm area of scattered scabs to their left lower back which was self-inflicted due to scratching. The physician was notified and an order to apply hydrocortisone cream to the area twice daily for seven days was given. Nurses' notes, dated 05/01/2025 and 05/02/2025, documented Resident 67 was on alert for self-inflicted abrasions. Nurses' notes, 05/03/2025 and 05/04/2025 documented Resident 67 had self-inflicted abrasions to their buttocks. Review of the April and May 2025 MAR/TAR showed staff were not monitoring Resident 67's abrasions to the buttocks or left lower back. Review of the EHR showed there was no documentation about the abrasions Resident 67's on left shoulder, right flank, left flank, left lower back or buttocks. On 06/04/2025 at 12:40 AM, when asked if they were aware of Resident 67's complaints of pruritis and the self-inflicted abrasions to the left shoulder and right and left flanks Staff S, Licensed Practical Nurse, indicated they were and had just received an order to start hydroxyzine (an antihistamine) every six hours as needed for itching. Review of the EHR on 06/09/2025 showed an order for hydroxyzine was obtained on 06/04/2025, but no documentation about Resident 67's self-inflicted abrasions to the left shoulder or right and left flanks was found. On 06/09/2025 at 11:27 AM, Staff B, Director of Nursing, said when abrasions or other skin issues are identified, they should be placed on the TAR to monitor until resolved. When asked if that occurred for the abrasions noted to the resident left lower back, buttocks, left shoulder or right and left flanks Staff B, stated, Not that I can see. Reference WAC 388-97-1060(1) .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Fluid Intake> Resident 41 was admitted to the facility on [DATE]. Review of the Quarterly MDS, dated [DATE], showed the r...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Fluid Intake> Resident 41 was admitted to the facility on [DATE]. Review of the Quarterly MDS, dated [DATE], showed the resident was cognitively intact, had a diagnosis of end stage renal disease, and required dialysis during the assessment period. An end stage renal disease care plan, revised 05/01/2025, had a goal that the resident would not have any signs and symptoms (s/sx) of fluid volume overload or fluid volume deficit through the next review. Interventions included dialysis three times a week, monitoring for s/sx of hypervolemia (excessive fluid in the body) and hypovolemia (low levels of fluid in the body caused by various factors including dehydration.) A nutritional risk care plan, revised 05/01/2025, documented the resident was on a 1500 milliliter (ml)/day fluid restriction and directed staff to record food and fluid intake. Review of the resident's physician's orders, showed a 04/15/2025 order for a 1500 ml per day fluid restriction. Dietary was to provide 1080 ml per day, or 360 ml per meal and nursing was to provide 420 ml per day, or 210 ml per shift (12 hour (hr) shifts) for a 24 hour total of 1500 ml. Review of the June 2025 Medication Administration Record (MAR) showed nurses were directed to document the fluids provided on their shift (day/night shift) and night shift was to reconcile the fluids provided by nursing, with the fluids provided with meals, and calculate the resident's 24 hour fuid intake. Review of documentation from 05/23/2025 -06/05/2025 (14 days) showed facility staff failed to consistently document fluid intake for all meals and failed to accurately calculate the residents 24 hour fluid intake on 14 of 15 days reviewed, as follows: - 05/23/2025- meal monitor- 1718 ml; Nursing- 330 ml for a total of 2048 ml; staff documented 1500 ml - 05/24/2025- meal monitor- 480 ml (dinner not recorded); Nursing- 820, 24hr total=1360; staff documented N/A - 05/25/2025- meal monitor- 990 ml; Nursing- 360 ml, 24 hr. total=1350 ml; staff documented 1420 ml - 05/26/2025- meal monitor- 480 ml (lunch not recorded); Nursing- 360 ml, 24 hr total=840 ml; staff documented 1420 ml - 05/27/2025- meal monitor- 20 ml (lunch/dinner not recorded); Nursing- 360 ml, 24 hr total= 380 staff documented 1420 ml - 05/28/2025- meal monitor- 240 ml (lunch/dinner not recorded); Nursing- 570 ml, 24 hr total= 810 staff documented 1420 ml - 05/292025- meal monitor- 720ml; Nursing- 560 ml, 24 hr. total= 1280 staff documented 0 ml - 05/302025- meal monitor- 640 ml (lunch not recorded); Nursing- 570 ml, 24 hr total= 1210 staff documented 210 ml - 05/31/2025- meal monitor- 720 ml (lunch not recorded); Nursing- 410 ml, 24 hr total= 1130 staff documented 1500 ml - 06/02/2025- meal monitor- 900 ml (one missing meal; Nursing- 690 ml, 24 hr total= 1590 ml; staff documented 1500 ml - 06/03/2025- meal monitor- 1200 ml; Nursing- 420 ml, 24 hr. total= 1590 ml; staff documented 350 ml - 06/04/2025- meal monitor- 360 (breakfast/lunch not recorded); Nursing-570 ml, 24 hr total= 930ml; staff documented 240 ml - 06/05/2025- meal monitor- 1200 ml (breakfast/ not recorded); Nursing-570 ml, 24 hr total= 1770ml; staff documented 0 ml. On 06/011/2025 at 3:37 PM, Staff A, Administrator, confirmed Resident 41's fluid intake was incomplete and inaccurate. Staff A indicated the orders had been input in in a confusing manner, which likely contributed to the inaccurate tabulation. Reference WAC 388-97 -1060 (3)(h) Based on observation, interview and record review, the facility failed to ensure significant weight loss was identified, and nutritional interventions were implemented and evaluated for effectiveness for 1 of 2 sampled residents (Residents 45) reviewed for nutrition. Additionally, the facility failed to have a system in place that ensured fluid intake was accurately monitored, documented, and 24-hour intake totals were calculated and evaluated for 1 of 1 resident (Resident 41) reviewed with a fluid restriction. These failures placed residents at risk for continued weight loss, malnutrition, fluid volume overload, fluid and electrolyte imbalances and other medical complications. Findings included . <Nutrition> Resident 45 was admitted to the facility on [DATE]. The Significant Change Minimum Data Set (MDS, an assessment tool), dated 04/06/2025, documented Resident 45 was severely cognitively impaired. On 12/03/2024, the resident weighed 131 lbs. On 05/12/2025, the resident weighed 112 pounds which was a -14.50 % Loss. Resident 45 was prescribed a CCHO diet Regular (Level 7-RG7) (controlled carbohydrate diet in conjunction with the International Dysphagia Diet Standardisation Initiative (IDDSI) Level 7 for Regular foods. This suggests a diet planned for individuals who need consistent carbohydrate intake for blood sugar management (like in diabetes) and can safely consume regular textured foods). A physician's order, dated 09/06/2023, documented resident was to have a health snack at night. Resident 45's Nutrition Care Plan, documented Resident did not have unplanned significant weight changes through the next 90 days as evidenced by their weight record. A Nutritional Evaluation, dated 02/16/2025, documented Resident's intake was excellent, they ate independently and consumed greater than 75% of their meals. Resident was noted with weight stability without unplanned significant changes over 90 and 180 days. On 06/06/2025 at 9:24 AM, Staff P, Registered Nurse Unit Manager, said if a resident was identified as losing weight, staff would make a referral to the Registered Dietitian for a case review with the Nutrition At Risk (NAR) team do be done weekly. Staff P said the NAR team would discuss appropriate interventions and notify the family. When asked about Resident 45's weight loss, Staff P said they were unaware of any weight loss for Resident 45. When shown the weights under the vitals tab in the Electronic Health Record (EHR), Staff confirmed Resident 45 had lost weight, resulting in a 14.50% weight loss. Staff P reviewed the EHR and confirmed no further weight loss interventions had been implemented. At 10:22 AM, Staff B, Director of Nursing Services, said when a resident had lost weight, staff were able to make a Nursing to Nutrition note that went directly to the Registered Dietitian (RD). The RD would review the resident's nutritional status before they attended the Nutrition At Risk meeting, where the residents' case would be discussed and interventions would be implemented. When asked about Resident 45's weight loss, Staff B said they were unaware of any weight loss for Resident 45. Staff B was shown Resident's 45's 14.50% weight loss. Staff B said they would look in the interventions and respond back with any new information found. No response or new information was provided.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure sufficient qualified nursing staff were available to provide restorative nursing services for 2 of 2 residents (Residents 8 and 61) reviewed for limited range of motion. The failure to have sufficient qualified staff to provide restorative nursing services resulted in the therapy department not referring residents for restorative nursing programs, who they acknowledged were at risk for declines in range of motion (ROM), contracture formation/progression, and would have been referred for and benefited from restorative services, had sufficient staff been available to provide them. This failure placed residents at risk for decreased ROM, contractures, impaired skin integrity, increased dependence on staff for care needs and a diminished quality of life. Findings included . <Restorative Services> 1) Resident 61 was admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS, an assessment tool), showed the resident was cognitively impaired, required maximal/substantial assistance with most activities of daily living (ADLs), had limited functional rom to both lower extremities, and did not receive restorative nursing services. An Occupational Therapy (OT) Evaluation and Plan of Treatment, dated 8/23/2025, documented the reason for therapy was impaired balance, mobility, gross motor coordination and problem solving, resulting in limitations in the areas of mobility and self-care. It was assessed that due to the residents documented physical impairments and associated functional deficits, Resident 61 was at risk for further decline in function and mobility. An OT Discharge Summary, dated 09/11/2024, showed under Discharge Recommendations and Status staff documented restorative nursing programs were not indicated at this time. An OT Evaluation and Plan of Treatment, dated 01/02/2025, documented the reason for the current referral was due to new onset of decrease in functional mobility, decrease in strength, falls/fall risk, functional limitation with ambulation, and limited and painful movement. An OT Discharge Summary, dated 01/15/2025, showed under Discharge Recommendations and Status, staff documented restorative nursing programs were not indicated at this time. A bilateral knee contracture care plan, initiated on 07/15/2024, showed on 4/29/2025 the resident was to start a passive ROM restorative nursing program which directed the restorative aide to perform passive ROM to both lower extremities for three sets, then apply splints to both lower extremities for four to six hours, seven days a week. Review of the electronic health record (EHR) showed the restorative nursing program was never implemented. Review of the May 2025 Treatment Administration Record (TAR) showed the splints were placed on the TAR with direction to apply for four to six hours from 2:00 PM - 6:00 PM, and to check skin integrity when removed. On 06/06/2025 at 12:50 PM, Staff AA, Director of Rehabilitation, was asked why Resident 61, who was assessed to be at risk for further decline in function and mobility, was not referred to restorative nursing to maintain gains made with therapy and/or prevent further decline in the 09/11/2024 and 01/15/2025 OT discharge summaries. Staff AA acknowledged Resident 61 would have benefited from restorative nursing services, but explained OT did not refer the resident to restorative nursing because the facility did not have staff to provide the services. 2) Resident 8 was admitted to the facility on [DATE]. Review of the Quarterly MDS, dated [DATE], showed the resident was cognitively impaired, was dependent on staff for ADLs, had impaired functional ROM to both upper and lower extremities and did not receive restorative nursing services. A Physical Therapy (PT) Evaluation and Plan of Treatment, dated 07/07/2021, documented Resident 8 was referred to therapy for a decline in ROM, strength and ability to perform functional activities without physical assistance. A PT Discharge Summary, dated 10/05/2021, showed the therapist had documented under Discharge Recommendations and Status the resident was referred for a restorative splint and brace program. A PT Discharge Summary, dated 05/12/2022, showed the therapist had documented under Discharge Recommendations and Status the resident was referred to restorative nursing for a bilateral lower extremity ROM program. Review of the EHR showed there was no documentation to show the 10/05/2021 referral for a restorative splint and brace program or the 05/12/2022 referral for a bilateral lower extremity rom program were ever initiated. On 06/09/2025 at 1:43 PM, Staff AA, Director of Rehabilitation, confirmed that there had been a lot of residents that would have benefited from restorative nursing services and would have typically been referred, but were not due to the lack of restorative staff to provide the programs. On 06/09/2025 at 2:18 PM, Staff A, Administrator, and Staff B, Director of Nursing, both confirmed the facility did not currently provide restorative nursing services due to a lack of sufficient and qualified staff. Reference WAC 388-97-1080 (1), 1090 (1) .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0847 (Tag F0847)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure the facility's binding arbitration agreements (legal document that required the use of a third party to resolve disputes) was reviewed and explained in a form, manner, and/or language understood by the resident and/or their legal representative for 3 of 3 sampled residents (Residents 39, 70, & 28) reviewed for binding arbitration agreements. This failure placed residents at risk for lacking understanding of the legal document signed, forfeiture (loss or giving up of something) of the right to a jury or court, and a diminished quality of life. Findings included . The facility's blank Arbitration Agreement, dated 07/2024, was reviewed on 06/06/2025, and documented: A. Resident and Resident's Representative ARE NOT required to sign the Agreement as a condition of admission to or as a requirement to continue to receive care at the Center. C. This agreement waives the right to a trail by judge or Jury. 1. Disputes to be Arbitrated. The Parties shall submit for binding arbitration pursuant to this Agreement, any and all claims or controversies arising out of or in any way relating to: (i) the Center's admission Agreement; (ii) the Resident's stay at the Center, including all prior stays at the Center; and (iii) disputes regarding interpretation or enforceability, or both, of this Agreement, whether such claims or controversies described in (i)-(iii): (x) arise out of state or federal law, whether existing now or arising in the future; (y) include statutory, compensatory, or punitive damages; or (z) sound in breach of contract, negligence, tort, or breach of statutory duties (including, without limitation, claims based on personal injury or death), regardless of the basis for any duty or of the legal theories upon which the claim is asserted. 2. Waiver of Judge or [NAME] Trial. By signing this Agreement, the Parties expressly and irrevocably waive any right to trial by judge or jury. 3. Right to Revoke. Resident or Resident's Representative may revoke this Agreement by providing written notice to the Center within thirty (30) calendar days of signing the Agreement. If any alleged dispute arises before the Center receives such notice, this Agreement shall be binding with respect to such dispute. <Resident 39> Resident 39 was admitted to the facility on [DATE]. The admission Minimum Data Set, (MDS, an assessment tool), dated 04/16/2025, documented Resident 39 was cognitively intact. On 06/06/2025 at 11:51 AM, when asked what their understanding was of an arbitration agreement, Resident 39 stated, I don't know what an arbitration agreement is. Resident 39 said they vaguely remember the facility saying something about an arbitration agreement, but they did not know what it was. When asked if they understood they were giving up their right to a court proceeding, Resident 39 said no. When asked if it was explained they did not have to sign the agreement as a term of admission to the facility, Resident 39 said no. When asked if it was explained that the resident only had 30 days to revoke the arbitration, Resident 30 said no. When asked if the arbitration agreement was explained in a way that they understood, Resident 39 stated, no, not like you're explaining it to me. Resident 39 said they would not have signed it, if they did not have too. <Resident 70> Resident 70 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], documented Resident 70 was cognitively intact. On 06/06/2025 at 12:54 PM, when asked what their understanding was of the facility's arbitration agreement, Resident 70 stated, I don't know, I don't know what I signed. I signed what ever they put in front of me. I don't know what I was signing. When asked if the arbitration agreement was explained in a manner they understood, Resident 70, said they did not recall. Resident 70 said they were at the hospital, then the next thing they were at the facility, and they did not know why they were sent here. Resident 70 said nothing was explained to them. <Resident 28> Resident 28 was admitted to the facility on [DATE]. The 5 Day MDS, dated [DATE], documented Resident 28 was severely cognitively impaired and had an active Power of Attorney (POA, a legal document that allows one person to grant another person the power to act on their behalf). On 06/09/2025 at 9:50 AM, when asked what their understanding was of the facility's arbitration agreement, Resident 28's POA, stated, It wasn't explained by the facility, they just sent it over. Resident 28's POA said the facility emailed them the packet and said sign it, nothing was explained and there were no directions with the admission packet. Resident 28's POA said there was no discussion about the rights they were giving up. Resident 28's POA said they would have liked the facility to explain the arbitration agreement to them. On 06/09/2025 at 10:14 AM, Staff G, Business Office Manager (BOM), said no residents were currently entered into a dispute or had any resolved disputes. Staff G said the arbitration agreement was provided to the resident at the time of admission or within 72 hours. The resident was able to agree or disagree with the arbitration agreement. Staff G said they go over the arbitration agreement with every resident, it was explained that it was a legal voluntary document. Staff G stated, let me give you, my [NAME]. This is a voluntary agreement, if you are considering suing us, we ask you come to us first, before going to court. If you don't want to, then you can rescind the decision, I ask for it in writing and provide it to me. Staff G repeated the [NAME] twice. No explanation was provided that included this was not a term of admission, no timelines were provided (30 days to rescind) or that the resident was giving up right to a court hearing. When asked about the timeline (30 day to rescind), Staff G stated, I do not give timeline, there are no timelines. When asked how they assess a resident with cognitive delays, Staff G said they asked resident basic questions to see if the resident was cognitively aware and abale to sign. Staff G said if there were concerns with cognitive abilities, they would reach out to Social Services to acquire about Brief Interview for Mental Status (BIMS, performance-based cognitive assessment tool used to screen for cognitive impairment). Staff G said if a resident did not have the cognitive ability to understand then the facility would reach out to the family or next of kin and would provide the admission packet with the arbitration agreement to them. When asked about family or next of kin not being able to sign in person, Staff G said the facility used DocuSign (electronic signature system) and they would have a conversation via phone call with the family/next of kin. On 06/09/2025 at 10:52 AM, when asked about the arbitration agreement process, Staff A, Administrator, with Staff H, Regional Clinic Manager, present, said the arbitration agreement was given to residents upon admission, they agree or decline to sign it and it was stored in the resident's file under the document manage tab. When asked their understand of the arbitration agreement, Staff H said it was explained that it was a basic admission agreement that the resident and the facility would go to mediation first, instead of going to court or jury. Staff H said the resident has the choice to sign the agreement and can change their mind at any time, as many times as they want. Staff H said there is no grace time and it was not a requirement for admission. It was explained to Staff A and Staff H, that the information provided by Staff G (BOM), did not include that it was not a term of admission, no timelines were provided (30 days to rescind) or that the resident was giving up right to a court/jury hearing. When asked does it meet expectation that residents were lead to believe they still have court options, were not informed of 30 days timeline requirement for revocation and were no not provided information that signing Arbitration agreement was not a term of admission to the facility, Staff A and Staff H did not answer the question. When asked again if this met their expectation, Staff A asked to review the Arbitration Agreement. Staff reviewed the electronical copy of the Arbitration agreement. Staff H said the residents were told that it was a voluntary agreement. When asked a third time, if this met their expectation, Staff H asked to again hear Staff G' explanation of the arbitration agreement. Staff G's [NAME] was recited to Staff A and Staff H again. When asked again, if giving the resident false information or incorrect information met their expectation, Staff H stated, her verbalizing needs to be worked on, but the implication is there. When asked again, if this met their expectation, Staff H said no and Staff A did not respond. No associated WAC.

May 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observations, interviews and record review, the facility failed to implement the plan of care for 1 of 3 (Resident 1) residents reviewed for quality of care. This failure placed residents at risk for clinical complications, discomfort, lack of nutrition and a diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses including diabetes and multiple sclerosis (a disease affecting your brain and spinal cord). The Minimum Data Set, an assessment tool, dated 04/11/2025, showed the resident had a pressure ulcer, required substantial/maximal assistance with bed mobility, was dependent on staff for transfers and had severe cognitive impairment. Resident 1's current care plan showed the following: -Focus Area-the resident has a stage III (pressure ulcer with full thickness loss of skin exposing subcutaneous tissue) pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure) present on the sacrum (tailbone), revised 04/29/2025. Interventions showed the importance of frequent repositioning. - Focus Area-ADL [activities of daily living] self-care deficit, revised 04/30/2025. Interventions showed for dressing resident required total assistance, for personal hygiene required extensive assistance, for bed mobility the resident was a max assist of two staff, resident was incontinent and was on scheduled check/change, required 1:1 assistance with meals in dining room as tolerated, resident was extensive assist with eating and was highly encouraged and assisted to w/c [wheelchair] and dining. On 05/08/2025 at 11:22 AM, Resident 1 was observed lying in bed. The head of the bed was straight up at 90 degrees. The resident was slumped in the bed, lying on their right side with their head bent forward at an angle. When asked if they were comfortable the resident said, no. On 05/08/2025 at 1:35 PM, Resident 1 was observed in the same position, lying on their right side in bed. The head of the bed had been lowered to approximately 45 degrees. On 05/08/2025 at 1:37 PM, when asked if the Resident 1 was going to get up for the day, Staff A, Certified Nursing Assistant (CNA), said Resident 1 usually got up into the wheelchair but the resident had an incident the other day and slid out of the wheelchair and landed on the floor, so they were trying to get him a new chair. Staff A said they thought the resident and his wife preferred him to be up and said the resident would sit up and go to the dining room for meals. Resident 1's progress notes, dated 05/05/2025, showed a nursing communication to therapy for a possible change in condition in the following areas: falls and W/C [wheelchair] positioning, the resident had slid out of wheelchair today after lunch. Resident 1's progress notes, dated 05/07/2025, showed a therapy to nursing communication. The note showed the therapist recommended repositioning when needed and placing resident back to bed after meals and when fatigued. On 05/15/2025 at 9:58 AM, 11:16 AM and 12:00 PM, Resident 1 was observed lying in bed. The head of the bed was upright at 90 degrees. The resident was lying on their right side with a pillow wedged under their left hip. The resident's legs were pulled up to their abdomen and their head rested against the wall at a downward angle. The resident had a hospital gown on that exposed their bare chest. The resident's hair was not combed. On 05/15/2025 at 12:25 PM, Staff B, CNA, was observed delivering a meal tray to Resident 1's room. On 05/15/2025 at 12:26 PM, Resident 1 was observed lying in bed with the head of the bed upright at 90 degrees. The resident was lying on their right side with a pillow wedged under their left hip. The resident's legs were pulled up to their abdomen and their head rested against the wall at a downward angle. The resident had a hospital gown on that exposed their bare chest. The resident's hair was not combed. A bedside table with a meal tray on it was in front of the resident. The items on the tray were uncovered. No staff were observed in the room. The resident was turned on their side and unable to maneuver to use the utensils to eat. On 05/15/2025 at 12:33 PM, Staff A, CNA, said they were assigned to care for Resident 1. When asked if they were going to get the resident out of bed, Staff A said they were going to but the aide that had the resident the day before told them not to. On 05/15/2025 at 12:46 PM, Resident 1 was observed in the same position they had been observed at 9:58 AM, 11:16 AM, 12:00 PM, 12:26 PM; observed lying in bed, the head of the bed was upright at 90 degrees. The resident was lying on their right side with a pillow wedged under their left hip. The resident's legs were pulled up and their head rested against the wall at a downward angle. The resident had a hospital gown on that exposed their bare chest. The resident's hair was not combed. The meal on the overbed table was observed to be untouched. Staff C, Administrator, was brought into Resident 1's room. Staff C said the resident was unable to eat due to the position of the resident in the bed. On 05/15/2025 at 4:31 PM, Staff D, Director of Nursing, said Resident 1 should have been assisted out of bed and into their wheelchair. Staff D said if the resident refused, they should have been assisted with their meal in the room, and repositioned in the bed. Staff D said they expected the staff to follow the resident's plan of care. WAC Reference 388-97-1020 (1)(2)(a)(b) .

Mar 2025 3 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Deficiency F0760 (Tag F0760)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure medications to prevent seizures were administered per physician orders for 1 of 3 residents (Resident 6) reviewed for quality care. Resident 6 experienced harm when they were found unresponsive, required Cardio-Pulmonary Resuscitation (CPR/an emergency procedure consisting of chest compressions combined with giving breaths of air) and was hospitalized when their medication for seizures were not administered for multiple doses due to the unavailability of the medications, resident refusals, and failure to notify the physician of the omissions. This failure placed all residents at risk for medical complications and a diminished quality of life. Findings included . Review of the facility policy titled, Medication Administration, revised 12/2024, showed staff were to document if a resident refused and or a dose was omitted in the EMR [electronic medical record]. The policy showed that it was not acceptable to omit a dose by indicating NA for medication not available from pharmacy, staff were to remove a dose from emergency kit or contact the pharmacy, if the medication was not available, contact the physician for further orders. Review of the facility policy titled, Refusal of Medication, Treatment and/or Dietary restrictions, revised 1/2024, showed the facility would review and offer alternative interventions as appropriate if medication was refused and notify physician and resident representative of resident's wishes. Resident 6 was admitted on [DATE] with diagnoses of dementia and seizure disorder. The Minimum Data Set Assessment, an assessment tool, dated [DATE] showed the resident had severe cognitive impairment. On [DATE] at 3:09 PM, Collateral Contact 1 (CC1) said in the evening of [DATE], they were called by a facility licensed nurse and were told Resident 6's eyes rolled back, and they attempted to arouse the resident with a sternal rub and were unsuccessful. CC 1 said the nurse indicated they initiated CPR, called 911 and the resident was taken to the emergency room. CC 1 said they contacted the emergency room nurse and were told they believed the resident had a seizure due to not receiving their medications for seizures. CC 1 contacted the facility, and the licensed nurse confirmed the resident hadn't received their seizure medications for a few days. CC1 said they had not been notified prior to this episode by the facility that there were problems with administering the resident's medications and were upset about what the resident was put through. Resident 6's care plan, alteration in neurological status with potential for seizure activity r/t [related to] epilepsy, revised [DATE], showed an intervention of; medications as ordered for seizure activity. Resident 6's behavior care plan, revised [DATE], showed the resident had a behavior problem r/t resisted care and refused to take medication. The target behavior care plan, dated [DATE], showed one of the interventions for refusals of care/medications was to refer to MD [medical doctor] as needed for additional treatment and eval [evaluation]. Resident 6's physician orders, dated [DATE], showed an order for Valproic Acid 250 milligrams (mg) per 5 milliliters (ml) give 5ml four times per day for epilepsy (seizure disorder). An order, dated [DATE], for Dilantin 200mg two times per day for epilepsy. An order, dated [DATE], for Levetiracetam 10ml two times per day for epilepsy. Resident 6's laboratory results, dated [DATE], showed the Valproic acid level low at 43 microgram (ug)/ml, normal reference range 50-100. Keppra (Levetiracetam) level was within normal range at 37.5 ug/ml, (reference range 10.0-40.0 ug/ml). Laboratory results, dated [DATE], showed phenytoin levels elevated at 2.7 ug/ml (normal reference range 1.0-2.0). Resident 6's Medication Administration Record (MAR), dated February 2025, showed the resident refused their Valproic Acid medication, Dilantin medication and their Levetiracetam medication on [DATE] and [DATE] at bedtime. The resident's MAR, dated [DATE], showed the resident did not receive their Valproic acid medication on [DATE] at 12:00 PM, 4:00 PM and 8:00 PM and refused it on [DATE] at 8:00 PM. The MAR further showed the resident refused their Dilantin and Levetiracetam medication on [DATE] at bedtime. Resident 6's progress notes, dated [DATE], showed the following medication administration notes: at 14:26 (2:26 PM) the Valproic acid was not available in the cart at 18:37 (6:37 PM) re-check with pharmacy and will be coming in tonight at 23:45 (11:45 PM) follow up with pharmacy and will deliver tonight. Review of Resident 6's EMR on [DATE], showed no documentation the physician and/or resident representative was notified of the resident's refusal of medications on [DATE], [DATE], [DATE] and/or the unavailability of the valproic acid on [DATE]. Resident 6's progress notes, dated [DATE], showed the LN [licensed nurse] reported the resident had become unresponsive and pulseless (no heartbeat) they started CPR, and medics took the resident to the hospital. Resident 6's hospital emergency room records, dated [DATE] at 18:56 (6:56 PM), showed the chief complaint as, resident was brought to the emergency from the facility by EMS [emergency medical services] for a seizure, the facility staff started CPR for unknown amount of time, felt pulse, patient had pulse for medics. The record showed per EMS the patient had not taken seizure meds for 2 days. The record showed hospital laboratory results, collected on [DATE] at 18:58 PST (6:58 PM), showed Phenytoin (Dilantin) level low at 5.5 micrograms (mcg)/ml (normal reference range is 10.0 -20.0 mcg/ml) and Valproic Acid level low at 36 mcg/ml (normal reference range is 50.0-100.0 mcg/ml). The record showed the resident was given intravenous (medication administered into the resident's veins) Dilantin and Valproic acid. The record showed the subtherapeutic (a dose or concentration of a drug that is below what is used for treating disease or producing an optimal therapeutic effect) levels most likely led to seizure. The record showed the assessment/plan for the resident was acute UTI [urinary tract infection] and seizure secondary to subtherapeutic anticonvulsant (medication used to prevent or control seizures) medication. On [DATE], Staff A, Acting Director of Nursing, said they reviewed Resident 6's medical record and found no notification to the resident's physician and/or representative of the medication refusals or the unavailability of the medication. Staff A said the staff should have notified the physician of the refusals and the unavailability of medications, especially seizure medications. WAC Reference 388-97-1060 (3)(k)(iii) .

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review, the facility failed to provide assistance with bathing, dressing and personal hygiene for 2 of 4 residents (Resident 1 and 2) reviewed for quality of care. This failure placed residents at risk for poor hygiene, loss of dignity and a diminished quality of life. Findings included . <Resident 1> Resident 1 was admitted on [DATE]. The Minimum Data Set Assessment (MDS), an assessment tool, dated 03/07/2025, showed the resident was cognitively intact and required substantial assistance from staff for bathing, dressing and supervision/touching assistance for personal hygiene. On 03/27/2025 at 11:06 AM, Resident 1 was observed lying in bed. The resident said they had their first shower on 03/11/2025 (11 days after admission) after repeatedly asking for a shower. The resident said no one had offered to assist them with getting ready for the day. The resident said the staff did not routinely offer to get them out of bed, assist them to the bathroom, clean up for the day, brush their teeth and/or get ready for bed at night, they don't do that here. Resident 1's care plan, revised 03/17/2025, showed the resident required one person level of assistance with bathing/showering two times per week and as necessary. The care plan showed the resident required total assistance with personal hygiene care and ext [extensive] assist of 1 staff for dressing. Review of Resident 1's bathing task documentation, dated 03/26/2025, showed the resident had received one shower since admission on [DATE]. <Resident 2> Resident 2 was admitted on [DATE]. The MDS, dated [DATE], showed the resident was cognitively intact. On 03/27/2025 at 11:35 AM, Resident 2 was observed lying in bed, wearing sweatpants and a shirt. The head of resident 2's bed was elevated, and the resident was eating their lunch from a tray on a table parallel to the bed. Resident 2 said the staff did not offer showers, provide assistance to get out of bed and/or to wash up for the day, that is not going to happen here. The resident said they were lucky to get a staff member to come to their room everyday and they were at the facility for several days before they were able to obtain a toothbrush and toothpaste. The resident said they were in the bed 24 hours per day and maybe every three days the staff would change their clothes. Resident 2's care plan, revised 03/19/2025, showed the resident required one person level of assistance with bathing/showering two times per week and as necessary. The care plan showed the resident required set up assistance with personal hygiene care and set up assist upper [upper body] and mod [moderate] assist for dressing. Review of Resident 2's bathing task documentation on 03/26/2025, showed since admission on [DATE] the resident received one shower and had one shower that was offered and refused. <Final interviews> On 03/27/2025 at 12:02 PM, Staff E, Certified Nursing Assistant, said they were assigned to care for Resident 1 and 2. Staff E said they had not provided assistance to Resident 1 and Resident 2 that morning for getting out of bed, dressing and/or personal hygiene, I was too busy. On 03/27/2025 at 4:00 PM, Staff A, Acting Director of Nursing, said they expected the nursing staff to provide care and assistance per the resident's plan of care. Staff A said they expected the nursing staff to provide at a minimum for morning and evening care; personal hygiene, mouth care, dressing/undressing and assistance with getting in and/out of their bed. WAC Reference 388-97-1060 (2)(c) .

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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. Based on observation, interview and record review, the facility failed to ensure 3 of 6 staff members (Staff B, C and D) used personal protective equipment (PPE) in accordance with the Centers for Disease Control (CDC) guidelines when caring for residents with known COVID 19 (an infectious virus causing respiratory illness that may cause difficulty breathing and could lead to severe impairment or death) infections. This failure placed residents and staff at risk for contracting and spreading COVID 19. Findings included . A 06/24/2024 CDC update titled, Infection Control Guidance: SARS-CoV-2 (the virus that causes COVID 19), showed residents should be placed on transmission based precautions and when health care personnel enter the room of a patient with suspected or confirmed COVID 19, they should use a N95 respirator (a mask that filters 95% of airborne particles), gown, gloves, and eye protection. A 04/12/2024 CDC guidance titled, CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, showed staff were to remove and discard PPE, other than respirators, upon completing a task before leaving the patient's room. If a respirator was used, it should be removed and discarded after leaving the patient room and closing the door. A 08/09/2023 Washington State Department of Health aerosol precaution sign, showed the PPE required for caring for residents with COVID 19, including gown, gloves, N95 respirator and eye protection. <Staff B> On 03/25/2025 at 10:46 AM, Resident 3's room was observed with an aerosol precaution sign on the door. Staff B, Licensed Practical Nurse, entered the resident room wearing a gown, gloves, N95 respirator and eye protection. At 10:52 AM, prior to exiting the room, Staff B doffed (took off) the gown and gloves. Staff B exited the room with the N95 respirator and eye protection on. Staff B removed the eye protection and cleaned it with disinfecting wipes. Staff B did not remove the N95 respirator. Staff B continued down the hallway wearing the same N95 respirator and engaged with residents and staff in the hallway. At 1:50 PM, Staff B said they usually changed their N95 respirators after caring for a resident with COVID 19 but had forgotten. <Staff C> On 03/25/2025 at 10:57 AM, Resident 3's room was observed with an aerosol precaution sign on the door. Staff C, Certified Nursing Assistant (CNA), entered the resident's room wearing a gown, gloves, N95 respirator and eye protection. Upon exiting the room Staff C doffed the gown, gloves and performed hand hygiene. Staff C exited the room and without changing the N95 respirator and/or the eye protection, proceeded down the hallway engaged with other residents and assisted them with refreshments. At 12:02 PM, Resident 4's room was observed with an aerosol precaution sign on the door. Staff C entered the room wearing a gown, gloves, N95 respirator and eye protection. Staff C removed the gown and gloves prior to exiting the room. Staff C exited the room without changing the N95 respirator and/or eye protection and proceeded down the hallway into another resident unit. <Staff D> On 03/25/2025 at 1:26 PM, Resident 5's room was observed with an aerosol precaution sign on the door. Staff D, CNA, entered the room wearing a gown, gloves, N95 respirator and eye protection. Staff D removed the gown and gloves prior to exiting the room. Staff D exited the room without changing the N95 respirator and/or eye protection and proceeded down the hallway with the eye protection flipped up onto their head. At 1:42 PM, Staff D said when they exit a resident's room that was positive with COVID 19, they remove their gown and gloves but not their N95 respirator and/or eye protection. Staff D said they felt like they should, but additional N95 respirators and/or eye protection were not always available. <Final interview> On 03/27/2025 at 4:00PM, Staff A, Acting Director of Nursing, said residents with COVID 19 were placed on aerosol precautions. Staff A said they expected when staff entered rooms of residents on aerosol precautions, they would wear a N95 respirator, eye protection, gown and gloves and remove all the PPE upon exiting the room. Staff D said the staff did not follow their infection control procedures when caring for the residents with COVID 19. Reference WAC 388-97-1320 (1)(a)(2)(b) .

Feb 2025 2 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Pressure Ulcer Prevention (Tag F0686)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to accurately assess and take timely action to prevent the development of pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure) experienced by 1 of 1 closed record Resident reviewed for wound care. Resident 1 experienced actual harm when they developed pressure ulcers to both heels which required hospitalization for surgical intervention, intravenous (administered through the vein) antibiotics and below the knee amputation (BKA) of their right lower extremity (RLE). These failures placed residents at risk for pressure ulcer development, deterioration of existing pressure ulcers, pain, and a decreased quality of life. Findings included . Review of the facility's policy titled, Wound Prevention and Treatment, revised 02/03/2023, showed that wounds including pressure injuries and significant skin tears would be monitored weekly and documentation of size, color, odor, healing progression, notifications and other pertinent information related to the skin conditions would be documented in the electronic medical record. Physician notification and resident/resident representative notification would be completed as needed. Resident 1 was admitted on [DATE] with diagnoses including developmental delay, diabetes and morbid obesity. The Minimum Data Set, an assessment tool, dated 01/27/2025, showed the resident was cognitively intact, at risk for pressure ulcers and required staff assistance for bed mobility and was dependent for out of bed transfers. Review of Electronic Health Record (EHR) showed Resident 1 had long standing orders since admission for weekly diabetic foot checks. The EHR showed Resident 1 had a history of pressure ulcers, the most recent to their left lateral foot that was documented as resolved 12/03/2024 by wound consultant team. Resident 1's skin evaluation, dated 01/13/2025, showed no skin impairments on the resident's feet and/or heels. Resident 1's skin evaluation, dated 01/20/2025, showed the resident's left heel was reddened with a 6.0 centimeters (cm) by 2.0 cm scabbed area. Resident 1's physician order, dated 01/26/2025, showed an order for staff to monitor bilateral heel wounds and apply dressings every Tuesday, Thursday and Friday. Resident 1's medical provider notes, from date of service of 01/27/2025, showed resident was seen by an Advanced Registered Nurse Practitioner (ARNP) and Resident 1's skin was noted to be warm, dry, pink, intact other than rash to the posterior of the left lower extremity and it was healing and no drainage on sheet noted. Resident 1's progress notes, dated 01/28/2025, documented a nursing assistant had noticed a small amount of blood on Resident 1's right heel and the skin looked pulled back, when nurse went to assess she noted an area around the resident's right heel wound that looked macerated (skin condition that occurs when skin softens and breaks down due to prolonged exposure to moisture) as if resident had been picking at it and they had pulled back a large layer of skin, presenting as a 5x4 area of skin tear. Resident was placed on alert and their care plan was updated. The progress note documented the resident would sit cross legged/duck style and lean their upper body over the lower body thereby applying pressure to the heels and was encouraged to reposition and staff placed pillows to help with pressure relief. Review of the EHR showed the following: On 01/29/2025, there were no notes found regarding Resident 1's feet. On 01/30/2025 at 1:24 AM, a note was made showing, dressings to feet are intact, foam booties in place. On 01/31/2025, there were no notes found regarding Resident 1's feet. The three times a week dressing changes on the January 2025 Treatment Administration Record (TAR) were checked off as having been completed throughout January. On 02/01/2025 at 1:37 AM, a note was made showing, dressings to feet are intact, foam booties in place. Resident 1's care plan, revised 02/02/2025, showed the resident had a pressure area on left foot at the lateral aspect (outside edge) of the 5th toe (pinky toe) with a goal the pressure ulcer would show signs of healing and remain free from infection. The care plan showed an intervention of assess/record/monitor wound healing weekly and prn [as needed] and measure length, width, and depth where possible, assess and document status of wound perimeter, wound bed and healing progress and report improvement and declines to the Medical Doctor (MD). The care plan showed the resident had a skin tear on the right heel, with a goal the skin tear would heal with no s/s [signs and symptoms] of infection and interventions to monitor/document location, size and treatment of skin tear, report abnormalities, failure to heal, signs and symptoms of infection, maceration to MD. On 02/02/2025 and 02/03/2025, there were no notes found regarding Resident 1's feet. The next formally documented skin evaluation (last was 01/20/2024), dated 02/04/2025, showed the bottom of the resident's right heel with a skin tear 5 x 4 and ongoing treatment of the resident's left heel that showed it was reddened with a 6.0 cm x 2.0 cm scabbed area. A physician order dated 02/05/2025, showed an order for wound consultant to evaluate and treat as indicated and a dressing to the right heel to be changed daily. Resident 1's progress notes, dated 02/05/2025, showed new orders were received for wound consultant to evaluate and treat. The note showed the LN [licensed nurse] asked the wound team consultant to look at the wound and wanted the resident to be on their rounds the next week. The wound consult was submitted and new treatment orders were received from the provider for cleansing and dressing daily. Review of Resident 1's progress notes, dated 02/06/2025 through 02/10/2025, showed no documentation of assessment or monitoring of Resident 1's skin which was ordered for daily monitoring and dressing changes during this time. Resident 1's wound consultant report, dated 02/11/2025, showed an assessment of large ulcers to the resident's bilateral feet with maceration and erythema (redness of the skin) with a concern for underlying osteomyelitis (infection in the bone), risk of amputation and the resident needed to be sent to the ED [emergency department] for evaluation. Resident 1's hospital records, with date of admission as 02/11/2025, showed when the resident presented to the hospital emergency room where the medical provider's assessment showed chronic, very foul-smelling decubitus (damage to an area of the skin caused by constant pressure on the area for a long time) ulcerations (open wounds) in the bilateral calcaneal (heel bone) areas. Resident 1's hospital records showed a podiatrist (medical doctor that specializes in feet and lower leg issues) consult, dated 02/12/2025, documented decubitus ulcer of heel bilateral, a right heel 6.0 x 6.0 centimeters (cm) full-thickness ulceration with necrotic tissue (dead tissue) with purulence (presence of pus) with the ability to probe deep to the bone, a left lateral heel with 4.0 cm x 4.0 cm area of necrotic purulent tissue with inability to probe deep to bone and a full thickness ulceration about the plantar left fifth metatarsal head (the long bone on the outside of the foot) with inability to probe deep to bone. The consult showed the right side with necrotic infected tissue and the left side had significant necrotic infected tissue loss. The consult showed the podiatrist did not think the right lower extremity was salvageable and they hoped the left lower extremity could be salvaged with aggressive tissue debridement (removal of damaged tissue from a wound), and long term intravenous (medication administered in the vein) antibiotic (medication for infection) therapy. On 02/20/2025, the hospital record showed the resident had a right BKA [below the knee amputation] on 02/19/2025 and received intravenous antibiotics. On 02/12/2025 at 12:03 PM, Staff A, Registered Nurse (RN)/Staff Nurse, said they worked the day shift, three days on and then three days off on a rotating schedule with Staff D, Licensed Practical Nurse (LPN)/Staff Nurse and were assigned to Resident 1. Staff A said Resident 1 would sit up in bed on their legs. Staff A said they reported it to the medical provider on 01/26/2025 when they found the resident's right heel with blood on it, and it had appeared that the resident had peeled the skin off the heel. Staff A said the left heel had scabs on it and it looked like it was forming a deep tissue injury (a type of pressure injury that occurs when prolonged pressure damages the underlying soft tissues). Staff A said the medical provider said to put pillows under the resident's legs so the resident could not sit on their legs and the medical provider was aware staff had asked the wound consultant to see the resident. Staff A said the wounds on both heels were soaking through the dressings. Staff A said after 01/27/2025, the wounds on both heels got worse and were deep tissue wounds and the previous week (week of 02/03/2025) both heels were draining and open wounds. On 02/12/2025 at 12:49 PM, Staff B, Unit Manager/LPN, said they would expect to see a wound assessment when wounds were discovered on a resident. Staff B said they had obtained the physician order for the wound consultant to see Resident 1 on 02/05/2025, for the wound on the right heel. Staff B said they were not aware the wounds had escalated and thought the wound consultant and/or Staff C would see the Resident, I thought the resident was on the weekly caseload with the wound consultant. On 02/12/2025 at 1:54 PM, Staff C, Unit Manager/RN, said they were assigned to accompany the wound consultants when they rounded on residents. Staff C said Resident 1 had a pressure wound on their left lateral foot that the wound consultants had resolved back in December of 2024. Staff C said they knew nothing about wounds on Resident 1's feet until the previous week (week of 02/03/2025) so they had mentioned to the wound consultant they needed to see the resident. Staff C said Resident 1 had COVID (had tested positive 01/24/2025) and the wound consultants would not see residents when they were on isolation. Staff C said they did not know Resident 1 had new wounds and did not assess the wounds until 02/11/2025 with the wound consultant. Staff C stated, I didn't now he had new wounds. I never saw them until yesterday. I did not go and assess; I had no idea they looked that bad. If I would have known, I didn't know it was to that extent. On 02/21/2025 at 11:04 AM, Staff D, said they were assigned to Resident 1 approximately three days per week and were very familiar with the resident's care. Staff D said they were completing dressing changes to the resident's left and right heel three times per week and then the right heel dressing was changed to daily on 02/05/2025. Staff D said on 02/04/2025, they were concerned that the resident's heels were getting worse. Staff D said they were darker in color with drainage and becoming larger in size. Staff D said that was why on 02/04/2025 they stopped the wound consultant in the hallway to ensure they had Resident 1 on their list to see. Staff D said the wound consultant confirmed they would see the resident the following week. Staff D acknowledged their only documentation of the wounds was signing the treatment administration record when they completed the dressing changes. On 02/21/2025 at 2:39 PM, Staff E, Director of Nursing Services/RN said Resident 1's skin assessments and documentation had not captured the resident's skin condition, stating, there were inaccuracies. Staff E said the nursing staff had not communicated the condition of Resident 1's wounds effectively to the interdisciplinary team to help the resident in a timely manner. WAC Reference 388-97-1060 (3)(b) .

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review, the facility failed to implement care plan interventions for 2 of 3 residents (Resident 2 and 3) reviewed for quality of care. This failure placed residents at risk for poor hygiene, clinical complications, and a diminished quality of life. Findings included . <Resident 2> Resident 2 was admitted to the facility on [DATE] with diagnoses including dementia and depression. The Minimum Data Set (MDS), an assessment tool, dated 11/20/2024, showed Resident 2 was dependent on staff for transfers, bed mobility, dressing, hygiene and had cognitive impairment. Resident 2's self-care deficit care plan, revised on 07/20/2021, showed the resident had hearing aids. Staff were to ensure the resident had them on in the am and out at night. The care plan showed the resident was to set up at the sink and encouraged to assist with hygiene. Resident 2's ADL [activity of daily living] care plan, revised on 08/16/2024, showed the resident was to have TED hose (compression socks that help to prevent blood clots in the legs) on in am and off at HS [bedtime] and was dependent on staff for transfers and dressing. On 02/07/2025 at 12:51 PM and 02/12/2025 11:21 AM, Resident 2 was observed lying in bed wearing a hospital gown and was not wearing hearing aids. On 2/10/2025 at 12:34 PM, Collateral Contact 1 (CC 1), said the staff did not get the resident out of bed unless CC 1 became upset. CC 1 said they would like the resident to get up to their wheelchair and go out into the hallway and get out of their room. CC 1 said staff told them the resident refuses. CC 1 said they had told the staff to contact them if the resident refused to get out of bed so they could speak with the resident and CC 1 also gave the staff approaches to utilize due to Resident 1's dementia. CC 1 said when they visited, they often found the resident had not been cleaned. On 02/12/2025 at 11:34 AM, Staff F, Certified Nursing Assistant (CNA), said they were assigned to Resident 2 and had worked at the facility for approximately a month. Staff F said they had never seen Resident 2 out of bed. Staff F said when they were trained on the unit the staff told them Resident 2 was bed bound so they had not asked and/or encouraged the resident to get out of bed. Staff F said Resident 2 did not wear hearing aids and they just talked loud to them. When asked if Resident 2 was wearing TED hose, Staff F said the resident was not and they were not aware they wore them. On 02/21/2025 at 11:37 AM, Resident 2 was observed lying in bed wearing a hospital gown, no TED hose on their legs and was not wearing hearing aids. On 02/21/2025 at 11:48 AM, Staff F, CNA, said they had to prioritize the care they gave and had not had time to provide dressing and/or hygiene assistance to Resident 2 that morning. Staff F said they had changed the resident's brief but had to prioritize other resident's care and now had to assist in the dining room. Staff F said they did not ask Resident 2 if they wanted to get out of bed, he doesn't get up and had not dressed the resident yet and/or changed their hospital gown. Staff F said they weren't aware Resident 2 wore hearing aides but said it would be lovely if they did because it would make for better communication with the resident. On 02/21/2025 at 1:59 PM, Staff C, Unit Manager, said Resident 2 did occasionally get out of bed and wore TED hose. Staff C said they knew nothing about the hearing aids. <Resident 3> Resident 3 was admitted [DATE]. The MDS, dated [DATE], showed the resident was cognitively intact and required assistance with bathing. On 02/10/2025 at 3:25 PM, Resident 3 said they were supposed to get a shower on Mondays and Thursdays. Resident 3 said they were admitted on a Monday and did not receive a shower but thought it was because they were just admitted but they did not get a shower for the rest of the week and did not receive a bed bath, the only time I was wiped down was when I wet the bed. Resident 3's care plan, revised 02/02/2025, showed the resident required one person assistance with bathing/showering frequently and as necessary. The care plan showed Resident 3 required moderate assistance with personal hygiene. Resident 3's task report for bathing, dated 01/27/2025 through 02/02/2025, showed no showers documented. On 02/21/2025 at 1:59 PM, Staff C, Unit Manager, reviewed Resident 3's medical record and said they did not see any reason the resident had not received a shower. <Final Interview> On 02/21/2025 at 2:39 PM, Staff E, Director of Nursing, said Resident 2 and Resident 3's care plans were not consistently implemented by facility staff, and they were working on their care plan system. Reference WAC 388-97-1020 (3) .

Dec 2024 1 deficiency 1 IJ

CRITICAL (J) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Accident Prevention (Tag F0689)

Someone could have died · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review the facility failed to ensure the resident environment was safe and free from hazards for 17 of 17 sampled residents (1 ,2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, and 17) residing in the facility's locked dementia unit. Resident 1 experienced harm when they sustained a significant second degree burn (burn that affects the epidermis [outer layer of skin] and the dermis [middle layer of skin] to the left hip when they were found unsupervised seated on a baseboard heater. This failure placed all residents on the dementia unit at risk for serious injury and decreased quality of life and constituted an Immediate Jeopardy (IJ). On 12/10/2024, the facility was notified of an IJ at CFR 483.25, F 689, Accidents/Hazards/Supervision/Devices, when a resident sustained burns after being found unsupervised against a baseboard heater at the facility and placed other residents at risk of serious injury. The facility removed the immediacy on 12/13/2024 with an onsite verification by review of the temperature logs, staff education related to temperature checks and verification of repairs to the baseboard heaters which ensured an effective system was in place to safeguard, protect and prevent residents from hazards. <Dementia Unit> The dementia unit had 17 residents who resided on a locked dementia unit. Electronic health records indicated 16 of 17 residents had cognitive impairment and were at risk for wandering behaviors and indicated 17 of 17 residents had dementia or other cognitive impairing diagnoses. There were heaters in every resident room and in two common areas, that were accessible to all residents. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease (a brain disorder that can cause problems with memory, thinking and behaviors), dementia (a group of symptoms that affects memory, thinking and interfers with daily life) and hypertension (high blood pressure). The Minimum Data Set (MDS), an assessment tool, dated 09/07/2024, showed the resident had cognitive impairment with hallucinations and delusions, had wandering behaviors and had one fall since admission and required staff assistance for activities of daily living. Resident 1's care plan, dated 07/2022, showed Resident 1 required staff assistance for bathing, was independent with transfers and ambulation, had impaired safety awareness and was an elopement risk due to wandering. Resident 1's progress note, dated 12/06/2024 at 7:53 AM, showed Resident 1 was found on the floor with their back against the heater with redness to the left side of the back, left arm and the left hip initial accessment of the affected area showed a 4.5 inches by 1/2 inch white linear burn and reddened area of approximately 3 by 4 inches. Resident 1's hospital documentation, dated 12/06/2024, showed the resident sustained a three percent body surface area, partial thickness burn to their left buttocks and some redness to the skin on the left posterior arm and back with some broken blisters. Resident 1 was discharged back to the facility with wound treatment orders. Review of the facility's investigation, dated 12/06/2024, showed Resident 1 was found sitting on the baseboard heater in the resident's room by Staff F, Nursing Assistant (NA). Staff F moved the resident away from the heater and left the resident to find the nurse. Staff F and a nurse returned to the resident. The resident was assessed and sent to the hospital for evaluation and treatment. The facility was unable to determine why the resident was next to the baseboard heater. Resident 1's first documented skin assessment after return from the hospital, dated 12/08/2024, showed a 6 inch by 12 inch burn with blisters and open areas with yellow drainage. Resident 1's wound assessment, dated 12/10/2024, showed a large 11 cm x 18 cm x 0.12 cm (4.3 inch x 7 inch) second degree, partial thickness, deep burn on the left buttock wrapping around the hip. On 12/09/2024 at 10:52 AM, Staff F, said they were the NA on night shift on 12/06/2024. Staff F said she saw the resident out of her bed, sitting on the heater in the resident's room waving at her. Staff F said she moved the resident away from the heater and saw the resident's skin was between the panels of the heater and the left hip was burned. It was pretty bad .I freaked out and left the room to get the nurse .I had 16 residents that night by myself. Staff F said she and the nurse returned to the resident's room and Resident 1 had moved back against the heater. Staff F said they moved the resident away from the heater. Staff F said the resident was sent to the hospital for evaluation. Staff F said the resident was checked on at 2:00 AM and was found at approximately 3:30 AM. On 12/09/2024 at 12:23 PM, Staff E, NA said the baseboard heaters were hard to regulate in the dementia unit. On 12/09/2024 at 12:30 PM, Staff A, former Administrator, said since she had been administrator the facility had not had any issues related to the baseboard heaters and she was not aware of reported issues with the baseboard heaters. Staff A said prior to her working as the administrator she was aware that there was some issue with a heater but was not aware of the details. The Administrator said Resident 1 sustained a large second degree burn to the left hip from the baseboard heater in the resident's room. She said the facility completed an investigation and thought the resident sustained a burn after a fall onto the heater. On 12/09/2024 at 12:40 PM, Resident 1's wound care was observed with Licensed Practical Nurse (LPN), Staff D. Resident 1's left hip had a large burn over the left hip, red in color and a small fluid filled blister remained intact in middle of the burn. The wound care was completed by Staff D and tolerated well by the resident. On 12/09/2024 at 12:40 PM, Staff D said she felt like the baseboard heaters in the dementia unit were hard to adjust. Staff D said some heaters didn't work properly and were too hot or too cold, especially in the day room. On 12/10/2024 at 3:15 PM, observation of the following rooms baseboard heater temperatures with Staff A, C (Director of Nursing) and E (Maintenance Director): - room [ROOM NUMBER]- The top of the baseboard was touched and was too hot to touch as it would burn the skin. - Resident day room - The top of the baseboard was touched and was too hot to touch as it would burn the skin. - room [ROOM NUMBER] - The top of the baseboard was touched and was too hot to touch as it would burn the skin. It was determined at that time by Staff A, C and E that the facility infrared thermometer was not functioning accurately as the readings were coming up in the moslty mid 70 degree Fahrenheit (F) range despite being so hot to the touch, and the facility did not have a replacement infrared thermometer in the facility. On 12/10/2024 at 4:45 PM, observation of 10 resident rooms in the dementia care unit was completed with Staff A, C and E. Staff E said she had gone to the dementia care unit and turned all baseboard heaters down a short time prior. Rooms 40, 41, 42, 43, 44, 45, 47, 49 and the dining room baseboard heaters were still too hot to hold the hand on as it would burn the skin. Rooms 46, 48 and the day room were cooler to the touch. On 12/12/2024 at 11:00 AM, Staff B, Interim Administrator, said an electric company was in the facility and replacing all thermostats on the baseboard heaters in the dementia unit. Reference WAC 388-97-1060 (3)(g) .

Nov 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review the facility failed to follow their policy to prevent resident elopement for 1 of 3 residents (Resident 4) reviewed for accidents. This failure placed residents at risk of elopement, accidents and a decreased quality of life. Findings included . Review of the facility policy, titled Elopement Prevention, dated 11/2022, showed elopement prevention included completing an admission assessments, elopement evaluations, identifying risk factors and hazards and could have included previous elopements, desire to leave the center and cognitive impairments. The policy included completing an elopement care plan and developing individualized interventions which may have included the electronic monitoring/alarm system to be used and to check through observation that the resident was wearing the device, if one was applied by indicating this on the Treatment Administration Record (TAR). Resident 4 was admitted to the facility on [DATE] with diagnoses including hepatic encephalopathy (brain disorder that occurs when toxic substances build and reach the brain due to liver dysfunction) and cirrhosis of the liver (permanent scarring that damages the liver and interferes with its functioning). The Minimum Data Set (MDS), an assessment tool, dated 08/12/2024 showed the resident had cognitive impairment and required staff assistance for bathing and staff supervision for transfers and ambulation. Resident 4's progress note, dated 08/13/2024, showed the resident left the building unattended and the resident returned to the facility with police. Resident 4's progress note, dated 08/14/2024, showed the resident has made no further attempts at elopement. Resident 4's progress note, dated 08/15/2024, showed the resident has made no further attempts at elopement. Resident 4's progress note, dated 08/15/2024, showed a wander guard (monitoring system worn by an at-risk resident to alert caregivers when resident exits or enters designated areas) was applied to Resident 4's left ankle. Review of Resident 4's record showed no physicians order for a wander guard. Review of the facility accident and incident logs showed no documentation of Resident 4's elopement on 08/13/2024. Resident 4's progress note, dated 08/26/2024, showed an elopement code was overheard at 11:00 AM that Resident 4 was missing from the facility and had been observed at a traffic light down the street. Resident 4's care plan did not indicate the resident was at risk for elopement. On 11/05/2024 at 12:50 PM, the Staff A, Administrator, acknowledged Resident 4 left the facility against medical advice (AMA) on 08/26/2024. Staff A acknowledged the resident had eloped from the facility for a short period of time previously and the resident returned to the facility and a wander guard was applied to the resident. Staff A acknowledged the resident's care plan did not indicate the resident was at risk of elopement or had eloped and there was not a physician's order for the wander guard. Staff A acknowledged the facility did not follow their policy. At 1:20 PM, Staff C, Resident Care Manager (RCM) said she was on duty when Resident 4 eloped from the facility on 08/15/2024. Staff C said she called the elopement drill, called the police and notified the next of kin. Staff C said, I don't know what happened, I thought I put an order in for a wander guard. Staff C said the wander guard alarm had not been functioning properly. Staff C acknowledged there was not a physician's order in the medical record for the wander guard and the care plan did not indicate the resident was at risk for elopement. Staff C said the resident eloped from the facility on 08/26/2024, returned to the facility and then Resident 4 left against medical advice on 08/26/2024. Reference WAC 388-97-1060 (g) .

Sept 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review the facility failed to assess and treat pain for 1 of 3 residents (Resident 1) reviewed for pain. Failure to implement interventions to reduce pain, including administration of pain medication placed residents at risk of experiencing episodes of untreated pain and for a diminshed quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses including a fractured left femur (thigh bone) with repair, neuropathy (nerve problem that causes pain, numbness, tingling, swelling and muscle weakness) and hypertension. The Minimum Data Set (MDS), an assessment tool, dated 07/31/2024, showed Resident 1 was cognitively intact and was on a scheduled pain medication regimen. Resident 1's Physicians' orders showed the following orders: - 07/24/2024 - oxycodone 5 milligrams (mg) (narcotic medication used to treat pain) by mouth every 4 hours as needed for pain. - 07/24/2024 - pregabalin (medication to treat nerve pain) 75 mg two times daily. Resident 1's electronic Medication Administration Record, dated 07/2024, showed the resident did not receive any medications on 07/24/2024 and received oxycodone 5 mg on 7/25/2024. Resident 1's admission assessment, dated 07/25/2024 at 8:19 AM, indicated the resident was having throbbing, burning pain when moving and when at rest to the left hip. On 09/16/2024 at 12:50 PM, Resident 1 said she was admitted to the facility on [DATE] at approximately 6 PM from a hospital. Resident 1 said she had a broken leg which required surgery. Resident 1 said when she got to the facility the nurse told her they did not have orders for her so they could not give her any medications. Resident 1 said she was having a lot of pain and was yelling at them because I was upset. Resident 1 said they were in pain all night and could not get anything for pain until the next day. At 1:55 PM, Staff C, Licensed Practical Nurse (LPN), said they received report on 07/25/2024 at 6 AM from Staff D, LPN. Staff C said Staff D said Resident 1 was upset because she had not received pain medication. Staff C said Staff D was new to the night shift and was not sure why Staff D did not administer the medications. Staff C said Resident 1 complained of pain during the initial visit to resident's room and Staff C administered pain medication when available from the pharmacy. At 3:45 PM, Staff D said Resident 1 was admitted to the facility on [DATE] and arrived in the evening. Staff D said it was their first admission and Staff D did not have access to the Omnicell (secure electronic medication dispensary) to get medications out of it and the nurse he worked with did not have access either. Staff D said to get a narcotic medication out of the Omnicell you needed two nurses to sign for the medication. Staff D said the pharmacy did not deliver the medication and Resident 1 was not given any medications for that shift. Staff D said he had not been trained on admissions and could not find the orders. Staff D stated he was not aware of an on-call nurse or who to contact. Staff D said, I explained that to the resident. On 09/17/2024 at 12:30 PM, the Director of Nursing Services (DNS), Staff B, said all nurses have access to the Omnicell to obtain medication for newly admitted residents and if there were issues obtaining the medication Staff D should have contacted her, another nurse, or the Administrator. Staff B acknowledged Staff D did not assess or treat the resident's pain on 07/24/2024. Reference WAC 388-97-1060(1) .

May 2024 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to provide a written notice to the resident, the resident representatives, and representative of the Office of the State Long-Term Care Ombudsman of an emergency transfer for 1 of 3 residents (1) reviewed for hospitalizations. This failure placed residents and/or their representatives at risk of not being able to make informed decisions about transfers and prohibited access to an advocate who could inform the resident/representative of their options and rights. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses including chronic inflammatory demyelinating polyneuritis (a condition resulting in loss of sensation in the arms and legs). The quarterly Minimum Data Set (MDS) assessment, dated 11/25/2023, documented Resident 1 had no cognitive impairment and required moderate to total dependence on staff for assistance with activities of daily living. The MDS documented Resident 1 had an active plan to return to the community. No referrals had been made for discharge planning. On 05/23/2024 at 5:18 PM, Resident 1 said the facility did not provide a notice of transfer when they were transferred to the hospital from a scheduled appointment. Progress notes, dated 02/16/2024, documented Resident 1 was transferred to the hospital on [DATE] directly from an appointment. The resident was admitted to the intensive care unit. Review of the Resident 1's electronic record showed no documentation the required written notification of transfer was provided to the resident, their representative or Office of the State Long-Term Care Ombudsman. On 05/24/2024 at 4:18 PM, Staff B, Registered Nurse and Director of Nursing Services, said Resident 1 was transferred to the hospital from a clinic appointment. The facility did not complete the notification of transfer because the resident did not transfer from the facility. Staff B said the facility did not notify the Office of the State Long-Term Care Ombudsman of Resident 1's transfer to the hospital. Reference WAC 388-97-0120 (2)(a-d), -0140(1) .

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Transfer (Tag F0626)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to consider re-admission of a resident after an unplanned hospitalization for 1 of 1 sample residents (1) reviewed for permitting residents to return to the facility. This failure placed residents at risk for increased anxiety related to being placed in an unfamiliar environment, and a diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses including chronic inflammatory demyelinating polyneuritis (a condition resulting in loss of sensation in the arms and legs). The quarterly Minimum Data Set (MDS), an assessment tool, dated 11/25/2023, documented Resident 1 had no cognitive impairment and required moderate to total dependence on staff for assistance with activities of daily living. The MDS documented Resident 1 had an active plan to return to the community. No community referrals had been made for discharge planning. The care plan, dated 12/30/2022, documented Resident 1 wished to return home upon discharge. Resident 1 required home health services and written instruction on medications, nutrition, and home exercises. Progress notes, dated 02/16/2024, documented Resident 1 was transferred to the hospital on [DATE] directly from an appointment. The resident was admitted to the intensive care unit. Review of the Resident 1's electronic record showed no documentation related to the inability to provide care for the resident, a notice to the resident regarding need for discharge, discussions with the hospital related to Resident 1's discharge, updated and ongoing discharge planning, or discussion with Resident 1 regarding refusal to allow the resident to return to the facility. On 05/23/2024 at 5:18 PM, Resident 1 said while at the facility, she received infusions for chronic inflammatory demyelinating polyneuritis. The infusions improved her quality of life and managed the loss of sensation in her legs. The infusion clinic required an escort be present because Resident 1 required assistance with her mobility. The day the facility discharged her, the resident went to the infusion appointment and their staff explained her vital signs were unstable. The clinic transferred the resident to the hospital. Resident 1 expected to hear from the facility during the hospitalization but no one reached out to see how she was doing or to discuss plans to return to the facility. Resident 1 contacted the facility towards the end of the hospitalization and spoke with Staff D, Business Office Manager. Staff D told Resident 1 the facility could not provide the level of care Resident 1 needed. Resident 1 said the facility did not provide her any notice indicating they could not provide care for the resident. Resident 1 said she felt the infusion clinic requiring an escort attend prompted the facility to say they could not provide the care the resident needed. The resident felt this was the reason the facility would not accept her back. Resident 1 said staffing was the facility's responsibility and she should not have to suffer as a result. Resident 1 said eventually, the hospital was able to assist her in transferring home. While Resident 1 was happy to be home, the resident felt the facility did not make the efforts required for a safe discharge. On 05/24/2024 at 3:55 PM, Staff D said she spoke with Resident 1 and told the resident they could not accept her back because they could not provide care for her. Staff D said Staff A, Administrator or Staff B, Registered Nurse and Director of Nursing Services, told her to inform Resident 1 of this discussion. On 05/24/2024 at 4:18 PM, Staff B said the facility could not provide the care Resident 1 needed because the infusion clinic required an escort. The infusions lasted 8 hours each visit and they could not provide staff for the amount of time required. Staff B said they attempted to get family to attend infusion appointments but they were not receptive. Staff B said they discussed this concern during care conference and were actively looking for a suitable location for Resident 1. Staff B said there were no current discharge planning notes showing the facility's efforts to find placement for Resident 1 in a setting that could meet the resident's needs. Staff A said she spoke with Resident 1 regarding the facility's inability to meet the needs of the resident. Staff A said they did not provide a formal notice or other documentation to notify the resident of the facility's intent. Staff A said there were no notes documented in the medical record regarding these conversations. Staff A said she should of documented the conversations. Reference WAC 388-97-0120 (4)(b) .

May 2024 17 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0561 (Tag F0561)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview, and record review, the facility failed to honor bathing and room preferences for 2 of 4 sampled residents (Residents 24 and 74) reviewed for choices. This failure placed residents at risk for poor hygiene, diminished quality of life and not being able to make choices considered important by the resident. Findings included . 1) Resident 24 admitted to the facility on [DATE] with a neurological condition (condition that affects the brain, spinal cord, and nerves). During an interview on 05/05/2024 at 11:25 AM, Resident 24 stated, sometimes the aides don't have time for showers so there have been weeks that I've only received one instead of two. Review of the annual Minimum Data Set (MDS, a required assessment tool), dated 03/15/2024, showed Resident 24 was able to make their needs known and their preferences showers were very important to the resident. Review of Resident 24's care plan (CP) showed the resident was to have a bath or shower twice a week on Wednesday and Saturday. Review of Resident 24's bathing documentation in the resident's electronic health records (EHR), from 04/10/2024 through 05/01/2024 showed the resident did not have a bath/shower on 04/13/2024 or on 05/04/2024. During an interview on 05/07/2024 at 8:43 AM, Staff M, Residential Care Manager, said based on review of the EHR, Resident 24 was not receiving two showers per week and should have been. Staff M said all refusals should be documented. During an interview on 05/09/2024 at 11:58 AM, Staff B, Director of Nursing Services (DNS), said they were unable to locate shower sheets for the missing days to show Resident 24 was receiving two showers per week. 2) Resident 74 admitted to the facility on [DATE] with diagnoses including anxiety, depression and post-traumatic stress disorder (a mental health condition that develops following a traumatic event). During an interview on 05/06/2024 at 10:18 AM, Resident 74 said I have been in this room three weeks, I was told by social services I could go back to original room after quarantine, but now I'm being told I'm not going back to original room, I want to go back to my old room. During an interview on 05/09/2024 at 12:18 PM, Staff L, Certified Nursing Assistant, said Resident 74 complained everyday about going back to their old room. Staff L said they spoke with management about the resident's concern and were told the room assignments were not going to be changed. During an interview on 05/09/2024 at 11:54 AM, Staff B, Director of Nursing Services, said there was no plan to move Resident 74 back to their previous room because there was currently a new admission in the room. During an interview on 05/09/2024 at 12:21 PM, Staff A, Administrator, said they were aware Resident 74 was unhappy with their current room situation and intended to relocate the resident back to their previous room but had not done so yet. Staff A said all residents who were relocated due to quarantine should have the right to move back to their room if they prefer. Reference WAC 388-97-0900(1) (3) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0569 (Tag F0569)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to notify 1 of 1 sampled resident (Resident 19), who was a Medicaid recipient, when their personal fund account balances reached $1800 (i.e. within $200 of the $2,000 resource limit beneficiaries could possess, without their Medicaid coverage being impacted). This failure placed the resident at risk for personal financial liability for their care and diminished quality of life. Findings included . Resident 19 admitted to the facility on [DATE] with a diagnoses including diabetes and depression. Resident 19 was able to make needs known. Review of Resident 19's Medicaid award letter, dated 12/08/2023, showed that according to the rules, the resident could keep up to $2,000 in resources, and if resources were over $2,000, they would need to report it to the state agency. Review of the Trial Balance document, dated 05/08/2024, showed Resident 19 had a balance of $2,888.64. Review of the personal fund account transactions history showed the balance had been over $2,000 for an extended period from August 2023 through May 2024. During an interview on 05/08/2024 at 1:20 PM, Staff H, Business Office Manager said they did not consistently provide residents with a quarterly personal fund statement. Staff H said they had recently discussed the balance with Resident 19 however it was a challenge to assist with spending the money because the resident already had a burial trust and rarely got out of bed to go shopping. During an interview on 05/09/2024 at 12:44 PM, Staff A, Administrator, said there should have been ongoing conversation if a resident's trust fund balance was within or over the resource limit. Staff A said the expectation was that trust fund balances would be discussed and documented at quarterly conferences to address a spenddown of the funds if needed. Reference WAC 388-97-0340(4)(a)(b)(5) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Grievances (Tag F0585)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review the facility failed to initiate a resident grievance for 1 of 1 sampled resident (Resident 74) reviewed for grievances. This failure placed the resident at risk of not receiving a grievance resolution, a denial of personal rights and a diminished quality of life. Findings included . Review of a the Grievance Policy Revised/Reviewed Date: 01/2023, 2/2024 showed: Employee Responsibilities Initiate the resident grievance report for all concerns. a. A resident/resident representative may complete the Resident Grievance Report and return it to an employee. The employee should maintain the anonymity of the resident/resident representative to the extent desired. b. Alternatively, the employee who receives the Grievance form from the resident/resident representative should assist the resident/resident representative as needed to complete the form. The employee shall maintain the anonymity of the resident/resident representative to the extent desired. Resident 74 admitted to the facility on [DATE] with diagnoses of anxiety, depression and post-traumatic stress disorder (a mental health condition that develops following a traumatic event). During an interview on 05/06/2024 at 10:18 AM, Resident 74 said I have been in this room three weeks, I was told by social services I could go back to original room after quarantine, but now I'm being told I'm not going back to original room, I want to go back to my old room. Resident 74 described the new room as ghetto and stated their previous room had a shower in it and they did not like the idea of using the shower room. Review of a progress note, dated 04/23/2024 at 5:35 PM, showed Resident 74 was on alert for airborne precautions related to COVID and a room change. During an interview on 05/09/2024 at 12:18 PM, Staff L, Certified Nursing Assistant, said Resident 74 complained everyday about going back to their old room. Staff L said they spoke with management about the resident's concern and were told the room assignments were not going to be changed. During an interview on 05/09/2024 at 11:54 AM, Staff B, Director of Nursing Services, said there was no plan to move Resident 74 back to their previous room because there was currently a new admission in the room and it was resident heavy on that side of the building for the nurse. Staff B said it was explained to Resident 74 several times and she just didn't like our answer. Staff B said they didn't understand why the private shower was a big deal because Resident 74 rarely utilized the shower when in the prior room. Staff B said they did not initiate a grievance nor were they aware if social services had initiated a grievance. Review of a document titled Grievance logs, dated November 1, 2023 through May 7, 2024, showed no grievance related to Resident 74's room change. During an interview on 05/09/2024 at 12:21 PM, Staff A, Administrator, said they were aware Resident 74 was unhappy with their current room situation but did not initiate a grievance because they intended to relocate the resident back to their previous room. Staff A said a grievance should have been initiated when Resident 74 repeatedly voiced a concern. Reference WAC 388-97-0460

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

PASARR Coordination (Tag F0644)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to follow the recommendations of the Preadmission Screen and Resident Review (PASARR, an in-depth tool to evaluate psychosocial and psychiatric need) Level II, for 1 of 2 residents (Resident 30) reviewed for PASARR. This failure placed residents at risk of not receiving necessary services to meet their mental health and intellectual disability care needs and a diminished quality of life. Findings included . Resident 30's quarterly Minimum Data Set (MDS, an assessment tool), dated 03/27/2024, showed the resident admitted to the facility on [DATE] with multiple diagnoses including anxiety, unspecified lack of expected normal physiological development in childhood, and colon/liver and lung cancers. Resident 30 was moderately cognitively impaired. Resident 30 had a Level II PASARR determinations on 12/27/2023, conducted by the state contracted PASARR evaluator. The determinations stated, The Individual is determined to have RC (Related Condition). The box under specialized services needed was filled in with Yes. It was stated under the comment section, she could benefit from services during this tough time. On 05/06/2024 at 10:12AM, Staff F, Social Services Assistant, said the PASARR assessor that completed the form would refer the resident to services. Resident 30's medical record documentation did not show any follow up was made to ensure the resident was referred to and received services. On 05/08/2024 at 10:16 AM, Staff F said she was unable to find any documentation that Resident 30 had received or would receive services. She said she would be reaching out to the PASARR evaluator to coordinate. Reference WAC 388-97-1915 (4) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to develop a baseline care plan (CP), within 48 hours of admission, that provided the minimum healthcare information necessary to meet residents' immediate care needs for 1 of 6 residents (Resident 129) reviewed, who recently admitted to the facility. This failure placed residents at risk for medical complications, unmet care needs and a diminished quality of life. Findings included . Review of the facility's Baseline Care Plan Policy, dated 02/01/2023, showed the facility would develop and implement a baseline care plan on new residents within 48 hours of admission. The baseline care plan would include the minimum healthcare information necessary to properly care for a resident, such as: a. Initial goals based on admission orders b. Physician orders c. Dietary orders d. Therapy orders e. Social Services and PASRR recommendations if applicable. Resident 129 admitted to the facility on [DATE] after hospitalization for respiratory failure secondary to chronic lung disease. Review of the admission Evaluation, dated 05/03/2024, showed the resident admitted on oxygen at four liters per minute via nasal cannula, received anticonvulsant medication for the treatment of seizures, required the use of an indwelling urinary catheter, and was on a 1500 milliliter (ml) per day fluid restriction. Review of the electronic health record showed a baseline CP was not developed or implemented for Resident 129 until 05/06/2024. On 05/08/2024 at 1:18 PM, when asked if a baseline CP had been developed and implemented within 48 hours of admission as required, Staff B, Director of Nursing, stated, no. Reference WAC 388-97-1020 (3) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview, and record review, the facility failed to ensure fluid intake was accurately monitored, documented, and assessed for 1 of 1 resident (Resident 129) reviewed with a fluid restriction. The failure to accurately record fluid intake and to calculate the resident's total 24-hour fluid intake, precluded staff from determining if Resident 129 was adherent with or was exceeding the ordered fluid restriction. This placed residents at risk for fluid volume overload, fluid and electrolyte imbalances, unidentified education needs and other medical complications. Findings included . Resident 129 admitted to the facility on [DATE]. Review of the admission Evaluation, dated 05/03/2024, showed the resident admitted with a diagnosis of heart disease and an order for a 1500 milliliter (ml) per day fluid restriction. The kitchen would provide 360 ml with meals and nursing would provide 210 ml on day and evening shift, for a total of 1500 ml/day. A nutrition/hydration at risk care plan, initiated 05/07/2024, showed Resident 129 was on a fluid restriction, and directed staff to monitor and record fluid intake. The electronic health record showed fluid intake with meals was recorded on the meal monitor and the Medication Administration Record (MAR), and fluids provided by nursing were recorded on the MAR. Review of the May 2024 MAR showed nurses were recording the amount of fluid they provided each shift, as well as the resident's fluid intake with each meal. When the fluid intake with meals documentation on the MAR was reconciled with the documentation on the meal monitor, it showed for the meals between 05/04/2024- 05/07/2024, the MAR and meal monitor had conflicting values on 10 of 12 meals: MAR Meal Monitor 05/04/2024 05/04/2024 Breakfast (B) - Blank B- 350 ml Lunch (L) - Blank L- 350 ml Dinner (D) - 360 ml D- 240 ml 05/05/2024 05/05/2024 B- Blank B- 220 ml L- Blank L- 240 ml D- 360 ml D- 240 ml 05/06/2024 05/06/2024 B- 360 ml B- 360 ml L- 360 ml L- 360 ml D- 240 ml D- 360 ml 05/07/2024 05/07/2024 B- 360 ml B- 240 ml L- 360 ml L- 240 ml D- unknown D- 360 ml Review of the May 2024 meal monitor and MAR showed there was no direction to staff to calculate Resident 129's 24-hour intake total, or documentation that it had occurred. On 05/08/2024 at 1:03 PM, Staff B, Director of Nursing, said Resident 129's fluid restriction orders were incomplete, and the documentation was both incomplete and inaccurate. Reference WAC 388-97-1060 (3)(i) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview, and record review the facility failed to ensure oxygen therapy was provided in accordance with physician's orders and accepted professional standards of practice for 1 of 2 residents (Resident 129) reviewed for respiratory care. Facility staffs' administration of oxygen without an order for oxygen, placed residents at risk for side effects related to oxygen therapy, respiratory compromise and/or unmet respiratory needs. Findings included . Resident 129 admitted to the facility on [DATE], after hospitalization for chronic lung disease, hypoxemia (low blood oxygen levels) and respiratory failure. Review of the admission Evaluation, dated 05/03/2024, showed the resident admitted to the facility on four liters of oxygen per minute (4L/min) via nasal cannula (NC). On 05/05/2024 at 1:28 PM, 05/06/2024 at 10:54 AM and 05/08/2024 at 11:18 AM, Resident 129 was observed in their room, receiving oxygen at 4L/min via NC. The oxygen tubing was undated and no humidifier bottle was in use. An oxygen therapy care plan, initiated 05/06/2024, showed Resident 129 received oxygen at 2-3L/min for chronic obstructive pulmonary disease. The interventions included direction to monitor for signs and symptoms of respiratory distress and to administer oxygen as ordered. Review of Resident 129's physician's orders on 05/08/2024, showed there was no order for the administration of oxygen, to change and the oxygen tubing and/or humidifier bottle routinely. On 05/08/2024 at 1:11 PM, when asked if Resident 129 had any oxygen maintenance and monitoring orders in place or an order to administer oxygen Staff B, Director of Nursing, stated, No. Staff B explained Resident 129's hospital transfer orders included an order for supplemental oxygen, but it was erroneously omitted when the orders were transcribed. Reference WAC 388-97-1060 (3)(j)(iv) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0745 (Tag F0745)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to provide medically related social services for 1 of 3 residents (Resident 30) reviewed for mood and behavior. The facility failed to monitor for mental health needs and coordinate necessary psychiatric consult/services. These failures placed residents at risk for unmet psychosocial needs, an increase in anxiety, and a diminished quality of life. Findings included . Resident 30 admitted to the facility on [DATE] with diagnoses including anxiety and Unspecified Lack of Expected Normal Physiological Development in Childhood. The admission Minimum Data Set (an assessment tool), dated 12/26/2023, showed Resident 30 was severely cognitively impaired. A Preadmission Screening and Resident Review (PASARR) Level II (an in-depth tool to evaluate psychosocial and psychiatric needs), dated 12/27/2023, showed, she could benefit from services during this tough time. The box under Specialized Services needed was filled in with yes. A provider note, dated, 12/20/2023, showed, will have psych provider follow up with patient. A provider note, dated 04/01/2024, showed, F/U [follow up] with Daiya psych provider. A provider note, dated 04/21/2024, showed, Daiya psych as needed. A Quarterly social services assessment, dated 03/25/2024, showed Resident 30 was having, increased anxiety, goal to return to community. Intervention - talking on phone with boyfriend. Multiple nursing notes from 03/12/2024 through 05/05/2024, documented an increase in anxiety with tearfulness, requests for as needed medications, screaming, throwing things, restlessness, and refusal of blood draws. The behaviors were documented to escalate when Resident 30 was unable to reach her partner by phone. The care plan was not updated with these behaviors or resident centered interventions. A nursing note, dated 03/13/2024, showed, resident continued to have behavioral episodes, such as crying, whining, and asking to sleep on the couch in the TV room. A nursing note, dated 03/14/2024, showed, resident refused blood draw again today. Resident believes if she refuses her blood draws that she will be taken to the hospital for her blood draw then discharge into a facility closer to her boyfriend. Provider notified of behaviors. A nursing note, dated 04/11/2024, showed Resident 30 would use the call light and when staff would respond Resident 30 would refuse to communicate with staff. A nursing note, dated 04/13/2024, showed, Resident came back again stating her stomach hurt, I replied she has had something already and that she needs to give it time to work. Resident then went to her room slammed the door and started making herself sick. LN entered the door and saw what she was doing and told her to quit making herself sick. Resident started screaming and throwing stuff in her room. Resident 30's Behavioral Care Plan, revised 04/23/2023, showed, has a behavior problem r/t [related to] dry heave holding stomach when boyfriend will not answer phone. Care Plan interventions included having fewer episodes of attention seeking behaviors, approaching resident in a calm manner, diverting attention, removal from triggering situation/take to an alternate location, and allowing resident to talk on phone without speaker on decrease amount of time on phone. On 05/05/2024 at 9:45 AM, Staff F, Social Services Assistant, said she was not sure what the plan was for Resident 30. A care conference was scheduled for 04/18/2024 but the resident's family member did not come or answer their phone. When asked if a referral was made based on the recommendation of the PASARR Level II, Staff F said the PASSAR assessor would have made the referral. When asked if Daiya psych had seen Resident 30, Staff F said she didn't know. On 05/09/2024 at 1:32 PM, Staff M, Resident Care Manager, stated, I don't know if she has seen anyone from the Daiya psych team, but I will make another referral. Reference WAC 388-97-0960 (1) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review, the facility failed to prepare and deliver food in a manner that conserved the nutritive value, palatability, an appetizing appearance, and that ensured meal temperatures were maintained for 6 of 6 residents (Residents 10, 54, 13, 23, 39 & 60) reviewed with pureed diets, and for 1 of 6 residents (Resident 46) reviewed for food quality. Dietary staffs' failure to follow written recipes when preparing pureed diets, to test and record holding temperatures including the time the food temperature was checked, and to ensure foods were not overcooked, placed residents at risk for decreased satisfaction with meals, poor intake, weight loss and a diminished quality of life. Findings included . <Brief Initial Tour> Observation on 05/05/2024 at 10:22 AM during the initial kitchen tour showed incomplete temperature logs. The logs had missing temperatures and there was no documentation of when the temperatures were taken. <Lunch Service> Observation of the lunch meal preparation on 05/072024 at 10:59 AM showed Staff K, Cook, was observed using a food processor to puree. Staff K was observed pouring unmeasured amounts of water into the food processor multiple times and checking the consistency with a spatula. During an interview on 05/07/2024 at 11:05 AM, Staff K said they did not document the time the food temperatures were taken because there was no designated area on the form. Staff K said they did not reference any recipe when making puree, they just poured water until the consistency looked good. During an interview on 05/07/2024 at 1:45 PM, Staff J, Dietary Manager, said it was the expectation that staff documented the time and temperatures on the Temp Log prior to and throughout each meal service. Staff J said the cooks should be following recipes for all the meals, every day, including pureed meals. <Resident Complaint> Resident 46 admitted to the facility on [DATE]. On 05/06/2024 at 10:17 AM, Resident 46 complained about facility food quality and stated, the meat is pretty tough. You have to saw on it a while to take a bite, then chew on it a while .it's tough. On 05/07/2024 the lunch was beef tips in gravy, rice, and carrots. At 1:03 PM a test tray was provided. The beef tips were gristly and difficult to chew, and the rice was over cooked with a mashed potato like texture. Reference WAC 388-97-1100 (1) (2) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0806 (Tag F0806)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review, the facility failed to ensure that 2 of 2 sampled residents (Residents 24 and 50) received foods that accommodated the residents' preferences and allergies. This failure placed the resident at risk for meal dissatisfaction, allergic reaction and diminished quality of life. Findings included . 1) Resident 24 admitted to the facility on [DATE] with a neurological condition (condition that affects the brain, spinal cord, and nerves). Observation during the lunch meal on 05/06/2024 at 12:02 PM showed Resident 24 eating lunch in the dinning room with another resident. Resident 24 was observed scraping their broccoli onto a separate plate. Resident 24 said they continued to get items on their dislike list, especially broccoli, which they also received the night before in a stir fry. During an observation and interview on 05/06/2024 at 12:13 PM, Staff J, Dietary Manager (DM) observed Resident 24's plate and tray card and said, it must have been an oversight by the cook again. Staff J said they had recently done an in-service on resident preferences related to food. Observation during the lunch tray line service on 05/07/2024 showed Staff K, Cook, plated beef tips with cooked tomatoes on Resident 24's plate which was loaded into the food cart for delivery to the unit. Review of the tray card showed cooked tomatoes under the dislikes lists. 2) Resident 50 admitted to the facility on [DATE] with diagnoses including diabetes and kidney failure. Observation during the lunch tray line service on 05/07/2024 showed Staff K, Cook, plated beef tips with cooked tomatoes on Resident 50's plate which was loaded into the food cart for delivery to the unit. When requested for the tray to be pulled and reviewed Staff K, Cook, reviewed the tray card which showed beef as an allergy. During an interview on 05/07/2024 at 1:49 PM, Staff J, DM, said the expectation was for staff to follow the tray cards related to preferences and allergies. During an interview on 05/09/2024 at 12:52 PM, Staff A, Administrator, said their expectation was not met, as staff should have paid special attention to resident allergies and preferences by highlighting the tray card each meal. Reference WAC 388-97-1100 (1) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0808 (Tag F0808)

Could have caused harm · This affected 1 resident

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. Based on observation, interview, and record review, the facility failed to appropriately provide specialized diets for 3 randomly observed residents (Resident 18, 69 and 428) during meal service. This failure placed the residents at risk for complications of their medical conditions, weight loss/gain and diminished quality of life. Findings included . Review of general diet lunch menu for 05/07/2024 showed the following: Beef tips, rice, seasoned carrots, dinner roll, chilled pears, juice and milk. Review of the diet spreadsheet provided showed the 05/07/2024 lunch meal for cardiac diet residents were to receive a wheat roll instead of a dinner roll. Observation on 05/07/2024 between 11:35 AM and 12:45 PM, showed Staff K, Cook, serving a general diet to include a dinner roll to all residents including Residents 18, 69 and 428 with tray cards that indicated a cardiac diet. Review of the diet spreadsheet showed cardiac diets and low cholesterol diets were to receive skim milk instead of 2% milk. Observation on 05/07/2024 between 11:35 AM and 12:45 PM, showed dietary staff providing all residents with 2% milk. During an interview on 05/07/2024 at 12:22 PM Staff K, Cook, said the facility only had dinner rolls and 2% milk. During an interview on 05/07/2024 at 1:49 PM Staff J, Dietary Manager said they did not have any skim milk on hand however the expectation was that tray cards were followed, or the dietician would be notified to determine if an alternative could be substituted. Reference WAC 388-97-1200(1) .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0568 (Tag F0568)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure quarterly personal fund statements were provided to residents with personal fund accounts for 4 of 4 sampled residents (Residents 4, 5,19 and 24) reviewed for personal fund accounts. This failure placed residents at risk of not having an accurate accounting of their personal funds held in trust by the facility. Findings included . 1) Resident 24 admitted to the facility on [DATE] with diagnoses including a neurological condition (a condition that affect the brain, spinal cord, and nerves) and was able to make needs known. During an interview on 05/05/2024 at 11:38 AM, Resident 24 said they had a personal funds account with the facility but never received statements of their balance. Review of the Trial Balance document, dated 05/08/2024, showed Resident 24 had a balance which was held in trust by the facility. Further review showed Residents 4, 5 and 19 also had balances. During an interview on 05/08/2024 at 1:20 PM, Staff H, Business Office Manager said they did not consistently provide residents with a quarterly personal fund statement. Staff H was unable to provide a timeframe when the most recent quarterly statements were provided. During an interview on 05/09/2024 at 12:44 PM, Staff A, Administrator, said they were not aware that quarterly personal funds statements were not provided to residents. Staff A said the expectation was that business office staff would provide a personal funds statement to the resident and/or resident representative on a quarterly basis. Reference: WAC 388-97-0340(3) .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 69> Resident 69 was admitted to the facility on [DATE] with multiple diagnoses including depression, pneumonia (...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 69> Resident 69 was admitted to the facility on [DATE] with multiple diagnoses including depression, pneumonia (an infection in the lungs) and anxiety. The admission Minimum Data Set (MDS, an assessment tool), dated 01/30/2024, indicated Resident 69 was moderately cognitively impaired. On 05/05/2024 at 10:12 AM, Resident 69 said she had a chest x-ray completed on 04/11/2024 due to feeling short of breath. A seven day course of Levaquin (an antibiotic) was started on 04/18/2024. The MAR showed Levaquin was not given on the 20 th or 21 st. Resident 69 stated, I was told the nurse couldn't find it. On 05/08/2024 at 10:14 AM, Staff G, Licensed Practical Nurse, said some antibiotics were available in the Pyxis (an automated medication distribution system) if needed. When asked if Levaquin would be in the Pyxis, she stated, yes, most likely. She said if the medication was not in the Pyxis, she would call the pharmacy. Staff G stated, any resident that starts an antibiotic is put on alert for side effects and effectiveness for the duration of the medication. Staff G said the nurses complete the alert charting under the progress notes in PCC (Point Click Care, a healthcare documentation system). There was no alert charting completed for Resident 69's antibiotic therapy. On 05/08/2024 at 10:26 AM, Staff B, DNS, stated, there are options if a mediation isn't available. The nurse should have tried to pull it from the Pyxis, called the pharmacy to had it satellited, or reached out to management for direction. Staff B said the nurse that approved the antibiotic put in the wrong type of note so the alert charting wasn't triggered. Reference WAC 388-97-1060 (3) Based on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice for 2 of 32 sample residents (Residents 129 & 69) reviewed. Facility nurses failed to obtain, accurately transcribe, follow, and/or clarify physician's orders when indicated. The facility failed ensure nurses only signed for tasks that were completed. These failures placed residents at risk for medication errors, delays in treatment, unmet care needs and potential negative outcomes. Findings included . <Resident 129> Resident 129 admitted to the facility on [DATE] with care needs related to heart and lung disease. <pain medication> Review of the Resident 129's May 2024 Medication and Treatment Administration Records (MAR/TAR) showed 05/03/2024 orders for oxycodone (narcotic pain medication) 2.5 milligrams (mg) every four hours as needed for pain, and oxycodone 5 mg every four hours as needed for pain. The orders did not provide instruction or the assessment method a nurse should have used to determine if oxycodone 5 mg or 2.5 mg should have been administered. On 05/08/2024 at 1:11 PM, Staff B, Director of Nursing (DNS), said the oxycodone order should have included parameters for use like a pain scale (e.g. pain scale 1-5, give 2.5 mg and 6-10, give 5 mg). Staff B indicated facility nurses should have identified the orders were inappropriately written and corrected and/or clarified them. <oxygen> Review of Resident 129's 05/03/2024 hospital transfer orders showed an order for oxygen therapy at four liters per minute, wean as tolerated. The order did not identify the method of delivery to be used. Review of Resident 129's electronic health record showed the resident did not have an order for administration of oxygen. Review of the facility's 05/03/2024 admission orders showed the oxygen order was never transcribed. On 05/05/2024 at 1:28 PM, 05/06/2024 at 10:54 AM and 05/08/2024 at 11:18 AM, Resident 129 was observed in their room, receiving oxygen at four liters per minute via nasal cannula. Observation of the oxygen concentrator revealed no humidifier bottle was in use and the oxygen tubing was undated. On 05/08/2024 at 1:11 PM, Staff B, DNS, said facility nurses should not have administered Resident 129 oxygen without an order. Additionally, Staff B said each nurse who worked the cart since the resident admitted , should have identified there was not an order for oxygen administration when they attempted to validate the oxygen flow rate was correct, and should have obtained and or clarified the order. On 05/08/2024 at 1:22 PM, Staff B, DNS, said the reason Resident 129 did not have a current oxygen administration order was due to a transcription error during the admission process.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0685 (Tag F0685)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident 69 was admitted to the facility on [DATE] with multiple diagnoses including depression, acute MI (Myocardial Infarction, heart attack), and anxiety. The MDS, dated [DATE], indicated Resident 69 had mild cognitive impairment and impaired vision. On 05/05/2024 at 12:19 PM, Resident 69 said she has had difficulty with nerve pain since the MI. She said it affected the right side of her tongue, her right leg, and her right eye. She stated, I have gray splatters in my right eye. I have to cover my right eye with my hand to be able to watch TV. She said she asked the Social Services Director about an eye appointment when she first admitted but she hadn't heard anything since. On 05/06/2024 at 10:14 AM, Staff F, Social Services Assistant, said the company the facility used for eye exams comes in every six months. Staff F stated, community appointments can be made if a resident needs to be seen sooner. Staff F did not know if Resident 69 had been seen by the eye exam company or if she had been seen in the community. On 05/08/2024 at 10:00 AM, Staff F showed documentation that the eye exam company had been in the facility on March 15th 2024, but Resident 69 was not seen due to a COVID infection. Staff F was not able to determine why Resident 69 was not seen in the community. Staff F stated, I only work five hours a month, the social services director quit last week, and the communication has never been very good. Staff F said the eye exam company was due back in the facility on June 7th 2024 and she would make sure Resident 69 was seen. Reference WAC 388-97-1060(3)(a) Based on interview and record review, the facility failed to provide services to maintain vision for 2 of 2 sampled residents (Residents 50 and 69) reviewed for vision/hearing. This failure placed residents at risk of inability to complete activities of daily living, a heightened risk of accidents and a diminished quality of life. Findings included . 1) Resident 50 admitted to the facility on [DATE] with diagnoses including diabetes and kidney failure. Review of Resident 50's admission Minimum Data Set (MDS, a required assessment tool) showed that the resident's vision was assessed to be moderately impaired. During an interview on 05/06/2024 at 9:27 AM, Resident 50 said they were having issues with their vision and they had been waiting for several months to be seen by the eye doctor. During an interview on 05/09/2024 at 11:39 AM, Staff F, Social Service Assistant, said the eye doctor conducts exams at the facility every three months. Staff F said they had recently found multiple appointments that were never made which had included Resident 50's eye exam. Staff F said the resident would be seen within the next month but should have been seen in March 2024. During an interview on 05/09/2024 at 12:37 PM, Staff A, Administrator, said it was the expectation as soon as the resident need was identified, an appointment should have been scheduled.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected multiple residents

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. Based on observation, interview, and record review, the facility failed to ensure sufficient qualified nursing staff were available to provide care and services as evidenced by information provided in Resident/Surveyor interviews for 4 residents (Residents 24, 63, 128 & 67) interviewed, and 2 staff (Staff C & Staff D) interviewed. The facility had insufficient staff to ensure residents received assistance with Activities of Daily Living (ADLs) including showers, nail care and shaving. These failures placed residents at risk for unmet care needs and a diminished quality of life. Findings included . <Resident Interviews/Observations> On 05/05/2024 at 11:25 AM, Resident 24 said sometimes aides didn't have time to give showers. On 05/05/2024 at 1:04 PM, Resident 63 said there was not enough staff and they were real busy. On 05/06/2024 at 11:36 AM, Resident 128 stated, I have had to wait four hours after requesting my pain pill, the excuse or what I was told was, 'I will tell the nurse again', or 'the nurse was on their rounds,' so I had to wait my turn. On 05/10/2024 at 11:41 AM, Resident 67 said wait times were 45 minutes, sometimes longer. Resident 67 said when the Certified Nursing Assistant's (CNA) were asked by residents for help, the CNA's would frequently respond with Not my run, which means they were told to stay on their hall. Resident 67 said agency aides would also not assist with answering call lights. <Staff Interviews> On 05/09/2024 at 12:02 PM, Staff C, CNA, said when they were not able to complete tasks due to not enough staff it is was usually showers that didn't get done. At 12:13 PM, when asked if they had enough time to complete all the daily tasks, Staff D, CNA, stated, sometimes. When asked what tasks they were not able to complete, Staff D said showers, nail care, shaving and Range of Motion exercises and this happened at least twice a week. <Resident Council Minutes> On 11/01/2023 Resident Council Meeting Minutes documented under Department issues: Nursing: Grievances put in. On 01/03/2024 Resident Council Meeting Minutes documented under Department issues: Nursing: No entry. On 02/07/2024 Resident Council Meeting Minutes documented under Department issues: Nursing: Resident not being checked when suppose to. On 03/06/2024 Resident Council Meeting Minutes documented under Department issues: Nursing: No entry. On 04/04/2024 Resident Council Meeting Minutes documented under Department issues: Nursing: Nurse didn't want to come in Resident's rm (room) when Resident having chest . (page cut off). On 05/01/2024 Resident Council Meeting Minutes documented under Department issues: Nursing: Call lights not being answered. No soaking feet when supposed to. On 05/10/2024 at 10:00 AM, Staff B, Director of Nursing Services, said she knew the facility was having staffing issues, they were cited prior for shortage of staff. When asked about the missing Registered Nurse (RN) coverage, Staff B, said it was an issue and acknowledged the missing RN coverage dates. At 10:48 AM, Staff A, Administrator, said they were having staffing issues, they had been cited prior for lack of RN coverage and acknowledged the multiple missing days without an RN on duty. Reference F561 Reference WAC 388-97-1080 .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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. Based on observation, interview, and record review, the facility failed to ensure refrigerator temperatures were recorded for 1 of 2 refrigerators in the locked medication rooms. This failure placed residents at risk for receiving medications that were not properly stored. Findings included . On 05/08/2024 10:03 AM, Staff E, Registered Nurse (RN) went into the medication room by the nurse station that was near the front entrance of the facility and they could not find a temperature log for the locked refrigerator. When asked if there was a temperature log, Staff E said, not that I see. When asked if there should have been a temperature log, Staff E said, yes and it is recorded by the staff on the night shift. On 05/08/2024 10:13 AM, Staff B, RN and Director of Nursing Services (DNS), went into the medication room at the nurse station near the entrance to the facility and she could not locate the log for the locked refrigerator temperatures. When asked if there should have been a temperature log, Staff B said, yes and it is usually placed on top of the refrigerator. On 05/10/2024 at 10:59 AM, Staff B, RN and DNS said the refrigerator temperatures should be monitored and documented and if the night shift nurse could not find the log, they should start a new log. Reference WAC 388-97-1300 (2) .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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. Based on observation and interview, the facility failed to ensure food was stored and served under safe and sanitary conditions in one of one kitchen. These failures placed residents at potential risk for cross contamination, food borne illnesses and diminished quality of life. Findings included . <Brief Initial Tour> Observation of the industrial refrigerator on 05/05/2024 at 10:10 AM, showed several uncovered cups of juice on a rolling cart. Additional observation showed several bowls of uncovered pudding on a separate rolling cart in the path of a fan blowing with visible dust/debris blowing. Observation of the industrial freezer on 05/05/2024 at 10:14 AM, showed a package of hot dogs, chicken patties and manicotti unsealed and undated. The chicken patties and manicotti had a thick layer of frost on them. Observation on 05/05/2024 at 10:11 AM, showed three plastic containers of used spices without a date. <Follow-up kitchen observation> Observation of the industrial refrigerator during the lunch meal preparation on 05/07/2024 at 10:10 AM, showed uncovered desserts in the path of a fan with visible dust/debris blowing. During an interview on 05/07/2024 at 10:19 AM, Staff J, Dietary Manager, said the desserts should not have been in the path of the fan and the DM disposed of them. Staff J said they needed to find out if staff were required to cover the desserts because they were being transported via a food cart. Staff J said the evening staff was responsible for pouring the juices the night before and that they should have been covered and labeled. Staff J said all food should have been dated when opened and sealed properly to preserve food quality. During an interview on 05/09/2024 at 12:52 PM, Staff A, Administrator, said the expectation was that food would be stored, prepared and served according to required guidelines. Reference WAC 388-97-1100 (3) .

Jan 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0727 (Tag F0727)

Could have caused harm · This affected 1 resident

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. Based on interview and record review, the facility failed to provide eight consecutive hours of direct care supervision by a Registered Nurse (RN) for 2 of 32 days reviewed and failed to meet the State RN staffing requirement of 24-Hour RN coverage for 32 of 32 days reviewed for RN staffing. This failure placed residents at risk for delay in resident assessmnents, identification of changes in condition, provision of care and services outside the scope of practice of the Licensed Practical Nurse (LPN), and unmet care needs. Findings included . Review of the daily RN staffing hours report provided by Staff B, Director of Nursing Services (DNS), on 01/23/2024, showed between 12/22/2023 and 01/22/2024 the facility did not have any RN coverage on two days: 12/24/2023 and 12/28/2023. The report showed the following hours of consecutive RN coverage: seven days of eight-hour coverage, ten days of 12-hour coverage, 12-days of 16-hour coverage, and one day of 20-hour coverage. In an interview on 01/23/2024 at 1:45 pm, Staff B stated they were in the facility on 12/24/2023 and 12/28/2023 to perform RN specific duties and provide coverage but did not count towards the direct care RN hours because they were the DNS. Staff B stated they were aware the facility did not provide 24-hour RN coverage dispite their recruiting and retention efforts, which is why they applied for the RN staffing waiver. Staff B stated the facility specifically requested RN's when they contacted nurse staffing agencies for staffing needs and they discussed RN staffing coverage in their daily morning clinical meeting and at monthly Quality Assurance Performance Improvement (QAPI) meetings. REFERENCE: WAC 388-97-1080(3)(a). .

Aug 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0551 (Tag F0551)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure the resident's designated legal representative were included in decisions to act on the resident's health needs for 1 of 4 sampled residents (1) reviewed for exercised rights of the representative related to transfer and discharge. This failure placed the resident at risk for violation of the resident's rights for health care decision-making by the designated legal representative and an unsafe/unplanned discharge. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses including congestive heart failure (the heart no longer adequately pumps) and diabetes. The Minimum Data Assessment, an assessment tool, dated 06/17/2023, showed Resident 1 had no cognitive impairment and required extensive assistance with activities of daily living. Resident 1's medical record showed the durable power of attorney (POA) documents, dated 07/11/2023, immediately appointed Family Member (FM) 1 and FM 2 to manage Resident 1's health care decisions. The facility noted receipt of document on 07/13/2023. The care plan, dated 07/13/2023, showed the facility would follow Resident 1's Advance Directive designating FM 1 and FM 2 as the medical decision maker. The care conference notes, dated 06/28/2023, showed the facility staff, family, and resident discussed discharge plans. Discharge plans included moving to an assisted living facility in the community. No other concerns noted at this time. There were no further notes regarding Resident 1's discharge plan. The progress notes, dated 07/17/2023, documented staff found Resident 1 required a dressing change to wounds on the legs. The family present were asking many questions about Resident 1's legs. Family reported to staff they wanted the resident transported to the emergency room (ER) due to concerns about the wound. The staff attempted to discuss status with family further and educate on wound care. The resident was transported to the ER after order received from facility medical provider. The notes documented the resident would not be returning. There was no documentation in the record showing discharge planning was discussed with Resident 1 or either POA. On 08/25/2023 at 3:41 PM, Staff B, Licensed Practical Nurse, said she cared for Resident 1 on 07/17/2023. Staff B said Resident 1 was stable and did not offer complaints on this day. Staff B said FMs were present in the building and insisting on transferring Resident 1 to the ER due to his wounds, which were stable. Staff B said there were no indication for transfer. Staff B said she reported the concerns to leadership. Later, it was decided the resident would be discharging to the ER then to a community setting. Staff B said she never observed Resident 1 being included in these discharge conversations. The resident did not voice concerns or display a change in his condition. Staff B said the FMs visiting were not ones she saw regularly and there was little interaction with staff. Staff B said she did not believed they were the Resident 1's POAs. At 4:01 PM, Staff D, Social Service Director; and Staff E, Social Service Designee; said they were assisting Resident 1's FM with discharge on [DATE]. Staff D said they were working on discharge planning for Resident 1 in coordination with the FM/POAs prior to this visit. Staff D and Staff E said on the date of Resident 1's discharge, the FMs and staff had a long discussion about the desire to discharge Resident 1 to the ER then to a facility in the community. Staff D and Staff B said there was no communication with the receiving facility to ensure the resident's needs would be met or to discuss treatments like the resident's wound care. They did not know if the resident was actually accepted to another facility. Staff D and Staff E said they were unsure if the FMs they dealt with were the Resident 1's POAs and did not think to contact designated POAs. Social Services did not discuss the plans with the resident as well. Staff D and Staff E said there was no documentation in the medical record related to the meetings/discussions related to Resident 1's discharge. Staff D said she thought this was a planned discharge but said it was not typical to discharge to an ER. At 4:12 PM, Staff A, Administrator, said she was aware Resident 1 was sent to the hospital on [DATE]. Nursing had assessed the resident and he was stable. The FM insisted on transferring the resident. Staff A said the hospital informed the facility the resident had no facility to transfer to after the ER visit. Staff A said they verified from the FM the resident was not returning and discharged the resident in the computer system. Staff A said they would have readmitted the resident if the hospital could provide new doctors' orders. No one reached out to Staff A again. Staff A said she did not know if the FMs at the facility on 07/17/2023 were Resident 1's POAs. Staff A said this should have been verified and a discussion should have occurred with the resident as well. Reference WAC 388-97-0240 (1-9) .

Jun 2023 16 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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. Based on observation and interview, the facility failed to respect and value the residents' private space by not knocking and/or announcing themselves for 1 of 2 sampled residents (25) reviewed for resident rights for dignity. This failure placed residents at risk for being treated with lack of dignity and a diminished quality of life. Findings included . On 06/05/2023 at 9:21 AM, Staff K, Certified Nursing Assistant (CNA), was observed entering Resident 25's room four times without knocking or announcing entry. At 9:22 AM, Resident 25 said she called her room the freeway. The resident said it was a parade of staff that came in and out of the room, and they do not knock prior to entering. At 10:22 AM, when asked how the staff ensure a resident was provided with dignity and privacy when enter a resident's room or providing care, Staff P, Nursing Assistant Registered, stated, It's a lot of little things but when I enter I always knock first, announce who I am, I sanitize my hands, let them know what I am doing in their room, always ask permission for what I want to do, and even if I am rushing in my mind I take it slow with the resident. At 10:39 AM, when asked how staff ensure a resident is provided dignity and privacy when entering a resident's room or providing care, Staff Q, Licensed Practical Nurse, stated, Knocking, telling them my name, talking them through everything I want to do, and answering their questions. On 06/06/2023 at 11:20 AM, facility staff were observed entering the room two times without knocking or announcing entry. On 06/07/2023 at 9:38 AM, facility staff were observed entering the room two times without knocking or announcing entry. On 06/09/23 at 9:22 AM, facility staff were observed entering the room one time without knocking or announcing entry. On 06/09/2023 at 10:14 AM, when asked how staff ensure a resident is provided dignity and privacy when enter a resident's room or providing care, Staff I, Resident Care Manager, stated, Knock, introduce myself, let them know my department, shut the door, and pull the curtain. Reference WAC 388-97-0300 .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure the resident and/or the resident's representative was informed and provided consent before administering a psychotropic (mind altering) medications for 1 of 6 sampled residents (Resident 65) reviewed right to be informed and make treatment decisions. This failure placed the resident and/or their representative at risk of not being fully informed of the risks and benefits before making decisions about their medications. Findings included . Resident 65 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease. The quarterly Minimum Data Set, an assessment tool, dated 03/07/2023, documented Resident 65 was severely cognitively impaired. A physician's order, dated 06/07/2023, documented Resident 65 was prescribed buspirone (an antianxiety medication) 10 milligrams (mg) three times a day for anxiety. A Progress Note date, 06/07/2023, documented, New order for buspirone 10 mg. VM (voicemail) left for husband POA (power of attorney). The Electronic Health Record (EHR) did not show documentation of a consent from the resident or the resident's representative to administer the psychotropic medication. On 06/09/2023 at 9:08 AM, Staff J, Licensed Practical Nurse (LPN), said she was not allowed to administer psychotropic medications without a consent from the resident or resident's representative. Staff J said in this case, the resident could not provide consent due to Alzheimer's diagnosis. Staff J said the medication should not have been administrated without a consent. At 9:37 AM, Staff I, Resident Care Manger and LPN, said she checked the computer system every morning to make sure a consent had been obtained for all new medications, including psychotropics. After reviewing there was not a consent obtained for the psychotropic medication, Staff I said the medication should not have been administered without a consent. At 10:23 AM, Staff B, Director of Nursing Services and Registered Nurse, said a consent should have been obtained before administering the medication. Reference WAC 388-97-0260 (1)-(3) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview, and record review, the facility failed to maintain and provide a safe, sanitary, and homelike environment for 1 of 3 sampled residents (Resident 42) reviewed for homelike environment. This failure placed residents at risk for a diminished quality of life. Findings included . Resident 42 was admitted to the facility on [DATE]. The quarterly Minimum Data Set, an assessment tool, dated 05/01/2023, documented Resident 42 was severely cognitively impaired. Review of the Electronic Health Record (EHR) showed Resident 42 had no inventory list when he entered the facility. On 06/07/23 at 8:56 AM, Resident 42's room was observed to only contained one brown sofa chair, a small TV on a countertop across the room, a radio on the dresser next to the bed, one small picture of a sailboat on the wall and a pair of tennis shoes next to the bed. No other personal items were present in the room. On 06/09/23 at 10:03 AM, Staff I, Resident Care Manger and Licensed Practical Nurse, said Resident 42 did not have any belongings when he was admitted to the facility. Staff I said the resident's room did not feel very homelike and they could have done a better job making it feel more homelike. At 10:38 AM, Staff C, Social Services Assistant, said Resident 42 did not come with any belongings, except the clothes he was wearing. The resident's room did not feel homelike. Reference WAC 388-97-0880 (1) .

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure potential misappropriation of property was investigated for 1 of 3 sampled residents (Resident 75) reviewed for abuse. This failure placed residents at risk for abuse, misappropriation of property and a diminished quality of life. Findings included . Facility's policy, Prevention and Reporting: Resident Mistreatment, Neglect, Abuse, Including Injuries of Unknown Source, and Misappropriation of Resident Property, documented the facility must thoroughly investigate all alleged violation and retain documents showing that all alleged violations are thoroughly investigated. Resident 75 was admitted to the facility on [DATE]. The 5-Day Minimum Data Set, an assessment tool, dated 04/21/2023, documented the resident was cognitively intact. Resident 75's Electronic Health Record (EHR) and the facility's May 2023 incident reporting log showed no documentation of an initiation of an incident report or that the facility had investigated Resident 75's facility reported incident of an allegation of misappropriation of property. On 06/09/2023 at 12:05 PM, Staff C, Social Services Assistant, said she had made a report of alleged misappropriation of property to the Adult Protective Services (APS) immediately after the Resident 75's discharge conference on 05/09/2023. Staff C said she had verbally informed her supervisors of making the report on the same day. Staff C was unable to provide any documentation of the incident, including the APS confirmation number. At 12:38 PM, Staff B, Director of Nursing Services and Registered Nurse, said she was informed of the incident on the day it occurred. Staff B stated, This was an external issue, so we don't really deal with it. Referral was sent to APS. Staff B was unable to produce additional information regarding the incident. At 1:20 PM, Staff A, Executive Director, stated, The girls don't have any documentation. Staff A said she would expect staff to document incidents per the facility's policy on Prevention and Reporting. Reference WAC 388-97-0640 (6)(a)(b) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0645 (Tag F0645)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASARR) assessment was completed to reflect accurate mental health diagnoses for 1 of 6 sampled residents (Resident 17) reviewed for PASARR. This failure placed residents at risk of not receiving mental health services and a diminished quality of life. Findings included . The facility's PASARR Requirements policy, dated 04/26/2023, documented, 1. Following admission of a resident, the nursing facility must: a. Review all level 1 screening for accuracy. If at any time the facility finds that the previous level 1 screening was incomplete, erroneous, or is no longer accurate, the facility must immediately complete a new screening using the department's standardized level 1 form, following the directions provided by the department's PASRR program. If the corrected level 1 screening identified a possible serious mental illness or intellectual disability or related condition, the facility must notify DDA (Developmental Disabilities Administration) and/or the mental health PASRR evaluator so a level II evaluation can be conducted . Resident 17 was admitted to the facility on [DATE] with diagnoses including depression (mood disorder that causes a persistent feeling of sadness and loss of interest) and a psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions). The quarterly Minimum Data Set, an assessment tool, dated 03/12/2023, documented Resident 17 had severe cognitive impairment, depression, and a psychotic disorder. Review of Resident 17's Level 1 PASARR, dated 09/02/2022, did not document a serious mental illness indicator to include Mood Disorders or a Psychotic Disorder. Resident 17's Level 1 PASARR did not indicate a Level II evaluation was indicated. A corrected PASARR was not available from the facility. On 06/08/2023 at 1:00 PM, Staff C, Social Services Assistant, said when a resident was admitted , she reviewed the PASARR for accuracy. Staff C said if a PASARR was incorrect upon admission, she would follow up and re-do the PASARR. Staff C said if a resident was diagnosed with a mental disorder after admission which indicated a new PASARR was required, she would re-do the PASARR so it is correct. Staff C stated, [Resident 17's PASARR] was wrong from the get-go. It should have been re-done. At 2:20 PM, Staff B, Director of Nursing Services and Registered Nurse, said it was her expectation a PASARR would be re-done if it did not capture all the resident's appropriate diagnoses and a level 2 PASARR completed if appropriate. Reference WAC 388-97-1975 (1)(9) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Bowel Management> Resident 20 was admitted to the facility on [DATE] and re-admitted on [DATE]. The 5-day MDS, dated [DAT...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Bowel Management> Resident 20 was admitted to the facility on [DATE] and re-admitted on [DATE]. The 5-day MDS, dated [DATE], showed Resident 20 was cognitively impaired. Resident 20's Bowel Task activity record, dated 05/12/2023 through 06/07/2023, documented no bowel movements (BMs) from 05/26/2023 through 05/31/2023, 6 days. The Electronic Health Record (EHR) documented Resident 20 had physician orders, dated 02/20/2023, for the bowel protocol: --Milk of Magnesia [MOM, a laxative] . Give 30 ml [milliliters] by mouth as needed for constipation - Give at bedtime or at resident preferred time if no BM on 3rd day --Dulcolax [a laxative] Suppository (Bisacodyl) Insert 1 suppository rectally every 24 hours as needed for constipation If no results from MOM after 12 hours. --Fleet Enema . Insert 1 application rectally every 24 hours as needed for constipation If no results from dulcolax in 4-6 hours. If no results from enema, notify MD. Resident 20's May 2023 eMAR did not show PRN (as needed) constipation medications were given from 05/26/2023 through 05/31/2023. Resident 20's progress notes, dated 05/26/2023 through 05/31/2023, did not show documentation of BMs, constipation or use of PRN constipation medications. On 06/08/2023 at 9:48 AM, Staff J, LPN, said in the morning she looked at the dashboard on the EHR and it would warn if a resident had not had a BM in 64 hours. Staff J said she would then check the resident's chart for BM activity, task bar for BM activity, and ask the resident if they had a BM. If not, the bowel protocol was started. At 10:51 AM, Staff I, Residential Care Manager and LPN, said she looked on the dashboard for clinical alerts related to BMs every morning. Staff I said a resident was flagged on the dashboard at 64 hours if they did not have a BM and was then placed on the bowel list. Staff I said she gave the bowel list to the floor nurses. Staff I said the PRN bowel protocol should start at 72 hours and was initiated if the resident had not had a bowel movement. Staff I said there was no documented BM in Resident 20's medical record from 05/26/2023 through 05/31/2023 and no documentation of a refusal of the bowel protocol. Staff I said Resident 20 should have been started on the bowel protocol after 72 hours of no BM. At 2:20 PM, Staff B said it was her expectation for the nurses to initiate the bowel protocol per physician orders. Staff B said Resident 20 should have had the bowel protocol started after 72 hours of no BM. Reference WAC 388-97-1060 (1) . Based on interview and record review, the facility failed to ensure physician orders for an anticoagulant (medication that thins the blood) and an antibiotic were implemented and failed to ensure residents received timely interventions for constipation for 2 of 5 sampled residents (83 & 20) reviewed for quality of care related to unnecessary medications. These failures placed residents at risk for medical complications, worsening physical conditions and a decreased quality of life. Findings included . <Medication Administration> Resident 83 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS), an assessment tool, dated 05/29/2023, documented the resident was cognitively intact. A physician order, dated 06/01/2023, documented, Hold warfarin (an anticoagulant) 05/31 [2023] and 06/01 [2023]. Recheck INR [laboratory blood test used to adjust warfarin dose based on how thin the blood is] 06/02/2023. Resident 83 had an physician order noting, check Coumadin [also known as warfarin] logbook every shift to ensure accuracy of dose and next INR every shift. This order was checked/documented on, indicating the logbook was reviewed to ensure accurate and current Coumadin orders were in place, by every shift except the night shift on 06/01/2023. Resident 83's June 2023 Electronic Medication Administration Record (eMAR) documented warfarin orders were not obtained until 06/05/2023. A physician order, dated 06/05/2023, documented one 2.5 milligrams (mg) tab of warfarin was to be administered at bedtime for atrial fibrillation (an abnormal beating of the heart that can cause blood clots). A physician order, dated 06/01/2023, documented one 100 mg pill of doxycycline (an antibiotic) was to be given twice a day for 3 days for chronic obstructive disease with exacerbation (a chronic inflammatory lung disease that causes obstructed airflow from the lungs that is currently flared up). Resident 83's June 2023 eMAR showed the doxycycline order was confirmed and ready for administration on 06/05/2023. On 06/08/2023 at 12:40 PM, Staff C, Licensed Practical Nurse (LPN), said there was a Coumadin log kept at the nurses' station and should be monitored each shift by the floor nurse. The Coumadin log informed the nurse what the most current Coumadin orders were, when they were received and when the next INR (lab) should be drawn. Staff C if new orders were not obtained, then the nurse assigned to that resident should notify the doctor for orders. At 12:45 PM, Staff C said orders that were left as pending should be monitored each shift for confirmation. Staff C said some nurses were lazy and would not confirm orders, but they should be confirmed when the order was placed in pending by the nurse assigned to that patient. At 2:50 PM Staff B, Director of Nursing Services and Registered Nurse, said each nurse should have checked the Coumadin logbook prior to their shift to ensure there were current orders and a lab was set up. Staff B said if there were not orders the nurse should have contacted the medical provider and obtained orders. Staff B said it was discovered that a physician order, dated 06/1/2023, documented to hold Coumadin on 05/31 [2023] and 06/01 [2023]. Staff B said orders should have started on 06/02/2023 and did not and a medication error report was completed. At 3:06 PM, Staff B said the nurses working on the medication carts should confirm all pending orders for their respective patients. Staff B said this resident's doxycycline order should have been confirmed and not left as pending.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review, the facility failed to ensure physician orders and standards of care were followed for 1 of 1 sampled residents (Resident 16) reviewed for tube feeding (food provided through tube directly to gut). This failure placed residents at risk for medical complications, including aspiration (inhaling food contents into lungs) and development of a lung infection. Findings included . Review of the facility's policy entitled Enteral Tubes (tube feeding), dated 12/22/2022, documented, Head of Bed [HOB] must remain at 30-45 degrees if resident is receiving continuous feeding. Resident 16 was admitted to the facility on [DATE]. The quarterly Minimum Data Set, an assessment tool, dated 03/08/2023, showed Resident 16 was severely cognitively impaired. Resident 16's Nutrition Care Plan, dated 03/30/2023, documented, Keep HOB increased 35-45 degrees at all times while TF [tube feeding] is running. A physician order, dated 12/26/2018, directed staff to ensure Resident 16's HOB was elevated 30-45 degrees during feeding. On 06/05/2023 at 3:33 PM, Resident 16 was observed in bed with their TF running and HOB slightly elevated, less than 30 degrees. On 06/06/2023 at 9:45 AM, Resident 16 was observed in bed with their TF running and HOB slightly elevated, less than 30 degrees. On 06/07/2023 at 9:16 AM, Resident 16 was observed in bed with their TF running and HOB slightly elevated, less than 30 degrees. At 2:01 PM, Resident 16 was observed in bed with their TF running and HOB slightly elevated, less than 30 degrees. On 06/08/2023 at 9:38 AM, Resident 16 was observed in bed with their TF running and HOB slightly elevated, less than 30 degrees. At 12:56 PM, Staff K, NAR (Nursing Assistant Registered), said Resident 16 must have their head elevated above 30 degrees at all times. At 1:48 PM, when asked how the facility was ensuring Resident 16's HOB was at 30 degrees, Staff H, Licensed Practical Nurse (LPN), held their arm up, bent it at an angle and said most people can tell angles and can tell if the bed is at 30 degrees. When asked if there was an indicator on the bed that showing how many degrees the bed is at, Staff H said no. Staff H stated, [Resident 16 is] very stiff and can't bend past 30 degrees. He has so many contractures. On 06/09/2023 at 9:27 AM, Resident 16 was observed in bed with their TF running and HOB slightly elevated, less than 30 degrees. At 2:06 PM, Staff K, Certified Nursing Assistant (CNA), said the HOB needed to be at 30 degrees at all times. When asked how they could tell if the HOB was at 30 degrees, Staff K said that you could just tell. At 2:52 PM, when asked what was expected for a resident receiving nutrition via feeding tube, Staff B, Director of Nursing Services and Registered Nurse, stated, The resident's HOB should be up at least 30 degrees. 45 [degrees] is better. Reference WAC 388-97-1060 (3)(f) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident 3 was admitted on [DATE]. The quarterly MDS, dated [DATE], documented Resident 3 was cognitively intact. Resident 3's physician orders documented an order for Continuous oxygen at 2 liters per nasal cannula, may titrate [adjust] up to 3 liters to keep oxygen saturation between 90%-96% every shift related to Chronic Obstructive Pulmonary Disease with exacerbation [a group of diseases that cause airflow blockage and breathing-related problems]. Resident 3's care plan did not addressed how many LPMs to give for the supplemental oxygen. Resident 3's June 2023 eTAR showed an oxygen order was signed by the floor nurse every 6 AM-6 PM shift and every 6 PM-6 AM shift indicating the resident's oxygen was being monitored and running at 2 LPM. 06/05/2023 at 11:33 AM, Resident 3's oxygen concentrator was observed running at 2 LPM. Resident 3 said they had been on oxygen for several years and had always been on 2 LPM. 06/06/2023 at 8:55 AM, Resident 3's oxygen concentrator was observed off. Resident 3 said the oxygen concentrator should always be on. Staff D, RN, stated, It's supposed to be on. I don't know why it isn't on. I'll go check it out. 06/07/2023 at 1:58 PM, Resident 3's oxygen concentrator was observed on at 4 LPM. 06/08/2023 at 9:28 AM, Resident 3's oxygen concentrator was observed on at 4 LPM. At 12:46 PM, Resident 3's oxygen concentrator was observed on at 4 LPM. At 1:35 PM, when asked how they knew how much oxygen a resident should be on, Staff H, LPN, said it was on the Electronic Medication Administration Record (eMAR). After pulling up the order in the electronic health record, Staff H said the order was for 2 LPM. At 1:40 PM, Resident 3's oxygen concentrator was observed with Staff H. The oxygen concentrator was set for 4 LPM. Staff H lowered the concentrator down to 2 LPM. Staff H said they had been off for the last three days and would have to look to see if there had been any changes to the orders. At 2:34 PM, Staff B, said cart nurses were responsible for ensuring oxygen concentrator were set to the ordered LPM for their assigned residents. When asked how they know how much oxygen a resident was to receive, Staff B stated, There's an order and it shows up on the resident's eMAR. Reference WAC 388-97-1060 (3)(j)(vi) Based on observation, interview and record review, the facility failed to ensure physician's orders were followed related to supplemental oxygen for 2 of 3 sampled residents (Residents 57 & 3) reviewed for respiratory care. This failure placed residents at risk for respiratory distress and a diminished quality of life. Findings included . Review of the facility policy entitled, Oxygen Management, dated 07/2019 and revised on 12/2022, noted to adjust liter flow to amount that is prescribed by physician. The black ball on liter gauge should be positioned in the middle of the number line. 1) Resident 57 was admitted on [DATE]. The annual Minimum Data Set (MDS), an assessment tool, dated 04/30/2023, documented Resident 57 was cognitively intact. Resident 57's Physician orders documented an order for O2 [oxygen] 2l/nc (liters via nasal cannula), keep saturations above 92% every shift for SOB [shortness of breath]. Resident 57's care plan did not address the liters per minute (LPM) of oxygen. Resident 57's June 2023 Electronic Treatment Administration Record (eTAR) documented an oxygen order was signed by the floor nurse, every 6 AM-6 PM shift and every 6 PM-6 AM shift, showing the oxygen was being monitored and running at 2 liters per minute. On 06/05/2023 at 10:12 AM, Resident 57's oxygen concentrator was observed running at 4 LPM. On 06/06/2023 at 10:11 AM, Resident 57's oxygen concentrator was observed running at 4 LPM. On 06/07/2023 at 9:26 AM, Resident 57's oxygen concentrator was observed running at 4 LPM. On 06/08/2023 at 10:24 AM, Resident 57's oxygen concentrator was observed running at 5 LPM. At 12:34 PM, Staff C, Licensed Practical Nurse (LPN), said only nurses adjusted the LPM on tanks and concentrators. Staff C said the floor nurse would visualize the LPM as needed each shift worked for their assigned residents. At 2:05 PM, Staff B, Director of Nursing Services and Registered Nurse, said there was an order in the eTAR that the nurses should be signing off each shift documenting that the correct liters of oxygen were running. Staff B said if the tank/concentrator was not on the correct setting, the nurse should adjust the LPM immediately.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure residents were free from unnecessary medications by not monitoring anticoagulant complications for 1 of 5 sampled residents (55) reviewed for unnecessary medications. This failure placed residents at risk for medical complications and a diminished quality of life. Findings included . Resident 6 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], documented the resident was moderately cognitively impaired. A physician order, dated 05/21/2023, documented Resident 6 was prescribed rivaroxaban [an anticoagulant medication] give 1 tablet by mouth at bedtime. Resident 6's Anticoagulant Care Plan, initiated 01/05/2023, documented the intervention to, Monitor/document signs and symptoms of anticoagulant complications. Resident 6's EHR did not show documentation of monitoring for complications of anticoagulants. On 06/08/2023 at 1:40 PM, Staff B, Director of Nursing Services and Registered Nurse, indicated Resident 6 was on an anticoagulant medication. Staff B said orders for side effect monitoring had to be added manually for certain anticoagulants. Staff B said the order for anticoagulant side effect monitoring was added the previous day, 06/07/2023 (over four months after the care planned intervention was initiated). Staff B said Resident 6 should have been on an anticoagulant side effect monitor. Reference WAC 388-97-1060 (3)(k)(i) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic (affecting the mind) medications by not monitoring target behaviors (the basis for medication use to either modify, remove, or add a resident specific behavior) and side effects (adverse reaction); and failed to ensure Gradual Dose Reductions (GDR) were attempted for psychotropic medications for 2 of 5 sampled residents (65 & 55) reviewed for unnecessary psychotropic medications. These failures placed residents at risk for medical complications, receiving unnecessary medications and a diminished quality of life. Findings included . 1) Resident 65 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's Disease (a progressive disease that affects memory and other mental functions). The quarterly Minimum Data Set (MDS), an assessment tool, dated 03/07/2023, documented Resident 65 was severely cognitively impaired. A physician order, dated 10/05/2021, documented Resident 65 was prescribed hydroxyzine (an antihistamine medication often used for anxiety) 10 milligrams every 8 hours as needed. A physician order, dated 05/03/2022, documented Resident 65 was prescribed sertraline (antidepressant) 75 mg in the morning. A physician order, dated 10/26/2022, documented monitoring for the following antidepressant side effects; Anticholinergic [turns off system in body responsible for fight or flight], dry mouth, blurred vision, weight gain, urinary retention, blood pressure changes, cardiac arrhythmia, muscle tremors, insomnia, nightmares, impaired memory, concentration, increased confusion in elderly, GI problems, sedations, drowsiness, agitation, headache, rash, photosensitivity as needed. The order did not include monitoring of psychotropic medication target behaviors for the use of the antidepressant. A physician order, dated 05/06/2023, showed staff were to document for behavior by documenting the number of episodes of anxiety and number of episodes of tearfulness. The order did not include monitoring of psychotropic side effects for the use of the anti-anxiety medications/medications being given for anxiety. A physician order, dated 05/24/2023, documented Resident 65 was prescribed buspirone (antianxiety) 10 milligrams (mg) three times a day. Resident 65's May 2023 Electronic Medication Administration Record (eMAR) and May 2023 Electronic Treatment Administration Record (eTAR) did not show documentation of target behavior monitoring for antidepressant and side effect monitoring for the antianxiety medications. On 06/09/2023 at 9:37 AM, Staff I, Resident Care Manager and Licensed Practical Nurse, said there should have been side effect monitoring for the antianxiety medications and target behavior monitoring for the antidepressant. At 10:23 AM, Staff B, Director of Nursing Services and Registered Nurse, said there should be have been side effect monitoring and target behavior monitoring for all psychotropic medications. 2) Resident 55 was admitted to the facility on [DATE]. The annual MDS, dated [DATE], documented Resident 55 was severely cognitively impaired. Review of the Electronic Health Record (EHR) documented Resident 55's last GDR was June 2022 for mirtazapine (an antidpessant). On 06/09/2023 at 9:56 AM, Staff I said she did not know why a GDR had not been completed since June 2022 and there should have been another attempt. At 10:23 AM, Staff B said there should have been at least one additional GDR for the psychotropic medication. Reference WAC 388-97-1060 (3)(k)(i) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure influenza and pneumococcal vaccines were offered to 1 of 5 sampled residents (Resident 20) reviewed for vaccinations. This failure placed residents at risk for developing influenza and/or pneumonia with potential negative outcomes and a diminished quality of life. Findings included . The facility's Influenza Vaccine Policy, version 2.3, undated, documented, Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents and employees, unless the vaccine is medically contraindicated or the resident or employee has already been immunized. The facility's Pneumococcal Vaccine Policy, version 2.1, undated, documented, Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated . Assessment of pneumococcal vaccination status will be conducted within five (5) working days of the resident's admission if not conducted prior to admission. Resident 20 was admitted to the facility on [DATE] and re-admitted on [DATE]. The 5-day Minimum Data Set (MDS), an assessment tool, dated 05/19/2023, documented Resident 20 was cognitively impaired. The 5-day MDS, dated [DATE], and 5-day MDS, dated [DATE], documented Resident 20 did not receive the influenza vaccine in the facility for the current year's influenza season with the noted reason of, not offered, and Resident 20 was not up-to-date with the pneumococcal vaccine with the stated reason of not offered. Review of Resident 20's Electronic Health Record (EHR) did not show documentation of the resident's influenza or pneumococcal vaccine status. The EHR did not document if Resident 20 was assessed for, offered, or received an influenza or pneumococcal vaccine. On 06/08/2023 at 12:18 PM, Staff A, Administrator, said they did not have influenza or pneumococcal vaccination documentation for Resident 20. At 2:20 PM, Staff B, Director of Nursing Services and Registered Nurse, said it was the responsibility of the Infection Preventionist to offer influenza and pneumococcal vaccine upon admission. Staff B said Resident 20 should have been offered the influenza and pneumococcal vaccinations upon admission and said she couldn't find them. Reference WAC 388-97-1340 (1) (2) .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review, the facility failed to ensure the call light was within reach for 3 of 6 sampled residents (Residents 11, 20 & 17) reviewed for accommodation of needs. This failure placed residents at risk of not being able to request needed assistance and a diminished quality of life. Findings included . Review of the Resident Call System policy, dated 09/2022, showed, The facility must be adequately equipped to allow residents to call for staff assistance through a communication system which notifies a staff member or to a centralized staff work area from each resident's bedside and toilet/bathing areas . The call light communication system must be accessible to residents while in their bed or within reach while in the room . The call light communication system should be accessible to a resident if lying on the floor. 1) Resident 11 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS), an assessment tool, dated 05/03/2023, documented Resident 11 was cognitively impaired. Resident 11's Care Plan, dated 02/28/2023, documented the resident was At risk for falls/injury r/t [related to] poor safety awareness, dementia. Interventions, dated 11/29/2016, included, Keep needed items, water, etc, in reach. On 06/05/2023 at 11:10 AM, room [ROOM NUMBER] was observed with one call light mechanism located on the wall between two resident beds. A pull string was hanging down the wall from the call light mechanism approximately 10 inches. Resident 11 was observed lying awake in bed on his right side unable to reach the call light pull string on the wall. On 06/06/2023 at 8:50 AM, Resident 11 was observed lying in bed unable to reach the call light pull string hanging down the wall approximately 10 inches. On 06/07/23 at 8:48 AM, Resident 11 was observed lying in bed with eyes closed. Resident 11's call light pull string, approximately 10 inches long, was hanging down the wall out of the resident's reach. On 06/09/23 at 8:48 AM, Resident 11 was observed lying in bed with eyes open watching television. Resident 11's call light pull string, approximately 10 inches long, was hanging down the wall out of the resident's reach. At 8:52 AM, when asked about the location of the call light string to pull to call for help, Resident 11 pointed to the call light mechanism located on the wall. When asked if the resident could reach it, Resident 11 shook his head no. When asked, But you know where it is, Resident 11 again pointed to the call light mechanism on the wall with the short cord. 2) Resident 20 was admitted to the facility on [DATE] and re-admitted on [DATE]. The 5-day MDS, dated [DATE], documented Resident 20 was cognitively impaired. Resident 20's Care Plan, dated 02/20/2023, documented the resident was At risk for falls/injury r/t Cardiovascular diagnosis, Deconditioning, Gait/balance problems, Poor communication/comprehension, Unaware of safety needs, impulsiveness. Interventions, dated 02/20/2023, included, Be sure call light is within reach and encourage resident to use it for assistance as needed. Provide a safe environment with: even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, and personal items within reach. On 06/05/2023 at 10:13 AM, room [ROOM NUMBER] was observed with one call light mechanism located on the wall between two resident beds. A pull string was hanging down the wall from the call light mechanism approximately 10 inches. Resident 20 was observed lying in bed leaning to his right side unable to reach the call light pull string on the wall. On 06/07/2023 at 8:46 AM, Resident 20 was observed lying in bed on his back with eyes closed. The call light pull string was hanging down the wall approximately 10 inches, and out of Resident 20's reach. 3) Resident 17 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], documented Resident 17 had severe cognitive impairment. Resident 17's Care Plan, dated 09/02/2022, revised 10/03/2022, documented the resident was At risk for falls/injury r/t Confusion, Gait/balance problems, History of falls, Pain. Interventions, dated 02/20/2023, included, Provide a safe environment with: even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, and personal items within reach. On 06/05/2023 at 3:00 PM, room [ROOM NUMBER] was observed with one call light mechanism located on the wall between two resident beds. A pull string was hanging down the wall from the call light mechanism approximately 5 feet long, out of reach for residents lying in bed. On 06/06/2023 at 8:51 AM, Resident 17 was observed lying in bed unable to reach the call light pull string hanging down the wall in room [ROOM NUMBER]. On 06/07/2023 at 8:49 AM, Resident 17 was observed lying in bed with the call light pull string hanging down the wall, not within reach. On 06/09/23 at 8:45 AM, Resident 17 was observed lying in bed with eyes closed. The call light pull string was hanging down the wall out of Resident 17's reach. At 10:40 AM, Staff I, Residential Care Manager and Licensed Practical Nurse, said residents should have their call light within reach, even if they have a diagnosis of dementia. When showed the call light pull cord in room [ROOM NUMBER] for Resident 11 and Resident 20, Staff I stated, They can't reach that. At 10:54 AM, Staff A, Administrator, said Resident 11 could not reach his call light pull string. Staff A said Resident 11 needed the call light pull string changed so he could reach it and would have it fixed. Reference WAC 388-97-0860 (2) .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) Resident 3 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], documented the resident was cognitively intact. Resident 3's EHR documented the resident had a DPOA (durable power of attorney), but a copy of the DPOA was not found in the EHR. On 06/07/2023 at 2:45 PM, Staff D, RN, said Resident 3 had a DPOA, but she was unable to find the documentation in the EHR. Staff D said the DPOA documentation should be in the file. At 2:50 PM, Staff B said a copy of the DPOA documentation should be in the file. 4) Resident 70 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], documented the resident was cognitively intact. Resident 70's EHR documented the resident had a Durable Power of Attorney (DPOA), but a copy of the DPOA was not found in the EHR. On 06/07/2023 at 2:45 PM, Staff D said Resident 70 had a DPOA, but she was unable to find the documentation in the EHR. Staff D said the DPOA documentation should be in the file. At 2:50 PM, Staff B said a copy of the DPOA documentation should be in the file. Reference WAC 388-97-0300 (1)(b), (3)(a-c) Based on interview and record review, the facility failed to obtain, provide, and/or assist with completing Advance Directives (ADs) for 4 of 6 sampled residents (Residents 6, 59, 3 & 70) reviewed for ADs. This failure placed residents at risk for losing their right to have their healthcare preferences and/or decisions honored. Findings included . 1) Resident 6 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS), an assessment tool, dated 04/13/2023, documented the resident was moderately cognitively impaired. Review of Resident 6's EHR (electronic health record) did not show documentation of an AD. 2) Resident 59 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], documented the resident was moderately cognitively impaired. Review of Resident 59's EHR did not show documentation of an AD. On 06/07/2023 at 1:27 PM, Staff B, Director of Nursing Services and Registered Nurse (RN), said she could not locate AD's for Residents 6 and Resident 59. At 2:05 PM, Staff C, Social Services Assistant, said she would obtain ADs from new admission residents from their admission paperwork. Staff C said if a resident did not have an AD, she would follow up with the resident. Staff C said if the resident refused, she would document in progress notes the resident refusal. Staff C said there was no documented refusals and no ADs for Residents 6 and Resident 59 in the medical records.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0583 (Tag F0583)

Could have caused harm · This affected multiple residents

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. Based on observation and interview, the facility failed to ensure resident medical information was maintained in a manner to ensure privacy and confidentiality when staff failed to secure the electronic medical records for 3 of 8 sampled residents (Residents 43, 31 & 6) reviewed for privacy and confidentiality. This failure placed residents at risk of their medical information not being kept confidential and a diminished quality of life. Findings included . On 06/08/2023 at 11:09 AM Staff H, Licensed Practical Nurse (LPN), was observed leaving the medication (med) cart, on the B wing, to enter a resident's room. The computer screen on the med cart was observed open and logged into the electronic charting program with private resident healthcare information viewable. At 11:13 AM, Staff H was observed returning to the med cart. At 11:19 AM, Staff H was observed leaving the med cart to administer medications to a resident. The computer screen on the med cart was observed open and logged into the electronic charting program with private resident healthcare information viewable. At 11:22 AM, Staff H was observed returning to the med cart. At 11:27 AM, Staff H was observed leaving the med cart to administer medications to a resident. The computer screen on the med cart was observed open and logged into the electronic charting program with private patient healthcare information viewable. At 11:31 AM, Staff H was observed returning to the med cart. At 11:32 AM, Staff H said the computer screen should be locked or closed so no one could see resident information anytime the med cart was left unattended. At 2:42 PM, Staff B, Director of Nursing Services and Registered Nurse, said resident information should not be visible except to the nurse. If a nurse was going to leave the med cart, then the screen should be locked so no personal information could be observed. Reference WAC 388-97-0360 (1)(b) .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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. Based on observation and interview, the facility failed to ensure all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 4 of 7 medication storage areas (2 carts and 2 rooms) reviewed for medication storage. This failure placed residents at risk of receiving wrong or ineffective medications and treatments. Findings included . <Drug and Biological Labeling> On 06/05/2023 at 10:39 AM, the A1 medication cart was observed and showed four bottles of various creams, requiring a provider order, were not labeled with patient name nor was a pharmacy label attached to the bottles. On 06/08/2023 at 1:23 PM, the medication cart in the locked resident unit was observed with Staff O, Licensed Practical Nurse (LPN) and showed six bottles of powders and creams, requiring provider order, were not labeled with a patient name nor was a pharmacy label attached to the bottles. Staff O stated, The pharmacy label with the patient's name, medication name, provider, order date, etcetera, was required on all medications. Staff O said if the information was missing, they would let the RCM [Resident Care Manager] know and not use it and it would be destroyed. On 06/09/2023 at 10:14 AM, Staff I, RCM, said medications that were not properly labeled were destroyed. <Drug and Biological Storage> On 06/05/2023 at 10:39 AM, the A1 medication storage room was observed and showed refrigerator temperatures were not regularly recorded on the refrigerator temperature log. In April 2023 there were nine missing recordings of the refrigerator temperature. In May 2023 there were 16 missing recordings of the refrigerator temperature. On 06/08/2023 at 1:23 PM, the medication storage room in the locked resident unit was observed and showed refrigerator temperatures were not regularly recorded on the refrigerator temperature log. In June 2023 there were seven missing recordings of the refrigerator temperature (7 of 8 opportunities). Facility staff were unable to locate the refrigerator temperature logs for any months previous to June 2023. Staff O said the nurses recorded the temperatures twice per day. On 06/09/2023 at 10:14 AM, Staff I said the nurse on shift was responsible for recording the temperature twice a day. Reference WAC 388-97-1300 (2) .

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0727 (Tag F0727)

Could have caused harm · This affected most or all residents

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. Based on interview and record review, the facility failed to provide at least eight hours of Registered Nurse (RN) supervision for 15 of 30 days reviewed for RN coverage. This failure placed residents at risk for not receiving needed care and supervision of care. Findings included . The facility's Staffing Pattern State Task Form, dated 05/05/2023 through 06/05/2023, documented there was no RN coverage for 15 of 30 days reviewed. On 06/09/2023 at 2:44 PM, Staff B, Director of Nursing Services and Registered Nurse, said the facility had difficulty getting RN's in the area. Staff B said the facility was advertising on [job search engines], offering sign on bonuses, and offering 12-hour shifts for interested nurses. Staff B said if the facility did not have an RN on shift for a required RN task, the resident would be sent to the hospital for RN tasks to be completed. Reference WAC 388-97-1080 (3) .

Jun 2023 2 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review, the facility failed to ensure the resident environment was safe and free from hazards when a resident received a significant burn from hot coffee for 1 of 1 sampled residents, and failed to supervise resident interactions and implement interventions to prevent a resident-to-resident altercation for 2 of 2 sampled residents (1 & 2) reviewed for accident hazards and supervision. This caused harm to Resident 1 when hot coffee spilled on the resident causing blisters and redness. These failures placed residents at risk for burns, unwanted touching and a diminished quality of life. Findings included . <Burn> Resident 1 was admitted to the facility on [DATE] with diagnoses including cerebral palsy (a disorder affecting the ability to move) and epilepsy (a disorder causing seizures). The quarterly Minimum Data Set (MDS), an assessment tool, dated 03/23/2023, documented Resident 1 has severe cognitive impairment and required total dependence from staff with activities of daily living (ADLs). The care plan, dated 04/14/2023, documented staff would assist the resident with meals and serve hot liquids in a mug with a lid. The Daily Production (meal temperature log), dated 04/28/2023 through 05/05/2023, documented staff were not consistently documenting hot beverage temperatures. The Facility Investigation, dated 05/05/2023, documented Resident 1 requested coffee at supper. The coffee carafes, used for resident coffee, were empty. Staff went directly to the kitchen coffee pot and poured the coffee for the resident. The coffee was very hot so the nursing assistant (NA) cooled the coffee for about 10 minutes. The staff then delivered the coffee to the resident. About 10 -15 minutes later, staff heard the resident yell and was found with spilled coffee with a burn to the chest. The burn was 4 centimeters (cm) x 15 cm and red with blisters. Resident 1 was evaluated at the emergency room and required dressing changes twice daily to the wound. The facility investigation found coffee temperatures in kitchen coffee pot ranged from 178-182 degrees Fahrenheit. Interventions included staff would use a sippy cup for Resident 1 for all liquids due to hand tremors. Staff would check temperatures on hot liquids before meal service. On 05/08/2023 at 2:25 PM, Resident 1 was observed in bed. A bandage was covering a burn to the chest. The resident was slouched in bed and leaning far to the right side. A tremor was noted to her hands. The resident said the burn was from spilled coffee. Resident 1 said she had some pain but it was manageable with pain medication. The resident declined an observation of the wound and was unable to answer any further questions. At 2:27 PM, Staff F, Nursing Assistant (NA), said staff were to get coffee from the carafes. Staff F said staff should not be getting coffee from the kitchen because the coffee was too hot. Staff F said Resident 1's hands shook so a sippy cup was always used with coffee. 06/08/2023 4:03 PM, Staff D, Dietary Manager, said the staff obtained the coffee from the kitchen instead of the carafes, which was much hotter. Staff D said she was unsure why the staff came into the kitchen to get the coffee instead of using the carafe. Staff D said dietary staff were not monitoring the hot liquid temperatures consistently. Staff D said they now monitor liquids every meal. Staff D said they implemented a resident safe temperature range for hot liquids of 125-155 degrees. They did not have a safe range prior to the burn. On 4:27 PM, Staff B, Registered Nurse (RN) and Director of Nursing Services (DNS), said Resident 1 was doing well and the burn was nearly healed. The facility implemented temperature checks and parameters for temperature ranges. Staff B said the carafes were empty which was why staff retrieved coffee from the kitchen. All staff have been educated on using the carafes and proper temperature ranges. <Resident to Resident> Resident 1 was admitted to the facility on [DATE] with diagnoses including cerebral palsy (a disorder affecting the ability to move) and epilepsy (a disorder causing seizures). The quarterly MDS, dated [DATE], documented Resident 1 had severe cognitive impairment and required total dependence from staff with ADLs. Resident 1's care plan, dated 04/14/2023, documented Resident 1 had potential for psychosocial well-being related to allegations on 01/18/2023 and 03/30/2023. The care plan showed the guardian consented to hand holding and rubbing of shoulder. Staff were to ensure safety by providing reminders for only hand holding and shoulder rubbing by other resident. Resident 2 was admitted to the facility on [DATE] with diagnoses including end-stage kidney disease. The quarterly MDS, dated [DATE], documented Resident 2 had no cognitive impairment and required limited assistance with ADLs. Resident 2's care plan, dated 01/19/2023, documented Resident 2 had a history of verbally abusive behaviors towards other residents. Staff were directed to analyze triggers to determine how to de-escalate behaviors. The care plan did not provide interventions for staff regarding the touching behaviors towards Resident 1. The facility investigation, dated 01/18/2023, documented Resident 2 was observed touching Resident 1's breast. The allegation was reported to the State Agency and investigated. Another witness did not see touching and no witnesses were identified. Both residents denied inappropriate touching. Resident 2 agreed to limit his touching of Resident 1 and was placed on one-to-one monitoring. The facility investigation, dated 03/30/2023, documented Resident 2 was observed, while in the dining room, touching Resident 1's breast and putting hands down her shirt. The allegation was reported to the State Agency and investigated. Witnesses and Resident 1 and Resident 2 denied allegation. The facility was unable to substantiate the allegation and would monitor the residents for psychosocial harm. On 06/06/2023 at 9:45 AM, Resident 2 was observed in the dayroom with Resident 1. Resident 2 was caressing Resident 1's arm. Resident 2 ran his hand up and down Resident 1's arm and wrist, up the shoulder with Resident 2's hand up Resident 1's sleeve, then across their chest to below the collar bone. On 06/08/2023, at 10:15 AM, Resident 2 was observed in the dayroom next to Resident 1. Resident 2 caressed Resident 1's left hand. Resident 2's hand then followed up Resident 1's arm up to her shoulder across the upper chest putting his hand up Resident 1's sleeve. Staff B was notified of the observation. Staff B intervened and Resident 2 became angry, yelling out and swung his hand at Staff B. At 3:50 PM, Staff E, NA, said Resident 2 had some alleged behaviors of touching Resident 1. Staff E said staff were to monitor Resident 2's whereabouts in the facility and monitor Resident 2 when alone with Resident 1. The residents were allowed to sit by each other but could not touch. Staff E said if any inappropriate touching occurred, staff would separate the residents and report the observation. At 4:16 PM, Staff C, Licensed Practical Nurse and Resident Care Manager, said Resident 1 and Resident 2 had developed a friendship in the past. They like to sit by each other and rub hands which was the only acceptable form of touching. Staff C said staff had set aside time so the residents could spend time together while supervised. Staff C said today was the first day there was an issue related to rubbing of the arm. When asked about Resident 2 rubbing up under Resident 1's sleeve, Staff C said that would not be acceptable. Staff C said there were not any interventions on Resident 2's care plan related to the resident's behavior towards Resident 1. On 4:27 PM, Staff B said Resident 1 and Resident 2 were friends. They say they love each other as friends. Staff B said the staff caring for Resident 2 should be monitoring his whereabouts. Staff B said staff missed Resident 2 going into the day room on 06/08/2023. Staff B said Resident 2 was alert and oriented and continued to deny the allegation. Resident 1 had never shown any change in her behavior related to the relationship with Resident 2. Resident 1 had cognitive impairment and Resident 1's guardian was okay with appropriate touching. Staff B said it was not appropriate for Resident 2 to rub up under Resident 1's sleeve. Staff B said Resident 2 did not have a current care plan to direct staff how to manage the interactions with Resident 1. Reference WAC 388-97-1060 (3)(g) .

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review, the facility failed to ensure care plan updates were completed for 1 of 5 sampled residents (2) reviewed for care plan revisions. This failure placed residents at risk of not receiving current interventions for their care needs and a diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses including cerebral palsy (a disorder affecting the ability to move) and epilepsy (a disorder causing seizures). The quarterly Minimum Data Set (MDS), an assessment tool, dated 03/23/2023, documented Resident 1 has severe cognitive impairment and was totally dependent on staff with activities of daily living (ADLs). Resident 2 was admitted to the facility on [DATE] with diagnoses including end-stage kidney disease. The quarterly MDS, dated [DATE], documented Resident 2 had no cognitive impairment and required limited assistance with ADLs. Facility Investigations, dated 01/18/2023 and 03/30/2023, documented allegations of inappropriate touching of Resident 1 by Resident 2. Resident 2's care plan, dated 01/19/2023, documented Resident 2 has a history of verbally abusive behaviors towards other residents. Staff should analyze triggers to determine how to de-escalate behaviors. The care plan did not provide interventions for staff regarding behaviors towards Resident 1. On 06/06/2023 and on 06/08/2023, Resident 2 was observed inappropriately touching of Resident 1. On 06/08/2023 at 3:50 PM, Staff E, Nursing Assistant, said Resident 2 had some alleged behaviors of touching Resident 1. Staff E said staff were to monitor Resident 2's whereabouts in the facility and monitor the situation if Resident 2 was alone with Resident 1. Staff E said the residents were allowed to sit by each other, but they could not touch. Staff E said if any inappropriate touching occurred, staff were to separate the residents and report their observation. On 4:16 PM, Staff C, Licensed Practical Nurse and Resident Care Manager, said the residents liked to sit by each other and rub hands, which is the only acceptable form of touching. Staff C said today was the first day there was an issue related to rubbing of the arm. After reviewing Resident 2's care plan, Staff C said there were not interventions related to the resident's behavior towards Resident 1. On 4:27 PM, Staff B, Registered Nurse and Director of Nursing Services, said Resident 2's care plan related to behaviors towards Resident 1 were resolved at some point and was no longer current. Staff B said the care plan should be updated to include updated interventions. Reference WAC 388-97-1020 (5)(b) .

Apr 2023 4 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to provide activities of daily living (ADLs) for residents dependent on staff assistance related to bathing for 2 of 5 sampled residents (4 & 6) reviewed for ADLs. This failure placed residents at risk for poor hygiene and a diminished quality of life. Findings included . 1) Resident 4 was admitted to the facility on [DATE] with diagnoses including diabetes and knee and hip contractures (a tightening of the ligaments causing shortening and stiff of joints). The quarterly Minimum Data Set (MDS), dated [DATE], documented Resident 4 had no cognitive impairment and required extensive assistance from staff with ADLs. The care plan, dated 09/15/2022, documented Resident 4 would have showers on Monday and Thursday evenings. On 03/20/2023 at 3:45 PM, Resident 4 said the facility was not consistently providing showers. Resident 4 said he would complain and showers would improve, but then showers started to be missed again. Resident 4 said he has gone weeks without showers. Resident 4's bathing record, dated 03/29/2023 through 04/29/2023, documented two showers were provided in 30 days, on 03/30/2023 and on 04/08/2023 (two of eight opportunities). Resident 4's progress notes, dated 03/29/2023 through 04/29/2023, did not document a shower refusal or a reason for a shower refusal. 2) Resident 6 was admitted to the facility on [DATE] with diagnoses including diabetes. The quarterly MDS, dated [DATE], documented Resident 6 had no cognitive impairment and required extensive assistance from staff with ADLs. The care plan, dated 11/16/2022, documented Resident 6 required assistance with bathing. On 03/16/2023 at 1:20 PM, Resident 6 said she did not always get showers. Resident 6 said while residents received showers, there was not any staff on the floor. The resident said showers get missed when they are too busy. Resident 6's bathing record, dated 03/29/2023 through 04/29/2023, documented four showers were provided in 30 days, on 03/29/2023, on 04/12/2023, on 04/15/2023, and on 04/16/2023 (four of eight opportunities). Resident 6's progress notes, dated 03/29/2023 through 04/29/2023, did not show documentation of a shower refusal or a reason for a shower refusal. On 04/17/2023 at 2:30 PM, Staff E, Licensed Practical Nurse, said staffing was short. Residents were not getting care, including showers, timely. On 04/28/2023 at 4:50 PM, Staff B, Director of Nursing Services and Registered Nurse, said the residents should be getting showers according to their plan of care. Reference WAC 388-97-1060 (1) .

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review, the facility failed to ensure residents with limited range of motion (ROM) received appropriate care and treatment to prevent further decrease in ROM for 2 of 5 sampled residents (7 & 4) reviewed for ROM. This failure placed residents at risk for the development of contractures (a fixed tightening of muscle, tendons, ligaments, or skin that prevents normal movement), pain, and a decreased quality of life. Findings included . 1) Resident 7 was admitted to the facility on [DATE] with diagnoses including traumatic brain injury. The quarterly Minimum Data Set (MDS), dated [DATE], documented Resident 7 had severe cognitive impairment and required extensive assistance from staff with activities of daily living (ADLs). The Restorative Program Initiation or Quarterly Evaluation, dated 04/18/2022, documented the resident was bed bound and dependent on staff for mobility and required passive ROM with AM and PM care. Staff would document how resident tolerated ROM and minutes spent with resident. The medical record did not include documentation of a Restorative Program (RP) including ROM. No further evaluations of the RA program occurred after 04/18/2022. The [NAME] (care directives), undated and reviewed on 04/05/2023, documented staff would provide ROM with AM and PM care. An email from the Staff B, Director of Nursing Services (DNS) and Registered Nurse (RN), dated 03/02/2023 at 3:02 PM, documented the facility did not have an active RA program at this time, so a list of residents RP was not provided (as requested on 03/01/2023). Staff B documented she did not think this was accurate. On 03/31/2023 at 3:15 PM, Staff G, Nursing Assistant (NA), said she did restorative care for Resident 7 when caring for the resident. Staff G said there was a couple of residents on a restorative program but she was unsure of other residents on the program. Staff G said the ROM should be documented in the medical record. Staff G said there was a new staff member who would be starting a RP. On 04/17/2023 at 2:40 PM, Resident 7 was observed lying in bed. Resident 7 had a cloth in his right hand that was in a tight fist. Resident 7's knees were bent and in a curled position. On 04/18/2023 8:05 PM, Staff K, NA, said she was unaware of any residents on a RA program in the facility. On 04/28/2023 at 4:50 PM, Staff B said a new staff member would be implementing the RP and had started working on organizing the program. Staff B said she could not provide documentation of RP for Resident 7. Staff B could not provide names of residents on a RP. Staff B said they had not had a RP for about two weeks. 2) Resident 4 was admitted to the facility on [DATE] with diagnoses including diabetes and knee and hip contractures. The quarterly MDS, dated [DATE], documented Resident 4 had no cognitive impairment and required extensive assistance from staff with ADLs. The care plan, dated 09/15/2022, documented therapy to evaluate and treat as ordered. Physical Therapy (PT) Evaluation and Plan of Treatment, dated 12/16/2022 to 02/13/2023, documented therapy provided wheelchair management. Orthopaedic orders, dated, 01/06/2023, documented physical therapy (PT) to evaluate and treat the residents contractures. Perform stretching and range of motion to aggressively and progressively stretch the hip and knee flexion to counteract contractures. No order for PT services was entered into the medical records after appointment on 01/06/2023. Summary of Skilled Services, dated 01/09/2023, documented Resident 4 was discharged from therapy services. A RP was recommended for active and passive ROM. No program was documented in the medical record. The notes did not address the order for ROM. Progress notes, dated 01/11/2023, documented Resident 4 asked staff about the delay in starting ROM. Staff told the resident they were going to start working on this. Progress notes, dated 02/11/2023, documented therapy was unable to perform the ROM as ordered. Referred to DNS and Director of Rehab for next steps. Progress notes, dated 02/21/2023, documented referral for therapy evaluation related to contracture management. Physical Therapy PT Evaluation and Plan of Treatment, dated 02/22/2023 to 04/22/2023, did not address the order for ROM. No attempts to contact the orthopedic doctor to discuss ROM were documented. Therapy staff were not available to be interviewed during this survey. On 03/23/2023 at 3:45 PM, Resident 4 said he developed contractures to his knees while recovering from a long illness. Resident 4 wished to return home and wanted aggressive treatment to see if they could improve his contractures and mobility. Resident 4 said the facility first sent him to an orthopedic doctor who could not address his concerns. A new referral was made to the correct doctor who recommended more intense ROM. Resident 4 went to this appointment on 01/06/2023. Resident 4 said no therapy, specifically for the ROM, was started for a long time after the appointment. Resident 4 was frustrated because he could not get an answer as to why there was such long delay. Resident 4 said the contractures had not gotten worse and he was currently in therapy. Resident 4 said he did not know if he was getting the intensive ROM and was told by a therapist it would not work anyway. Resident 4 said RP did not start when he was not receiving therapy including ROM. Resident 4 was observed in bed with knee contractures limiting his mobility. On 04/18/2023 at 8:05 PM, Staff K said she normally worked on Resident 4's wing. Staff K said she was not aware of any resident who received restorative or range of motion on this wing. On 04/28/2023 at 4:50 PM, Staff B said Resident 4 did see orthopedics but she could not say if the resident was getting ROM. Staff B said Resident 4 did not have a restorative program implemented. Staff B said she could not speak to the delay in the ordered ROM program. Reference WAC 388-97-1060 (3)(d) .

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure hydration was administered and monitored for residents at risk for dehydration for 1 of 5 sampled residents (2) reviewed for hydration. This failure placed residents at risk for medical complications, change in health status, and a decreased quality of life. Findings included . Resident 2 was admitted to the facility on [DATE] with diagnoses including diabetes, pressure ulcers, and obesity. The admission Minimum Data Set, dated [DATE], documented Resident 2 had severe cognitive impairment and required extensive assistance from staff with activities of daily living. The care plan, dated 03/03/2023, documented Resident 2 required supervision with eating. Provider notes, dated 03/18/2023, documented Resident 2's urine was turbid (cloudy and thick). A urinalysis was ordered. Staff were directed to push oral fluids. The March 2023 Medication Administration Record (MAR) documented staff would push at least 2 (2000 milliliters) liters of fluids daily on every shift. The MAR showed staff documented twice daily the amount of fluids given. The order did not direct staff on actions if Resident 2 was not reaching 2 liters a day. The resident did not receive 2 liters a day and the record did not show staff followed up on fluid intake. The daily totals for 03/18/2023 to 03/22/2023 included: --03/18/2023: 240 cc (cubic centimeters - 1 cc is equivelent to 1 milliliter) --03/19/2023: 440 cc --03/20/2023: 1140 cc --03/21/2023: 340 cc --03/22/2023: 120 cc Progress notes, dated 03/23/2023, documented Resident 2 was transferred to the hospital due to a high white blood cell count. Hospital emergency room notes, dated 03/22/2023, documented Resident 2 had dry mucous membranes and required intravenous fluids for dehydration. On 04/25/2023 at 2:58 PM, Staff D, Licensed Practical Nurse (LPN), said staff should be documenting all fluid intake in the MAR when fluids are ordered. Staff D said nursing should check and address orders which are unclear or entered wrong. Staff D said she did not think the resident could drink that amount (2000 cc) in a day. Staff D said the order should have additional slots to enter fluid amount instead on just twice daily. Staff D said she did not recall Resident 2 having hydration concerns. On 04/28/2023 at 3:00 PM, Staff C, LPN, said 2 liters of fluid was a lot and the order was not entered correctly. Staff C said the order should have been clarified. There should have been a directive on what to do if the resident was not meeting the required fluid intake. Staff C said she thought they were keeping Resident 2 hydrated. Staff C said Resident 2 was dependent on staff for drinking all fluids. At 4:56 PM, Staff B, Director of Nursing Services and Registered Nurse, said staff should have been clarifying and addressing these orders. Staff B said staff should have followed up if the resident was unable to meet the fluid intake goal. Reference WAC 388-97-1000 (1)(b)(2)(k), -1060 (3)(h) .

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure enteral nutrition and fluids (delivery of nutrients through a feeding tube directly into the stomach or small intestine) was administered in accordance with physician's orders (POs) and professional standards of practice for 1 of 2 sampled residents (1) reviewed for tube feeding management. This failure placed residents at risk for medical complications, change in health status, and a decreased quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses including intellectual disabilities and Barrett's Esophagus (a condition where the esophagus becomes inflamed and thickened making it difficult to swallow). The quarterly Minimum Data Set, dated [DATE], documented Resident 1 had severe cognitive impairment, was totally dependent on staff with mobility and eating, and required tube feeding for nutrition. The care plan, revised 02/14/2023, documented Resident 1 had swallowing problems and required a feeding tube. Staff would give water flushes as ordered. The physician orders, dated 01/17/2023, documented a change in Osmolite (nutritional feeding) from a continuous feeding to a bolus feeding (way to send formula through a feeding tube in a shorter timeframe). Staff would give 300 mL bolus every 6 hours for a total of 1200 mL and 100 calories per day. No order was given for water flushes. Provider communication form, dated 01/22/2023, documented a request for clarification of the administration of the water flushes of 325 mL per bolus. Staff were inquiring if flushes should be delivered manually or use a pump to administered the water. The provider noted they would check with the Director of Nursing Services (DNS). No further follow up was documented in the medical record. The physician orders, dated 01/27/2023, documented staff would flush with 325 cc (ml) of water for a total of 2600 mL per 24 hours. The order did not indicate the amount of flush or time staff administered the water flush. The Osmolite bolus was increased to 325 mL every 6 hours. The Physician Orders, dated 02/03/2023, documented an increase to Osmolyte from 325 mL to 400 mL boluses every 6 hours. The February 2023 Medication Administration Record showed staff continued to administer 325 ml bolus from 02/03/2023 to 02/07/2023. Progress notes, dated 02/07/2023, documented Resident 1 had coffee ground residual from the feeding tube. The resident was transferred to the hospital. emergency room notes, dated 02/07/2023, documented Resident 1's sodium levels were critically elevated at 193 (normal is 135-145). The note showed the resident was likely not getting enough free water and changing the tube feeding from continuous to bolus. The note showed Resident 1 was ill- appearing and dehydrated with dry mucous membranes. The Discharge summary, dated [DATE], documented Resident 1 continued to have elevated sodium levels and unstable vital signs. The resident passed away on 02/10/2023. On 04/25/2023 at 2:58 PM, Staff D, Licensed Practical Nurse (LPN), said the resident's flush orders should have been entered in the MAR so staff could document the amount of flush and the time it was administered. Staff D said staff documented 325 mL of feeding when they should have been administering 400 mL. On 04/28/2023 at 3:00 PM, Staff C, LPN, said she identified the concerns with documenting the flush and feeding order documentation. Staff C said nursing should have been double checking the orders and administering correctly. Staff C said she did not recall Resident 1 appearing ill prior to hospitalization. Staff C said Resident 1 used to get an order of intravenous fluid and it was discontinued; and wondered if this could have contributed. Staff C said she did not see signs of dehydration. At 4:56 PM, Staff B, Director of Nursing Services and Registered Nurse, said she noted the concerns with the fluids and flushes. Staff B said staff should have been documenting orders correctly and identifying any discrepancies with orders. Reference WAC 388-97-1060 (3)(f) .

Dec 2022 4 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0557 (Tag F0557)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to provide personal belongs for three of four residents (5, 6, 7) reviewed for isolation precautions during a COVID-19(an infectious disease-causing respiratory illness with symptoms including cough, fever, new or worsening malaise [a general feeling of discomfort/uneasiness], headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death) outbreak in the facility. This failure placed residents at risk for increased feelings of isolation, anxiety, and decrease quality of life. Findings included . <Resident 5> Resident 5 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS), an assessment tool, dated 09/22/2022, showed the resident was cognitively intact. The care plan, dated 11/17/2022, documents Resident 5 is a risk for psychosocial well-being concerns related to COVID-19 precautions. Staff will provide methods for communicating with family/visitors and provide in-room activities of the resident's choice. On 12/09/2022 at 9:25 AM, Resident 5 said when he was moved into the isolation unit, he was not sent with his belongings. The resident said he was told his belongings needed to be disinfected. Resident 5 said some belongings missing included his glasses, cell phone, and beard trimmer. The resident said he was unable to speak with his family during this time because he did not have his phone. Resident 5 said he did not his leg braces (used to prevent tightening of the leg muscles) for 4-5 days. Resident 5 said the television in the room he was transferred to worked so poorly he could not watch a football game he was looking forward to seeing. The resident said his roommate, Resident 6, did not have his hearing aids during isolation. Resident 5 said he was told he would be in isolation for 10 days, but it ended up being 21 days. Resident 5 said isolation without his belongings was the closest thing to being in prison he has experienced. Staff G, Nursing Assistant, agreed with Resident 5's statements assuring the resident she would retrieve those items today. <Resident 6> Resident 6 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], showed the resident was moderately cognitively impaired. The care plan, dated 11/17/2022, documents Resident 6 is a risk for psychosocial well-being concerns related to COVID-19 precautions. Staff will provide methods for communicating with family/visitors and provide in-room activities of the resident's choice. The care plan, dated 10/28/2021, documents Resident 6 experiences auditory loss requiring hearing aids. On 12/09/2022 at 11:50 AM, Resident 6 was observed in bed. The resident was no longer in isolation and in a new room. Boxes are piled up on a wheelchair on his side of the room. It is hard for Resident 6 to hear. Resident 6 said he did not have some belongings while in isolation. The resident points to the boxes saying some items have been returned. Resident 6 said the hardest part about being in isolation was they took me away from my God. Resident 6 clarified he did not have his Bible during his time in isolation. Resident 6 said he was happy to have his things back. At 11:58 AM, Staff G said some residents did not have belongings in their room during isolation. They were told the items needed to be disinfected. Some residents did not have personal hygiene products such as toothbrushes or electric razors. They did not have replacement items on hand for the residents. <Resident 7> Resident 7 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS), dated [DATE], showed the resident was moderately cognitively impaired. The care plan, dated 09/02/2021, documents Resident 7 is a risk for psychosocial well-being concerns related to COVID-19 precautions. Staff will provide methods for communicating with family/visitors and provide in-room activities of the resident's choice. On 12/14/2022 at 2:35 PM, Resident 7 said she missed her personal belonging while she was in isolation. Some of the items she did not have during this time were personal care items such as a razor, comb, clothing, and glasses. Resident 7 said she also missed being able to use her writing supplies. The resident said it was the little things that were hard to be without. Resident 7 said she was told her belongings had to be sterilized before they could be returned. Resident 7 said her belongings were returned after isolation ended. At 3:37 PM, Staff E, Licensed Practical Nurse, said she worked in the COVID-19 unit. Staff E said there were some residents who did not have their personal belongings but some who did. Staff E said she hear their belongings were boxed up and stored. Staff E said it was tough for the residents. Staff E said the resident's felt like they were in Siberia. On 12/21/2022 at 3:42 PM, Staff B, Registered Nurse and Director of Nursing Services, said the resident's belongings were boxed up because they had to do room changes for the residents who were positive for COVID-19. If resident's requested certain belongings, they were brought to them. Staff B said she understood it would be hard for the resident's to be without their belongings while in isolation. Staff B said there was a delay in removing isolation due to missing documentation related to their clinical status. This caused some residents to be in isolation longer than expected. Staff B said she understood this practice impacted the resident's rights to access their belongings. At 4:15 PM, Staff A, Administrator, said the residents should have transferred to the COVID-19 unit with the belongings they wanted to take with them. The residents should have had items such as glasses and hearing aids during isolation. Reference: (WAC) 388-97-0860(1)

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide Pneumococcal and Influenza vaccines for one of five sampled residents (1) reviewed who requested immunization administration. This failure placed residents at risk of exposure to a contagious virus and increased the risk for respiratory complications. Findings included . Resident 1 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS), an assessment tool, dated 11/15/2022, showed the resident was moderately cognitively impaired. The Pneumococcal, COVID-19 & Annual Vaccine Information and Request form, dated 10/10/2022, documented Resident 1's guardian requested administration of pneumococcal and influenza vaccinations. The medical record did not have documented evidence showing administration of the vaccinations. On 12/21/2022 at 3:42 PM, Staff B, Registered Nurse and Director of Nursing Services, said Resident 1 did not get their vaccinations as requested on the consent. Staff B said the resident should have received their vaccinations. Reference WAC 388-97-1340 (1), (2), (3)

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0887 (Tag F0887)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure one of five residents (1) were administered the COVID-19 (an infectious disease-causing respiratory illness with symptoms including cough, fever, new or worsening malaise [a general feeling of discomfort/uneasiness], headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death) vaccination when requested. This failed practice placed the resident at risk of COVID-19 infection and increased the risk for respiratory complications. Findings include . Resident 1 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS), an assessment tool, dated 11/15/2022, showed the resident was moderately cognitively impaired. The Pneumococcal, COVID-19 & Annual Vaccine Information and Request form, dated 10/10/2022, documented Resident 1's guardian requested administration of COVID-19 vaccination. The medical record did not have documented evidence showing administration of the vaccination. The Progress Notes, dated 11/14/2022, documents Resident 1 tested positive for COVID-19. On 12/21/2022 at 3:42 PM, Staff B, Registered Nurse and Director of Nursing Services, said Resident 1 did not get their vaccinations as requested on the consent. Staff B said the resident should have received their vaccinations. WAC Reference 388-97-1780 (2)(b)(d)

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain accurate medical records for four of five sampled residents (1, 3, 4, 5) reviewed for resident records. This failure placed residents at risk for having unmet needs and delayed removed from isolation precautions. Findings included . The COVID-19(an infectious disease-causing respiratory illness with symptoms including cough, fever, new or worsening malaise [a general feeling of discomfort/uneasiness], headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death) Facility Policy and Procedure, revised 06/2022, documents residents will be screened every shift for COVID-19 signs and symptoms including, but not limited to, a fever above 100 degrees, loss of smell/taste, cough, nausea/vomiting, sore throat, diarrhea, shortness of breath, congestion/runny nose, fatigue, muscle/body aches, and headaches. <Resident 1> Resident 1 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS), an assessment tool, dated 11/15/2022, showed the resident was moderately cognitively impaired. The Progress Notes, dated 11/14/2022, documents Resident 1 tested positive for COVID-19. Resident 1 remained in isolation until 11/28/2022. The Weights & Vitals documentation, dated 11/14/20222 through 11/28/2022, shows staff did not document Resident 1's vital signs on 11/16/2022, 11/17/2022, 11/19/2022, 11/21/2022, 11/23/2022, 11/24/2022, 11/25/2022, 11/26/2022, 11/27/2022, and 11/28/2022. The Progress Notes, dated 11/14/20222 through 11/28/2022, shows staff did not documentation monitoring of Resident 1's signs and symptoms of COVID-19 or monitoring of the resident status each shift on 11/16/2022, 11/17/2022, 11/19/2022, 11/21/2022, 11/22/2022, 11/23/2022, 11/24/2022, 11/25/2022, 11/26/2022, 11/27/2022, and 11/28/2022. <Resident 3> Resident 3 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], showed the resident was severely cognitively impaired. The Progress Notes, dated 11/28/2022, documents Resident 3 was moving to the COVID-19 unit. The Weights & Vitals documentation, dated 11/28/20222 through 12/08/2022, shows staff did not document Resident 3's vital signs. The Progress Notes, dated 11/28/20222 through 12/08/2022, shows staff did not documentation monitoring of Resident 3's signs and symptoms of COVID-19 or monitoring of the resident status each shift on 11/28/2022, 11/29/2022, 11/30/2022, 12/01/2022, 12/04/2022, 12/05/2022, 12/06/2022, 12/07/2022, and 12/08/2022. <Resident 4> Resident 4 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], showed the resident was cognitively intact. The Progress Notes, dated 11/14/2022, documents Resident 4 tested positive for COVID-19. Resident 4 remained in isolation until 11/25/2022. The Weights & Vitals documentation, dated 11/14/20222 through 11/25/2022, shows staff did not document Resident 4's vital signs on 11/14/2022, 11/16/2022, 11/19/2022, 11/21/2022, 11/23/2022, and 11/25/2022. The Progress Notes, dated 11/14/20222 through 11/24/2022, shows staff did not documentation monitoring of Resident 4's signs and symptoms of COVID-19 or monitoring of the resident status each shift on 11/14/2022, 11/15/2022, 11/16/2022, 11/17/2022, 11/18/2022, 11/19/2022, 11/20/2022, 11/21/2022, 11/22/2022, 11/23/2022, and 11/24/2022. <Resident 5> Resident 5 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], showed the resident was cognitively intact. The Progress Notes, dated 11/17/2022, documents Resident 5 tested positive for COVID-19. The Weights & Vitals documentation, dated 11/17/20222 through 12/08/2022, shows staff did not document Resident 5's vital signs on 11/17/2022, 11/19/2022, 11/21/2022, 11/23/2022, 11/24/2022, 11/25/2022, 11/26/2022, 11/27/2022, 11/28/2022, 11/29/2022, 12/01/2022, 12/02/2022, 12/03/2022, 12/04/2022, 12/05/2022, 12/06/2022, 12/07/2022, and 12/08/2022. The Progress Notes, dated 11/17/20222 through 12/08/2022, shows staff did not documentation monitoring of Resident 1's signs and symptoms of COVID-19 or monitoring of the resident status each shift on 11/17/2022, 11/19/2022, 11/23/2022, 11/24/2022, 11/25/2022, 11/26/2022, 11/27/2022, 11/28/2022, 11/29/2022, 12/01/2022, 12/02/2022, 12/03/2022, 12/04/2022, 12/05/2022, 12/06/2022, 12/07/2022, and 12/08/2022. On 12/09/2022 at 11:44 PM, Resident 5 said vital signs and symptoms of COVID-19 was monitored regularly while he was in isolation. At 11:58 AM Staff G, Nursing Assistant, said they worked in the COVID-19 unit regularly. Staff G said they were obtaining vital signs regularly, but are unable to enter the vitals into the computer system, so they give them to the nursing staff to enter. Staff G said they do not believe the residents were not monitoring during their illness with COVID-19. At 12:30 PM, Staff D, Licensed Practical Nurse, said residents should be monitored for signs and symptoms of COVID-19 including vital signs every shift. Staff D said the data should be documented in the resident's medical record. Staff D said they have been using a lot of agency staff so this may contribute to the missed documentation. On 12/21/2022 at 3:42 PM, Staff B, Registered Nurse and Director of Nursing Services, said a full set of vital signs and an assessment of COVID-19 signs and symptoms the resident may be experiencing should be documented in the medical record on each shift. Staff B said they have identified missed charting as an issue. Staff B said missed documentation resulted in a delay in removing some residents from isolation. Staff B said when there were some recent process changes, this documentation stopped as well. Staff B said vitals and monitoring should continue to be documented. Reference WAC 388-97-1720(1)(a)(i-iv)(b)

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"What changes have you made since the serious inspection findings?"
"Why is there high staff turnover? How do you retain staff?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• Licensed and certified facility. Meets minimum state requirements.

Concerns

• Multiple safety concerns identified: 1 life-threatening violation(s), 3 harm violation(s), $159,534 in fines. Review inspection reports carefully.
• 79 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
• $159,534 in fines. Extremely high, among the most fined facilities in Washington. Major compliance failures.
• Grade F (0/100). Below average facility with significant concerns.

Bottom line: Trust Score of 0/100 indicates significant concerns. Thoroughly evaluate alternatives.

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About This Facility

What is Fir Lane Care's CMS Rating?

CMS assigns FIR LANE CARE an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Washington, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Fir Lane Care Staffed?

CMS rates FIR LANE CARE's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 58%, which is 12 percentage points above the Washington average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.

What Have Inspectors Found at Fir Lane Care?

State health inspectors documented 79 deficiencies at FIR LANE CARE during 2022 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 3 that caused actual resident harm, and 75 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.

Who Owns and Operates Fir Lane Care?

FIR LANE CARE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by CALDERA CARE, a chain that manages multiple nursing homes. With 135 certified beds and approximately 82 residents (about 61% occupancy), it is a mid-sized facility located in SHELTON, Washington.

How Does Fir Lane Care Compare to Other Washington Nursing Homes?

Compared to the 100 nursing homes in Washington, FIR LANE CARE's overall rating (1 stars) is below the state average of 3.2, staff turnover (58%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting Fir Lane Care?

Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the facility's high staff turnover rate.

Is Fir Lane Care Safe?

Based on CMS inspection data, FIR LANE CARE has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Washington. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at Fir Lane Care Stick Around?

Staff turnover at FIR LANE CARE is high. At 58%, the facility is 12 percentage points above the Washington average of 46%. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?

Was Fir Lane Care Ever Fined?

FIR LANE CARE has been fined $159,534 across 3 penalty actions. This is 4.6x the Washington average of $34,674. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.

Is Fir Lane Care on Any Federal Watch List?

FIR LANE CARE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 135
Avg. Residents: 82
Occupancy: 61.1%
Ownership: For profit - Limited Liability company
Chain: CALDERA CARE
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
High Turnover: -5
1 Immediate Jeopardy citation: -12
3 Actual Harm citations: -15
79 Deficiencies: -10
Fines ($159,534): -15
Final Score: 0/100

Nearby Alternatives

SHELTON HEALTH & REHAB CENTER 2-star

View all in SHELTON →

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Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 505230